Temporomandibular disorders and bruxism - up-to-date assessment and screening tools the general dentist should be aware of.

The recently proposed shortened screening tools for temporomandibular disorders (TMD) and bruxism should enable a better assessment of these conditions by the general dentist.

Standardised Tool for the Assessment of Bruxism.

OBJECTIVE: This paper aims to present and describe the Standardised Tool for the Assessment of Bruxism (STAB), an instrument that was developed to provide a multidimensional evaluation of bruxism status, comorbid conditions, aetiology and consequences. METHODS: The rationale for creating the tool and the road map that led to the selection of items included in the STAB has been discussed in previous publications. RESULTS: The tool consists of two axes, specifically dedicated to the evaluation of bruxism status and consequences (Axis A) and of bruxism risk and etiological factors and comorbid conditions (Axis B). The tool includes 14 domains, accounting for a total of 66 items. Axis A includes the self-reported information on bruxism status and possible consequences (subject-based report) together with the clinical (examiner report) and instrumental (technology report) assessment. The Subject-Based Assessment (SBA) includes domains on Sleep Bruxism (A1), Awake Bruxism (A2) and Patient's Complaints (A3), with information based on patients' self-report. The Clinically Based Assessment (CBA) includes domains on Joints and Muscles (A4), Intra- and Extra-Oral Tissues (A5) and Teeth and Restorations (A6), based on information collected by an examiner. The Instrumentally Based Assessment (IBA) includes domains on Sleep Bruxism (A7), Awake Bruxism (A8) and the use of Additional Instruments (A9), based on the information gathered with the use of technological devices. Axis B includes the self-reported information (subject-based report) on factors and conditions that may have an etiological or comorbid association with bruxism. It includes domains on Psychosocial Assessment (B1), Concurrent Sleep-related Conditions Assessment (B2), Concurrent Non-Sleep Conditions Assessment (B3), Prescribed Medications and Use of Substances Assessment (B4) and Additional Factors Assessment (B5). As a rule, whenever possible, existing instruments, either in full or partial form (i.e. specific subscales), are included. A user's guide for scoring the different items is also provided to ease administration. CONCLUSIONS: The instrument is now ready for on-field testing and further refinement. It can be anticipated that it will help in collecting data on bruxism in such a comprehensive way to have an impact on several clinical and research fields.

Assessment of awake bruxism-Combinational analysis of ecological momentary assessment and electromyography.

PURPOSE: No consensus exists regarding the examination methods and assessment criteria for awake bruxism (AB). In this study, masticatory muscle activity measured using electromyography (EMG) was recorded simultaneously with the ecological momentary assessment (EMA) of bruxism events. Data were collected to identify distinctive EMG parameters in AB. METHODS: A total of 104 individuals were classified into the bruxism (BR) or control (CO) groups based on clinical findings. The participants recorded EMA on a tablet device under continuous EMG recording using a data log-type wireless EMG device. For EMA recording, a warning was randomly provided three times each hour for five hours. A receiver operating characteristic (ROC) curve was obtained based on EMA and EMG events. Maximum voluntary contraction (MVC) at the time of maximum bite force was set at 100%. The muscle activity was assessed as a relative value. RESULTS: Based on discriminant analysis, analysis of participants who had four or more positive clenching EMA responses was appropriate. The assessed parameters for the EMG cutoff value determination procedure, which combined EMG and EMA, resulted in a cutoff value that enabled the distinction between the BR and CO groups. The area under the ROC curve was 0.77 and the cut-off value was 3.2 events/hour under the EMG of 20% MVC with a duration of ≥1 s. CONCLUSIONS: This is the first study to report a combined analysis of the EMA and EMG. These results suggest its effectiveness as a cutoff value for AB screening.

Assessment of awake bruxism by a novel bruxism screener and ecological momentary assessment among patients with masticatory muscle myalgia and healthy controls.

