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Association Between Sleep Bruxism and Psychosocial Factors in Children and Adolescents: A
Systematic Review
Graziela De Luca Canto, Vandana Singh, Paulo Conti, Bruce D. Dick, David Gozal, Paul W. Major and Carlos
Flores-Mir
CLIN PEDIATR published online 10 November 2014
DOI: 10.1177/0009922814555976
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555976
research-article2014
CPJXXX10.1177/0009922814555976Clinical PediatricsDe Luca Canto et al
Original Article
Association Between Sleep Bruxism
and Psychosocial Factors in Children and
Adolescents: A Systematic Review
Clinical Pediatrics
1­–10
© The Author(s) 2014
Reprints and permissions:
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DOI: 10.1177/0009922814555976
cpj.sagepub.com
Graziela De Luca Canto, DDS, MSc, PhD1,2, Vandana Singh, DDS, MSc2,
Paulo Conti, DDS, MSc, PhD3, Bruce D. Dick, PhD, RPsych2,
David Gozal, MD4, Paul W. Major, DDS, MSc, FRCD(C)2,
and Carlos Flores-Mir, DDS, MSc, DSc, FRCD(C)2
Abstract
Objective. To summarize the association between sleep bruxism and psychosocial factors in children and adolescents.
Design. Individual search strategies for five databases were developed. The references cited in the selected articles
were checked and a partial gray literature search was undertaken. Only articles that used the international diagnostic
criteria for sleep bruxism as proposed by the American Association of Sleep Medicine were included. Any form
of reporting of psychosocial factors was considered. Results. Of the 44 retained articles, only 7 studies were finally
included for the qualitative/quantitative synthesis. No evidence supportive of an association between sleep bruxism
and psychosocial factors in children younger than 5 years emerged. A significant association was present in children
between 6 and 11 years old and in adolescents 12 to 17 years old. Risk of bias was low–to-moderate in most of
the included studies. Conclusion. The current available evidence suggests an association between sleep bruxism and
psychological factors in children older than 6 years.
Keywords
sleep bruxism, review, psychosocial factors
Introduction
Bruxism is defined as the “repetitive jaw-muscle activity characterized by clenching or grinding of the teeth
and/or by bracing or thrusting of the mandible.”1
Bruxism has 2 distinct circadian manifestations: It can
occur during sleep (sleep bruxism [SB]) or during wakefulness (awake bruxism [AB]).2
The prevalence of SB in children (younger than 12
years) reported in a recent systematic review is highly
variable (3.5% to 40.6%), with a commonly described
reduction with age and without sex differences.3 Another
study reported that the prevalence of bruxism in adolescents was 19%.4
As a result of periodic mechanical grinding, SB can
lead to tooth wear, tooth mobility, and other clinical
findings such as tongue/cheek indentation, masticatory
muscle hypertrophy, temporomandibular joint pain,
headaches, and masticatory muscle pain or fatigue.5
The diagnosis of bruxism is often challenging.6
Despite the stated existence of the condition, no universally accepted criteria for AB diagnosis have been
reported in the literature. One of the most widely
accepted criteria for the diagnosis of SB was proposed
by American Academy of Sleep Medicine (AASM)7 and
includes the presence of tooth grinding or clenching
sounds during sleep and o one or more of the following
concurrent signs and symptoms: abnormal wear of the
teeth, jaw muscle discomfort, fatigue, or pain and jaw
lock on awakening or masseter muscle hypertrophy on
voluntary forceful clenching.7
1
Federal University of Santa Catarina, Florianópolis, Santa Catarina,
Brazil
2
University of Alberta, Edmonton, Alberta, Canada
3
University of São Paulo, São Paulo, Brazil
4
The University of Chicago, Chicago, IL, USA
Corresponding Author:
Graziela De Luca Canto, Universidade Federal de Santa
Catarina (UFSC), Departamento de Odontologia–CCS, Campus
Universitário–Trindade, Florianópolis, Santa Catarina, 88040-900,
Brazil.
