Biofeedback vs. Botox: Which Works Better for Daytime Teeth Grinding?
New clinical trial finds behavioral therapy more effective than injections for managing awake bruxism
Background: Understanding Awake Bruxism
Awake bruxism (AB) — the habit of clenching or pressing the teeth during the day — is surprisingly common. It’s not just a bad habit; it’s linked to jaw pain, headaches, and temporomandibular disorders (TMD), a condition that affects the muscles and joints of the jaw.
Researchers have long debated how best to manage AB. Two popular options are biofeedback therapy (a behavioral method that helps patients relax their jaw muscles using real-time muscle activity data) and botulinum toxin type A (BTA) injections, better known as Botox, which temporarily weakens overactive muscles.
While Botox is often used for nighttime bruxism or TMD-related pain, its use for awake bruxism is still uncertain — especially when compared with non-invasive therapies like biofeedback.
The Study: Comparing Two Treatments
A team of researchers from Rio de Janeiro State University, University of Campinas (Brazil), and Karolinska Institutet (Sweden) conducted a randomized clinical trial with 40 adults diagnosed with TMD and awake bruxism.
Participants were divided into two groups:
BIO Group: received four weekly sessions of electromyography-based biofeedback (Myobox® device).
BTA Group: received low-dose Botox injections in the masseter and temporalis muscles (40 units total per patient).
Researchers tracked each participant’s jaw activity using a smartphone app called BruxApp®, which monitors behaviors like sustained tooth contact, clenching, and jaw bracing. They also measured pain intensity and psychological factors (such as anxiety and depression) at the start, and again after 1, 3, and 6 months.
What They Found
After six months, the results were clear:
Biofeedback reduced teeth-contacting behavior and overall bruxism activity.
Participants in the BIO group showed a statistically significant drop in sustained tooth contact (p = 0.004) and total awake bruxism behaviors (p = 0.008).
Botox did not significantly reduce bruxism activity.
Despite its known muscle-relaxing effects, the BTA group showed no meaningful changes in jaw behaviors across all follow-ups.
Pain and psychological distress remained unchanged in both groups.
Neither treatment improved pain scores (Characteristic Pain Intensity) nor levels of anxiety, depression, or somatization.
In short: biofeedback helped people change their behavior, while Botox did not — at least not at the low doses tested.
Why It Matters
The findings suggest that awake bruxism is primarily a behavioral issue, not just a muscular one. Botox targets the muscles but doesn’t modify the underlying habits or stress-related triggers that cause clenching.
Biofeedback, on the other hand, helps patients recognize when they’re tensing their jaw and teaches them to relax it — promoting long-term self-regulation without invasive procedures or side effects.
The researchers emphasize that conservative, reversible treatments should be the first line of care for TMD-related bruxism. This aligns with current best-practice recommendations from international dental organizations like INfORM/IADR.
Study Limitations
The study included only patients with high-frequency bruxism (≥60% of the time), so the results may not apply to milder cases. Also, the Botox dose used was relatively low — future studies could explore whether higher or repeated doses change the outcome.
Still, this trial stands out as the first to directly compare Botox and biofeedback for awake bruxism over a six-month period.
Conclusion
“Biofeedback significantly reduced awake bruxism behaviors, whereas botulinum toxin did not improve pain or psychological outcomes,” the authors conclude.
“Given the behavioral nature of awake bruxism, biofeedback — a non-invasive, self-regulatory therapy — should be preferred over pharmacological interventions like Botox.”
Reference
Foscaldo, T. F., dos Santos Belo Junior, P. H., Ribeiro, G. R., de Proença, L. S., De la Torre Canales, G., & Senna, P. M. (2025). Comparing botulinum toxin and biofeedback therapies for awake bruxism: a randomized clinical trial.
BMC Oral Health, 25:1772.