BACKGROUND: Bruxism is a masticatory muscle activity occurring during sleep or wakefulness, involving grinding and clenching of teeth and/or jaw bracing. As yet, the aetiology, epidemiology and consequences of awake bruxism (AB) are largely unknown. OBJECTIVES: The aims of the study were to AB behaviours using a novel bruxism screener (BruxScreen) questionnaire part and Ecological Momentary Assessment (EMA; BruxApp©) on AB behaviours, and to investigate AB's prevalence among masticatory muscle myalgia patients and non-patients. METHODS: Altogether, 115 participants (masticatory myalgia patients referred to a specialist clinic (n = 67) and non-patients (n = 46)) filled in a bruxism screener questionnaire to report bruxism behaviours and jaw symptoms. A selection of both groups did a week-long EMA (patients n = 12, non-patients n = 11) to report AB behaviours. The chi-squared test was used to determine group differences in categorical variables. A logistic regression model was fitted to study the probability of AB. RESULTS: According to BruxScreen, bruxism behaviours and jaw symptoms were more frequent in patients than in non-patients (p < .001). Based on EMA, 14.6% of the behaviour in patients was tooth clenching; for non-patients, this was 0.5% (p < .000). Relaxed muscles were reported by patients and non-patients at 20.6% and 56.4%, respectively (p < .021). Logistic regression, adjusted by age and sex, revealed that patients reported AB 5 times more often than non-patients (OR 4.8, 95% CI 2.1-11.2). CONCLUSION: Awake bruxism behaviours are significantly more frequent in masticatory muscle myalgia patients than non-patients and associate with frequent bruxism-related symptoms. Self-reported teeth clenching seems to be the most significant sign of AB behaviour.

Translation and cultural adaptation of the Standardized Tool for the Assessment of Bruxism (STAB) and the Bruxism Screener (BruxScreen): A 12-step guideline.

BACKGROUND: Recently, the Standardized Tool for the Assessment of Bruxism (STAB) and the bruxism screener (BruxScreen) have been developed for use in research and clinical settings. OBJECTIVE: As to ascertain high-quality use of both instruments worldwide, it was our aim to develop a guideline for the translation and cultural adaptation of the STAB and the BruxScreen. METHODS AND RESULTS: This paper describes a 12-step guideline for the translation and cultural adaptation of the STAB and the BruxScreen. A format of a translation log is provided as well. Besides, a website has been created for the guidance of translation teams. CONCLUSION: Following the 12 steps, new language versions of the STAB and the BruxScreen will be ready for further testing (reliability, validity, responsiveness and interpretability) and, ultimately, application in research and clinics around the world.

Attitude of Italian dental practitioners toward bruxism assessment and management: A survey-based study.

INTRODUCTION: Bruxism is a spectrum of masticatory muscles activities. According to the recent evidence and international consensus, there is no indication to treat bruxism unless clinical consequences are present. The aim of the present study was to investigate the approach of Italian dentists to bruxism in their clinical practice. METHODS: An anonymous online survey was developed, composed by 26 items grouped into five sections: (1) Characteristics of the respondent (Q1-Q6); (2) Bruxism frequencies (Q7-Q11); (3) Bruxism assessment (Q12-Q15); (4) Bruxism management (Q16-Q20); (5) Occlusal splints therapy (Q21-Q26). RESULTS: A total of 384 practitioners, including specialists and non-specialists, participated in this survey. The majority of the respondents reported that 1-3 out of ten patients presented with bruxism. The diagnosis is mainly performed with non-instrumental methods, and facial pain and dental wear are the major clinical consequence associated with bruxism. Almost the entire sample of respondents report to offer occlusal splints to bruxism patients, and 41% refer to perform occlusal adjustments. Almost half of the respondents have never proposed any form of cognitive-behavioural therapy. CONCLUSION: The results of the current survey highlighted several inconsistencies in Italian dentists' approaches to bruxism, suggesting the need for better education of practitioners and for the development of a standardized protocol to assess and manage bruxism in dental practices.

