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Research Article
Specific Central Nervous System Medications Are Associated
with Temporomandibular Joint Symptoms
John K. Drisdale III, Monica G. Thornhill, and Alexandre R. Vieira
Department of Oral Biology, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, USA
Correspondence should be addressed to Alexandre R. Vieira; arv@pitt.edu
Received 23 February 2017; Accepted 24 May 2017; Published 16 July 2017
Academic Editor: Manal Awad
Copyright © John K. Drisdale III et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Aims. ere is evidence of association between bruxism and the increasingly common central nervous system stimulants prescribed
for attention decit hyperactivity disorder (ADHD), as well as the selective serotonin reuptake inhibitors (SSRIs) oen prescribed
for depression or anxiety. However, the evidence is not clear on whether these medications inducing bruxism are directly associated
with temporomandibular joint disorder (TMD). e aim of this work is to evaluate whether these medications are associated
with TMD symptoms. Methods. Medical history and participant data were obtained for patients from the University of
Pittsburgh School of Dental Medicine, Dental Registry and DNA Repository, dating back to . e chi-square test was used
to determine any statistically signicant associations. Results. ere were no statistically signicant associations between ADHD
stimulant medications or SSRIs and reported TMD symptoms. However, there were signicant dierences seen between specic
brands of medications and reported TMD symptoms. Individuals prescribed methylphenidate (Concerta) were less likely to report
temporomandibular joint discomfort (𝑝 = 0.01). Conversely, individuals prescribed citalopram (Celexa) were more likely to report
temporomandibular joint discomfort (𝑝 = 0.04). Conclusion. Signs and symptoms of temporomandibular joint dysfunction may
be inuenced by the use of certain medications prescribed for depression or attention decit hyperactive disorder.
1. Introduction
As of , more than . million Americans were prescribed
stimulant medications to treat attention decit hyperactivity
disorder (ADHD) []. One out of ten Americans above the age
of are prescribed antidepressants, selective serotonin reup-
take inhibitors (SSRIs) being the most common []. Central
nervous system- (CNS-) stimulant ADHD medications have
been associated with side eects such as bruxism [] that can
possibly cause TMD-like symptoms []. With the increasing
use of stimulant ADHD medications, it is important to see if
there is a relationship between these prescribed medications
and TMD symptoms [].
TMD can manifest in a variety of symptoms including
pain or tenderness in the face muscles or jaw joint, a limited
range of motion of the jaw, popping and clicking of the jaw,
and headaches []. In addition to the adverse symptoms of
TMD, treatment can oen be extensive as well as expensive.
TMD symptoms are also more commonly seen in the
female population. Of concern could be the recent increase in
use of stimulant ADHD medications in women aged to
[]. e inherent predisposition to TMD symptoms in women
combined with an increased use of ADHD medications
could possibly put this patient population at an increased
risk for developing TMD symptoms. Given this information,
we hypothesize that there is an association between ADHD
medications, as well as SSRIs, and the frequency of reported
TMD symptoms.
2. Subjects and Methods
All subjects in this study were participants in the Dental
Registry and DNA Repository of the University of Pittsburgh
School of Dental Medicine [–]. All participants sought
treatment at the University of Pittsburgh School of Dental
Medicine dating back to September . In April , data
from , individuals were queried from the registry and
repository for this study and individuals taking ADHD
and SSRI medications were selected for this study. erecords
Hindawi
International Journal of Dentistry
Volume 2017, Article ID 1026834, 5 pages
https://doi.org/10.1155/2017/1026834
International Journal of Dentistry
T : Comparison of the type of ADHD medication by the presence of TMD symptoms. e results show that Concerta is the ADHD
medication that is signicantly dierent compared to the rest.
TMD diagnosis Total
No discomfort Positive for discomfort
Type o f ADH D medi cation
None
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual −. .
Adderall
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual −. .
Concerta
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual . −2.7
Ritalin
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual . −.
Vy va ns e
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual . −.
Adderall and Vyvanse
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual . −.
Concerta and Ritalin
Count
Expected count . . .
% within type of medication .% .% .%
Adjusted residual . −.
Total
Count
Expected count . . .
% within type of medication .% .% .%
Bold highlights the highest adjusted residual.
of these individuals were evaluated to determine if they had
any TMD symptoms (pain or discomfort, cracking or clicking
when opening the mouth).
Chi-square tests were used to determine associations
between being prescribed any stimulant ADHD or SSRI
medications and TMD symptoms. e same was performed
for subjects prescribed any SSRI medication in search of a
signicant association between SSRIs and TMD symptoms.
We used the likelihood ratio for comparisons when we
violated the assumption of minimum expected cell count to
be used for Pearson’s chi-square. Alpha was established at %.
Standardized residuals were then compared to determine
which medication in each category was responsible for a
signicantly dierent report rate of TMD symptoms.
