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Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder Prevalence of bruxism in children receiving treatment for
attention deficit hyperactivity disorder: a pilot study
Ghadah A. Malki* / Khalid H. Zawawi** / Marcello Melis*** / Christopher V. Hughes****
The objective of this study was to evaluate reported bruxism among children affected by attentiondeficit hyperactivity disorder (ADHD). Thirty children diagnosed with ADHD and 30 healthy age andgender matched controls participated in the study. All subjects were examined for dental attrition, andthe parents were asked for signs and symptoms of bruxism in their children using a questionnaire.
Prevalence of oral parafunction was evaluated comparing ADHD children taking medications,ADHD children not taking medications, and controls. Subjects affected by ADHD and pharmaco-logically treated showed higher occurrence of bruxism compared to subjects affected by ADHD nottaking medicines and controls; and within the ADHD group taking medications, CNS-stimulants havebeen associated with such side effect more frequently than the other drugs.
INTRODUCTION
4. Non-rapid eye movement (NREM) parasomnias Attention-deficit-hyperactivity disorder (ADHD) e.g. sleep walking and sleep terrors. Most of the sleep research in ADHD has focused on dys- characterized by developmentally inappropriate somnias and sleep related involuntary movements.
hyperactivity, impulsivity, and inattention. Prevalence in However, as it was concluded that the association the population has been reported to range from 1.7% to between ADHD and sleep problems is intricate, 17.8%. Substantial clinical evidence shows an association and treatment with stimulant medications can be a between sleep problems and ADHD in children. Sleep disorders in children are not a unitary clinical problem.
They are commonly classified in the following groups: Psychostimulant drugs are the treatment of choice for children with ADHD. There is often an immediate 1. Dyssomnias e.g. insomnia and circadian rhythm and dramatic improvement in the conduct and acad- emic performance of children with behavioral distur- 2. Sleep-related involuntary movements e.g. bruxism, bances after administration of the medication. These periodic limb movement disorder and sleep talking, findings have been long-established by many 3. Sleep-related breathing disorders e.g. obstructive controlled short-term clinical studies of children, adolescents, and adults; an estimated 70% of thesubjects responded to methylphenidate, dextro-amphetamine, and pemoline, eliminating mostdebate over at least the short-term efficacy andsafety of these drugs. Gillberg et al.9 reported similar * Ghadah A. Malki, BDS, DScD, Pediatric Dentist, Dental Center, King Fahad Hospital. Jeddah, Saudi Arabia.
findings in a recent long-term study, although in a ** Khalid H. Zawawi, BDS, Postdoctoral Resident, Department of Oral Biology, Goldman School of Dental Medicine, Boston Bruxism has been associated with sleep disorders and has been reported to be aggravated by the consumption *** Marcello Melis, DMD, Rpharm, Private Practice, Cagliari, Italy.
of alcohol and some types of medications, it has also **** Christopher V. Hughes, DMD, PhD, Department of Pediatric Dentistry, Goldman School of Dental Medicine, Boston been observed in individuals with disturbances of the central nervous system. Bruxism is defined by theAmerican Academy of Orofacial Pain as: “A diurnal or Send all correspondence to Khalid H. Zawawi, BDS, Department ofOral Biology, Goldman School of Dental Medicine, Boston nocturnal parafunctional activity including clenching, University, 100 East Newton Street, Room # G-05, Boston, MA 02118.
bracing, gnashing and grinding of the teeth”. TheAmerican Sleep Disorders Association defines bruxism as: “Tooth grinding or clenching during sleep plus one of the following: tooth wear, sounds or jaw muscle The Journal of Clinical Pediatric Dentistry Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder discomfort in the absence of a medical disorder”.
7. Does you child experience morning headaches? Bruxism affects 15% to 100% of the population andseems to be related to local/mechanical factors, Subjects were also examined for signs of dental wear systemic/neurological factors and psychological factors.
(i.e. attrition, erosions and occlusal wear facets) and the The role of stress in the pathophysiology of bruxism severity and number of worn teeth was recorded. To is anecdotal, yet it is probably the factor to which most control for intra/inter examiner consistency, one exam- often the etiology of oral parafunctions is attributed.
iner performed the dental examinations.
Some investigators have suggested that bruxing is infact a type of sleep disorder and is linked to dreaming STATISTICAL ANALYSES
during sleep cycles, daytime emotional expression, For nominal data Chi square (2) analysis was per-
anxiety induced responses, or the anticipation of stress- formed to evaluate whether a statistical relationship exists between the groups. ANOVA was used to com- Bruxism can result in excessive tooth wear, muscular pare significant differences among the three groups for pain, degenerative temporomandibular joint disease, the number of worn teeth, followed by pair wise com- muscular hypertrophy, headache and periodontal tissue parisons. Dunnett-T3 correction method was used to injury. While tooth wear is visible to the dentist, the correct for type-I error. Regression analysis was used to effects of bruxism on the orofacial muscles, ligaments assess the relationship between the use of medications and joints are not easily recognized; nonetheless, they and tooth attrition. Fisher’s exact test and Student’s are often painful for the patient and have serious long t-test were used where appropriate. Data are presented as mean ± standard error of the mean (SEM). Analyseswere conducted using the Statistical Package for the STUDY OBJECTIVES
Social Sciences (SPSS Inc, Chicago, IL).