Awake bruxism in temporomandibular disorders patients referred to tertiary care: A retrospective study on its assessment and TMD management.

BACKGROUND: Bruxism is defined as a repetitive jaw-muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. Bruxism can occur during sleep (sleep bruxism, SB) or during wakefulness (awake bruxism, AB). To date, the effect of AB on the purported negative consequences of bruxism has remained unclear. OBJECTIVES: The assessment of AB, its relation to temporomandibular disorders (TMD) treatment modalities, and their possible outcomes were investigated among TMD patients resistant to treatment in primary care and referred to a tertiary care clinic. METHODS: The records of 115 patients were studied. Patients were referred to the Head and Neck Centre, Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital, for TMD treatment between 2017 and 2020. The data derived from the eligible patients' records included the following: background data (age and sex), referral data (reason and previous treatment), medical background (somatic and psychiatric), clinical and possible radiological diagnoses at a tertiary care clinic, treatment modalities for masticatory muscle myalgia, bruxism assessment, its possible treatment modalities and their outcomes, and overall management outcome. We analysed the outcomes of single treatment modalities and combined groups of modalities. For the demographic data, the Chi-squared test and Fischer's Exact test were used to determine the associations between the categorical variables. A Sankey-diagram was used to describe the flow of treatment. RESULTS: Temporomandibular joint-pain-dysfunction syndrome (K07.60) was the most frequent single reason to refer a patient to tertiary care (17.4%). At referral, men had myalgia (M79.1) significantly more often (p = .034) than women. Similarly, men had depression (p = .002) more often and other psychiatric diagnoses (p = .034). At tertiary care, the presence of AB was assessed in 53.9%, and self-reported AB was recorded in 48.7%. In patients with possible AB, those who were prescribed neuropathic pain medication showed significantly less improvement in symptoms (p = .021) than those who underwent splint therapy (p = .009). Overall, half of the patients showed overall improvement in their TMD symptoms from the treatment combinations. CONCLUSION: Despite several treatment modalities, only half of the patients showed improvement in their symptoms in the present study. A standardised assessment method encompassing all factors contributing to bruxism behaviours and their consequences is suggested.

Assessment of awake bruxism and oral mucosa indentation in adolescents.

BACKGROUND: Oral mucosa indentations can be signs of awake bruxism (AB) in adults, but this association has not yet been verified in adolescents. OBJECTIVES: To evaluate the frequency of AB in adolescents and determine whether there is an association between AB and oral mucosa indentation. METHODS: This study enrolled 66 high school students, mean age of 16.9 (±0.54) years. Clinical inspection was performed to assess the presence or absence of tongue, cheek and lip mucosa indentation. AB was assessed by the Ecological Momentary Assessment method using the WhatsApp mobile app. Messages were sent 15 times a day, 7 days, between 8:00 AM and 7:00 PM at random times to choose one of the five oral behaviours: teeth contact, teeth clenching, teeth grinding, mandible bracing and relaxed jaw muscles. The non-parametric Mann-Whitney U-test for independent samples, Friedman test for paired samples, Friedman pairwise multiple comparisons non-parametric test, Pearson's chi-squared tests, and z-test of comparisons between two proportions were performed (p < .05). RESULTS: During the week the frequency of AB behaviours was 56.20%, teeth contact was the most frequent (37.68% ± 22.26%), significantly more frequent than other AB behaviours; there was a greater frequency of cheek indentation (27.27%) and no difference between genders in oral behaviours and indentations (p > .05). A higher frequency of AB behaviours was observed in individuals with a greater frequency of cheek indentation (p < .05). CONCLUSIONS: Teeth contact and cheek indentation were the most frequent conditions among adolescents and AB behaviours are associated with this indentation.

Portable and wearable electromyographic devices for the assessment of sleep bruxism and awake bruxism: A literature review.

