Antidepressant-induced bruxism successfully treated with gabapentin

In vitro monitoring of HTR2A-positive neurons derived from human-induced pluripotent stem cells

The serotonin 5-HT_2A receptor (5-HT_2AR) has been receiving increasing attention because its genetic variants have been associated with a variety of neurological diseases. To elucidate the pathogenesis of the neurological diseases associated with 5-HT_2AR gene (HTR2A) variants, we have previously established a protocol to induce HTR2A-expressing neurons from human-induced pluripotent stem cells (hiPSCs). Here, we investigated the maturation stages and electrophysiological properties of HTR2A-positive neurons induced from hiPSCs and constructed an HTR2A promoter-specific reporter lentivirus to label the neurons. We found that neuronal maturity increased over time and that HTR2A expression was induced at the late stage of neuronal maturation. Furthermore, we demonstrated successful labelling of the HTR2A-positive neurons, which had fluorescence and generated repetitive action potentials in response to depolarizing currents and an inward current during the application of TCB-2, a selective agonist of 5-HT_2ARs, respectively. These results indicated that our in vitro model mimicked the in vivo dynamics of 5-HT_2AR. Therefore, in vitro monitoring of the function of HTR2A-positive neurons induced from hiPSCs could help elucidate the pathophysiological mechanisms of neurological diseases associated with genetic variations of the HTR2A gene.

Trazodone Treatment of Bruxism in a Patient With Severe Dementia

OBJECTIVES

The objective of this study was to report the effectiveness of trazodone for treatment of bruxism in dementia.

METHODS

A single case study of a 66-year-old man with severe vascular dementia and awake bruxism was performed.

RESULTS

The patient's bruxism responded robustly to titration of trazodone. He tolerated the medication with no untoward sedation or other adverse effects.

CONCLUSIONS

Bruxism is occasionally encountered in patients with advanced dementia and raises concerns about nutritional compromise and about potential need for poorly tolerated dental treatment. Trazodone may potentially be effective for bruxism in some patients.

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.

[Update in family medicine: Periodontal disease]

About 85-94% of the Spanish adults older than 35 experience gum problems, and about 15-30% suffer from periodontitis, being severe in up to 5-11% of them. Unlike other inflammatory conditions, periodontal disease rarely causes discomfort, or limits life or causes functional limitations until its advanced stages, when clinical signs and symptoms arise (gingival recession, pathological teeth migration, or mobility). Lack of knowledge about the disease, together with the idea that tooth loss is linked to ageing, frequently results in a late diagnosis, requiring extensive treatments with a worse prognosis. At Primary Care level, there is series of drugs have been related to periodontal disease (anticonvulsants, immunosuppressive drugs, and calcium channel blockers) as secondary effects, which vary as regards their frequency and severity depending of the amount of accumulated plaque. Stress and depression have also been reported to alter the immune response and to increase the inflammatory response as well as periodontal susceptibility. Certain systemic conditions, such as diabetes mellitus, cardiovascular disorders, respiratory diseases, as well as low-weight pre-term birth, have also been linked to periodontitis.

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.

Nocturnal bruxism in a patient with Behçet disease and posttraumatic stress disorder successfully treated with gabapentin

Bruxism is an involuntary movement, including teeth grinding and clenching, which occur primarily during sleep. Although Behçet disease and posttraumatic stress disorder both have a high prevalence of sleep problems, bruxism is extremely rare in these 2 disorders. Here, we report a rare case of concurrent Behçet disease and posttraumatic stress disorder, which presented with antidepressant-refractory sleep disturbance accompanied by teeth grinding, clenching, and snoring that was successfully treated with gabapentin.

The efficacy of gabapentin versus stabilization splint in management of sleep bruxism

PURPOSE

This study aimed to determine if the use of gabapentin is more efficacious than a stabilization splint with regard to the intensity of masseter muscle contractions and/or sleep quality for patients experiencing sleep bruxism (SB).

