Prevalence and associated factors to sleep bruxism in adolescents from Teresina, Piauí

Heloísa Clara Santos Sousa Marina de Deus Moura de Lima Neusa Barros Dantas Neta Raissa Quaresma Tobias Marcoeli Silva de Moura Lúcia de Fátima Almeida de Deus Moura About the authors

ABSTRACT:

Introduction:

Sleep bruxism (SB) is defined as a repetitive jaw muscle activity whose epidemiology in adolescents has been little studied. This cross-sectional study aimed to determine the prevalence of sleep bruxism and associated factors in adolescents.

Methodology:

The sample consisted of 594 students aged 11 to 14 years old from Teresina, Piauí, Brazil. Self-administered questionnaire was answered by parents/caregivers and dental clinical examination was performed. Pearson’s chi-squared test was used to assess the association between SB and independent variables. Poisson regression analysis with robust variance was applied, with results expressed in prevalence ratio (PR).

Results:

The prevalence of SB in adolescents was 22.2%. Multivariate analysis showed a higher prevalence of SB in male gender adolescents (PR = 1.41; 95%CI 1.04 - 1.89), presenting snoring (PR = 1.39; 95%CI 1.02 - 1.89) and difficulty falling asleep (PR = 1.92; 95%CI 1.38 - 2.66).

Conclusion:

SB is a frequent condition in adolescents, and the factors associated with its prevalence were: male sex, snoring and difficulty falling asleep.

Keywords:
Sleep bruxism; Epidemiology; Prevalence; Risk factors; Adolescent

INTRODUCTION

Sleep bruxism (SB) is a repetitive activity of the mandibular musculature, characterized by supporting or pushing the jaw, tightening or grinding the teeth during sleep11. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013; 40(1): 2-4. DOI: 10.1111/joor.12011
https://doi.org/10.1111/joor.12011...
. The condition has been associated with injuries to orofacial structures and negative impact on the quality of life of schoolchildren22. Hoz-Aizpurua JL, Díaz-Alonso E, Touche-Arbizu R, Mesa-Jiménez J. Sleep bruxism. Conceptual review and update. Med Oral Patol Oral Cir Bucal 2011; 16(2): e231-8. DOI: 10.4317/medoral.16.e231
https://doi.org/10.4317/medoral.16.e231...
,33. Aguilera AB, Lopez LG, Aguilera EB, Aizpurua JL, Torronteras AR, Saint-Gerons RS, et al. Relationship between self-reported sleep bruxism and pain in patients with temporomandibular disorders. J Oral Rehabil 2014; 41(8): 564-72. DOI: 10.1111/joor.12172
https://doi.org/10.1111/joor.12172...
,44. Carvalho AM, Lima MD, Silva JM, Neta NB, Moura LF. Bruxism and quality of life in schoolchildren aged 11 to 14. Cien Saude Colet 2015; 20(11): 3385-93. DOI: 10.1590/1413-812320152011.20772014
https://doi.org/10.1590/1413-81232015201...
. The prevalence of SB presents variable percentages in the different age groups55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
and there is little information about their epidemiology in adolescents66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
.

Most epidemiological studies on SB are performed with schoolchildren66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
,77. Serra-Negra JM, Ramos-Jorge ML, Flores-Mendoza CE, Paiva SM, Pordeus IA. Influence of psychosocial factors on the development of sleep bruxism among children. Int J Paediatr Dent 2009; 19(5): 309-17. DOI: 10.1111/j.1365-263X.2009.00973.x
https://doi.org/10.1111/j.1365-263X.2009...
,88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
,99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
,1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50., and the diagnosis is based on reports from family members describing characteristic sounds generated by grinding teeth during sleep77. Serra-Negra JM, Ramos-Jorge ML, Flores-Mendoza CE, Paiva SM, Pordeus IA. Influence of psychosocial factors on the development of sleep bruxism among children. Int J Paediatr Dent 2009; 19(5): 309-17. DOI: 10.1111/j.1365-263X.2009.00973.x
https://doi.org/10.1111/j.1365-263X.2009...
,88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
,99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
. Polysomnographic examinations are considered gold standard for diagnosis, but their use in population studies is still not feasible due to the high cost and the need for qualified professionals to perform the procedures11. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013; 40(1): 2-4. DOI: 10.1111/joor.12011
https://doi.org/10.1111/joor.12011...
,1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50.,1313. Raphael KG, Janal MN, Sirois DA, Dubrovsky B, Klausner JJ, Krieger AC, et al. Validity of self-reported sleep bruxism among myofascial temporomandibular disorder patients and controls. J Oral Reahabil 2015; 42(10): 751-8. DOI: 10.1111/joor.12310
https://doi.org/10.1111/joor.12310...
.