Email: [email protected]
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2
Clinical Pediatrics
A systematic review of psychological factors and
their association with SB in adults provided a description of some temperamental traits that characterize bruxers (eg, aggressiveness, hostility, perfectionism, and
stress sensitivity), and have also pointed out a high prevalence of psychosocial disorders in these individuals.2
However, we are unaware of any systematic analysis
of published studies that addressed SB in children and
adolescents, even though several published studies have
suggested a possible association between psychosocial
factors and bruxism in both children8-17 and adolescents.9,17 Therefore, the objective of this systematic
review is to evaluate whether SB is associated with psychosocial factors in children and adolescents.
Methods
This systematic review adhered to the Preferred
Reporting Items for Systematic Reviews and MetaAnalyses Checklist.18
Protocol Registration
No registration of the systematic review protocol was
completed. No systematic review protocol was available.
Study Design
A systematic review of human studies that evaluated the
association between SB and psychosocial factors in children and adolescents was undertaken.
Eligibility Criteria
Retained articles were only those that evaluated the
association between SB and psychosocial factors. SB
had to be determined by satisfying the international
diagnostic criteria as proposed by the AASM.7
In this review, “psychosocial factors” was used as an
umbrella term to group together all psychological (eg,
stress, anxiety and mood disturbances, temperamental
traits, and emotions) and social or environmental agents
(school satisfaction, cultural and economic conditions,
social behaviors, and expectations) that may have an
effect on an individual’s health.
The evaluated population was of individuals younger
than 18 years. Studies from any language or peerreviewed source were considered. Reviews, letters, and
personal opinions were not included.
Information Sources
Detailed individual search strategies for each of the following bibliographic databases were developed:
Cochrane, EMBASE, MEDLINE, PubMed, and Virtual
Health Library (BVS -Database that include articles in
Spanish and Portuguese from MEDLINE, LILACS,
Wholis, BBO and AdoLec.). The references cited in the
finally selected articles were also checked for any references missed in the electronic database searches. A partial gray literature search was taken using Google
Scholar. This search was limited to the first 100 most
relevant articles published in the past 5 years.
Search
Appropriate truncation and word combinations were
selected and adapted for each database search
(Appendix A, available online at http://cpj.sagepub.
com/content/by/supplemental-data). All references
were managed by reference manager software
(RefWorks–COS-ProQuest, LLC. © 7200 Wisconsin
Avenue, Suite 601 Bethesda, MD 20866, USA) and
duplicate hits were removed. End search date was June
6, 2014 across all databases.
Study Selection
The selection was completed in 1 phases. In phase 1, 2
reviewers independently reviewed the titles and abstracts
of all identified electronic database citations. Any studies that clearly did not fulfill the inclusion criteria were
discarded. In phase 2, the same selection criteria were
applied to the remaining full articles to confirm their eligibility. The same 2 reviewers independently participated in phase 2. Any disagreement in either phase was
resolved by discussion and mutual agreement between
the 2 reviewers. A third author was involved, when
required, to make a final decision.
Data Collection Process
Two authors independently collected key information
from the selected articles, after which cross checking
procedures ascertained the completeness of the retrieved
information. Any disagreement was resolved again by
discussion and mutual agreement between the authors. A
third author was involved, when required, to make a
final decision.
Data Items
For the included studies, the following information was
recorded: author, year of publication, sample size,
demographic features of the sample, objectives, data
collection instruments (eg, psychological tests), results,
and conclusions pertaining to the association between
SB and psychosocial factors. If the required data were
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3
De Luca Canto et al
not complete, attempts were made to contact the authors
to retrieve missing information.
Risk of Bias in Individual Studies
We evaluated the methodology of selected studies by
using the quality in prognosis studies tool (QUIPS).19
Two reviewers categorized each 6 bias domains (study
participation, study attrition, prognostic factors measurement, outcome measurement, study confounding,
statistical analysis, and reporting) in high, moderate or
low risk of bias. Any disagreement was resolved by discussion until a mutual agreement between the 2 authors
was attained. A third author became involved when
required to make a final decision.