MATERIALS AND METHODS

Twenty patients with SB participated in this clinical study. They were randomly divided into two treatment groups: stabilization splint group (n = 10) and gabapentin group (n = 10). The first polysomnographic examination was performed before the beginning of the experiment for all the participants. At the end of a 2-month period of stabilization splint therapy or gabapentin usage, a second polysomnographic recording was made.

RESULTS

Statistically significant reductions in the number of SB episodes per hour and per night, bruxism time index, total duration of SB episodes per night and number of SB episodes in stages NR I and NR II (p < 0.05) were observed in both groups after treatment. Both treatments significantly reduced the mean intensity of masseter muscle contractions during SB episodes. Moreover, the participants treated with gabapentin showed a significant improvement in total sleep time, slow wave sleep (stage III), and sleep efficiency (p < 0.05).

CONCLUSIONS

Gabapentin could be an effective treatment modality in SBs, especially in those with poor sleep quality.

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.

Bruxism physiology and pathology: an overview for clinicians

Awake bruxism is defined as the awareness of jaw clenching. Its prevalence is reported to be 20% among the adult population. Awake bruxism is mainly associated with nervous tic and reactions to stress. The physiology and pathology of awake bruxism is unknown, although stress and anxiety are considered to be risk factors. During sleep, awareness of tooth grinding (as noted by sleep partner or family members) is reported by 8% of the population. Sleep bruxism is a behaviour that was recently classified as a 'sleep-related movement disorder'. There is limited evidence to support the role of occlusal factors in the aetiology of sleep bruxism. Recent publications suggest that sleep bruxism is secondary to sleep-related micro-arousals (defined by a rise in autonomic cardiac and respiratory activity that tends to be repeated 8-14 times per hour of sleep). The putative roles of hereditary (genetic) factors and of upper airway resistance in the genesis of rhythmic masticatory muscle activity and of sleep bruxism are under investigation. Moreover, rhythmic masticatory muscle activity in sleep bruxism peaks in the minutes before rapid eye movement sleep, which suggests that some mechanism related to sleep stage transitions exerts an influence on the motor neurons that facilitate the onset of sleep bruxism. Finally, it remains to be clarified when bruxism, as a behaviour found in an otherwise healthy population, becomes a disorder, i.e. associated with consequences (e.g. tooth damage, pain and social/marital conflict) requires intervention by a clinician.

Urinary levels of catecholamines among individuals with and without sleep bruxism

INTRODUCTION

Sleep bruxism (SB) is characterized by repetitive and coordinated mandible movements and non-functional teeth contacts during sleep time. Although the etiology of SB is controversial, the literature converges on its multifactorial origin. Occlusal factors, smoking, alcoholism, drug usage, stress, and anxiety have been described as SB trigger factors. Recent studies on this topic discussed the role of neurotransmitters on the development of SB.

OBJECTIVE

Thus, the purpose of this study was to detect and quantify the urinary levels of catecholamines, specifically of adrenaline, noradrenaline and dopamine, in subjects with SB and in control individuals.

MATERIALS AND METHODS

Urine from individuals with SB (n = 20) and without SB (n = 20) was subjected to liquid chromatography. The catecholamine data were compared by Mann-Whitney's test (p </= 0.05).

RESULTS

Our analysis showed higher levels of catecholamines in subjects with SB (adrenaline = 111.4 microg/24 h; noradrenaline = 261,5 microg/24 h; dopamine = 479.5 microg/24 h) than in control subjects (adrenaline = 35,0 microg/24 h; noradrenaline = 148,7 microg/24 h; dopamine = 201,7 microg/24 h). Statistical differences were found for the three catecholamines tested.

CONCLUSION

It was concluded that individuals with SB have higher levels of urinary catecholamines.

Gabapentin in the treatment of mental illness: the echo chamber of the case series

BACKGROUND

Bipolar disorder is a common and debilitating psychiatric illness. Several antiepileptic drugs (AEDs) have been approved for the treatment of bipolar disorder. Gabapentin gained a large market share of AED use in the late 1990s in spite of a lack of randomized clinical trial (RCT) evidence and no labeled indication from the U.S. Food and Drug Administration for its use in psychiatric illness. This article describes the results of a literature review, the purpose of which was to examine the characteristics of studies conducted in humans concerning the efficacy of gabapentin in bipolar disorder.

