A randomized double-blind clinical trial of the effect of amitriptyline on nocturnal masseteric motor activity (sleep bruxism)

Can botulinum toxin injection alleviate the pain of bruxism? A Bayesian network analysis and a single-arm analysis

Background/purpose

There is inconsistent evidence regarding whether the botulinum toxin A (BTA) injection can relieve pain caused by bruxism. This study aimed to estimate the efficiency of BTA injection in relieving pain caused by bruxism at different follow-up periods.

Materials and methods

Five electronic databases were searched from 2005 to 2022 using search terms related to botulinum toxin and bruxism. Only controlled clinical trials were included. Two investigators reviewed each article and discussed any disagreements until a consensus was reached. Pain outcomes as evaluated by the visual analogue scale (VAS) were subjected to single-arm and Bayesian network meta-analyses. Pooling data were measured by a random-effects model.

Results

Eleven studies with a total of 365 bruxism patients were included. According to the single-arm analyses of the pooled data, the reduction in bruxism-related pain after BTA injection measured 4.06 points (95% CI = 3.37 to 4.75) on the VAS, and the pain relief was significant in the first 6 months after treatment (P < 0.01). According to the Bayesian analysis, BTA also resulted in significantly greater pain relief than oral splinting (mean difference (MD), -1.5; 95% credible interval (CrI) = -2.7 to -0.19) or saline injection (MD, -3.3; 95% CrI = -6.2 to -0.32).

Conclusion

BTA significantly relieves the pain of bruxism for 6 months after injection, and its therapeutic efficacy was higher than that of oral splinting. Nevertheless, further long-term follow-up randomized controlled trials comparing BTA with other management or drugs are warranted.

Dental practitioner approaches to bruxism: Preliminary findings from the national dental practice-based research network

OBJECTIVE

Bruxism is a repetitive masticatory muscle activity. This study investigates dental practitioners' approaches to bruxism assessment and treatment in practices.

METHODS

A brief 5 question questionnaire ("Quick Poll") on bruxism was conducted.

RESULTS

A total of 397 practitioners responded. More than half (55%) initiated treatment for bruxism on one to three patients per month. The majority believed that stress (97%) and sleep patterns (82%) affected bruxism in their patients. Interestingly, 96% offered an occlusal guard/appliance and 46% made occlusal adjustments.

CONCLUSION

This study highlights inconsistencies in practitioner approaches to bruxism assessment and management in clinical settings, suggesting gaps in practitioner knowledge evidenced by the varied responses.

ABBREVIATIONS

PBRN - Practice-Based Research NetworkMMA - Masticatory muscle activitySB - Sleep bruxismAB - Awake bruxismTMJ - Temporomandibular jointOSA - Obstructive sleep apnea.

Managements of sleep bruxism in adult: A systematic review

This systematic review aimed to update the management of sleep bruxism (SB) in adults, as diagnosed using polysomnography (PSG) and/or electromyography (EMG). Management methods covered were oral appliance therapy (OAT) with stabilization splints, cognitive-behavioral therapy (CBT), biofeedback therapy (BFT), and pharmacological therapy. A comprehensive search was conducted on MEDLINE, Cochrane Library, and Web of Science up to October 1st, 2021. Reference list searches and hand searches were also performed by an external organization. Two reviewers for each therapy independently performed article selection, data extraction, and risk of bias assessment. The reviewers resolved any disagreements concerning the assortment of the articles by discussion. Finally, 11, 3, 14, and 22 articles were selected for each therapy. The results suggested that OAT tended to reduce the number of SB events, although there was no significant difference compared to other types of splints, that the potential benefits of CBT were not well supported, and that BFT, rabeprazole, clonazepam, clonidine, and botulinum toxin type A injection showed significant reductions in specific SB parameters, although several side effects were reported. It can be concluded that more methodologically rigorous randomized large-sample long-term follow-up clinical trials are needed to clarify the efficacy and safety of management for SB.

