Which SSRIs or SNRIs are documented as least likely to cause bruxism?

Comment by InpharmD Researcher

Literature indicates mixed and uncertain evidence on the choice of serotonergic antidepressants in patients with a history of bruxism. Some studies report escitalopram, sertraline, fluoxetine, and citalopram have the lowest incidence of bruxism among serotonergic antidepressants; however, other analyses show higher incidences with fluoxetine and sertraline. It should be noted that the data were mainly based on retrospective studies and case reports. While there are limited studies regarding an association between SNRIs and bruxism, duloxetine and venlafaxine were among the medications with increased risk of bruxism.

Background

A 2018 systematic review included five analytical cross-sectional studies to assess the association between psychotropic medications and sleep bruxism (SB). One survey (N= 100) included patients with SB and observed the use of selective serotonin reuptake inhibitors (SSRI) revealed there is no association between SSRI use and SB (Odds ratio [OR] 1.024; 95% confidence interval [CI] 0.331 to 3.171). Another study (N= 75) subdividing patients with social phobia based on SSRI drug use stated there was no association between SSRIs versus control (p= 0.070). However, another study including 506 patients who were taking antidepressant medications for at least three months revealed that duloxetine (OR 2.16; 95% CI 1.12 to 4.17), paroxetine (OR 3.63; 95%CI 2.15 to 6.13), and venlafaxine (OR 2.28; 95%CI 1.34 to 3.86) were associated with increased risk for SB. However, there was no increased risk of SB in patients who were taking citalopram, escitalopram, fluoxetine, mirtazapine, and sertraline. The authors noted that the overall quality of evidence was considered very low and the results should be interpreted with caution. [1]

A 2021 review discussing the sleep bruxism and/or awake bruxism as an adverse effect of several classes of medications stated that the proposed selective serotonin reuptake inhibitors- (SSRIs) associated sleep and awake bruxism can be related to an excess of serotonin in nerve synapses that can result in an inhibitory effect on dopamine release leading to movement disorders. One systematic review of case reports showed that fluoxetine and sertraline among other SSRIs had the most common reported non-specific bruxism. The authors included another case report of a 6-year- old girl mentioning that the patient presented intense sleep bruxism following receiving fluoxetine. The authors also included another systematic review showing duloxetine and venlafaxine from serotonin-norepinephrine reuptake inhibitors (SNRIs) can increase the risk of sleep bruxism (Odds ratio [OR] 2.16; 95% confidence interval [CI] 1.12 to 4.17 and OR 2.28; 95% CI 1.34 to 3.86). The review’s authors identified medications that can potentially induce or aggravate sleep bruxism and/or awake bruxism (without comparing the risk potential) is provided in table 2. [2]

A 2018 systematic review of clinical case reports (n= 46 cases) involving antidepressant-induced bruxism identified fluoxetine (n= 12), sertraline (n= 7), and venlafaxine (n= 7) as the most commonly associated agents. Bruxism appeared three to four weeks after antidepressant initiation and resolved over a similar time period upon discontinuation. The most commonly reported successful interventions were the addition of buspirone 5 to 10 mg up to 3 times daily (n= 20), antidepressant discontinuation (n= 12), and dose reduction (n= 7). The review’s authors suggested a resolution may also be achieved using different agents such as tricyclic antidepressants (n= 1), antipsychotics (n= 3), bupropion (n= 1), or trazodone (n= 1). This review was limited to case reports only and may have found high instances of bruxism with fluoxetine and sertraline due to their wide use. [3]

Literature Review

A search of the published medical literature revealed 2 studies investigating the researchable question:

Are there preferred SSRIs or SNRIs that are documented as least likely to cause bruxism?

Level of evidence

C - Multiple studies with limitations or conflicting results Read more→

Please see Tables 1-2 for your response.

