Bruxism Splints in Children: Are They Recommended?

Bruxism in children is a common masticatory muscle activity characterized by repetitive tooth grinding or clenching during sleep or wakefulness.

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Although many children exhibit sleep bruxism at some stage of development, its presence does not automatically indicate the need for treatment.

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One of the most debated questions in pediatric dentistry is whether myorelaxant splints (occlusal splints) should be prescribed to manage bruxism in growing children.
Current scientific evidence indicates that splints should not be considered a routine treatment for pediatric bruxism because their effectiveness remains uncertain, while craniofacial growth and tooth eruption require careful clinical consideration. Instead, management should focus on identifying associated factors, evaluating symptoms, and individualizing treatment according to each child's clinical presentation.

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✅ What Is Bruxism in Children?
According to contemporary international consensus, sleep bruxism is a rhythmic or non-rhythmic masticatory muscle activity that may involve tooth grinding, clenching, bracing, or mandibular thrusting during sleep. In children, diagnosis is usually based on parental reports combined with clinical findings such as tooth wear, grinding sounds, muscle discomfort, or functional symptoms rather than instrumental confirmation alone.
Importantly, physiological tooth wear may occur during normal development, especially in the primary dentition. Therefore, tooth wear by itself should not be interpreted as definitive evidence that treatment is necessary. Clinical relevance depends on symptoms, progression, functional impairment, and associated risk factors.

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✅ Are Myorelaxant Splints Recommended for Children?
The short answer is not routinely.
Occlusal splints are widely used in adult dentistry for several indications, particularly temporomandibular disorders and tooth protection. However, evidence supporting their effectiveness for treating bruxism in children remains limited and inconclusive.
Recent systematic reviews evaluating pediatric sleep bruxism found that occlusal splints did not demonstrate consistent superiority over observation or other conservative approaches. Some small clinical studies reported reductions in parental reports of grinding, whereas others using objective muscle activity measurements found no significant reduction in sleep bruxism activity after splint therapy. Consequently, current evidence does not justify prescribing splints as the standard treatment for every child with bruxism.
The International Association of Paediatric Dentistry (IAPD) recognizes that occlusal splints may be included among individualized management options, but emphasizes that treatment should be based on comprehensive diagnosis rather than the presence of tooth grinding alone. Similarly, contemporary pediatric literature stresses that growth and continuous dental eruption require close monitoring whenever an intraoral appliance is used.

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✅ Evidence-Based Indications and Limitations
The following table summarizes the current clinical position regarding occlusal splints in pediatric patients.

Clinical Situation	Current Evidence-Based Interpretation
Asymptomatic sleep bruxism	Routine splint therapy is not recommended; periodic observation is generally preferred.
Progressive tooth wear with functional concern	A splint may be considered individually for tooth protection after comprehensive assessment.
Muscle pain or temporomandibular symptoms	Management should prioritize diagnosis of the underlying condition; splints are only one possible reversible therapy.
Mixed dentition and active eruption	Appliances require frequent monitoring and adjustment because dentition and occlusion are continuously changing.
Grinding without clinical damage	Education, monitoring, and evaluation of associated factors usually provide greater clinical value than immediate appliance therapy.

✅ When Could a Splint Be Considered?
Although splints are not routinely indicated, there are selected situations where an occlusal appliance may be considered by a pediatric dentist after careful evaluation.

Potential indications include:
▪️ Severe and progressive tooth wear with risk of structural damage.
▪️ Documented functional symptoms associated with excessive parafunctional activity.
▪️ Children presenting with painful masticatory muscle overload when a reversible appliance is considered appropriate within a broader management plan.
▪️ Situations where the primary objective is tooth protection rather than elimination of bruxism.
These indications should never be interpreted as automatic criteria. The decision depends on growth stage, dentition, eruption pattern, occlusal development, symptoms, and the presence of contributing medical or sleep-related conditions.

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✅ Why Are Splints More Complex in Growing Children?
Unlike adults, children experience continuous craniofacial growth and dental eruption. This biological characteristic represents the principal limitation of prolonged occlusal appliance therapy.
A splint fabricated during one developmental stage may gradually lose adaptation as teeth erupt or exfoliate. Poor adaptation may alter occlusal contacts or reduce appliance effectiveness, making regular clinical follow-up essential whenever a splint is prescribed. For this reason, pediatric occlusal splints should be regarded as carefully monitored reversible appliances rather than long-term universal therapy.

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💬 Discussion
The current literature demonstrates an important distinction between protecting the dentition and treating the bruxism itself. Occlusal splints may theoretically reduce mechanical consequences of grinding by distributing occlusal forces and protecting tooth surfaces; however, this does not necessarily mean they reduce the underlying masticatory muscle activity responsible for sleep bruxism.
Systematic reviews consistently conclude that the quality of available pediatric evidence is low and that treatment protocols remain insufficiently supported by robust randomized clinical trials. The most recent umbrella and systematic reviews emphasize that associated factors—including sleep disturbances, respiratory conditions, psychosocial influences, and individual clinical characteristics—should receive greater attention than routine appliance therapy. Therefore, contemporary pediatric dentistry favors an individualized, conservative, and evidence-based approach rather than universal splint prescription.

✍️ Conclusion
Myorelaxant splints are not routinely recommended for treating bruxism in children. Current scientific evidence does not demonstrate sufficient consistency to support their universal use as first-line therapy.
When clinically indicated, an occlusal splint should be prescribed primarily as a reversible protective intervention, not as a guaranteed treatment capable of eliminating pediatric bruxism. Comprehensive diagnosis, identification of associated factors, and periodic monitoring remain the foundation of evidence-based management in growing patients.