Efficacy of botulinum-A for nocturnal bruxism pain and the occurrence of bruxism events: a meta-analysis and systematic review

The purpose of this study was to explore the treatment efficacy of botulinum-A (BTX-A) in nocturnal bruxism. Five electronic databases (PubMed, Web of Science, Cochrane, Embase and Clinical Trials) were searched to identify related randomised controlled trials up to September 1, 2020. Five evaluation indices were extracted, namely, the pain at rest and at chewing (PR and PC), the number of bruxism events (NBE) and the self-assessment by patients (SA), to assess the treatment efficacy of BTX-A in bruxism. All data analyses were conducted using Review Manager (Version 5.3; The Cochrane Collaboration, London, United Kingdom). Six studies were included in this review. The sample was composed of 148 participants. Compared with the placebo group, the BTX-A group showed the significantly improved the PR index scores (MD, 1.16 cm; 95%CI, 0.65 to 1.67 cm; p < 0.00001), slightly improved the PC index scores (SMD, 0.25; 95%CI -0.14 to 0.64; p = 0.21), and the NBEs were significantly decreased in the before-injection group compared with that in the after-injection group (MD, 1.72; 95%CI, 0.60 to 2.85; p = 0.003). The results of this study suggest that BTX-A possesses significant therapeutic efficiency for the relief of pain and events of bruxism. However, whether the events of bruxism would recur or rebound after botulinum toxin injection needs more follow-up clinical evidence.

Signal acquisition and analysis of ambulatory electromyographic recordings for the assessment of sleep bruxism: A scoping review

Background

Ambulatory electromyographic (EMG) devices are increasingly being used in sleep bruxism studies. EMG signal acquisition, analysis and scoring methods vary between studies. This may impact comparability of studies and the assessment of sleep bruxism in patients.

Objectives

(a) To provide an overview of EMG signal acquisition and analysis methods of recordings from limited‐channel ambulatory EMG devices for the assessment of sleep bruxism; and (b) to provide an overview of outcome measures used in sleep bruxism literature utilising such devices.

Method

A scoping review of the literature was performed. Online databases PubMed and Semantics Scholar were searched for studies published in English until 7 October 2020. Data on five categories were extracted: recording hardware, recording logistics, signal acquisition, signal analysis and sleep bruxism outcomes.

Results

Seventy‐eight studies were included, published between 1977 and 2020. Recording hardware was generally well described. Reports of participant instructions in device handling and of dealing with failed recordings were often lacking. Basic elements of signal acquisition, for example amplifications factors, impedance and bandpass settings, and signal analysis, for example rectification, signal processing and additional filtering, were underreported. Extensive variability was found for thresholds used to characterise sleep bruxism events. Sleep bruxism outcomes varied, but typically represented frequency, duration and/or intensity of masticatory muscle activity (MMA).

Conclusion

Adequate and standardised reporting of recording procedures is highly recommended. In future studies utilising ambulatory EMG devices, the focus may need to shift from the concept of scoring sleep bruxism events to that of scoring the whole spectrum of MMA.

Bruxism in Acute Neurologic Illness

PURPOSE OF REVIEW

While traditionally encountered in ambulatory settings, bruxism occurs in patients with a variety of acute neurologic illnesses including encephalitis, intracerebral hemorrhage, traumatic brain injury, hypoxic-ischemic encephalopathy, and acute ischemic stroke. Untreated bruxism in acute neurologic illness can lead to tooth loss, difficulty in mouth care resulting in recurrent aspiration pneumonia, endotracheal tube dislodgement, and even tongue laceration or amputation. Inpatient clinicians should be aware of the etiologies and management strategies for bruxism secondary to acute neurologic illness.

RECENT FINDINGS

Management strategies for bruxism are varied and include pharmacologic and non-pharmacologic therapies in addition to onabotulinumtoxinA (BoNT-A). Bruxism impacts patients with a variety of acute neurologic illnesses, and emerging evidence suggests successful and safe treatment strategies.