Antidepressant-Induced Sleep Bruxism: Prevalence, Incidence, and Related Factors
Design	Retrospective cross-sectional prevalence study N= 807
Objective	To investigate the prevalence of bruxism due to specific antidepressant treatment and the differences in the prevalence of bruxism between controls (not taking antidepressants) and patients taking antidepressants
Study Groups	Antidepressant group, treated with an antidepressant for at least the preceding 3 months (n= 506) Control group, not treated with antidepressants or other psychotropic drugs for at least the preceding 3 months (n= 301)
Inclusion Criteria	Patients using selective serotonin reuptake inhibitors; serotonin and norepinephrine reuptake inhibitors, and noradrenergic and specific serotonergic antidepressants
Exclusion Criteria	History of cerebrovascular disease; neurological disease (except tension headache); uncontrolled endocrine abnormalities; cardiovascular and pulmonary system disease; bipolar mood disorder; schizophrenia or other psychotic disorders; mental retardation, as well as participants using combination therapy with other antidepressants, antipsychotics, mood stabilizers, antiepileptics, or anxiolytics
Methods	The study sample was gathered from two hospitals in Turkey. The sample was divided into 2 groups: the antidepressant group (n= 506) and the control group (n= 301). Sleep bruxism was established with reports from the study participants on the basis of the International Classification of Sleep Disorders: Diagnosis and Coding Manual Second Edition.
Duration	September 2013 through June 2014
Outcome Measures	Frequency of bruxism
Baseline Characteristics		Antidepressant (n= 506)	Control (n= 301)	p-value
	Age, years	38.51 ± 11.78	38.31 ± 11.01	0.804
	Female	360 (71.1%)	206 (68.4%)	0.427
	University-level education	120 (23.7%)	59 (19.6%)	0.260
	Marital status of single	85 (16.8%)	48 (15.9%)	0.274
	Smoking	156 (30.8%)	102 (33.9%)	0.391
	No significant differences at baseline
Results	Drug	n	Prevalence of bruxism	Odd Ratio (95% CI); p-value
	Sertraline	88	14 (15.9%)	1.05 (0.55 to 2.01); 0.868
	Citalopram	25	4 (16.0%)	1.06 (0.35 to 3.22); 1.000
	Paroxetine	91	36 (39.6%)	3.63 (2.15 to 6.13); 0.000
	Fluoxetine	46	6 (13.0%)	0.83 (0.33 to 2.07); 0.826
	Escitalopram	80	12 (15.0%)	0.98 (0.49 to 1.95); 1.000
	Venlafaxine	103	30 (29.1%)	2.28 (1.34 to 3.86); 0.003
	Mirtazapine	16	5 (31.2%)	2.52 (0.84 to 7.59); 0.151
	Duloxetine	57	16 (28.1%)	2.16 (1.12 to 4.17); 0.034
	Approximately 58% of the patients with bruxism using antidepressants reported that bruxism emerged after the initiation of antidepressant medication. The mean onset time of antidepressant-induced bruxism was 2.85 months after starting therapy. Bruxism secondary to antidepressant use was most commonly reported by those receiving paroxetine (n= 23, 25.0%), venlafaxine (n= 22, 21.4%), and duloxetine (n= 11, 19.3%). Escitalopram (n= 4, 5.0%), sertraline (n= 5, 5.7%), fluoxetine (n= 3, 6.5%), and citalopram (n= 2, 8.0%) were less frequently associated with bruxism.
Adverse Events	N/A
Study Author Conclusions	Paroxetine, venlafaxine, and duloxetine were most likely to be associated with the development of bruxism. Clinicians should carefully question patients to ensure that they have no history of bruxism (to prevent aggravation of a pre-existing complaint) and should inform them of this adverse effect when prescribing antidepressants, particularly paroxetine and serotonin and norepinephrine reuptake inhibitors.
InpharmD Researcher Critique	The sample may not be representative of all patients taking antidepressants. Additionally, the cross-sectional design is a limitation although use of a control group adds strength to the design.

References:

Uca AU, Uğuz F, Kozak HH, et al. Antidepressant-Induced Sleep Bruxism: Prevalence, Incidence, and Related Factors. Clin Neuropharmacol. 2015;38(6):227-230. doi:10.1097/WNF.0000000000000108

List of Medications Potentially Inducing or Aggravating Bruxism
Class of medication	Type of bruxism
Selective serotonin reuptake inhibitors (SSRIs) Citalopram Dapoxetine Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Vilazodone	Sleep and awake
Serotonin-norepinephrine reuptake inhibitors (SNRIs) Duloxetine Venlafaxine	Sleep Sleep and awake

References:

Adapted from:
de Baat C, Verhoeff M, Ahlberg J, et al. Medications and addictive substances potentially inducing or attenuating sleep bruxism and/or awake bruxism. J Oral Rehabil. 2021;48(3):343-354.