🎯 Clinical Recommendations
▪️ Do not prescribe an occlusal splint solely because parents report nocturnal tooth grinding.
▪️ Assess tooth wear progression, muscle symptoms, TMJ function, sleep history, and respiratory factors before deciding on treatment.
▪️ Consider splints only when there is a clear clinical objective, particularly protection of dental structures or management of specific reversible symptoms.
▪️ Schedule regular follow-up visits to monitor appliance fit during primary and mixed dentition, adapting the appliance as eruption and growth occur.
▪️ Refer for pediatric or sleep evaluation when clinical findings suggest obstructive sleep disorders or relevant systemic contributing factors.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). *Management of the developing dentition and occlusion in pediatric dentistry*. The Reference Manual of Pediatric Dentistry.
✔ American Academy of Pediatric Dentistry. (2024). *Temporomandibular disorders in children and adolescents, including those with special health care needs*. The Reference Manual of Pediatric Dentistry.
✔ Hardy, R. S., & Bonsor, S. J. (2021). The efficacy of occlusal splints in the treatment of bruxism: A systematic review. *Journal of Dentistry, 108*, 103621. https://doi.org/10.1016/j.jdent.2021.103621
✔ Huynh, N., Lavigne, G. J., et al. (2024). Sleep bruxism in children and adolescents: A scoping review. *Journal of Oral Rehabilitation, 51*(1). https://doi.org/10.1111/joor.13603
✔ International Association of Paediatric Dentistry. (2022). *Management of bruxism in children: Consensus recommendations*. IAPD Foundational Articles and Recommendations.
✔ Minervini, G., Franco, R., Marrapodi, M. M., et al. (2024). Sleep bruxism in children main methods of treatment: A systematic review with meta-analysis. *Journal of Clinical Pediatric Dentistry, 48*(5), 41–50. https://doi.org/10.22514/jocpd.2024.102
✔ Restrepo-Serna, C., & Winocur, E. (2023). Sleep bruxism in children, from evidence to the clinic: A systematic review. *Frontiers in Oral Health, 4*, 1166091. https://doi.org/10.3389/froh.2023.1166091
✔ Silva, F. S., et al. (2022). Management of idiopathic sleep bruxism in children and adolescents: A systematic review of the literature. *Journal of Oral Rehabilitation, 49*(2), 210–219.
✔ Soares, J. P., et al. (2024). Childhood and adolescents sleep bruxism treatment: A systematic review. *Sleep Science*.

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Amoxicillin-Clavulanate: When to Use It in Dentistry

Amoxicillin-clavulanate is a broad-spectrum β-lactam antibiotic used for selected odontogenic infections.

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Its combination of amoxicillin with clavulanic acid extends antibacterial activity against organisms that produce β-lactamases, making it useful when standard amoxicillin therapy is inadequate or broader antimicrobial coverage is clinically justified.

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However, broader coverage does not mean better routine treatment. Most dental infections should primarily be managed by definitive dental treatment, such as drainage, pulpotomy, pulpectomy, or root canal treatment, rather than systemic antibiotics alone.
Antibiotics are generally reserved for infections with systemic involvement, spreading infection, or situations in which definitive treatment cannot be provided immediately.

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✅ How Does Amoxicillin-Clavulanate Work?
Amoxicillin inhibits bacterial cell-wall synthesis. Clavulanic acid inhibits certain β-lactamases produced by bacteria, protecting amoxicillin from enzymatic degradation.
This combination therefore provides broader activity against some β-lactamase-producing oral bacteria than amoxicillin alone.
The clinical advantage must be balanced against greater antimicrobial exposure and a higher potential for gastrointestinal adverse effects compared with narrower-spectrum therapy.

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✅ When Should Amoxicillin-Clavulanate Be Considered?
The most important indication in routine dental practice is failure of appropriate first-line therapy.
For an immunocompetent adult with an odontogenic infection for which antibiotics are indicated, the ADA guideline recommends amoxicillin 500 mg three times daily for 3–7 days as a first-line option. If the patient does not improve or the infection progresses, therapy can be broadened by either adding metronidazole or switching to amoxicillin-clavulanate 500/125 mg three times daily for 7 days.
Clinical situations

Clinical situation	Role of amoxicillin-clavulanate
Localized infection without systemic involvement	Usually not indicated. Prioritize definitive dental treatment and drainage when appropriate.
Odontogenic infection with systemic involvement	An antibiotic may be indicated as an adjunct to urgent dental treatment. Amoxicillin is generally an appropriate first-line option.
Inadequate response to amoxicillin	Appropriate consideration. ADA guidance supports switching to amoxicillin-clavulanate or adding metronidazole.
Progressive or spreading odontogenic infection	May be appropriate depending on severity, timing of source control, and local guidelines. Severe infection may require urgent hospital or specialist management.
Routine dental procedure or uncomplicated dental pain	Not indicated. Antibiotics should not be used simply to treat pain or prevent routine postoperative complications.

✅ Amoxicillin vs. Amoxicillin-Clavulanate
Amoxicillin remains an important first-line choice when systemic antibiotic therapy is indicated in many odontogenic infections. The addition of clavulanate should be based on the clinical situation rather than used automatically.