Multitargeting the sleep-pain interaction with pharmacological approaches: A narrative review with suggestions on new avenues of investigation

The multimorbidity formed by sleep disturbances and pain conditions is highly prevalent and has a significant impact in global health and in the socioeconomic system. Although different approaches have been directed toward its management, evidence regarding an optimal treatment is lacking, and pharmacological options are often preferred. Health professionals (e.g., pain and sleep clinicians) tend to focus on their respective expertise, targeting a single symptom with a single drug. This may increase polypharmacy and the risk of drug interactions, adverse events, and mortality. Hence, the use of medications that can directly or indirectly improve sleep, pain, and other possible accompanying conditions without exacerbating them becomes especially relevant. The objectives of this comprehensive review are to: a) describe the beneficial or deleterious effects that some commonly used medications to manage pain have on sleep and sleep disorders; and b) describe the beneficial or deleterious effects that frequently prescribed medications for sleep may have on pain. Moreover, medications targeting some specific sleep-pain interactions will be suggested and future directions for improving sleep and alleviating pain of these patients will be provided with clinical and research perspectives.

Consecutive Controlled Case Series on Effectiveness of Opipramol in Severe Sleep Bruxism Management-Preliminary Study on New Therapeutic Path

BACKGROUND

Sleep bruxism (SB) management aims to reduce the number and magnitude of bruxism episodes per hour of a patient's sleep and, therefore, reduce the potentially negative clinical consequences. Opipramol belongs to the group of tricyclic antidepressants (TCAs) and is considered as an atypical TCA, as it acts primarily as a sigma receptor agonist. This study aimed to preliminarily determine the effectiveness of opipramol in the management of severe SB.

METHODS

A total of 19 otherwise healthy participants with severe SB diagnosed during stage I video polysomnography (vPSG) were subjected to an 8-week pharmacotherapy trial with a 100 mg bedtime daily dose of opipramol and were then analyzed by control stage II vPSG.

RESULTS

The participants included 14 females and 5 males, aged 20-47 years (mean ± standard deviation: 32.32 ± 8.12). A comparison of stage I and II vPSG recordings showed a decrease in all the studied SB parameters in 78.85% of participants. Only in a small group of participants (15.53%) was a non-significant increase of SB parameters observed.

CONCLUSIONS

A single 100 mg dose of opipramol at bedtime seems to positively affect the reduction of SB in otherwise healthy individuals diagnosed with severe SB. However, the subject requires further research on a larger population including a control group.

Bruxism: Best Evidence Consensus Statement

PURPOSE

The purpose of this Best Evidence Consensus Statement is to report on the prevalence, potential causes or association, treatment and cure of bruxism.

MATERIALS AND METHODS

A literature search limited to Clinical Trials, Randomized Controlled Trials, Systematic Reviews and Meta Analyses, with the key words bruxism, and prevalence identified 22 references, bruxism and causation 21, bruxism, and treatment 117, and bruxism and cure none.

RESULTS

Prevalence received 5 references which were relevant to the question researched. Causation received 11 relevant references, treatment 34 relevant references and cure none. Eighteen additional references were culled from the reference lists in the aforementioned articles.

CONCLUSIONS

Due to variations in demographics and the dependence on anamnestic data, the true prevalence of bruxism in any specific population is unknown. There is moderate evidence that psychosocial factors such as stress, mood, distress, nervousness, and feeling blue are associated with sleep bruxism (SB) as well as caffeine, alcohol, and smoking. There is no consensus on what symptoms of SB or awake bruxism (AB) should be treated. There is some evidence that occlusal devices and bio feedback therapies can be utilized in SB treatment. There is conflicting evidence in the use of Botulinum toxin A and no compelling evidence for the use of drug therapy to treat SB. There is not an established cure for bruxism. The clinician is best served in using caution in the dental rehabilitation of patients with severe occlusal wear.