OBJECTIVE: The current state of portable/wearable electromyographic (EMG) devices for assessment of bruxism was reviewed. METHODS: A search of full-text articles relevant to portable/wearable EMG devices capable of being used at home was performed. The data source used was MEDLINE via PubMed from January 1970 to July 2019. RESULTS: There were nine kinds of wearable EMG devices capable of being used under unrestrained conditions. Ultra-miniaturized wearable EMG devices with a level of performance equivalent to that of conventional stationary EMG devices have been developed and are being used during sleep and in the daytime. The devices have a high level of diagnostic accuracy for sleep bruxism. A definite cut-off value for awake bruxism has not been established. DISCUSSION: Assessment of sleep bruxism with a high level of accuracy can be performed using a portable/wearable EMG device. However, a definite cut-off value is required for assessment of awake bruxism.

Minimum measurement time of masseteric electromyogram required for assessment of awake bruxism during the daytime.

Objective: Assessments of diurnal awake bruxism (d-AB) using masseteric electromyogram (EMG) during various lengths of measurement time within a day were examined as the first step of research to clarify the minimum measurement time required for assessment of d-AB by subject.Methods: Subjects were 33 outpatients. Assessment of d-AB by EMG during partial measurement time (PMT) with durations ranging from 30 minutes to 6 hours was compared with that during total measurement time (TMT) used as the reference standard.Results: No significant difference was found between TMT data and PMT data. There were significant correlations in all combinations between TMT data and PMT data. Accuracy was 0.909 or more for 2.5 hours or longer.Discussion: The results suggest that the tendency of daytime muscle activity in 1 day can be assessed even by using masseteric EMG data obtained during a relatively short measurement time.

Electromyography of diurnal bruxism during assessment and treatment.

Diurnal bruxism among individuals with intellectual disabilities is often measured on the basis of its auditory products, thereby precluding the contingent presentation of stimuli during silent bruxism events. Electromyography (EMG) offers a technological solution to the identification of all bruxism events. EMG has not been previously evaluated in nonvocal clients with intellectual disabilities in the context of functional analysis and treatment. In the current series of analyses, we suggest a set of methods to implement EMG technology with this population. In Analysis 1, we propose a strategy for systematically identifying bruxism events. In Analysis 2 we evaluate an EMG staff-training package with naïve interventionists without past experience with EMG technology. Finally, Analysis 3 presents a practical example of this method during the functional analysis and treatment of a client with frequent diurnal bruxism.

Smartphone-based application for EMA assessment of awake bruxism: compliance evaluation in a sample of healthy young adults.

OBJECTIVE: A smartphone-based ecological momentary assessment (EMA) strategy to collect real time data on awake bruxism (AB) has been recently introduced. The aim of this study was to assess the compliance with its use over 1 week in a sample of healthy young adults. METHOD: Sixty (N = 60) healthy young adults (mean age 24.2 ± 4.1 years) used a dedicated smartphone application that sent 20 alerts at random times throughout the day. Upon alert receipt, the subjects had to report in real time their condition among five possible options: relaxed jaw muscles, teeth contact, teeth clenching, teeth grinding, and mandible bracing. Compliance rate with the app was assessed at the individual and group level in terms of percentage of answered alerts as well as number of days that were needed to reach the targeted observation period of 7 days with a compliance of at least 60%. RESULTS: The mean compliance recorded with the smartphone application was 67.8% of the total alerts. On average, 9.8 ± 3.2 days (range 7-19) have been necessary to achieve the targeted goal of 7 days with a minimum of 60% alerts/day. No gender differences were detected in any compliance data. Response rate was not different during weekdays or weekends. CONCLUSIONS: This investigation is the first attempt to assess individual compliance with EMA for reporting awake bruxism. Results suggest that a smartphone-based strategy can have interesting potential. The compliance rate reported in this study will serve as a comparison standpoint for future investigations. CLINICAL SIGNIFICANCE: Based on the recent multidisciplinary focus on the study of awake bruxism, EMA has emerged as a potential approach for use in the clinical and research settings. This investigation suggests that compliance with such strategy is good, thus making it worthy of adoption for the assessment of AB and its clinical implications.