Feature	Amoxicillin	Amoxicillin-Clavulanate
Spectrum	Narrower	Broader, including some β-lactamase-producing organisms
Typical role	First-line therapy when antibiotics are indicated	Broader therapy when clinically justified, particularly after inadequate response
Antimicrobial stewardship	Generally preferred when adequate	Should not replace narrower therapy without a clinical reason
Adverse effects	Generally well tolerated	More gastrointestinal adverse effects may occur

✅ Why Is Clavulanic Acid Important?
Some bacteria associated with odontogenic infections can produce β-lactamases, enzymes capable of inactivating certain β-lactam antibiotics. Clavulanic acid inhibits several of these enzymes and can therefore restore or extend the activity of amoxicillin against susceptible organisms.
This pharmacological advantage explains why amoxicillin-clavulanate may be useful after inadequate clinical response to amoxicillin. Nevertheless, antimicrobial susceptibility varies geographically, and treatment decisions should consider the clinical response, severity of infection, patient factors, and local antimicrobial guidance.

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✅ Evidence From Odontogenic Infections
Clinical evidence supports the effectiveness of amoxicillin-clavulanate in acute odontogenic infections. In a randomized study involving 472 patients, amoxicillin-clavulanate 875/125 mg twice daily was noninferior to clindamycin for clinical success, with overall success rates of 88.2% and 89.7%, respectively. Most adverse events were mild to moderate.
This evidence supports its clinical efficacy but does not establish amoxicillin-clavulanate as the preferred first-line antibiotic for every dental infection. Current antibiotic-stewardship principles favor the narrowest effective antimicrobial regimen.

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✅ When Should It Be Avoided?
Amoxicillin-clavulanate should not be prescribed simply because an infection is dental in origin.

It is generally inappropriate for:
▪️ Irreversible pulpitis without systemic infection
▪️ Symptomatic apical periodontitis without systemic involvement
▪️ Localized conditions that can be adequately treated with drainage or definitive dental therapy
▪️ Routine dental procedures without a specific indication for antibiotic prophylaxis
▪️ Situations in which the patient has a clinically significant penicillin allergy
The ADA specifically recommends against routine systemic antibiotics for most pulpal and periapical conditions and emphasizes definitive dental treatment as the primary intervention.

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✅ Important Safety Considerations
Before prescribing, clinicians should evaluate:

▪️ History of penicillin or β-lactam allergy
▪️ Previous antibiotic-associated adverse reactions
▪️ Hepatic disease or previous cholestatic reactions associated with amoxicillin-clavulanate
▪️ Renal function when clinically relevant
▪️ Current medications and potential interactions
▪️ Local antimicrobial resistance patterns
▪️ The possibility of a deep-space infection requiring urgent referral
Common adverse effects include diarrhea, nausea, and gastrointestinal discomfort. Unnecessary broad-spectrum antibiotic exposure also contributes to antimicrobial resistance and disruption of the normal microbiota.

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💬 Discussion
The clinical value of amoxicillin-clavulanate lies primarily in its ability to provide broader β-lactam coverage when narrower therapy is insufficient or when the clinical circumstances justify broader treatment.
Current evidence-based dental guidance emphasizes that antibiotic selection should follow, rather than replace, source control. Drainage, endodontic treatment, extraction, or other definitive procedures remain fundamental to managing odontogenic infection.
The decision to use amoxicillin-clavulanate should therefore be based on three questions: Is an antibiotic actually indicated? Is amoxicillin an adequate first-line choice? Has the patient failed to improve or does the infection justify broader coverage?
This approach is consistent with modern antibiotic stewardship, which seeks to achieve clinical efficacy while minimizing unnecessary broad-spectrum antimicrobial exposure.

✍️ Conclusion
Amoxicillin-clavulanate is not routinely the first antibiotic for dental infections. Its principal role is as a broader-spectrum option when an odontogenic infection requires systemic antibiotics and first-line amoxicillin is ineffective, or when the clinical characteristics of the infection warrant broader antimicrobial coverage.
Appropriate use requires simultaneous attention to source control, infection severity, allergy history, clinical response, and antimicrobial stewardship.

🎯 Clinical Recommendations
1. Do not prescribe amoxicillin-clavulanate for dental pain alone.
2. When systemic antibiotics are indicated, amoxicillin is generally an appropriate first-line option for immunocompetent adults without penicillin allergy.
3. Consider amoxicillin-clavulanate after inadequate response to appropriate first-line therapy, consistent with current ADA guidance.
4. Reassess the patient within approximately 3 days when antibiotics are prescribed.
5. Do not allow antibiotic therapy to delay drainage or definitive dental treatment.
6. Escalate urgently when there are signs of deep-space infection, airway compromise, severe systemic involvement, or rapidly progressive swelling.
7. Use the shortest clinically appropriate course and discontinue therapy when clinically indicated according to the applicable guideline.

📚 References

✔ American Dental Association. (2023). Antibiotic stewardship. ADA. https://www.ada.org/resources/ada-library/oral-health-topics/antibiotic-stewardship
✔ Lockhart, P. B., Tampi, M. P., Abt, E., Aminoshariae, A., Durkin, M. J., Fouad, A. F., Gopal, P., Hatten, B. W., Kennedy, E., Lang, M. S., Patton, L. L., Paumier, T. M., Suda, K. J., Swan, J., Treister, N. S., & Tampi, M. P. (2019). Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. The Journal of the American Dental Association, 150(11), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
✔ Segura-Egea, J. J., Gould, K., Şen, B. H., Jonasson, P., Cotti, E., Mazzoni, A., Sunay, H., Tjäderhane, L., & Dummer, P. M. H. (2018). European Society of Endodontology position statement: The use of antibiotics in endodontics. International Endodontic Journal, 51(1), 20–25. https://doi.org/10.1111/iej.12781
✔ Tancawan, A. L., Pato, M. N., Abidin, K. Z., Asari, A. S. M., Thong, T. X., Kochhar, P., Muganurmath, C., Twynholm, M., & Barker, K. (2015). Amoxicillin/clavulanic acid for the treatment of odontogenic infections: A randomised study comparing efficacy and tolerability versus clindamycin. International Journal of Dentistry, 2015, Article 472470. https://doi.org/10.1155/2015/472470

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Dexamethasone Use in Periodontal Surgery: Pros & Cons

Dexamethasone use in periodontal surgery has been investigated as a perioperative strategy to reduce the inflammatory response associated with surgical manipulation of periodontal tissues.

