Drug-Induced Bruxism

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Drug-Induced Bruxism
Vol. No: 30:01 Posted: 1/19/05
Olanrewaju Obisesan, PharmD
Supervising Pharmacist Rite Aid Pharmacy
Buffalo, New York


US Pharm. 2005;1:HS21-26.

Bruxism, which is characterized as the unnecessary grinding or clenching of teeth, is a problem that affects 8% to 21%1 of the U.S. population. Symptoms such as moderate to severe headache, muscle pain, temporomandibular joint dysfunction, and permanent tooth damage may persist if bruxism is left untreated. These symptoms, in turn, can decrease the productivity and overall quality of life of the patient involved. Some psychotropics, such as drugs in the selective serotonin reuptake inhibitor (SSRI), antipsychotic, and general antidepressant classes, have been implicated in inducing this condition as a secondary side effect in patients taking these medications. However, there have also been reports of some drugs that have alleviated or eliminated symptoms of bruxism, despite not being indicated for its treatment. This article is an attempt to compile and evaluate all the existing data signifying the association of medication administration, occurrence of bruxism, and possible treatments available for this condition. Reports from literature of certain psychotropics, including SSRIs (e.g., fluoxetine and paroxetine) and antipsychotics (e.g., haloperidol), claim that these drugs cause the symptoms associated with bruxism. But some drugs, such as buspirone, propranolol, gabapentin, and botulinum toxin, although not indicated for bruxism treatment, show promise in relieving the condition.

Prevalence and Symptoms
A condition that is sometimes drug-induced, bruxism has a negative effect on the overall productivity and quality of life of an individual by causing symptoms of moderate to severe headache, muscle pain, temporomandibular joint dysfunction, and permanent tooth damage.2

Although there are no approved medications indicated for the management of this secondary-induced condition, recent reports and literature spanning a few years attest to the effectiveness of some drugs and compounds that are remotely indicated to treat bruxism. Because there are no drugs directly indicated for bruxism, the need to effectively handle this manifestation means that the pharmacist should understand its etiology, drugs that might induce it (which are mainly psychotropics3,4 and will be the main focus on this topic), and possible medications that could be considered in an off-label use to either lessen or completely eliminate symptoms.

Societal Impact
Bruxism is characterized as "the grinding or clenching of teeth at other times than for the mastication of food."2,5 This condition, which ultimately causes a severe wearing down of the teeth through constant grinding, can also cause many other symptoms, including headaches, orofacial pain, and general discomfort to the patient involved. Studies have also shown these symptoms to be associated with adversely affecting the patient's economic productivity, social and psychological well-being, and overall quality of life.6 Absenteeism at work because of symptoms related to dental problems, although difficult to measure, can be roughly estimated to cost millions of dollars in lost wages to those affected and employed.6

Recent findings and literature have suggested that certain psychotropic drugs can cause this condition.3,4 Those possibly implicated in inducing bruxism are compounds from drug classes including SSRIs, antipsychotics, and general antidepressants and are listed in TABLE 1.

(Please visit the website to view the tables in this article.)

Despite that no exact mechanism can explain how the specifically mentioned psychotropics (especially SSRIs) induce bruxism, most theories point to the imbalances in dopaminergic and serotonergic activities, which can result in various movement disorders. These include dystonia and dyskinesia, movement disorders under which bruxism can be classified.

Inducers
The main drugs synonymous with inducing bruxism have been SSRIs.3,4 Various documented case studies have reported patients who experienced drug-induced bruxism after being prescribed an SSRI to treat depression.5 In one case study, a 20-year-old woman prescribed paroxetine to treat her diagnosed condition of depression experienced gritting of the teeth and intense jaw tenseness,2 conditions that are cardinal signs of bruxism and temporomandibular joint dysfunction. A comprehensive search of tertiary resources in the Annals of Pharmacotherapy linked SSRIs to 127 published reports of SSRI-induced movement disorders,7 which were precursors to bruxism. The antipsychotic haloperidol has also been linked to inducing bruxism. A 40-year-old male with a history of chronic paranoid schizophrenia and a 31-year-old female diagnosed with acute psychosis reported incidences of jaw clenching and contractions consistent with bruxism.8 Venlafaxine, another antidepressant, has also been linked to this condition.5 These drugs, indicated to treat mood disorders, caused this unwanted side effect, which is usually treated by discontinuing the suspected psychotropic culprit.