The search for factors associated with SB has been guiding the knowledge of possible predictors of the condition in different age groups1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
,1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50.,1414. Alajbeg IZ, Zuvela A, Tarle Z. Risk factors for bruxism among Croatian navy employees. J Oral Rehabil 2012; 39(9): 668-76. DOI: 10.1111/j.1365-2842.2012.02313.x
https://doi.org/10.1111/j.1365-2842.2012...
,1515. Castroflorio T, Bargellini A, Rossini G, Cugliari G, Rainoldi A, Deregibus A. Risk factors related to sleep bruxism in children: a systematic literature review. Arch Oral Biol 2015; 60(11): 1618-24. DOI: 10.1016/j.archoralbio.2015.08.014
https://doi.org/10.1016/j.archoralbio.20...
. Pathophysiological and genetic agents were suggested as possible factors associated with SB. However, psychosocial agents have received increasing attention1616. Lobbezoo F, Ahlberg J, Manfredini D, Winocur E. Are bruxism and the bite causally related? J Oral Rehabil 2012; 39(7): 489-501. DOI: 10.1111/j.1365-2842.2012.02298.x
https://doi.org/10.1111/j.1365-2842.2012...
,1717. Murali RV, Rangarajan P, Mounissamy A. Bruxism: conceptual discussion and rewiew. J Pharm Bioallied Sci 2015; 7(1): S265-70. DOI: 10.4103/0975-7406.155948
https://doi.org/10.4103/0975-7406.155948...
,1818. Manfredini D, Ahlberg J, Winocur E, Lobbezoo F. Management of sleep bruxism in adults: a qualitative systematic literature review. J Oral Rehabil 2015; 42(11): 862-74. DOI: 10.1111/joor.12322
https://doi.org/10.1111/joor.12322...
. Few factors associated with SB in adolescents are known; among them: temporomandibular joint sounds and stress66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
.

The objective of this study was to determine the prevalence of SB and associated factors in adolescents from Teresina, Piauí.

METHODOLOGY

ETHICAL ASPECTS

This is a cross-sectional observational study carried out after approval by the Research Ethics Committee, Protocol no. 508.040/CAAE 03362112.1.0000.5214, from Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brazil, conducted in accordance to Resolution 466/12 of the National Health Council.

SAMPLE

The study population was composed of adolescents aged between 11 and 14 years, enrolled in public and private schools in the city - which, according to data from the Municipal Education Department of Teresina, in 2011, accounted for 54,056 students.

The type of sampling adopted was complex conglomerates, with proportional allocation at each stage. The first stage consisted of areas of the city (20.8% north, 21.0% south, 17.0% southeast, 21.6% east and 19.6% downtown). The second stage, by the school models (25.9% private, 27.0% of the state public network and 47.1% of the municipal public network). The first sampling unit was defined by the schools; the second, by classes; and the third, by the students.