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Because postoperative pain and edema can affect comfort, mastication, and recovery, corticosteroids may provide an adjunctive benefit when appropriately selected.

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Current evidence suggests that perioperative dexamethasone can reduce postoperative pain and swelling, particularly during the first several days after periodontal flap surgery.
However, its benefits should be balanced against patient-specific contraindications, potential adverse effects, and the limited number of high-quality periodontal studies.

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✅ How Dexamethasone Works in Periodontal Surgery
Dexamethasone is a potent glucocorticoid with anti-inflammatory activity. It suppresses multiple inflammatory pathways, including the production of prostaglandins and other mediators involved in vascular permeability, tissue edema, and postoperative pain.
In periodontal surgery, this mechanism may attenuate the acute inflammatory response produced by flap elevation, tissue manipulation, and surgical trauma.
Importantly, dexamethasone is an adjunct to surgical and analgesic management, not a substitute for atraumatic surgical technique or appropriate postoperative analgesia.

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✅ Benefits of Dexamethasone in Periodontal Surgery

1. Reduction of postoperative pain
Randomized clinical trials have demonstrated a reduction in postoperative pain following periodontal flap surgery when dexamethasone is administered perioperatively.
A randomized trial involving 60 patients undergoing open-flap debridement found that an 8-mg preoperative dose of dexamethasone provided greater pain control and reduced the need for rescue acetaminophen compared with placebo.
More recently, a randomized crossover trial found that 8 mg of intravenous dexamethasone administered before periodontal flap surgery significantly reduced pain during the first 72 hours compared with placebo.

2. Reduction of postoperative swelling
The anti-inflammatory effect of dexamethasone may also reduce postoperative edema.
In the 2022 randomized trial, intravenous dexamethasone was associated with significantly less swelling during several postoperative assessment periods, including the early postoperative phase.
A 2024 randomized clinical study also reported less swelling on the first postoperative day after submucosal administration of 8 mg dexamethasone during periodontal flap surgery.

3. Potential improvement in early postoperative function
Reduction of inflammatory edema may facilitate early oral function. The 2024 submucosal study reported improved chewing efficiency and less reduction in mouth opening during the early postoperative period. However, these findings should be interpreted cautiously because the study included only 25 patients.

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✅ Routes and Timing of Administration
Dexamethasone has been studied through several administration routes, including oral, intravenous, and submucosal administration.

Approach	Evidence in Periodontal Surgery	Main Consideration
Preoperative oral	Evidence of reduced postoperative pain	Convenient; evidence remains limited
Intravenous	Reduced pain and swelling in randomized clinical trials	Useful when IV access is already established
Submucosal	Recent evidence suggests reduced pain and swelling	Avoids the need for IV access
Repeated postoperative dosing	Less consistently studied	Greater exposure is not necessarily associated with greater benefit

Factor	Clinical implication
Timing	Preoperative or perioperative administration is the approach most consistently investigated.
Dose	Studies have commonly evaluated single doses of 4–8 mg, but no universally established periodontal surgery regimen exists.
Route	IV and submucosal administration have demonstrated clinical effects; the optimal route remains uncertain.

The evidence should therefore not be interpreted as establishing 8 mg as a universal standard dose. The 8-mg regimen has been studied in clinical trials, but patient characteristics, surgical extent, route of administration, and local prescribing regulations must be considered.

✅ Limitations and Safety Considerations

1. Evidence remains limited
A 2024 systematic review identified only six randomized clinical trials involving 250 participants evaluating preemptive steroidal and nonsteroidal analgesia in periodontal surgery. The authors noted substantial methodological limitations, including risk of bias and heterogeneity in drugs and doses.
Consequently, dexamethasone should be regarded as a selective adjunct rather than routine therapy for every periodontal surgical procedure.

2. Hyperglycemia
Systemic corticosteroids can transiently increase blood glucose concentrations. This is particularly relevant in patients with diabetes or impaired glucose regulation.
Patient-specific risk assessment is therefore important before administration, especially when systemic corticosteroids are being considered.

3. Infection considerations
Corticosteroids suppress immune responses and can potentially exacerbate or mask infection. Current prescribing information warns that corticosteroids may reduce resistance to infection and obscure clinical signs of infection.
This does not mean that a single perioperative dose inevitably causes infection. Indeed, a large Cochrane review of perioperative dexamethasone in surgical patients found no evidence of increased postoperative wound infection with a single perioperative steroid exposure.
Nevertheless, dexamethasone should not be used to mask an inadequately controlled infection or as a substitute for appropriate antimicrobial or surgical management.

4. Not a replacement for conventional analgesia
Dexamethasone primarily modifies the inflammatory component of postoperative morbidity. It should not automatically replace evidence-based analgesic therapy.
Current dental pain guidelines support NSAIDs, alone or combined with acetaminophen, as first-line pharmacologic therapy for acute dental pain when not contraindicated.

5. Limited evidence regarding long-term periodontal outcomes
Most studies evaluate short-term outcomes such as pain, swelling, trismus, and analgesic consumption. There is insufficient evidence to conclude that perioperative dexamethasone improves long-term periodontal healing, attachment gain, or regenerative outcomes.

