Abstract
Stimulants-related bruxism has been previously reported; both diurnal and nocturnal. Here, authors report on a case of methylphenidate (MPH)-treated attention-deficit/hyperactivity disorder that developed nocturnal bruxism and failed multiple pharmacologic trials. Add-on clonidine has successfully helped with bruxisms while augmenting MPH response. This was achieved with great tolerability. This remains a viable option to deploy in such unusual clinical scenarios.
B
In child and adolescent psychiatric population, it has been reported with both stimulants (Mendhekar and Andrade 2008), atomoxetine (Yuce et al. 2013) and SSRIs as well (Sabuncuoglu et al. 2009).
Case Report
A 9-year-old Jordanian girl with a Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnosis of attention-deficit/hyperactivity disorder (ADHD)-combined presentation has been started on methylphenidate (MPH)-extended release osmotic-controlled release oral delivery system form 18 mg/day (0.6 mg/kg per day) after an 8-week trial of atomoxetine 40 mg/day (1.3 mg/kg per day) with poor response (American Psychiatric Association 2013). She showed early tangible behavioral response. On day 5, parents have reported audible teeth gnashing during sleep that has never been noticed before. With drug holidays on weekends, this totally dissipated. On resuming medications on weekdays, nocturnal bruxism reappeared. Dental evaluation was unrevealing. Sleep studies ruled out other parasomnias. No anxiety symptoms could be clinically elicited. Shifting her to immediate-release MPH 10 mg/day on two divided doses was not helpful mitigating bruxism and resulted ostensibly in behavioral decompensation. A trial of clonazepam 0.25 mg at night was prematurely aborted for oversedation and sialorrhea. A 3-week trial of buspirone was sorely futile and associated with bouts of agitation. Clonidine 75 μg qHS was then proposed. Two days later, bruxism entirely abated. Clonidine was well tolerated. The patient experienced no hemodynamic-related adverse effects. In addition, it helped with some evening rebound ADHD symptoms that were previously noticed by parents when medications tend to wear off. Twenty weeks have elapsed now at the time of writing of this report and the girl is faring very well as per parents' reports and in accordance with school reports spanning behavioral, academic, and social concomitants. Above all, bruxism has never been reported since then.
As this case illustrates, clonidine might be a viable option in cases of stimulant-related bruxism while augmenting behavioral/cognitive responses (through α 2A actions in prefrontal cortex) (Naguy 2016). Efficacy of clonidine for bruxism has been shown in an randomized controlled trial (Sakai et al. 2017). Some have contended bruxism to be a form of akathisia and hence the response to clonidine (Guaita and Hogl 2016).
It behooves clinicians to be vigilant to this unusual, yet bothersome, side effect of stimulants in ADHD that can cause enamel erosions and bed partner's insomnia and to consider clonidine as a potential therapeutic modality in such clinical scenarios.
Authors' Contribution
All authors have materially participated in the article preparation.
Footnotes
Disclosures
No competing financial interests exist.