Outcome Measures
http://cpj.sagepub.com/content/by/supplemental-data),
including one20 because of the inaccessibility of the full
text. Thus, only 7 studies remained for the final qualitative/quantitative synthesis. A flowchart of the process of
identification, inclusion, and exclusion of studies is
shown in Figure 1.
Study Characteristics
Two articles were published in a sleep medicine journal17,21 while the remaining 5 in dental journals.8,22-25
Sample size ranged from 20 individuals17 to 167 individuals.8 The selected studies were conducted in 5 different countries: Brazil,25 Colombia,24 Greece,8 Iran,23
Turkey,17 and the United States.21,22 All were published
in English. A summary of the study descriptive characteristics can be found in Table 1.
The presence of psychosocial factors in both groups of
subjects, with and without bruxism was analyzed. Any
type of related measurement was considered (categorical variables, continuous variables—mean difference,
odds ratio, and relative risk).
Risk of Bias Within studies
Synthesis of Results
Synthesis of Results
If the data from different studies were considered homogeneous enough to properly justify a meta-analysis, this
step was planned a priori.
As the data from the included studies were clearly and
significantly heterogeneous, a meta-analysis was not
justified. Therefore, only a qualitative synthesis could
be performed.
One study22 conducted in 5- to 6-year-old children
found that children with and without SB did not differ
significantly with respect to their personality traits.
However, 3 studies8,24,25 examined children between
ages of 6 and 8, 7 and 11, and 8 and 11 years, respectively, and identified a significant association between
bruxism and psychosocial disorders. Vanderas et al8
showed that epinephrine and dopamine had a significant
association with bruxism (relative risk ratio of 9.69
(95% confidence interval [CI] = 1.04-45.27), and of
2.89 (95% CI = 1.04-7.80) or 15.38 (95% CI = 1.6867.17), respectively, depending, of the catecholamine
levels. According to the authors,8 the relative risk of
developing bruxism increased with higher epinephrine
and dopamine levels. This dose–response trend considerably strengthened the positive relationship between
emotionally stressful states and bruxism. Ferreira-Bacci
et al25 found that around 83% of their SB sample needed
psychological or psychiatric interventions, and that
approximately 20% presented evidence of significant
physical and psychological manifestations of stress.
Restrepo et al24 reported a significant difference between
control and bruxism groups regarding tense personality
Risk of Bias Across Studies
We assessed the clinical heterogeneity (by comparing
variability among the participant’s characteristics and
outcomes studied), methodological heterogeneity (by
comparing the variability in study design and risk of
bias), and statistical heterogeneity.
Results
Study Selection
In the initial search (phase 1), 912 citations were identified across the 5 electronic databases plus 100 citations
from Google Scholar. After duplicates were removed,
638 different citations were considered. Then, in a comprehensive evaluation of the abstracts, 594 were
excluded. Therefore, only 44 articles were consequently
selected for phase 2 assessment. No additional study that
might have been inadvertently missed by the search procedures was identified from reviewing the reference list
of these 44 studies. From these remaining studies, 37
were later excluded (Appendix B, available online at
The reported methodological quality of the included
studies was ranged between low and high, depending of
the domains included in such studies (Table 2).
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Clinical Pediatrics
Google Scholar
(n=100)
Idenficaon
Records idenfied through database searching
(n=912)
MEDLINE
n=197
PUBMED
n=381
EMBASE
n=289
COCHRANE
n=14
BVS
n=31
Screening
Records aer duplicates removed
(n=638)
Records screened
(n=638)
Addional studies idenfied
from reference lists
(n=0)
Eligibility
Full-text arcles assessed for eligibility
(n=44)
Included
Records excluded
(n=594)
Full arcles excluded with
reasons (n=37)
Minimum criteria for SB
diagnosis not met (n=17)
Lack of clear descripon about
criteria for SB diagnosis (n=2)
No determinaon of the
associaon between SB and
psychosocial factors (n=6)
Adults (n=5)
No determinaon of the
associaon between SB and
psychosocial factors, and
minimum criteria for SB
diagnosis not met(n=6)
Not found (n=1)
Studies included in qualitave synthesis
(n=7)
Figure 1. Flow diagram of literature search and selection criteria.a
a
Adapted from PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).