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💬 Discussion
The current evidence supports a potential role for perioperative dexamethasone as an adjunct in periodontal surgery, particularly when postoperative inflammation is expected to be clinically significant.
The strongest periodontal evidence concerns reduction of early postoperative pain and swelling. Both intravenous and submucosal administration have demonstrated beneficial effects in randomized trials, while a recent systematic review supports the potential effectiveness of preemptive dexamethasone for postoperative pain.
However, the evidence base remains relatively small and heterogeneous. The 2024 systematic review specifically highlighted methodological limitations and the need for additional well-designed randomized trials.
Therefore, the clinical decision should be individualized rather than protocol-driven. Dexamethasone may be particularly reasonable when substantial postoperative inflammation is anticipated, while routine administration for uncomplicated periodontal procedures offers less clearly established incremental benefit.

✍️ Conclusion
Dexamethasone can reduce postoperative pain and swelling following periodontal surgery, with evidence supporting both systemic and local administration. Its anti-inflammatory effect makes it a potentially useful perioperative adjunct, particularly for procedures associated with greater tissue trauma.
Nevertheless, dexamethasone is not universally indicated. The relatively limited periodontal evidence, potential systemic effects, glucose elevation, infection-related considerations, and absence of demonstrated long-term periodontal benefits support a selective, patient-centered approach.
The most appropriate use is therefore as an adjunct to atraumatic surgical technique and evidence-based analgesia, rather than as routine medication for all periodontal surgical patients.

🎯 Clinical Recommendations
▪️ Consider perioperative dexamethasone selectively when postoperative pain or edema is expected to be clinically significant.
▪️ Do not interpret the commonly studied 8-mg dose as a universal periodontal protocol; dosing should be individualized according to the clinical situation and route of administration.
▪️ Consider submucosal administration when an IV route is unnecessary; current evidence suggests it can provide postoperative benefits without clear superiority of IV administration for pain or analgesic consumption.
▪️ Evaluate diabetes, infection, immunosuppression, corticosteroid exposure, and other relevant medical conditions before prescribing.
▪️ Maintain conventional evidence-based analgesia; dexamethasone should generally be considered an adjunct rather than a replacement for NSAID-based analgesic strategies when these are appropriate.
▪️ Avoid routine corticosteroid use when the expected inflammatory burden is low and the potential benefit is unlikely to justify systemic exposure.
▪️ Explain to patients that the principal expected benefit is short-term reduction of postoperative inflammatory symptoms, not improvement of long-term periodontal healing.

📚 References

✔ Altindal, D., Alsafadi, A., Alshujaa, B., Talmac, A. C., Ege, B., Calisir, M., & Alpaslan, N. Z. (2024). Effect of submucosal dexamethasone on postoperative pain, swelling and trismus after periodontal surgery: A randomized clinical study. Clinical Oral Investigations, 28(12), 681. https://doi.org/10.1007/s00784-024-06076-5
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Jr., Dhar, V., Dionne, R. A., Espinoza, L., Gordon, S. M., Hersh, E. V., Law, A. S., Li, B. S.-K., Schwartz, P. J., Suda, K. J., Turturro, M. A., Wright, M. L., Dawson, T., Miroshnychenko, A., Pahlke, S., Pilcher, L., Shirey, M., Tampi, M., & Moore, P. A. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. Journal of the American Dental Association, 155(2), 102–117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
✔ Lages, L. P. de D., Bergamaschi, C. de C., Lopes, L. C., da Frota, E. G., Silva, M. T., Monte, T. L., & Motta, R. H. L. (2024). Preemptive oral analgesia with steroidal and nonsteroidal anti-inflammatory drugs in periodontal surgery: A systematic review. Frontiers in Pharmacology, 15, 1385401. https://doi.org/10.3389/fphar.2024.1385401
✔ Vieth, M. P., Deas, D. E., Palaiologou, A. A., Diogenes, A., Mader, M. J., & Mealey, B. L. (2022). Effect of intravenous dexamethasone on postoperative pain and swelling following periodontal flap surgery: A randomized controlled trial of patient-centered outcomes. Journal of Periodontology, 93(2), 237–245. https://doi.org/10.1002/JPER.21-0153
✔ Wagner, J. C., Johnson, T. M., & Gilbert, W. A. (2022). Should periodontists prescribe postoperative oral corticosteroids to control pain and swelling? A systematic review. Clinical Advances in Periodontics, 12(2), 134–142. https://doi.org/10.1002/cap.10169
✔ Sauerland, S., Nagelschmidt, M., Mallmann, P., & Neugebauer, E. A. M. (2019). Adverse side-effects of dexamethasone in surgical patients—An abridged Cochrane systematic review. Anaesthesia, 74(8), 1013–1020. https://doi.org/10.1111/anae.14610
✔ Green, V. G., Polk, D. E., Turturro, M. A., Moore, P. A., & Carrasco-Labra, A. (2025). Evidence-based clinical practice guidelines for the management of acute dental pain. American Journal of Emergency Medicine, 89, 247–253. https://doi.org/10.1016/j.ajem.2024.12.054

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Teeth Whitening Overuse: Risks and Consequences

Teeth whitening is a popular and generally safe cosmetic dental treatment when used according to professional or manufacturer instructions. Most whitening products contain hydrogen peroxide or carbamide peroxide, which break down compounds responsible for tooth discoloration.

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However, repeated treatments, excessive exposure, higher-than-recommended concentrations, or unsupervised use can increase the risk of adverse effects.

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The consequences of teeth whitening overuse are usually related to tooth sensitivity and soft-tissue irritation, while evidence regarding permanent enamel damage is more complex.