To calculate the sample size, a prevalence of 35.3% (~ 36.0%)88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
, with a 95% confidence interval (95%CI) and a 4% error margin, was considered. Because this is a multi-stage sample, the effect of the design was corrected by a factor of 1.5 (deff). For the sample calculation, the Epi InfoTM (version 3.5.2; Centers for Disease Control and Prevention, Atlanta, GA, USA) was used. The calculation was obtained by the following Equation 1:

n=deff2pqNɛ2N+ 2pq(1)

In which

n is the sample that was calculated,

is the confidence level,

pq is the variance of the occurring phenomenon,

N is the population,

ε is the sample error.

From this formula, a sample size of 524 adolescents was obtained and 20% was added to compensate eventual losses, totaling 629 individuals asked to participate in the study.

A random sorting of the schools, classes and schoolchildren was carried out according to the city zones and the type of institution, as described in Table 1. The individuals that were present on the day of data collection were included in the study and, together with the parents/guardians, authorized the participation.

Table 1:
Number of adolescents to be analyzed, distribution by school networks and location zone.

CALIBRATION

For the standardization of the diagnosis of tooth wear, clinical examiner training was carried out by teachers at the UFPI Children’s Dental Clinic, who were experienced in epidemiological studies. Twenty adolescents who did not participate in the study were examined for intra-examiner agreement, obtaining a kappa value of 0.9. To this end, the subjects were examined twice, with an interval of two weeks.

PILOT STUDY

Before data collection, a pilot study was conducted with 52 adolescents from schools that did not participate in the sample, in order to evaluate the methods. There was no need to make changes to the methodology initially proposed.

DATA COLLECTION

Data collection was carried out from September to November 2013. Prior authorization was requested from the directors of the school units selected for the research. The principals sent a letter to the adolescents’ parents informing them that their children had been selected to participate in the study. The terms of consent and the parents’ questionnaire were attached to the letters.

As there was no questionnaire validated on the subject studied, the questionnaire addressed to parents was prepared based on the literature11. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013; 40(1): 2-4. DOI: 10.1111/joor.12011
https://doi.org/10.1111/joor.12011...
,55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
,66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
,77. Serra-Negra JM, Ramos-Jorge ML, Flores-Mendoza CE, Paiva SM, Pordeus IA. Influence of psychosocial factors on the development of sleep bruxism among children. Int J Paediatr Dent 2009; 19(5): 309-17. DOI: 10.1111/j.1365-263X.2009.00973.x
https://doi.org/10.1111/j.1365-263X.2009...
,88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
,99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
,1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50.,1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
,1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
,2020. Miamoto CB, Pereira LJ, Ramos-Jorge ML, Marques LS. Prevalence and predictive factors of sleep bruxism in children with and without cognitive impairment. Braz Oral Res 2011; 25(5): 439-45. DOI: 10.1590/S1806-83242011000500011
https://doi.org/10.1590/S1806-8324201100...
,2121. Sutin AR, Terracciano A, Ferrucci L, Costa-Junior PT. Teeth grinding: is emotional stability related to bruxism? J Res Pers 2010; 44(3): 402-5. DOI: 10.1016/j.jrp.2010.03.006
https://doi.org/10.1016/j.jrp.2010.03.00...
,2222. Ahlberg J, Lobbezoo F, Ahlberg K, Manfredini D, Hublin C, Sinisalo J, et al. Self-reported bruxism mirrors anxiety and stress in adults. Med Oral Patol Oral Cir Bucal 2013; 18(1): e7-11. DOI: 10.4317/medoral.18232
https://doi.org/10.4317/medoral.18232...
. The questions addressed socioeconomic conditions, demographic data and possible factors associated with the presence of SB. The socioeconomic and demographic questions investigated included gender99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
, age99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
, age, type of school (public or private), family income (categorized based on the Brazilian monthly minimum wage at the time of the interview, equivalent to BRL 678.00)88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
, maternal schooling (years of formal study) and marital status of the parents88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
,1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
.