International consensus on the assessment of bruxism: Report of a work in progress.

In 2013, consensus was obtained on a definition of bruxism as repetitive masticatory muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible and specified as either sleep bruxism or awake bruxism. In addition, a grading system was proposed to determine the likelihood that a certain assessment of bruxism actually yields a valid outcome. This study discusses the need for an updated consensus and has the following aims: (i) to further clarify the 2013 definition and to develop separate definitions for sleep and awake bruxism; (ii) to determine whether bruxism is a disorder rather than a behaviour that can be a risk factor for certain clinical conditions; (iii) to re-examine the 2013 grading system; and (iv) to develop a research agenda. It was concluded that: (i) sleep and awake bruxism are masticatory muscle activities that occur during sleep (characterised as rhythmic or non-rhythmic) and wakefulness (characterised by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible), respectively; (ii) in otherwise healthy individuals, bruxism should not be considered as a disorder, but rather as a behaviour that can be a risk (and/or protective) factor for certain clinical consequences; (iii) both non-instrumental approaches (notably self-report) and instrumental approaches (notably electromyography) can be employed to assess bruxism; and (iv) standard cut-off points for establishing the presence or absence of bruxism should not be used in otherwise healthy individuals; rather, bruxism-related masticatory muscle activities should be assessed in the behaviour's continuum.

Patents related to the treatment and diagnosis of bruxism.

INTRODUCTION: Bruxism is among the most chronic dental problems worldwide, and its perception may increase indicatively the condition of people's health, avoiding future health problems. Technologic solutions have improved considerably owing to new diagnostic and treatment technologies and their automation. This review aims to assess therapeutic methods for bruxism through analysis of patent applications spanning recent decades. AREAS COVERED: Patent families of bruxism, and products available on the market. Data were obtained through Questel Orbit from the European Patent Office on a worldwide basis using Cooperative Patent Classification (CPC), analyzing 134 patent families. The products on the market were mapped and classified as used for diagnosis, treatment, or both. EXPERT OPINION: This technological prospect has shown that the technological field of bruxism is growing toward smaller, automated devices; there is still no predominant owner of the technologies. Products are expected to provide home use with a high degree of reliability and specificity, using the Internet of Things (telemedicine associated with industry 4.0) and enabling real-time diagnosis.

Validity of three screening questions (3Q/TMD) in relation to the DC/TMD.

Temporomandibular disorders (TMD) are common but seem to be largely undetected within general dental care. To improve dentists' awareness of these symptoms, three screening questions (3Q/TMD) have been introduced. Our aim was to validate 3Q/TMD in relation to the diagnostic criteria for TMD (DC/TMD), while taking into account the severity level of the symptoms. The study population consisted of 7831 individuals 20-69 years old, who had their routine dental check-up at the Public Dental Health Service in Västerbotten, Sweden. All patients answered a health declaration, including the 3Q/TMD regarding frequent temporomandibular pain, pain on movement and catching/locking of the jaw. All 3Q-positives (at least one affirmative) were invited for examination in randomised order. For each 3Q-positive, a matched 3Q-negative was invited. In total, 152 3Q-positives and 148 3Q-negatives participated. At examination, participants answered 3Q/TMD a second time, before they were examined and diagnosed according to DC/TMD. To determine symptom's severity, the Graded Chronic Pain Scale and Jaw Functional Limitation Scale-20 (JFLS-20) were used. In total, 74% of 3Q-positives and 16% of 3Q-negatives met the criteria for DC/TMD pain or dysfunction (disc displacements with reduction and degenerative joint disorder were excluded). Fifty-five per cent of 3Q-positives had a TMD diagnosis and CPI score ≥3 or a JFLS-20 score ≥5, compared to 4% of 3Q-negatives. The results show that the 3Q/TMD is an applicable, cost-effective and valid tool for screening a general adult population to recognise patients in need of further TMD examination and management.