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✅ What Happens When You Overuse Teeth Whitening?
The main problem with excessive whitening is not simply that the teeth become "too white." Repeated exposure to peroxide can increase temporary changes in the tooth surface and make adverse effects more likely.
The most important consequences include:

1. Increased Tooth Sensitivity
Tooth sensitivity is the most common adverse effect of dental bleaching. Patients may experience short, sharp pain when consuming cold, hot, sweet, or acidic foods and drinks.
Sensitivity is generally temporary, but repeated bleaching sessions without adequate intervals may prolong or intensify symptoms. Higher concentrations and longer exposure times are also associated with a greater risk.

2. Gum Irritation and Chemical Burns
Whitening gel can irritate the gingiva when it comes into direct contact with soft tissues. Poorly fitting trays, excessive gel application, or inappropriate use of whitening products can increase this risk.
Mild irritation usually resolves after stopping exposure. More intense or persistent burning, ulceration, or white areas on the gingiva should be evaluated by a dentist.

3. Changes to Enamel Surface Properties
This is an area where the evidence requires careful interpretation.
Laboratory studies have reported changes in enamel microhardness, surface morphology, and permeability after exposure to peroxide. However, these findings do not necessarily mean that routine clinical whitening causes clinically significant enamel destruction.
A 2026 systematic review and meta-analysis found a statistically detectable but small reduction in enamel microhardness in laboratory studies. Importantly, the authors concluded that there was no clear evidence of clinically meaningful damage to enamel integrity when bleaching is performed according to recommended protocols.
Therefore, the greatest concern is not occasional, properly performed whitening, but repeated or inappropriate exposure.

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4. Greater Visibility of Yellow Dentin
Over-whitening does not make teeth infinitely whiter. Natural tooth color is influenced by both enamel and the underlying dentin.
When enamel becomes thinner or more translucent, the naturally yellowish dentin may become more visible. As a result, some patients may perceive their teeth as becoming less attractive and attempt additional whitening, creating a cycle of repeated treatment.

5. Uneven Tooth Color
Whitening agents affect natural tooth structure, but they do not whiten existing restorations such as composite fillings, crowns, veneers, or ceramic restorations.
Repeated whitening may therefore make the difference between natural teeth and restorations more noticeable.

6. Greater Risk From DIY Whitening
Home-made whitening methods involving acidic fruits, vinegar, abrasive powders, or poorly tested products should not be considered safer alternatives.
Some DIY approaches may combine chemical irritation with abrasion, potentially increasing enamel surface wear without providing predictable whitening results.

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✅ Common Consequences of Whitening Overuse

Problem	What Patients May Notice	Typical Response
Tooth sensitivity	Pain with cold, heat, sweets, or air	Usually temporary; reduce or stop bleaching
Gingival irritation	Redness, burning, or white irritated areas	Remove peroxide exposure and assess persistent lesions
Surface changes	Possible changes in enamel surface properties	Avoid excessive concentration or exposure time
Color mismatch	Restorations appear darker than natural teeth	Evaluate restorations before further whitening

✅ Who Should Be More Careful?
Whitening should be approached cautiously in patients with:

▪️ Untreated dental caries
▪️ Significant pre-existing tooth sensitivity
▪️ Exposed root surfaces
▪️ Gingival inflammation or recession
▪️ Cracked or structurally compromised teeth
▪️ Large existing restorations in the visible smile
▪️ Poorly controlled oral disease
A dental examination before whitening can identify problems that may become more uncomfortable during treatment.

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💬 Discussion
The evidence does not support the idea that every whitening treatment damages enamel permanently. In fact, current evidence suggests that appropriately performed tooth bleaching has a generally favorable safety profile.
The distinction between appropriate treatment and overuse is important. A 2018 Cochrane review found that tooth sensitivity and oral irritation were the most common adverse effects of home bleaching and tended to be more frequent with higher concentrations, although they were generally mild and temporary.
More recent evidence also supports caution with unsupervised over-the-counter use. A 2024 systematic review and network meta-analysis found that OTC whitening products can produce effective short-term color changes, but emphasized the need to counsel patients about potential risks when these products are used without professional supervision.
The newest evidence on enamel is particularly useful because a 2026 systematic review and meta-analysis detected small changes in enamel microhardness in laboratory studies but found no clear evidence of clinically meaningful enamel damage when recommended bleaching protocols are followed.
Thus, the primary clinical message is not that patients should avoid whitening altogether. Rather, they should avoid the misconception that more frequent or more concentrated bleaching produces a healthier or permanently whiter smile.

✍️ Conclusion
Excessive teeth whitening can increase the risk of tooth sensitivity, gingival irritation, and temporary changes in enamel surface properties. These effects are generally more closely associated with concentration, exposure time, frequency, and inappropriate use than with properly performed whitening itself.
For most patients, the safest approach is to use an evidence-based whitening protocol, follow product instructions, and obtain a dental evaluation when sensitivity, gum irritation, or persistent discoloration occurs.

🎯 Clinical Recommendations
▪️ Do not increase the concentration, application time, or frequency of a whitening product to obtain faster results.
▪️ For patients with sensitivity, consider reducing exposure or pausing treatment rather than continuing through significant discomfort.
▪️ Examine patients for caries, gingival problems, recession, cracks, and existing restorations before whitening.
▪️ Use dentist-supervised whitening when patients have significant sensitivity, complex discoloration, or extensive restorations.
▪️ Advise patients to avoid DIY acidic or highly abrasive whitening methods because their safety and effectiveness are not well established.
▪️ If sensitivity or soft-tissue irritation persists after stopping whitening, investigate other dental causes rather than assuming the symptoms are simply a normal whitening reaction.