The diagnosis of bruxism was based on the affirmative report of the parents about the grinding of teeth during sleep11. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013; 40(1): 2-4. DOI: 10.1111/joor.12011
https://doi.org/10.1111/joor.12011...
,66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
,77. Serra-Negra JM, Ramos-Jorge ML, Flores-Mendoza CE, Paiva SM, Pordeus IA. Influence of psychosocial factors on the development of sleep bruxism among children. Int J Paediatr Dent 2009; 19(5): 309-17. DOI: 10.1111/j.1365-263X.2009.00973.x
https://doi.org/10.1111/j.1365-263X.2009...
,88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
,99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
,1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
. Information on the presence of snoring99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
-1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
,1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
, headaches upon awakening1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
, deleterious oral habits (onicophagy, digital sucking, biting objects or other habits)1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50.,2020. Miamoto CB, Pereira LJ, Ramos-Jorge ML, Marques LS. Prevalence and predictive factors of sleep bruxism in children with and without cognitive impairment. Braz Oral Res 2011; 25(5): 439-45. DOI: 10.1590/S1806-83242011000500011
https://doi.org/10.1590/S1806-8324201100...
, general health problems (gastrointestinal, neurological/psychological, cardiac, respiratory, parasitic or other)55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
,99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
,2121. Sutin AR, Terracciano A, Ferrucci L, Costa-Junior PT. Teeth grinding: is emotional stability related to bruxism? J Res Pers 2010; 44(3): 402-5. DOI: 10.1016/j.jrp.2010.03.006
https://doi.org/10.1016/j.jrp.2010.03.00...
, difficulty sleeping99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
-1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
and parents’ perception of the presence of anxious behavior or not55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
,2121. Sutin AR, Terracciano A, Ferrucci L, Costa-Junior PT. Teeth grinding: is emotional stability related to bruxism? J Res Pers 2010; 44(3): 402-5. DOI: 10.1016/j.jrp.2010.03.006
https://doi.org/10.1016/j.jrp.2010.03.00...
-2222. Ahlberg J, Lobbezoo F, Ahlberg K, Manfredini D, Hublin C, Sinisalo J, et al. Self-reported bruxism mirrors anxiety and stress in adults. Med Oral Patol Oral Cir Bucal 2013; 18(1): e7-11. DOI: 10.4317/medoral.18232
https://doi.org/10.4317/medoral.18232...
.

The adolescents were examined in the school under artificial light (Pelican Startec model table lamp, 127 V) by a single examiner, who used sterilized cotton rollers, flat mouth mirror (Golgran®, São Paulo, Brazil) and exploratory probe (Golgran®, São Paulo, Brazil) recommended by the World Health Organization (WHO)2323. World Health Organization (WHO). Oral health surveys: basics methods. . Geneva: WHO; 1997.. The teenagers sat in a school chair, their heads positioned on the examiner’s lap. In the clinical examination, dental abrasions were evaluated2424. American Academy of Sleep Medicine (AASM). International Classification of sleep disorders. 2nd edition. Westchester: American Academy of Sleep Medicine; 2005., in which the presence of bright and polished facets on permanent incisors and/or molars (palatal surface, incisal edges and functional cusps) was verified2020. Miamoto CB, Pereira LJ, Ramos-Jorge ML, Marques LS. Prevalence and predictive factors of sleep bruxism in children with and without cognitive impairment. Braz Oral Res 2011; 25(5): 439-45. DOI: 10.1590/S1806-83242011000500011
https://doi.org/10.1590/S1806-8324201100...
,2424. American Academy of Sleep Medicine (AASM). International Classification of sleep disorders. 2nd edition. Westchester: American Academy of Sleep Medicine; 2005.. The data were annotated in an individual form.

DATA ANALYSIS

The data were scanned and analyzed in the Statistical Package for the Social Sciences® (SPSS) software version 18.0 for Windows. Pearson’s chi-squared test was applied to verify the association between the presence of SB and the independent variables. Poisson regression analysis with robust variance associated socioeconomic and clinical variables with a higher prevalence of SB. P-values ≤ 0.05, with 95%CI were considered statistically significant. In the multivariate analysis, a Backward Stepwise process was used. Variables with p ≤ 0.20 in the bivariate analysis were included in the model. The results were expressed in prevalence ratio (PR), measure of effect for prevalence studies.