International Journal of Dentistry
T : Comparison of the type of SSRI medication by the presence of TMD symptoms. e results show that Celexa is the SSRI that is
signicantly dierent compared to the rest.
TMD diagnosis Total
No discomfort Positive for discomfort
Type o f SSR I
None
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual . −.
Celexa
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual −2.4.
Lexapro
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual −. .
Prozac
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual . −.
Luvox
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual . −.
Paxil
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual −. .
Zolo
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual −. .
Lexapro and Zolo
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual −. .
Lexapro and Prozac
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual . −.
International Journal of Dentistry
T : C on t i nued.
TMD diagnosis Total
No discomfort Positive for discomfort
Lexapro and Paxil
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual −. .
Celexa and Zolo
Count
Expected count . . .
% within type of SSRI .% .% .%
Adjusted residual . −.
Total
Count
Expected count . . .
% within type of SSRI .% .% .%
Bold highlights the highest adjusted residual.
3. Results
e mean age of the participants was years, with %
of participants identifying as male (𝑁 = 179)and%female
(𝑁 = 290). Furthermore, the majority of participants were
White (𝑁 = 394; %). e remaining % were comprised
of Black individuals (𝑁=52), Hispanics (𝑁=6), and other
groups (𝑁=17).
ere was a trend, albeit not statistically signicant, for
being prescribed ADHD medication and reporting TMD
symptoms (𝑝 = 0.065). Likewise, there was no signi-
cant association between taking SSRIs and reporting TMD
symptoms (𝑝 = 0.12). We found dierences in occurrence
of reported TMD symptoms between the dierent ADHD
stimulant medications (𝑝 = 0.04, six degrees of freedom).
e likelihood ratio of . suggested that there is at least one
medication that is statistically signicant among the others
in regard to reported TMD symptoms. Further testing by
means of nding the expected counts and adjusted residuals
for each ADHD medication determined that Concerta was
the statistically signicant medication when compared to the
others (Table ). Additionally, taking the observed counts
versus the expected counts in Table into consideration also
depicts that subjects prescribed Concerta are less likely to
reportTMDsymptomsthansubjectsprescribedanyother
ADHD stimulant. ere were no dierences based on sex or
ethnic background (data not shown).
Similarly, the group of SSRIs also showed that there is a
medication with a signicant dierence in regard to reported
TMD symptoms (𝑝 = 0.075, degrees of freedom); thus
the likelihood ratio is of .. Celexa showed a dierence
in expected reporting of TMD symptoms when compared to
the other SSRIs (Table ). Additionally, taking the observed
counts versus the expected counts in Table into consider-
ation also depicts that subjects prescribed Celexa are more
likelytoreportTMDsymptomsthansubjectsprescribedany
other SSRI. ere were no dierences based on sex or ethnic
background (data not shown).
Being prescribed both an ADHD medication and SSRI
showed a trend, albeit not statistically signicant, for report-
ing TMD symptoms (𝑝 = 0.074).
4. Discussion
e results show that there is no formal signicant dier-
ence in TMD symptoms between those that are prescribed
ADHD medications and those that are not prescribed ADHD
medications. is same statement also holds true for subjects
prescribed SSRIs and those not prescribed SSRIs. However,
theredoesseemtobeasignicantdierencebetween the dif-
ferent medications prescribed. Our data shows that subjects
prescribed Concerta for ADHD are less likely to report TMD
symptoms when compared to subjects taking other ADHD
medications. It is also important to consider that our data
shows that subjects taking the SSRI Celexa are more likely to
report experiencing TMD symptoms than those prescribed
an SSRI other than Celexa.
is could be clinically important when treating patients
who are already at an increased risk for TMD. According to
numerous studies, including the National Institute of Dental
andCraniofacialResearch,womenareathigherriskthan
are men for developing TMD symptoms []. Since TMD is
a multifactorial disorder [], it may be wise to limit the
number of contributing factors targeted for intervention. For
example, a patient that is already predisposed to TMD may
benet from being prescribed Concerta versus other ADHD
stimulants due to Concerta’s lower frequency of reported
TMD symptoms. Similarly, the same patient population that
requires a SSRI prescription may benet from a SSRI other
than Celexa. Understanding better the contributing factors
to this multifactorial disorder could prove benecial to the
patient’s health and ultimately their quality of life.
In summary, we report here for the rst time that specic
ADNH and SSRI drugs may impact risks for developing
TMD.
International Journal of Dentistry
Conflicts of Interest
eauthorshavenoconictsofinteresttodeclare.
Acknowledgments
e authors thank the individuals that enthusiastically partic-
ipated in this study. e Dental Registry and DNA Repository
project is supported by theUniversity of Pittsburgh School of
Dental Medicine.
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