Factors associated with clinical decision-making in relation to treatment need for temporomandibular disorders.

OBJECTIVE: The aim of this study was to analyze dentist's clinical decision-making related to treatment need for temporomandibular disorders (TMD) in an adult population. MATERIALS AND METHODS: The study population comprised 779 randomly selected 35, 50, 65 and 75 year old individuals living in the county of Västerbotten, Sweden. The participants filled out a questionnaire and were examined clinically according to a structured protocol. The four examiners (two men, two women) were experienced dentists and were calibrated before the start of the study. After examination they individually assessed the need of treatment owing to TMD. RESULTS: In total, 15% of the study population was considered to have a treatment need owing to TMD. The highest estimate was noted for 35 and 50 years old women and the lowest for 65 and 75 years old men. Overall, 21% of the women and 8% of the men were considered to have a treatment need owing to TMD, with statistically significant differences between men and women for the 35 and 50 years old groups. Inter-individual variations in dentists' decisions were observed. In a multivariate analysis, female gender, signs and symptoms of TMD pain, signs and symptoms of TMD dysfunction and smoking were associated with estimated treatment need. CONCLUSIONS: The prevalence of estimated treatment need owing to TMD was fairly high, but the dentists' clinical decision-making process showed large inter-individual variability. The observation calls for further research on the factors affecting the decision-making process in care providers.

Oral diagnosis and treatment planning: part 4. Non-carious tooth surface loss and assessment of risk.

Non-carious tooth surface loss or tooth wear is becoming an increasingly significant factor affecting the long-term health of the dentition. The adverse effects of tooth wear are becoming increasingly apparent both in young persons and, as more people retain their teeth, into old age. This situation challenges the preventive and restorative skills of dental practitioners.

Assessment and maintenance of dental implants: clinical and knowledge-seeking practices of dental hygienists.

PURPOSE: This study surveyed dental hygienists in order to assess their routine approach for dental implant maintenance and to determine if a relationship exists between the formal education of dental hygienists and their previous attendance and interest in future implant related continuing education courses. METHODS: A survey was distributed to dental hygienists attending an annual national continuing education course. Participants voluntarily completed and submitted their survey before the end of the first day of the 3 day course. RESULTS: The results indicate that there is a statistically significant relationship between the level of formal education and implant related continuing education course attendance. Dental hygienists whose formal education did not include dental implant care were more likely to attend implant related continuing education courses than those whose formal education included this content. The majority of the dental hygienists expressed interest in continuing education courses on dental implants. Results of chi-square analysis show a statistically significant relationship between the type of education and interest in attending implant related continuing education courses. There was no statistically significant difference in continuing education interest between dental hygienists whose formal education did or did not include dental implants. CONCLUSION: Additional continuing education courses have been completed by most dental hygienists whose curricula did not include formal training on dental implant care. Most dental hygienists are interested in gaining additional knowledge whether or not their dental hygiene curriculum contained content on dental implants.

Assessment of bruxism in the clinic.

Bruxism is a much-discussed clinical issue in dentistry. Although bruxism is not a life-threatening disorder, it can influence the quality of human life, especially through dental problems, such as tooth wear, frequent fractures of dental restorations and pain in the oro-facial region. Therefore, various clinical methods have been devised to assess bruxism over the last 70 years. This paper reviews the assessment of bruxism, provides information on various assessment methods which are available in clinical situations and discusses their effectiveness and usefulness. Currently, there is no definitive method for assessing bruxism clinically that has reasonable diagnostic and technical validity, affects therapeutic decisions and is cost effective. One future direction is to refine questionnaire items and clinical examination because they are the easiest to apply in everyday practice. Another possible direction is to establish a method that can measure actual bruxism activity directly using a device that can be applied to patients routinely. More clinical studies should examine the clinical impact of bruxism on oral structures, treatment success and the factors influencing the decision-making process in dental treatment.