RESULTS

A total of 594 (94.4%) of the 629 adolescents selected were included in the final sample. The prevalence of SB was 22.2%. The majority of the adolescents were females (63.1%), public school students (74.1%), with a family income below the current minimum wage (55.2%). Wear was observed in 579 teeth (76.6% in incisors and 9% in molars) of 80.64% of the adolescents examined.

The distribution of independent variables associated with SB is described in Table 2. Positive association was observed in the bivariate analysis between SB and gender, age, anxious behavior, morning headache, snoring and sleep quality (p < 0.05).

Table 2:
Distribution of independent variables associated with sleep bruxism (n = 594).

The PRs obtained in the multivariate analysis of the variables associated to SB are presented in Table 3. Males (PR = 1.41; 95%CI 1.04 - 1.89), snoring (PR = 1.39; 95%CI 1.02 - 1.89) and sleep difficulties (PR = 1.92; 95%CI 1.38 - 2.66) were associated with a higher prevalence of SB in the final model.

Table 3:
Crude and adjusted prevalence ratio of variables associated with sleep bruxism (n = 594).

DISCUSSION

The present study contributes to the current state of knowledge by pointing out prevalence and factors associated with SB in an age group in which evidence is limited.

SB is a frequent condition in adolescents in Teresina, and the prevalence of SB found was higher than that reported for youngsters from another age group66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
and for adults2525. Manfredini D, Winocur E, Guarda-Nardini L, Paesani D, Lobbezoo F. Epidemiology of bruxism in adults: a systematic review of the literature. J Orofac Pain 2013; 27(2): 99-110. DOI: 10.11607/jop.921
https://doi.org/10.11607/jop.921...
, still lower than that reported for Brazilian children88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
, although the prevalence reported in children is variable55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
,2626. Manfredini D, Restrepo C, Diaz-Serrano K, Winocur E, Lobbezoo F. Prevalence of sleep bruxism in children: a systematic review of the literature. J Oral Rehab 2013; 40(8): 631-42. DOI: 10.1111/joor.12069
https://doi.org/10.1111/joor.12069...
. Studies have mentioned that the prevalence of SB decreases with age99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,2525. Manfredini D, Winocur E, Guarda-Nardini L, Paesani D, Lobbezoo F. Epidemiology of bruxism in adults: a systematic review of the literature. J Orofac Pain 2013; 27(2): 99-110. DOI: 10.11607/jop.921
https://doi.org/10.11607/jop.921...
,2626. Manfredini D, Restrepo C, Diaz-Serrano K, Winocur E, Lobbezoo F. Prevalence of sleep bruxism in children: a systematic review of the literature. J Oral Rehab 2013; 40(8): 631-42. DOI: 10.1111/joor.12069
https://doi.org/10.1111/joor.12069...
.

In population-based studies, it is possible that the prevalence is underestimated, because the diagnosis is made through the reports of parents, who do not always sleep in the same space as the individuals investigated1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50.. This is a limitation to be considered when interpreting the results. The comparison between prevalence studies is also hampered by the use of different ages within the age groups, diagnostic methods and non-specification of the form of bruxism - sleep or daytime11. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013; 40(1): 2-4. DOI: 10.1111/joor.12011
https://doi.org/10.1111/joor.12011...
,1111. Vieira-Andrade RG, Drumond CL, Martins-Junior PA, Corrêa-Faria P, Gonzaga GC, Marques LS, et al. Prevalence of sleep bruxism and associated factors in preschool children. Pediatr Dent 2014; 36(1): 46-50..