The objective of this study was to investigate bruxismin subjects diagnosed with ADHD, and evaluate the relationship between bruxism and the medications A total of 60 subjects (48 males and 12 females) were enrolled in the study, 30 diagnosed with ADHD (meanage 10.6±0.5) and 30 controls (mean age 10±0.4).
MATERIALS AND METHODS
The results of the questionnaire showed that ADHD Patients seeking dental treatment attending the subjects reported more grinding during the day (2 = 10.4,
outpatient dental clinic at Franciscan Children’s p=0.002), more clenching or grinding during sleep Hospital were asked to participate in the study. All (2 = 6.2, p=0.025) and the parent/guardian felt that the
young patients between the age of 5 years to 15 years, subject’s teeth are getting worn down more frequently and diagnosed with ADHD were recruited. Thirty when compared to the control group (2 = 11.9, p=0.001).
patients were diagnosed with ADHD, 24 subjects were No significant differences were observed for the remaining receiving medications for ADHD and 6 were not questions investigating morning headaches, face pain, jaw receiving medications at the time of the interview and clicking and face pain during the night (p>0.05) (Table 1).
examination. The diagnosis of ADHD was based on When evaluating the number of teeth with attrition/ medical history. Thirty age and gender matched healthy wear facets between the groups, independent Student’s children attending the dental office for regular treat- t-test showed that ADHD subjects had more teeth with attrition/wear facets than controls, mean = 6.1±1.2 and The study was reviewed and approved by the Institutional Review Board at Franciscan Children’s Since 6 subjects in the ADHD group were not on Hospital. After an informed consent was obtained, medication, the ADHD group was further divided into parents/guardians were asked to answer “Yes or No” two groups, ADHD receiving medications and ADHD ANOVA was conducted to evaluate significant dif- 1. Does your child clench or grind his/her teeth during ferences between the numbers of worn teeth (teeth with attrition/wear facets) among the three groups 2. Does your child clench or grind his/her teeth during (ADHD receiving medications, ADHD not receiving medications and controls). There was a significant dif- 3. Do you feel that his/her teeth are getting worn ference between the groups (Fdf = 2, 56, = 10.0, p<0.0001). Follow-up tests were conducted to evaluate 4. Does he/she experience jaw clicking while eating, pair wise differences among the means. ADHD chil- dren receiving medications had a significant higher number of worn teeth (mean=7.2±1.4) compared to 6. Does your child wake up in the middle of the night ADHD children not receiving medications (mean = 1.8±0.8) and controls (mean=1.5±0.5), p=0.008 and The Journal of Clinical Pediatric Dentistry Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder Table 1. Results of the chi-square tests (2) for the answers to the questionnaire given to the Parents/guardians.
Does your child clench or grind his/her teeth during the day?
Does your child clench or grind his/her teeth during sleep?
Do you feel that his/her teeth are getting worn down?
Does he/she experience jaw clicking while eating, yawing or any other movements?
Does he/she complain of facial pain?
Does your child wake up in the middle of the night complaining of facial pain?
Does you child experience morning headaches?
Values are number of subjects who answered yes and percentage. NS indicates not significant Table 2. Summary of the medications used by the ADHD subjects during the interview.
Medication Class
No. of Subjects (percentage)
Total percentage
Selective Serotonin Reuptake Inhibitors (SSRI’s) Adrenergic Blockers
p=0.002, respectively. The difference between the Regression analysis was conducted using the num- number of worn teeth for the ADHD children not ber of worn teeth as the dependant variable. The results receiving medications was not significantly different showed that there was a significant association between from the controls (p>0.1) (Figure 1).
the use of CNS-stimulants (e.g. methylphenidate, Since ADHD subjects receiving medications amphetamines) and tooth wear (p<0.05). Moreover, exhibited significantly higher number of worn teeth subjects receiving CNS-Stimulants had more teeth with compared to the other two groups, it was of interest attrition (mean = 8.9±1.5) compared to subjects not to find which medication could be associated with using these medications (mean = 3.0 (0.9), t The Journal of Clinical Pediatric Dentistry Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder Figure 1. Comparison between the number of worn teeth for the
Figure 2. Comparisons between the mean number of worn teeth
ADHD children receiving medications, ADHD children not receiving for Subjects receiving CNS-stimulants and subjects who do not in the ADHD group receiving medications.