(P = .024) and anxiety (P = .007), whereby the SB group
had increased values.
In a study that specifically targeted adolescents (12-14
years old), Katayoun et al23 reported higher prevalence of
psychosocial disorders in subjects with SB, particularly in
the areas of thought disorders (P< .005), conduct disorders (P< .050), and antisocial disorders (P< .060). The
result of odds ratio revealed that an adolescent with SB
had a 16-fold increased probability for psychosocial disorders than comparable adolescent without SB.
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5
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Sample/Setting
SB group: 10 (5 boys/5
girls) referred to the
sleep or dental clinic for
complaints of grinding
sounds during sleep and
abnormal tooth wear
Control group: 10 (5
boys/5 girls) nonbruxers
USA
SB group: 25 bruxers
Control group: 25
nonbruxers
Only girls who attended
summer camp, Tehran,
Iran
Herrera
et al,21
2006
Katayoun
et al,23
2008
Kuch et al,22 SB group: 50 (25 boys/25
1979
girls)
Control group: 50 (25
boys/25 girls)
Rosemount School
District, Minneapolis,
USA
Vanderas
SB group: 129 (74 boys/55
et al,8
girls)
Control group: 38 (17
1999
boys/21 girls)
Public schools, Greece
Author,
Year
Yes
12-14
5-15
(9.2)
6-8
No
Yes
5-6
Age
(Years)
Yes
Case-Control
Study
Missouri
Children’s
Picture Series
Instrumenta
Youth Self Report
To determine the
correlation between Questionnaire
(YSR)
psychosocial
disorders and
bruxism
Main Conclusion
Thought disorders, conduct disorders,
antisocial disorders
(continued)
Emotional stress is a
Logistic multiple Bruxer children had a
prominent factor in
higher mean epinephrine,
regression
the development of
norepinephrine, and
analysis
bruxing behavior
dopamine. The relative
risk between 1 and
9.69, and 1 to 15.38,
respectively, depending on
the catecholamine levels,
in a 95% CI. Epinephrine
(P = .03) and dopamine
(P = .01) had a significant
association with bruxism
Student’s t test The K-BIT score correlated Suggested that bruxer
children have a
strongly with the
(2-tailed)
internalizing problems (r = higher arousal
Two-tailed
index, which may be
0.76, P = .047, analysis of
Pearson
variance), and externalizing associated with an
correlations
increase incidence
problems scale (r =
of attention0.74, P = .006, analysis
behavior problems
of variance). The most
significant of the individual
subscales were the
somatic problems scale
(r = 0.85, P = .010, analysis
of variance) and conduct
problems (r = 0.760, P =
.04, analysis of variance)
Fischer exact
Reported higher prevalence Suggested the
existence of
test
of thought disorders (P<
an association
.005), conduct disorders
between bruxism
(P< .050) and antisocial
and psychosocial
disorders (P< .060) in
disorders
bruxers. The odds ratio
revealed that a bruxer
adolescent has 16 times
greater probability for
psychosocial disorders
than a nonbruxer one
Bruxism at age 5 or
6 appears to have
little psychological
significance
Stress
Findings
None of the test group
Analysis of
means scores differed
variance
significantly from the
Student’s t test
control group mean
(2-tailed)
scores (P> .05)
Statistical
Analysis
Conformity, masculinity/femininity,
maturity, aggression, inhibition, activity
levels, sleep disturbance, somatization
Psychosocial Factors
Daytime cognitive behavioral
To assess the daytime Kaufman Brief
Intelligence Test
behavior and
(K-BIT)
cognitive impact of
Achenbach
bruxism
Child Behavior
Checklist (CBCL)
Urinary test of
To investigate
catecholamines
the association
(epinephrine,
between urinary
norepinephrine,
catecholamines as
biomarkers of stress dopamine)
and the presence of
bruxism
To determine
if correlation
between bruxism
and personality
characteristics
Objectives
Table 1. Summary of Descriptive Characteristics of Included Articles.