The present study observed that boys present a higher prevalence of SB than girls, a result that corroborates those presented by Renner et al.1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
, Lam et al.99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
and Kato et al.2727. Kato T, Velly AM, Nakane T, Matsuda Y, Maki S. Age is associated with self-reported sleep bruxism, independently of tooth loss. Sleep Breath 2012; 16(4): 1159-65. DOI: 10.1007/s11325-011-0625-7
https://doi.org/10.1007/s11325-011-0625-...
. However, it disagrees with the observation of Serra Negra et al.88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
, who conducted a study with a different age group. The prevalence of SB in males may represent a characteristic of SB distribution in this age group, and may be related to the fact that boys are more agitated and, in general, motivated to contain their emotions, which would favor the occurrence of involuntary movements1212. Renner AC, Silva AA, Rodriguez JD, Simões VM, Barbieri MA, Bettiol H, et al. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2012; 40(3): 277-87. DOI: 10.1111/j.1600-0528.2011.00644.x
https://doi.org/10.1111/j.1600-0528.2011...
.

In the current study, SB was associated with the adolescent’s age, as in another study2727. Kato T, Velly AM, Nakane T, Matsuda Y, Maki S. Age is associated with self-reported sleep bruxism, independently of tooth loss. Sleep Breath 2012; 16(4): 1159-65. DOI: 10.1007/s11325-011-0625-7
https://doi.org/10.1007/s11325-011-0625-...
. Investigations are still needed to explain the mechanism involved2727. Kato T, Velly AM, Nakane T, Matsuda Y, Maki S. Age is associated with self-reported sleep bruxism, independently of tooth loss. Sleep Breath 2012; 16(4): 1159-65. DOI: 10.1007/s11325-011-0625-7
https://doi.org/10.1007/s11325-011-0625-...
. Carra et al.1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
verified a lower SB frequency in individuals older than 12 years, which was not verified in the present study. However, they mentioned that the observation may be related to the fact that the parents visit their children in their room less frequently after reaching that age, influencing the reports1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
.

Frequent psychosocial factors in adolescence, such as stress, anxiety, depression, neuroticism, hyperactivity, mental and emotional health problems have been associated with the presence of SB55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
,66. Emodi Perlman A, Lobbezoo F, Zar A, Rubin PF, Van Selms MK, Winocur E. Self-Reported bruxism and associated factors in israeli adolescents. J Oral Rehabil 2016; 43(6): 443-50. DOI: 10.1111/joor.12391
https://doi.org/10.1111/joor.12391...
,88. Serra-Negra JM, Paiva SM, Seabra AP, Dorella C, Lemos BF, Pordeus IA. Prevalence of sleep bruxism in a group of Brazilian schoolchildren. Eur Arch Paediatr Dent 2010; 11(4): 192-5. DOI: 10.1007/BF03262743
https://doi.org/10.1007/BF03262743...
,99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
. In this and other studies, anxiety was associated55. Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod 2014; 19(6): 54-61. DOI: 10.1590/2176-9451.19.6.054-061.oar
https://doi.org/10.1590/2176-9451.19.6.0...
,2121. Sutin AR, Terracciano A, Ferrucci L, Costa-Junior PT. Teeth grinding: is emotional stability related to bruxism? J Res Pers 2010; 44(3): 402-5. DOI: 10.1016/j.jrp.2010.03.006
https://doi.org/10.1016/j.jrp.2010.03.00...
,2222. Ahlberg J, Lobbezoo F, Ahlberg K, Manfredini D, Hublin C, Sinisalo J, et al. Self-reported bruxism mirrors anxiety and stress in adults. Med Oral Patol Oral Cir Bucal 2013; 18(1): e7-11. DOI: 10.4317/medoral.18232
https://doi.org/10.4317/medoral.18232...
and, as a clinical implication, this suggests that psychological treatment could be a positive factor for the control of the condition77. Serra-Negra JM, Ramos-Jorge ML, Flores-Mendoza CE, Paiva SM, Pordeus IA. Influence of psychosocial factors on the development of sleep bruxism among children. Int J Paediatr Dent 2009; 19(5): 309-17. DOI: 10.1111/j.1365-263X.2009.00973.x
https://doi.org/10.1111/j.1365-263X.2009...
.