Medications and addictive substances potentially inducing or attenuating sleep bruxism and/or awake bruxism

Bruxism is a repetitive jaw‐muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. It can occur during sleep, indicated as sleep bruxism, or during wakefulness, indicated as awake bruxism. Exogenous risk indicators of sleep bruxism and/or awake bruxism are, among others, medications and addictive substances, whereas also several medications seem to have the potential to attenuate sleep bruxism and/or awake bruxism. The objective of this study was to present a narrative literature on medications and addictive substances potentially inducing or aggravating sleep bruxism and/or awake bruxism and on medications potentially attenuating sleep bruxism and/or awake bruxism. Literature reviews reporting evidence or indications for sleep bruxism and/or awake bruxism as an adverse effect of several (classes of) medications as well as some addictive substances and literature reviews on medications potentially attenuating sleep bruxism and/or awake bruxism were used as starting point and guidelines to describe the topics mentioned. Additionally, two literature searches were established on PubMed. Three types of bruxism were distinguished: sleep bruxism, awake bruxism and non‐specified bruxism. Generally, there are insufficient evidence‐based data to draw definite conclusions concerning medications and addictive substances inducing or aggravating sleep bruxism and/or awake bruxism as well as concerning medications attenuating sleep bruxism and/or awake bruxism. There are insufficient evidence‐based data to draw definite conclusions concerning medications and addictive substances inducing or aggravating sleep bruxism and/or awake bruxism as well as concerning medications attenuating sleep bruxism and/or awake bruxism.

Bruxismo durante o Sono

Bruxismo durante o sono (BS) é uma parassonia caracterizada por movimentos involuntários e estereotipados com ranger dos dentes durante o sono. A prevalência do BS é igual nos dois sexos, variando de 3% a 20% na população geral, sendo mais comum nos jovens. O BS secundário é causado por transtornos neurológicos ou pode estar associado a transtornos primários do sono e antidepressivos inibidores seletivos da recaptação da serotonina. Já o BS primário apresenta fatores de predisposição genética ou psicológica, má oclusão dentária, disfunção leve dos gânglios da base e combinações desses fatores. Os principais sinais e sintomas do BS incluem o ruído característico de ranger dos dentes, desgaste dentário, dor local, hipertrofia dos músculos masseteres e temporais, cefaléias, disfunção da articulação temporomandibular, sono de má qualidade e sonolência diurna. O diagnóstico clínico de BS é feito por meio da história do paciente, do cônjuge e do exame odontológico. A polissonografia documenta a presença de episódios de ranger dos dentes, permitindo identificar alterações da arquitetura do sono, presença de microdespertares, abalos mioclônicos de membros inferiores, roncos e distúrbios respiratórios sonodependentes. O tratamento deve ser direcionado para os fatores etiológicos com base no BS secundário. Não existe tratamento-padrão para o BS primário, devendo este ser individualizado ao paciente. O tratamento odontológico do BS primário e secundário com placas de repouso tem como objetivo prevenir danos das estruturas orofaciais e aliviar dor craniofacial. O tratamento comportamental inclui técnicas de relaxamento, abstinência de cafeína e tabaco. O tratamento farmacológico do BS primário e secundário emprega drogas agonistas dopaminérgicas, benzodiazepínicos ansiolíticos, buspirona, hipnóticos não-benzodiazepínicos, como o zolpidem, relaxantes musculares, certos antidepressivos, como mirtazapina, nefazodona, trazodona, bupopriona e drogas antiepilépticas, como a gabapentina. Aplicações locais de toxina botulínica nos músculos masseteres e temporais podem ser utilizadas em casos de bruxismo intenso não-responsivo à terapêutica convencional.

Use of antidepressants in dentistry: A systematic review

OBJECTIVE

Previous research has suggested that antidepressants can be used in oral health care. The aim of this systematic review was to search for scientific evidence of the efficacy of the use of antidepressants in dentistry.

MATERIALS AND METHODS

The clinical question was as follows (PICO question): dentistry patients (Patients); antidepressants (Intervention); no use or placebo or other drug (Comparison); and efficacy in oral health problems (Outcome). An electronic search was conducted in seven databases, as well as a manual search without restriction regarding language and date of publication. Two independent reviewers selected studies based on eligibility criteria, extracted data and assessed methodological quality based on the PEDro scale. The PROSPERO record is number CRD42016037442.

RESULTS

A total of 15 randomized controlled trials were associated with the use of antidepressants to control chronic or acute pain in dentistry, among other conditions such as bruxism and burning mouth syndrome. The most commonly used drug in clinical trials was amitriptyline (more than 50% of studies).