METHODS

Publications relevant to this topic were identified based on a PUBMED search as well as an examination of references from a published systematic review and citations from relevant review articles.

RESULTS

The search located 29 studies published between 1997 and 2007, with the greatest number of articles published in 1998 and 1999. Of these 29 publications, 15 involved uncontrolled case series, while 6 were single case reports. The sample size in the studies was generally small, and often we could not identify the funding source. Despite the generally weak study design in the identified publications, the authors of the articles often commented on the promising nature of gabapentin therapy for bipolar disorder. However, 4 small, randomized trials in heterogeneous populations demonstrated little if any evidence of such efficacy. Nine letters to the editor demonstrated a similar pattern.

CONCLUSIONS

The large number of case series concerning gabapentin is striking. The number of reports and their distribution in many different journals created a type of "echo chamber" effect, through which the sheer number of publications and citations may give legitimacy to the practice of using gabapentin for bipolar disorder. Although the case series were generally of poor quality, their publication in peer-reviewed journals may have been partially responsible for the widespread use of an ineffective medication.

Pharmacological approaches to the treatment of residual symptoms

Despite the efficacy of currently available antidepressant treatment, residual symptoms are common among individuals treated for major depressive disorder and are associated with an increased risk of relapse and poor psychosocial functioning. However, distinguishing treatment-emergent side effects from residual symptoms can be challenging for clinicians. Anxiety, sleep disturbance, somnolence/fatigue, apathy and cognitive dysfunction are among the more frequent residual symptoms. Approaches to the management of residual symptoms include addressing treatment-emergent side effects and co-morbid conditions, optimizing antidepressant dosing and using augmentation therapy. Clinicians are often guided in their decisions by anecdotal impressions. Studies assessing the evaluation and treatment of residual symptoms and side effects will contribute importantly to the optimal acute and long-term management of depression.

Posttraumatic stress disorder: psychopathology, medical management, and dental implications

PTSD is a chronic mental illness that may arise after an individual experiences or witnesses a life-threatening event. Symptoms consist of persistent reexperiencing of the event, avoidance of reminders of the event, a numbing of positive emotions, and social withdrawal. A depressed mood and excessive use of alcohol and tobacco may accompany the disorder. PTSD afflicts approximately 5% of men and 11% of women. Dental disease may be extensive because of neglect of oral hygiene compounded by cigarette smoking. Dental treatment includes preventive education, oral cancer screening, and prescribing saliva substitutes or stimulants and anticaries agents to combat medication-induced xerostomia. Precautions must be taken when prescribing or administering certain analgesics, antibiotics, or sedative agents that may adversely interact with the psychiatric medications or when performing surgery because of the long-term effects of alcohol abuse.

Late-life depression: its oral health significance

Late-life depression (LLD) initially occurs after age 65 and is a major public health concern because elderly people who are at high risk constitute an ever-expanding segment of the population. LLD is a mental illness in which mood, thought content, and behavioural patterns are impaired, causing individual distress, compromising social function and impairing self-maintenance skills (e.g. bathing, dressing, hygiene). It is characterised by marked sadness, or a loss of interest or pleasure in daily activities and may be accompanied by weight change, sleep disturbance, fatigue, difficulty concentrating, and high suicide rate. Individuals under treatment for LLD and those whose illness has not been diagnosed or treated often present to the dentist with significant oral disease. LLD is frequently associated with a disinterest in performing oral hygiene, a cariogenic diet, diminished salivary flow, rampant dental decay, advanced periodontal disease, and oral dysesthesias. Many medications used to treat the disease magnify the xerostomia and increase the incidence of dental disease. Appropriate dental management necessitates a vigorous preventive dental education programme, the use of artificial salivary products, antiseptic mouthwash, daily fluoride mouthrinse and special precautions when administering local anaesthetics with vasoconstrictors and prescribing analgesics.