Patients with SB generally have morning headaches1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
,2020. Miamoto CB, Pereira LJ, Ramos-Jorge ML, Marques LS. Prevalence and predictive factors of sleep bruxism in children with and without cognitive impairment. Braz Oral Res 2011; 25(5): 439-45. DOI: 10.1590/S1806-83242011000500011
https://doi.org/10.1590/S1806-8324201100...
,2828. Palinkas M, Canto GL, Rodrigues LA, Bataglion C, Siéssere S, Semprini M, et al. Comparative capabilities of clinical assessment, diagnostic criteria, and polysomnography in detecting sleep bruxism. J Clin Sleep Med 2015; 11(11): 1319-25. DOI: 10.5664/jcsm.5196
https://doi.org/10.5664/jcsm.5196...
, an association confirmed in the present study. Such a finding suggests that the presence of this symptom may contribute to the diagnostic hypothesis of SB. Carra et al.1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
have mentioned that repetitive muscle contractions may be associated with tension headache or both conditions may share common risk factors with no causal relationship. Nevertheless, we recommend that studies with designs that allow the investigation of this hypothesis are conducted.

The presence of snoring was one of the factors associated with the higher prevalence of SB, corroborating the results presented by other authors99. Lam MH, Zhang J, Li AM, Wing YK. A community study of sleep bruxism in Hong Kong children: association with comorbid sleep disorders and neurobehavioral consequences. Sleep Med 2011; 12(7): 641-5. DOI: 10.1016/j.sleep.2010.11.013
https://doi.org/10.1016/j.sleep.2010.11....
,1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
and suggesting this respiratory disorder related to sleep as a predictor of the condition. It is possible that, in the event of an obstruction, SB favors the reestablishment of normal breathing1010. Rossi D, Manfredini D. Family and school environmental predictors of sleep bruxism in children. J Orofac Pain 2013; 27(2): 135-41. DOI: 10.11607/jop.1057
https://doi.org/10.11607/jop.1057...
,1919. Carra MC, Huynh N, Morton P, Rompré PH, Papadakis A, Remise C, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119(5): 386-94. DOI: 10.1111/j.1600-0722.2011.00846.x
https://doi.org/10.1111/j.1600-0722.2011...
. However, such an association needs to be better elucidated.

Problems related to sleep quality are common symptomatic consequences reported in individuals with bruxism2222. Ahlberg J, Lobbezoo F, Ahlberg K, Manfredini D, Hublin C, Sinisalo J, et al. Self-reported bruxism mirrors anxiety and stress in adults. Med Oral Patol Oral Cir Bucal 2013; 18(1): e7-11. DOI: 10.4317/medoral.18232
https://doi.org/10.4317/medoral.18232...
, a finding that was also confirmed in our results. Higher prevalence of SB was found in individuals with difficulty sleeping. One possible justification is that SB has been described as a complex nervous system excitation response, which can be accompanied by body movements, increased heart rate, and respiratory changes2222. Ahlberg J, Lobbezoo F, Ahlberg K, Manfredini D, Hublin C, Sinisalo J, et al. Self-reported bruxism mirrors anxiety and stress in adults. Med Oral Patol Oral Cir Bucal 2013; 18(1): e7-11. DOI: 10.4317/medoral.18232
https://doi.org/10.4317/medoral.18232...
.

CONCLUSION

Sleep bruxism is a frequent condition in adolescents, and the factors associated with their higher prevalence were: male sex, snoring and difficulty sleeping.

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    » https://doi.org/10.1007/s11325-011-0625-7
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    » https://doi.org/10.5664/jcsm.5196

  • Financial support: none

History

  • Received
    27 Oct 2016
  • Accepted
    22 Dec 2016
  • Online publication
    28 May 2018
Associação Brasileira de Pós -Graduação em Saúde Coletiva São Paulo - SP - Brazil
E-mail: revbrepi@usp.br