CONCLUSIONS

Antidepressants may be effective in dentistry for acute and chronic pain, but there is a large amount of methodological heterogeneity among the evaluated studies. In summary, there is rationality for the indication of this class of medicine in dentistry in specific clinical situations.

Reevaluating Antidepressant Selection in Patients With Bruxism and Temporomandibular Joint Disorder

Temporomandibular joint disorder (TMD) is a broad pain disorder that refers to several conditions affecting the temporomandibular joint of the jaw and the muscles of mastication. As with most pain disorders, a high prevalence of depression and anxiety is associated with TMD. Research has shown that selective serotonin reuptake inhibitors (SSRIs), the first-line drug therapy for major depressive disorder, may not be suitable for TMD patients because SSRIs can induce teeth-grinding, otherwise known as bruxism. This is problematic because bruxism is believed to further exacerbate TMD. Therefore, the purpose of this literature review is to better understand the mechanism of SSRI-induced bruxism, as well as discuss alternative antidepressant options for treating depression and anxiety in patients with bruxism and TMD. Alternative classes of antidepressants reviewed include serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, atypical antidepressants, and monoamine oxidase inhibitors. Findings indicate that dopamine agonists and buspirone are currently the most effective medications to treat the side effects of SSRI-induced bruxism, but results regarding the effectiveness of specific antidepressants that avoid bruxism altogether remain inconclusive.

Current Treatments of Bruxism

Despite numerous case reports, the evidence for treatment of bruxism is still low. Different treatment modalities (behavioral techniques, intraoral devices, medications, and contingent electrical stimulation) have been applied. A clinical evaluation is needed to differentiate between awake bruxism and sleep bruxism and rule out any medical disorder or medication that could be behind its appearance (secondary bruxism). A polysomnography is required only in a few cases of sleep bruxism, mostly when sleep comorbidities are present. Counselling with regard to sleep hygiene, sleep habit modification, and relaxation techniques has been suggested as the first step in the therapeutic intervention, and is generally considered not harmful, despite low evidence of any efficacy. Occlusal splints are successful in the prevention of dental damage and grinding sounds associated with sleep bruxism, but their effects on reducing bruxism electromyographic (EMG) events are transient. In patients with psychiatric and sleep comorbidities, the acute use of clonazepam at night has been reported to improve sleep bruxism, but in the absence of double-blind randomized trials, its use in general clinical practice cannot be recommended. Severe secondary bruxism interfering with speaking, chewing, or swallowing has been reported in patients with neurological disorders such as in cranial dystonia; in these patients, injections of botulinum toxin in the masticatory muscles may decrease bruxism for up to 1–5 months and improve pain and mandibular functions. Long-term studies in larger and better specified samples of patients with bruxism, comparing the effects of different therapeutic modalities on bruxism EMG activity, progression of dental wear, and orofacial pain are current gaps of knowledge and preclude the development of severity-based treatment guidelines.

Sleep bruxism: a comprehensive overview for the dental clinician interested in sleep medicine

Sleep bruxism (SB) is a common sleep-related motor disorder characterized by tooth grinding and clenching. SB diagnosis is made on history of tooth grinding and confirmed by polysomnographic recording of electromyographic (EMG) episodes in the masseter and temporalis muscles. The typical EMG activity pattern in patients with SB is known as rhythmic masticatory muscle activity (RMMA). The authors observed that most RMMA episodes occur in association with sleep arousal and are preceded by physiologic activation of the central nervous and sympathetic cardiac systems. This article provides a comprehensive review of the cause, pathophysiology, assessment, and management of SB.

Sleep-related movement disorders

Several movement disorders may occur during nocturnal rest disrupting sleep. A part of these complaints is characterized by relatively simple, non-purposeful and usually stereotyped movements. The last version of the International Classification of Sleep Disorders includes these clinical conditions (i.e. restless legs syndrome, periodic limb movement disorder, sleep-related leg cramps, sleep-related bruxism and sleep-related rhythmic movement disorder) under the category entitled sleep-related movement disorders. Moreover, apparently physiological movements (e.g. alternating leg muscle activation and excessive hypnic fragmentary myoclonus) can show a high frequency and severity impairing sleep quality. Clinical and, in specific cases, neurophysiological assessments are required to detect the presence of nocturnal movement complaints. Patients reporting poor sleep due to these abnormal movements should undergo non-pharmacological or pharmacological treatments.