Possible Treatments
In contrast, some studies reported how the use of certain drugs not indicated for bruxism treatment can be helpful in either decreasing or completely eradicating symptoms of bruxism. Buspirone, used in the management of anxiety, has been shown to be efficacious in treating bruxism.5 Various published case studies attest to the relief or elimination of symptoms from bruxism after the initiation of buspirone into therapy concurrently with SSRIs, with no documented side effects.5,9 In some other published studies, propranolol, a nonselective beta-adrenergic?blocking agent, and gabapentin,9 an anticonvulsant agent, have also been proven to be effective in treating symptoms of bruxism despite their nonindication. In another study involving 18 patients (ages 3 to 40) that spanned a period of eight years,8 the botulinum toxin, a substance acting at peripheral cholinergic synapses to prevent the release of neurotransmitters to exert an anticholinergic effect and induce paralysis, was also shown to be effective in relieving bruxism in controlled doses. Table 2 lists medications and habits that have been shown to cause bruxism and the medications indicated to be efficacious in treating it, compiled from a comprehensive search and analysis of published literature. The drugs mentioned as effective in bruxism treatment are discussed in further detail in table 3.

Education
Information on possible side effects of bruxism when taking the mentioned psychotropics should be given to patients for whom these medications are prescribed. The pharmacist, who is likely the first point of contact by the patient and also likely to report bruxism as a side effect of a suspect psychotropic, should be aware of this condition and possible medications that could be prescribed to treat it. These medications can then be suggested to the physician or dentist who may be unaware of the possible nonindicated medications that could relieve this condition.

Conclusion
Historically, bruxism has been dealt with by discontinuing the suspected drug thought to cause this condition. The unavailability of medications indicated for treatment has been the main reason for this standard approach. The availability of the drugs not indicated for bruxism but capable of relieving it provides more options to physicians and dentists to treat this condition, along with more alternatives for the pharmacist to suggest and refer to other clinicians.

REFERENCES
1. Brown ES, Hong SC. Antidepressant-induced bruxism successfully treated with gabapentin. J Am Dent Assoc. 1999;130:1467-1469.
2. Romanelli F, Adler DA, Bungay KM. Possible paroxetine-induced bruxism. Ann Pharmacother. 1996;30:1246-1248.
3. Wise M. Citalopram-induced bruxism. Br J Psychiatry 2001;178:182.
4. Ellison JM, Stanziani P. SSRI-associated nocturnal bruxism in four patients. J Clin Psychiatry. 1993;54:432-434.
5. Apter JT, Allen LA. Buspirone: future directions. J Clin Psychopharmacol. 1999;19:86-93.
6. Hollister MC, Weintraub JA. The association of oral status with systemic health, quality of life, and economic productivity. J Dent Educ. 1993;57:901-912.
7. Gerber PE, Lynd LD. Selective serotonin-reuptake inhibitor-induced movement disorders. Ann Pharmacother. 1998;32:692-698.
8. Amir I, Hermesh H, Gavish A. Bruxism secondary to antipsychotic drug exposure: a positive response to propranolol. Clin Neuropharmacol.1997;20:86-89. 9. Tan EK, Jankovic J. Treating severe bruxism with botulinum toxin. J Am Dent Assoc. 2000;131:211-216.
10. Hicks RA, Lucero-Gorman K, Bautista J, Hicks GJ. Ethnicity and bruxism. Percept Mot Skills. 1999;88:240-241.

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