Buspirone Effectiveness in treatment of SSRI induced Bruxism, a comprehensive systematic review

The aim of this paper is to do a systematic review using the PRISMA ow system about Buspirone role in treatment of induced bruxism by selective serotonin reuptake inhibitors SSRIs families. We did a comparison between patients with bruxism who received intervention by Buspirone and the controls of Buspirone intervention in a review. We included in the review the research articles including case reports and full text articles and excluded the systematic and literature reviews in purpose of having specic data about the topic. The databases were Pubmed and Google scholar.

We explored the available and recent research articles and systematic reviews, as well as the chapters and letters for SSRI and Bruxism relation including treatments interventions and we collected our databases according to our selected topic which is Buspirone relation to Bruxism. We chose Buspirone from the rest of the drugs because it is the most effective and the one with the most published literature.
We aim to add more useful reviews for researchers to collect better information about Buspirone and Bruxism.
A study summarizes the clinical features and treatment of antidepressant-associated bruxism and associated jaw pain through a systematic review of case reports [2]. 4 cases support the concept of buspirone acting as a full agonist at the presynaptic 5-HT somatodendritic receptors located on the cell bodies of raphe serotonergic neurons that project to the ventral tegmental area VTA of the midbrain [3].
Another study suggests an association between SSRI treatment and the onset or exacerbation of nocturnal bruxism. In addition, they suggest that a decrease in SSRI dosage or the addition of buspirone may relieve SSRI-associated NB [4]. The use of SSRIs might be associated with the occurrence of bruxism [5]. A review states that there is insu cient evidence based data to draw de nite conclusions concerning the effects of various drugs on bruxism [6]. Clinicians should be aware that the potential for paroxetineinduced bruxism exists and that buspirone may be an appropriate therapeutic intervention [7]. Many cases highlight that nocturnal bruxism can occur in response to any of the SSRIs, and that induction may be dose-dependent. They add to the literature suggesting that nocturnal bruxism can be treated with buspirone [8]. a study reports the case of a patient with severe OCD and SSRI-induced bruxism successfully treated with low-dose aripiprazole [9]. Purpose of one of the literature reviews 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 [10]. The case of antihistaminergic drugs which may induce bruxism as a consequence of their disinhibitory effect on the serotonergic system [11]. Another study highlights the importance of recognizing SSRI-induced bruxism and the possible related adverse dental side effects. Furthermore, this report supports the e cacy of a treatment strategy in adolescents, which has previously been reported only for adult patients [12]. One study reports cases of bruxism induced by high doses of escitalopram ( rst report of escitalopraminduced bruxism) and venlafaxine, who were treated by dose adjustment. Subsequently we discuss the need for buspirone in such cases [13]. Another study evaluates reported bruxism among children affected by attention de cit hyperactivity disorder (ADHD) [14]. Bruxism should be considered as a possible adverse effect of venlafaxine [15]. A study reports a case of duloxetine-induced bruxism in a patient with generalized anxiety disorder [16]. Fluoxetine and paroxetine, SSRIs used for the treatment of anxiety and depression, may initiate or aggravate SB. Clinicians should consider that SSRIs may be the cause of SB when SSRI users are referred to dental clinics for SB symptoms. As there is a shortage of research on this subject [17]. Another study presents 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 [18].
Effective treatment of social phobia SP may mitigate bruxism [19]. A study documents the successful monitoring of uoxetine-induced nocturnal bruxism in a healthy adult without a change in the patient's medication regimen [20].
A 61-year-old patient with major depression and selective serotonin reuptake inhibitor-induced bruxism was successfully treated with a course of bilateral electroconvulsive therapy. Both the depressive symptoms and bruxism completely remitted after six treatments. Possible mechanisms of this effect are discussed [21].
The collected studies explore the role of Buspirone in treatment of bruxism. A study used Buspirone in the intervention for one patient [23]. Another study used a group of medications (SSRI): temozolamide. Ldopa, gabapentin, clonazepam, clonidine, baclofen, buspirone, and propran-olol were not effective for bruxism. Mirtazapine 15 mg/ day was started and increased to 30 mg/day [24]. A case report for two patients detects symptoms of fear, headache, anxiety (something will happen to his mother) stomachache and diagnosis: separation anxiety disorder [25]. The primary Intervention: 15 mg/day uoxetine and the mother complained her son, the patient, grinds his teeth 1-2 h/night. Second intervention was uoxetine continued, added 5 mg Buspirone three times a day [25]. A study of one patient aging 7 years old had symptoms: fear of darkness, inattention, hyperactivity, di culty in concentration, fear of losing his mother and tooth grinding, no abnormal nocturnal movement [26]. Diagnosis was ADHD and SAD. Intervention was 5mg/d single dose Buspirone [26]. Another study of a patient also had 7 years old had symptoms of severe bruxism, mostly diurnal, previously diagnosed PDD NOS, born prematurely, complex medical history ( born THC+, developed necrotizing entérocolites, chronic lung disease, unspeci ed metabolic disease, asthma, GERD, short intestine syndrome, cirrhosis, portal hypertension [27]. Intervention was 1.5 mg buspirone daily for a week then 2.5 mg x2 daily. 5mg x3 daily showed improvement, later given melatonin to treat insomnia caused by Buspirone 6mg daily [27]. Another study of a patient aging 6 years old had symptoms of lack of attention, lack of concentration, getting bored with activities quickly, failure in school, and behavioral problems. Medication was atomoxetine 10 mg/day,increased to 18 mg/day. Later on to 40 mg/day (at 40 mg nocturnal bruxism started) following discontinuation of atomoxetine, bruxism stopped, after continuation of atomoxetine bruxism reappeared, later started on 5 mg Buspirone [28].  [29]. Another study of a patient of 28 years old received Meds: Paroxetine 10 mg/d increased to 20 mg/d (dentist noted signs of bruxism 4 months after treatment) started on 5 mg/d Buspirone [30]. A study of a patient aging 6 years old and sex was female, had Seperation Anxiety Disorder. Medication used was: Fluoxetine 7.5 mg/d resulted in nocturnal bruxism, treated with Buspirone 5 mg/d, uoxetine increased to 10 mg/d and then to 30 mg/d [31].
Another study conducted using intervention of buspirone on four patients [32]. A study done on one patient aging 15 years old. The used medications were: uoxetine 20 mg/d. Symptoms after intervention were severe bruxism and intervention was Buspirone 10 mg/night added [33]. Symptoms: severe headaches, anhedonia, feeling of worthlessness and sadness, inability to concentrate. Diagnosis was depressive mood, muscle contraction headaches. Medications used were paroxetine 10 mg/nightly, doubled after 7 days. Side effects were severe nocturnal bruxism. Treatment used was 5 mg/nightly Buspirone [34]. Diagnosis of another patient was Generalized Anxiety Disorder. Medications used were started on 60 mg/d Duloxetine (started experiencing onsets of bruxism so dosage was reduced to 30 mg/d),Duloxetine stopped, patient then started on 5 mg/d Buspirone, increased to 20 mg/d [35]. Case 1: age: 29, sex: female, Diagnosis: type 2 bipolar disorder. Previous meds: couldn't tolerate steratline. paroxetine induced bruxism and tinnitus. Mood lability stabilized with valproic acid. Venlafaxine 37.5 mg/d for a week, increased to 75 mg/ x2 a day. (After two weeks of 75 mg x2 a day she started experiencing bruxism symptoms) Started on 10 mg/d Buspirone, increased to 30 mg/ x2 a day and Vena axine adjusted to 75 mg/d. Case 2: age: 36, sex: female, diagnosis: major depressive disorder, panic disorder. Previous meds: Phenelzine 75 mg/d. Another patient reported symptoms of this period when she was being titrated with phenel-zine, she developed akathisia in addition to other complications such as anticholinergic toxicity (confusion, ataxia, urinary re-tention, and blurry vision) and orthostatic hypotension, started on Buspirone 10 mg/d [36]. Meds: venlafaxine 37.5 mg/d titrated up to 150 mg/d. Patient reported severe nocturnal bruxism after a week. (Patient previously reported bruxism on escitalopram and uoxetine) Clonazepam 2 mg/d started and no relief in bruxism. Buspirone started 10 mg/d then increased to 20 mg/d [37].
Other patients received medications: antidepressant dosage n=1, Buspirone n=3. Patients developed nocturnal bruxism in 2 to 4 weeks after starting treatment with uoxetine and sertraline [38]. Another patient received atomoxetine 10 mg/d. Onsets of bruxism began in 4 weeks, and started Buspirone 10 mg/d and showed signi cant improvement [39].