Effectiveness of botulinum toxin type A treatment of neck pain related to nocturnal bruxism: a case report

OBJECTIVE

This case report describes a patient with nocturnal bruxism and related neck pain treated with botulinum toxin type A (BTX-A).

CLINICAL FEATURES

The patient was a 27-year-old man with nocturnal bruxism and difficulty in active mouth opening and chewing and neck pain at rest. His numeric pain score was 7 of 10. Surface electromyography of the temporalis and masseter muscles showed typical signs of hyperactivity, characterized by compound muscle action potential amplitude alterations.

INTERVENTION AND OUTCOME

After clinical evaluation, he was treated with BTX-A to reduce masseter and temporalis muscle hyperactivity. After 3 days of treatment with BTX-A, with each masseter muscle injected with a dose of about 40 mouse units with a dilution of 1 mL and with temporal muscle bilaterally injected with 25 mouse units with the same dilution, a decrease in bruxism symptoms was reported. Neck pain also decreased after the first treatment (visual analog scale of 2/10) and then resolved completely. After 4 weeks, electromyography showed the reduction of muscle hyperactivity with a decrease in the amplitude of the motor action potential. The same reduction in signs and symptoms was still present at assessment 3 months posttreatment.

CONCLUSION

These findings suggest that BTX-A may be a therapeutic option for the treatment of bruxism and related disorders.

Bruxismo do sono: possibilidades terapêuticas baseadas em evidências

INTRODUÇÃO: o bruxismo do sono (BS) é uma desordem de movimentos estereotipados e periódicos, associados ao ranger e/ou apertar de dentes durante o sono, decorrentes da contração rítmica dos músculos mastigatórios. Essa condição não é uma doença, porém quando exacerbada pode ocasionar desequilíbrio e alteração das estruturas orofaciais. Dessa forma, surge a necessidade de se obter terapêuticas efetivas e seguras para o controle e o manejo do paciente bruxômano. As alternativas de tratamento variam desde terapêuticas orodentais e farmacológicas até técnicas comportamentais-cognitivas. OBJETIVOS: através de uma revisão sistemática da literatura, tendo como bases de pesquisa a Medline, Cochrane, Embase, Pubmed, Lilacs e BBO, no período compreendido entre 1990 e 2008, e com enfoque em estudos clínicos randomizados e quasi-randomizados, revisões sistemáticas e meta-análises, esse trabalho teve como objetivo analisar e discutir métodos de tratamento para o BS. RESULTADOS: pela análise da literatura verifica-se que existe uma grande quantidade de opções terapêuticas para o BS, porém muitas das terapias não têm suporte científico que as sustente. Assim, a escolha terapêutica deve ser pautada em evidências científicas e no bom senso clínico, objetivando uma melhora na qualidade de vida do paciente bruxômano.

On the pharmacotherapy of sleep bruxism: placebo-controlled polysomnographic and psychometric studies with clonazepam

OBJECTIVES

Sleep bruxism (SB) is a parasomnia defined as a stereotyped movement disorder characterized by grinding or clenching of the teeth during sleep. Pathophysiologically, SB is the result of biological and psychosocial influences. Treatment comprises behavioral, orthodontic and pharmacological interventions. While benzodiazepines and muscle relaxants have been reported by clinicians to reduce bruxism-related motor activity, placebo-controlled studies are lacking. Thus, the aim of the present study was to investigate the acute effects of clonazepam (Rivotril) as compared with placebo, utilizing polysomnography and psychometry.

