[Music] welcome to psychiatry education forums Coffee Club and topic is antidepressants induced bruxism and this will be discussed in following five sections so these sections are actually five questions first question is what is bruxism and why is bruxism recognition important second is what is mechanism behind bruxism with the antidepressants use third is which antidepressants can increase the risk of bruxism fourth is who is at high risk of getting bruxism with antidepressant use and last is management strategies for antidepressant induced bruxism so let's begin our coffee Club now hello welcome everyone I am Elena Fellini open and I'm very pleased today to welcome dr. Harvinder Singh who most of you know already using this website dr. Harvinder Singh has been running this educational forum for nearly three years now he's an excellent orator excellent speaker as you all know already he's an outpatient psychiatrist working at Reno Nevada he has a wealth of knowledge on the clinical practice which he is distilling over years and providing to us in as dewdrops so to speak so today we're going to have one more do drop of his wisdom and today we're going to discuss an issue that's very close to his his heart the side-effects of treatments and we're going to deal with a rather unusual side effect but rather troublesome side effect bruxism in in patients who take antidepressants thank you very much dr. dr. Singh for being here and answering some of the questions that I have I have to say I haven't seen a lot of this drug system problem myself in so I was really enthralled to be what you put together the paper but you published last year this topic a very rare piece of paper which is very helpful for practitioners who come across this problem thank you for doing that and I also had a chance to look at your presentation which I was very pleased to see very helpful resonates with some of my practical questions that I might have when I see a patient like that so let me start with asking you a very straightforward question dealing with this topic what is breakfast um and how does this relevant to psychiatry so thank you dr. Palin yep and for a very very nice introduction so let's start with bruxism first so bruxism is mainly in layman's term is the joke on traction but happening more often than usual and this can present as either somebody's jaw clenching a lot or grinding of their teats and mostly if you look at the literature a bruxism is mainly of two types it's either sleep bruxism which is only happening at sleep or awake bruxism which is happening also during daytime and I feel that this is very very important topic clinically relevant topic for every physician who prescribes antidepressant or I should say any serotonergic medication so this not only applies to psychiatry but also to internal medicine family medicine and our sleep medicine physician and also dentist I'll talk about that why is that relevant in few minutes but this is what bruxism is in a very brief are terms that's very helpful introduction dr. Singh at the point that you mentioned it's not just a catalyst who needs to know it because antidepressants are being used by many other practitioners now as you as you say so thank you for highlighting that my next question is something that's really interesting questions me because often my knowledge becomes a blur over time but if I understand them Anderson behind an issue I try to I tend to retain it for longer so I'm just gonna ask you this question how do you think antidepressants cause paroxysms now that is I think the most difficult and most important question for everyone who prescribes these medication so when I published this literature review I looked at almost every case report and case series published on this and almost every article gave this one hypothesis in mechanism so basic theory is that medications that increases serotonin they causes hyperactivity in the serotonergic neuron so if you look at that serotonergic neurons going from raphe nucleus to ventral tegmental area this hyperactivity in certain logic neuron causes indirect hypo activity in the mesocortical pathway runs from ventral tegmental area to our prefrontal cortex and thereby to the masticatory muscle and various other areas basic theory is serotonergic medication hyperactivity indirectly reducing the activity in the mesocortical pathway and causing bruxism and this is one of the main reason why one of the medication that we will talk in the treatment section moving forward booster on is helpful in that area I will talk more about that moving forward but this is a very very hypothesized mechanism of action why antidepressants do that so if a patient comes to me and asks me why am I having this problem I should invoke these certain logic hypothesis to explain that next antastic thank you yeah so I other question which is you know very practically relevant for me I mean you mentioned a mechanism you mentioned it's important for us to know but could we have some sort of rank in our mind which antidepressant causes more bruxism risk and which one is a little safer in practice yeah there and and this is very important question again I think this is the question that every psychiatrist every physician asked when they encountered can I change medication or which medication is more risky or less risky and that was a reason why we did this literature review to begin with and the answer is not ideal so what I will do is I'm going to share few slides so that it is more easy for everyone to understand ok so this is a paper that we published into 2019 our literature review so let's rank these medications in various classes so what happened is when I we looked at many many arcades with articles and total we found 46 published case reports on that see here out of that 34 what related to SSRIs which is selective serotonin reuptake inhibitors and out of those fluoxetine was ranked 1 followed by so trolling but I have mentioned this in the paper also that I assume the fluoxetine is high because that was the oldest antidepressant the first one that came in to market but again when you look at SSRI fluoxetine so trolling and issa tallow pram they were very high but I was able to find almost every SSRI causing this bruxism as a side effect and when you look at snri class which is selective nair nor up in a certain and norepinephrine reuptake inhibitors they only be only found when the faxing and duloxetine as the moon most common causes but out of these eleven cases nine were related to venlafaxine and moving forward and this was actually uh like a surprise for me which is bupropion which is which have mostly no effect on the serotonin reuptake we found one case of that I thinking was the pro pian is very safe because it should not cause that hyperactivity of the serotonergic neuron but this stirred a case was published for bupropion as our formulation and also looking at other medications like milk a subpoena and trazadone i was not able to find any articles on that and and as you can see the literature review was published last year in 2019 so before this presentation what I did was I also looked at maybe there is some new studies published after that I found a positive study for mirtazapine actually there was a case published uh a patient with cerebral glioblastoma he developed bruxism and they chose millet has opinion bruxism resolved milk as Athene is one of the better of medication in my opinion and in few minutes i will talk about treatment planning for bruxism and trazadone is one of the treatment there we'll talk more about it cold milk has a bean trazadone make sense and then tricyclic antidepressant and ma wise i was not able to find any articles on that and when i talk about treatment planning i will just talk very briefly about my personal experience with tricyclic antidepressant I have found them actually helpful in fuels my patients with bruxism but we'll talk about them in few minutes sure yeah lets me go back to our video okay thank you for that visual I'm a very visual person I like to you know see things so I can remember better I cannot remember the SSRIs especially the more commonly used ones have very higher propensity oxidant sertraline citalopram as well as SSRIs benefaction and antioxidant so it looks like you know anything that blocks the reuptake of serotonin would have an effect to you know increase the chances but when it comes to antagonists like gossip in trazadone we don't seem to have the same same machine exactly that's very helpful so friends this marks the end of our first part of this coffee Club video discussion on antidepressants induced bruxism in our second video we will talk about topic number four which is who is at high risk of getting bruxism with antidepressant use and the last and I think most important and clinically relevant topic else how can we manage bruxism with antidepressant use and we'll talk about various treatment strategies and the whole section is available in our 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