📚 References

✔ American Dental Association. (2024). Whitening. American Dental Association. https://www.ada.org/resources/ada-library/oral-health-topics/whitening
✔ Eachempati, P., Kumbargere Nagraj, S., Kiran Kumar Krishanappa, S., Gupta, P., & Yaylali, I. E. (2018). Home-based chemically-induced whitening (bleaching) of teeth in adults. Cochrane Database of Systematic Reviews, 2018(12), CD006202. https://doi.org/10.1002/14651858.CD006202.pub2
✔ Márton, P., Antal, M., Kiss-Dala, S., Agócs, G., Qian, X., Hegyi, P., Varga, G., & Ábrám, E. (2026). Enamel damage from tooth-whitening—A systematic review and meta-analysis. Journal of Dentistry, 172, 106786. https://doi.org/10.1016/j.jdent.2026.106786
✔ Zanolla, J., Marques, A. B. C., da Costa, D. C., de Souza, A. S., & Coutinho, M. (2017). Influence of tooth bleaching on dental enamel microhardness: A systematic review and meta-analysis. Australian Dental Journal, 62(3), 276–282. https://doi.org/10.1111/adj.12494
✔ Toledo, F. L., et al. (2024). Assessment of color changes and adverse effects of over-the-counter bleaching protocols: A systematic review and network meta-analysis. Clinical Oral Investigations. https://doi.org/10.1007/s00784-024-05595-5

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Cracked Tooth Treatment: Causes, Diagnosis & Care

Cracked tooth treatment requires more than simply covering a visible crack. A dental crack represents a structural disruption that may progress under repeated occlusal loading and may eventually affect the dentin, dental pulp, or periodontal tissues.

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The clinical objective is to identify the cause, determine the extent of the crack, assess pulpal and periodontal status, and stabilize the remaining tooth structure.

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Early management is particularly important because an untreated crack may progressively extend and compromise tooth survival.

✅ Dental Crack vs. Dental Fracture
A dental crack is a structural discontinuity that does not necessarily separate the tooth into segments. In current endodontic terminology, a cracked tooth involves a crack extending into dentin, with its depth and extension often initially uncertain.
A fracture generally indicates a more extensive structural disruption and may involve separated or partially separated tooth segments. A split tooth represents a more advanced stage in which the tooth is completely separated into two or more segments.
A superficial craze line, by contrast, is confined to enamel and generally does not represent a clinically significant structural crack. Treatment is usually unnecessary unless esthetic concerns exist.

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✅ Why Does a Dental Crack Develop?
The etiology is usually multifactorial rather than attributable to a single event. Important predisposing and contributing factors include:
▪️ Occlusal overload and parafunctional habits, particularly clenching and bruxism.
▪️ Unfavorable occlusal contacts or interferences.
▪️ Extensive restorations or loss of tooth structure.
▪️ Tooth morphology and cusp anatomy.
▪️ Repeated masticatory loading, particularly with hard foods.
▪️ Age-related changes in dentin.
▪️ Stress generated during restorative procedures.
The current evidence emphasizes that both the structural condition of the tooth and the magnitude and direction of applied forces influence crack development and propagation.
Identifying the Causative Factors
Treatment should not focus exclusively on the visible crack. The mechanical environment responsible for crack initiation or progression should also be evaluated.
Occlusal examination should assess wear facets, premature contacts, functional cusp loading, parafunctional activity, and other conditions capable of repeatedly stressing the affected tooth. When appropriate, management of these factors should accompany restorative treatment.

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✅ Diagnosis of a Cracked Tooth
Diagnosis requires correlation of clinical findings because early cracks may not be visible radiographically or even under direct examination.
Important diagnostic procedures include:
▪️ Pulp sensibility testing to establish pulpal status.
▪️ Bite testing to reproduce pain associated with crack movement. ▪️ Transillumination to identify crack lines. ▪️ Magnification with loupes or an operating microscope. ▪️ Periodontal probing, particularly to identify isolated narrow defects. ▪️ Occlusal analysis. ▪️ Periapical radiographs when indicated. ▪️ CBCT in selected inconclusive cases, recognizing that CBCT does not reliably visualize all dental cracks.
A crack may produce cold sensitivity, sharp pain during biting or release of pressure, or persistent discomfort. However, some cracks remain asymptomatic, making clinical examination particularly important.

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✅ How Is a Cracked Tooth Treated?
Treatment should be individualized according to crack extension, tooth structure, symptoms, pulpal diagnosis, periodontal status, and risk of further propagation.

Clinical Condition	Preferred Approach	Main Objective
Superficial enamel craze line	Observation; esthetic treatment only when indicated	Avoid unnecessary intervention
Vital tooth with shallow, low-risk crack	Monitoring and control of etiologic factors	Prevent progression while preserving tooth structure
Vital tooth with symptomatic crack	Adhesive composite stabilization or cuspal coverage according to structural risk	Reduce tooth flexure and protect the crack
Cracked tooth with irreversible pulpitis or necrosis	Root canal treatment followed by definitive restorative protection	Manage pulpal disease and stabilize the tooth
Extensive non-restorable crack	Extraction when predictable restoration is not possible	Prevent progression and further biological complications

✅ Is Fluoride Useful for a Dental Crack?
Fluoride should not be considered a treatment that repairs a true dentinal crack.
Fluoride can promote remineralization of demineralized enamel and is valuable in caries prevention. However, a structural crack extending into dentin is a mechanical defect and cannot be biologically “sealed” or regenerated with fluoride.
Therefore, fluoride may be appropriate when the tooth also presents an indication for caries prevention or enamel remineralization, but it should not replace mechanical stabilization and restorative management when a clinically significant crack is present.