METHOD

Ten drug-free outpatients (6 females, 4 males), aged 46.5 +/- 13.1 years, suffering from SB (ICD-10: F45.8; ICSD: 306.8) and having been treated by bite splints were included in the trial. Comorbidity was high: 7 patients presented nonorganic insomnia related to adjustment or anxiety disorders (5 patients) or depression (2 patients); all patients had a concomitant movement disorder (6 restless legs syndrome, 4 periodic leg movement disorder). After one adaptation night, patients received placebo and 1 mg clonazepam 1/2 hour before lights out in a single-blind, nonrandomized study design. Objective sleep quality was determined by polysomnography, subjective sleep and awakening quality by rating scales, objective awakening quality by psychometric tests. Clinical evaluation was based on the Pittsburgh Sleep Quality Index (PSQI), the Zung Depression (SDS) and Anxiety (SAS) Scales, the Quality of Life Index, the Epworth Sleepiness Scale and the International Restless Legs Syndrome Study Group (IRLSSG) Scale.

RESULTS

On admission, SB patients exhibited deteriorated PSQI, SAS, SDS and IRLSSG measures. As compared with placebo, 1 mg clonazepam significantly improved the mean bruxism index from 9.3 to 6.3/h of sleep. Furthermore, it significantly improved the total sleep period, total sleep time, sleep efficiency, sleep latency and time awake during the total sleep period, and increased stage 2 sleep and movement time. Periodic leg movements decreased significantly, while the apnea index and apnea-hypopnea index increased marginally, but remained within normal limits. Subjective sleep quality improved as well, while in mood, performance and psychophysiology no changes were observed.

CONCLUSION

Acute clonazepam therapy significantly improved not only the bruxism index but also objective and subjective sleep quality, with unchanged mood, performance and psychophysiological measures upon awakening, suggesting good tolerability of the drug.

Non-rapid eye movement parasomnias

Non-rapid eye movement parasomnias are unique physical or experiential phenomena that disrupt sleep. Non-rapid eye movement parasomnias are common in children, but they typically outgrow them. Sleep-stage shifts caused by sleep-disordered breathing and associated arousals may be precipitating events for episodes of parasomnia. Seizure disorders should always be considered in the differential diagnosis for the evaluation of parasomnias. Violent or injurious sleepwalking should be rapidly evaluated and treated.

Treating severe bruxism with botulinum toxin

BACKGROUND

Locally administered botulinum toxin, or BTX, is an effective treatment for various movement disorders. Its usefulness in treating bruxism, however, has not been systematically evaluated.

SUBJECTS AND METHODS

The authors studied 18 subjects with severe bruxism and whose mean duration of symptoms was 14.8 +/- 10.0 years (range three-40 years). These subjects audibly ground their teeth and experienced tooth wear and difficulty speaking, swallowing or chewing. Medical or dental procedures had failed to alleviate their symptoms. The authors administered a total of 241 injections of BTX type A, or BTX A, in the subjects' masseter muscles during 123 treatment visits. The mean dose of the BTX A was 61.7 +/- 11.1 mouse units, or MU (range 25-100 MU), per side for the masseter muscles.

RESULTS

The mean total duration of response was 19.1 +/- 17.0 weeks (range six-78 weeks), and the mean peak effect on a scale of 0 to 4, in which 4 is equal to total abolishment of grinding, was 3.4 +/- 0.9. Only one subject (5.6 percent) reported having experienced dysphagia with BTX A.

CONCLUSION

The results of this study suggest that BTX administered by skilled practitioners is a safe and effective treatment for people with severe bruxism, particularly those with associated movement disorders. It should be considered only for those patients refractory to conventional therapy. Future placebo-controlled studies may be useful in further evaluating the potential of BTX in the treatment of bruxism.

Antidepressant-induced bruxism successfully treated with gabapentin

BACKGROUND

Symptoms consistent with bruxism are a common chief complaint in dental practice. The authors describe a case of bruxism likely induced by the antidepressant venlafaxine and successfully treated with gabapentin.

CASE DESCRIPTION

A case of bruxism, anxiety, insomnia and tremor is reported in a man with bipolar disorder that developed a few days after he initiated venlafaxine therapy for depression. The patient's psychiatrist prescribed gabapentin for anxiety symptoms, and shortly thereafter the man experienced a complete resolution of the bruxism.

CLINICAL IMPLICATIONS

On the basis of this case and the available literature, the authors conclude that bruxism secondary to antidepressant therapy may be common. Thus, dentists should inquire about the use of these medications in patients who have bruxism. Gabapentin may offer promise in the treatment of this condition.