DISCUSSION
ADHD children receiving medications had higher In 1993, the number of prescriptions in the United prevalence of tooth attrition and more daytime grind- States for methylphenidate (a CNS-stimulant) for chil- ing, we compared ADHD children using CNS-stimu- dren with ADHD was 2.5 times higher than in 1990.
lants to children using other medications, and a signifi- This increase aroused concern about abuse or over cant difference was found: children using CNS-stimu- prescribing. These stimulants cause muscular hyperac- lants had a 2.5-fold higher number of worn teeth.
tivity and dyskinesia. Nonetheless, the value of stimu- The results of this study seem to agree with the pre- lant drugs in reducing symptoms of ADHD is widely viously reported studies where occurrence of bruxism accepted. The value in children with relatively mild was noticed after administration of SSRIs and antipsy- symptoms or with coexisting disorders is less clear. The chotic drugs. Also another study showed the marked drugs can be safely administered to children with effect of methylphenidate on oral parafunctions, ADHD and epilepsy and methylphenidate, but not although associated to valproic acid for the treatment dextroamphetamine, gives positive results in children of ADHD and epilepsy, confirming what was observed with ADHD and tic disorders decreasing disruptive in the present study. On the other hand, whether the behavior without necessarily worsening the tics.
use of ADHD medications is the cause of such symp- Selective serotonin reuptake inhibitors (SSRIs) are toms cannot be confirmed because of some limitations also medicines used for the treatment of ADHD. They of the study. One limitation is due to the fact that we are widely prescribed anti-depressants that enhance did not evaluate the effect of different dosages of each serotonin neurotransmission. The use of SSRIs has medication on bruxism. The use of higher or lower dose been associated with the occurrence or worsening of of the drug administered might have biased the results several extra-pyramidal reactions such as dyskinesia, of the comparison between methylphenidate and the restless leg syndrome, dystonia and bruxism. Fitzgerald other medicines. Table 2 summarizes the medications and Healy observed diurnal bruxism secondary to used by the ADHD subjects included in the study and SSRI medication in 5 of 6 patients. Bruxism persisted in the percentage of subjects using each drug.
2 of the patients after the drug was discontinued. Also The second limitation consists in the small number Amir et al.33 found acute bruxism and akathisia occur- of ADHD children not receiving medications, only six ring as an early side effect of antipsychotic drug for the children, making a clear association between ADHD children taking medications and bruxism difficult. This The present study evaluated the possible parafunc- limited number of ADHD children not treated with tional habits among children diagnosed with ADHD medicines could be attributed to the fact that these especially the ones receiving medications for this disor- children are put on medications as soon as they are der. It was also found that there was a higher preva- lence of day and night grinding among the ADHD chil- The present report suggests that there could be an dren treated with medication when compared to the association between ADHD medications and parafunc- other two groups. When evaluating the number of worn tional activity, especially focusing on the use of CNS- teeth it was found that the ADHD group receiving stimulants (e.g. methylphenidate or amphetamines). This medications had significantly more signs of attrition association could be further established by increasing the compared to the other two groups. After realizing that sample size, especially in the ADHD group, who do not The Journal of Clinical Pediatric Dentistry Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder receive medications, and controlling for the type of med- 14. Melis M, Abou-Atme YS. Prevalence of bruxism awareness in a ication used and the different dosages. This would give a Sardinian population. Cranio 21: 144-51, 2003.
15. Glaros AG, Rao SM. Bruxism: a critical review. Psychol Bull 84: clearer picture of the eventual associations and improve the discriminating power of the statistical analyses. How- 16. Okeson JP. Etiology of functional disturbances in the mastica- ever, although oral parafunctional activities are common tory system. In: Okeson JP, ed. Management of temporo- occurrences and vary with each individual, in some mandibular disorders and occlusion. 4th ed. St. Louis: Mosby patients enrolled in the study they were extremely 17. Pierce CJ, Chrisman K, Bennett ME, Close JM. Stress, anticipa- destructive and resulted in extremely frustrating prob- tory stress, and psychologic measures related to sleep bruxism.
lems for the dentist. It is therefore appropriate not to overlook the problem, regularly examining ADHD 18. Goulet JP, Lund JP, Montplaisir JY, Lavigne GJ. Daily clenching, patients, especially those taking medications and in par- nocturnal bruxism and stress and their association with TMD ticular CNS-stimulants, and eventually intervening to symptoms [abstract]. J Orofac Pain 75: 120, 1993.
19. Westrup DA, Keller SR, Nellis TA, Hicks RA. Arousability and avoid damage to the oral structures.
bruxism in male and female college students. Percept Mot Skills75(3 Pt 1): 796-8, 1992.
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