Methods:
We selected the systematic review type of reviews to answer a question we proposed about bruxism and SSRI. The proposed question is: We made an inclusion and exclusion criteria for the systematic review. We searched using the terms "Buspirone and Bruxism" in the databases' search engine. The inclusion criteria were research articles and case reports. We decided the exclusion criteria to be the books, chapters, reviews, and letters to the editors.

Study selection:
We used the PRISMA ow chart system by generating a chart on the PRISMA ow chart generator [22]. We searched using the terms Buspirone and Bruxism in the database Pubmed and Google Scholar. A total of 68 citations were obtained: 23 citations in PubMed and 45 citations in Google Scholar. The inclusion criteria applied were research articles and case reports, while the exclusion criteria were reviews, letters to the editor, books, and chapters. A total of 44 articles were excluded after the rst screening: title and abstract reading. A total of 7 articles were excluded after the second screening: full text reading and data extraction. The included papers were 17 papers.
Charting the data: Results: The data of the collected papers are represented in a Conclusions: After doing the study and ltering the results according to our proposed question and the collected papers and previous research, we found a the following conclusions:-

Declarations
We declare that the data used and authorship is ethically approved by the board ethical research guidelines.

Con ict of interest:
There is no con ict of interests.

Figure 1
Buspirone and Bruxism PRISMA Flow Chart.