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✅ Restorative Treatment in a Vital Cracked Tooth
When the pulp is normal or affected by reversible pulpitis, preservation of pulp vitality should be prioritized whenever the tooth remains restorable.
Depending on crack extension and structural risk, treatment may include:
▪️ Direct bonded composite restoration in appropriately selected cases.
▪️ Cuspal coverage with an onlay or other indirect restoration when greater structural protection is required.
▪️ Interim stabilization with bonded composite or a provisional restoration when pulpal response needs to be reassessed before definitive treatment.
The 2025 systematic review by Gavriil et al. found high one-year tooth survival in symptomatic vital cracked teeth, although the certainty of evidence was very low. Indirect restorations, particularly onlays, showed favorable pulp outcomes compared with some alternative approaches.
Current consensus also emphasizes that there is no single restorative protocol appropriate for every cracked tooth. The extent of the crack, remaining tooth structure, symptoms, occlusal forces, existing restorations, and parafunctional habits should influence the choice of restoration.

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✅ Monitoring and Prevention of Crack Progression
A crack with a normal pulp, minimal symptoms, limited extension, and low structural risk may sometimes be monitored rather than immediately restored.
However, active treatment becomes more appropriate when there is significant structural compromise, persistent symptoms, extensive restorations, unfavorable occlusal loading, or a high risk of crack propagation.
Preventive management should include:
▪️ Reduction of excessive occlusal loading when clinically indicated.
▪️ Management of parafunctional habits.
▪️ Avoidance of repeated excessive forces on the affected tooth.
▪️ Periodic clinical and pulpal reassessment.

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💬 Discussion
The management of a cracked tooth is fundamentally a structural and biological problem, rather than simply a cosmetic one. A crack may provide a pathway for bacterial penetration and may progressively affect the pulp and periodontal tissues under continued mechanical loading.
The current evidence supports a conservative philosophy when appropriate: preserve pulp vitality, preserve sound tooth structure, control etiologic factors, and stabilize the tooth according to its structural risk.
Importantly, direct composite restoration can be appropriate in selected vital cracked teeth, but it should not be considered universally equivalent to cuspal coverage. Treatment selection must remain case-specific because the evidence does not establish a single superior restorative protocol for every presentation.

✍️ Conclusion
Cracked tooth treatment should be directed at both the structural defect and the factors responsible for its progression. Fluoride may support enamel remineralization when indicated, but it does not repair a dentinal crack.
For a vital and restorable tooth, treatment may range from monitoring and etiologic control to adhesive composite stabilization or cuspal coverage, depending on the extent and mechanical risk of the crack. When irreversible pulpal disease or necrosis develops, root canal treatment followed by definitive restorative protection may be indicated.
Early diagnosis, preservation of tooth structure, control of occlusal forces, and appropriate restoration are central to improving the long-term prognosis.

🎯 Clinical Recommendations
1. Do not treat a dental crack with fluoride alone. Fluoride supports remineralization but does not repair structural dentinal disruption.
2. Identify and control contributing mechanical factors, particularly parafunction and unfavorable occlusal loading.
3. Preserve pulp vitality whenever clinically possible in a restorable cracked tooth.
4. Select direct composite or cuspal coverage according to structural risk, rather than applying a uniform restorative protocol.
5. Do not perform root canal treatment solely because a crack is present; establish the pulpal diagnosis first.
6. Reassess cracks periodically when observation is selected, because progression may occur despite an initially favorable presentation.

📚 References

✔ Gavriil, D., Kakka, A., & Del Fabbro, M. (2025). The effect of single versus multiple-stage restorative approaches on the pulp outcomes of symptomatic vital cracked teeth: A systematic review and meta-analysis. Journal of Endodontics, 51(10), 1362–1375. https://doi.org/10.1016/j.joen.2025.06.013
✔ Kakka, A., Gavriil, D., & Whitworth, J. (2022). Treatment of cracked teeth: A comprehensive narrative review. Clinical and Experimental Dental Research, 8(5), 1218–1248. https://doi.org/10.1002/cre2.617
✔ Krell, K. V., & Rivera, E. M. (2018). A study of crack lines in posterior teeth. Journal of Endodontics, 44(4), 611–614.
✔ Li, F., Diao, Y., Wang, J., Hou, X., Qiao, S., Kong, J., Sun, Y., Lee, E.-S., & Jiang, H. B. (2021). Review of cracked tooth syndrome: Etiology, diagnosis, management, and prevention. Pain Research and Management, 2021, 3788660. https://doi.org/10.1155/2021/3788660
✔ Patel, S., Teng, P.-H., Liao, W.-C., Davis, M. C., Fidler, A., Haupt, F., Fabiani, C., Ordinola-Zapata, R., & Bose, R. (2025). Position statement on longitudinal cracks and fractures of teeth. International Endodontic Journal, 58(3), 379–390. https://doi.org/10.1111/iej.14186
✔ Zhang, S., Xu, Y., Ma, Y., Zhao, W., Jin, X., & Fu, B. (2024). The treatment outcomes of cracked teeth: A systematic review and meta-analysis. Journal of Dentistry, 142, 104843. https://doi.org/10.1016/j.jdent.2024.104843
✔ Kaur, S., Puzhankara, L., Shenoy, N., Kini, K. S., & Singhal, D. K. (2026). Saving the split: An umbrella review on therapeutic approaches for cracked tooth syndrome. Journal of Conservative Dentistry and Endodontics, 29(1), 11–19. https://doi.org/10.4103/JCDE.JCDE_796_25

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