Late-life depression: psychopathology, medical interventions, and dental implications

BACKGROUND

Late-life depression (LLD) initially occurs after age 65 years and is a major public health concern because the elderly who are at high risk constitute an ever-expanding segment of the population. LLD is a mental illness in which mood, thought content, and behavioral patterns are impaired, causing the individual distress, compromising social function, and impairing self-maintenance skills (eg, bathing, dressing, hygiene). LLD characterized by marked sadness or a loss of interest or pleasure in daily activities and may be accompanied by weight change, sleep disturbance, fatigue, difficulty in concentration, and a high suicide rate. Diagnosis of LLD is sometimes complicated by a denial of mood change and an inability to distinguish symptoms of a concurrent physical illness from those of a depressive etiology. The disorder is most frequently treated with antidepressant medications, and although older individuals have a recovery rate that is comparable with younger adults, they often take longer to recover, have more frequent relapses, and are more sensitive to the side effects of the drugs.

CLINICAL IMPLICATIONS

Individuals undergoing treatment for LLD and those whose illness has not been diagnosed or treated often are seen with significant oral disease by the dentist. Dentists need to be cognizant of how to safely and compassionately provide care to those already receiving mental health services. They must also be familiar with the psychiatric symptoms of the disorder to effectuate a timely referral to a physician of those with occult or relapsing disease. LLD is frequently associated with a disinterest in oral hygiene, a cariogenic diet, diminished salivary flow, rampant dental decay, advanced periodontal disease, and oral dysesthesias. Many medications used to treat the disease magnify the xerostomia and increase the incidence of dental disease. Appropriate dental management necessitates a vigorous preventive dental education program, the use of artificial salivary products, antiseptic mouthwash, daily fluoride mouth rinse, and special precautions in administration of local anesthetics with vasoconstrictors and prescription of analgesics.

CONCLUSION

Dentists who invoke appropriate precautions can usually provide a full range of services to individuals with LLD, thereby enhancing patient self-esteem and contributing to the psychotherapeutic aspect of management.

Behavioural effects of the new anticonvulsants

Of the 9 new anticonvulsants that have been marketed recently in the UK or US, a number appear to have either adverse or beneficial effects on behaviour. There is now a considerable database of information, in terms of the number of patients treated and/or the number of published reports, on vigabatrin, lamotrigine, gabapentin and topiramate. Oxcarbazepine has been available in some centres for several years and there is extensive experience with the drug in Scandinavia. It appears that the profile of adverse and beneficial effects is similar to that of carbamazepine. Behavioural effects have probably been greatest with vigabatrin, with psychosis, depression and other behavioural problems recorded, but the use of this drug has been limited because of the concern about visual field constriction. The cognitive and behavioural effects of topiramate have caused concern, but these may be much less of a problem if lower starting dosages and escalation rates are used. Psychosis and depression have been associated with topiramate, as they have with another carbonic anhydrase inhibiting drug, zonisamide. Although zonisamide has been used for many years in Japan and Korea, experience elsewhere with this drug is currently very limited. Gabapentin seems to be less associated with adverse behavioural effects than some of the other new anticonvulsant drugs. The reports of behavioural disturbance with gabapentin in children may be related to dose escalation. Behavioural disturbance as a direct result of lamotrigine seems to be uncommon, although indirect effects on behaviour, through the so-called 'release phenomenon' from improved seizure control and consequent ability to misbehave, can occur. Positive behavioural effects have been described with several of the new anticonvulsants, particularly gabapentin, lamotrigine and oxcarbazepine; all of these drugs may have mood-levelling effects that could be of value in treating affective disorders. The information on tiagabine and levetiracetam is too limited to allow any firm conclusions to be drawn with regard to positive or negative behavioural effects. When interpreting reports of behavioural changes with anticonvulsants, it is important to avoid attributing the effect to the drug when one or more of the other multiple causes of behavioural disturbance in people with epilepsy may be responsible or when an indirect effect such as 'forced normalisation' may be the cause. Many of the published studies are retrospective and unblinded rather than double-blind, placebo-controlled, prospective trials, implying that much of the data must be interpreted with caution at this stage.