6
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Sample/Setting
SB group: 29 (18 boys/11
girls) seeking routine
dental care and with
episodes of tooth
grinding/clenching
No control group
School of Dentistry, São
Paulo, Brazil
SB group: 35 (18 boys/17
girls) consecutively
referred to 2 different
hospitals, Turkey
Control Group: 35
(18 boys/17 girls)
who were seen in
an outpatient dental
clinic for a routine oral
inspection, not on basis
of any specific dental
complaint.
Turkey
Yes
8-17
7-11
(8.8)
8-11
(9.45)
Yes
No
Age
(Years)
Case-Control
Study
Instrumenta
Psychosocial Factors
Statistical
Analysis
Findings
Main Conclusion
Childhood Anxiety State-trait anxiety, anxiety sensitivity,
To examine statedepressive symptom levels, and
Sensitivity Index
trait anxiety,
psychiatric disorders
anxiety sensitivity, State-Trait Anxiety
Inventory for
depressive
Children
symptoms levels,
Children
and psychiatric
disorders in children Depression
Inventory
and adolescents
with SB
Children’s
To describe the
Personality
personality traits
and the anxiety level Questionnaire
(CPQ)
of bruxer children
Conners’s Parents
Rating Scales
(CPRS)
Suggested that SB is
Mann-Whitney At least 1 psychiatric
related to anxiety
disorder was present
U test,
sensitivity
in 42.9% of the patient
Fisher’s
group and 17.1% of the
analysis.
control group (P< .05).
Multivariate
Trait and state anxiety,
logistic
anxiety sensitivity, and
regression
the severity of depression
analysis
symptoms were also
higher in the SB group (P<
.05). After the multivariate
analysis, the associations
between state and trait
anxiety, depression, and
SB became statistically
insignificant, while the
association with anxiety
sensitivity persisted
There is a possible
Student’s t test Statistically significant
Anxiety level, personality traits
etiological
difference between the
(outgoing-reserved, intelligent-dull,
control and bruxism group relationship
ego strength-weakness, excitableregarding tense personality between tense and
placid, dominant-submissive, happy-gohigh personality
(P = .024 and anxiety
lucky-serious, conscientious-frivolous,
trait and bruxism
(P = .0007)
venturesome-shy, sensitive-tough,
restrained-vigorous, shrewdartless, apprehensive-self-assured,
self-controlled-lax, tense-relaxed,
low-anxiety-high anxiety, introversionextraversion, tough-mindedness)
Behavioral problems
Stress
Descriptive
82.76% of the sample
Rutter’s Child
To evaluate the
and potential
statistics
needed psychological or
behavioral profile of Behavior Scale-A2
emotional problems
psychiatric intervention
(Brazilian version)
a group of bruxer
can be risk factors
and 18.75% presented
Child Stress Scale
children
to bruxism in
significant physical
children
and psychological
manifestations of stress
Objectives
Abbreviations: SB, sleep bruxism; CI, confidence interval.
a
The references of validation of the instruments are available in Appendix D, available online at http://cpj.sagepub.com/content/by/supplemental-data.
Türkog˘lu
et al, 17
2013
FerreiraBacci et
al,25 2012
Restrepo et SB group: 26
al,24 2008 Control group: 26
Montessori School,
Medellin, Colombia
Author,
Year
Table 1. (continued)
7
De Luca Canto et al
Table 2. QUIPS Risk of Bias Assessment Instrument for Prognostic Factor Studies.a
Biases (Summary)
Issues to Consider for Judging
Overall Rating of “Risk of Bias”
Study
participation
The study sample represents the
population of interest on key
characteristics, sufficient to limit
potential bias of the observed
relationship between PF and
outcome
Study attrition
Loss to follow-up (from baseline
sample to study population
analyzed) is not associated with key
characteristics (ie, the study data
adequately represent the sample)
sufficient to limit potential bias to
the observed relationship between
PF and outcome
PF measurement PF is adequately measured in study
participants to sufficiently limit
potential bias
Outcome
Outcome of interest is adequately
measurement
measured in study participants to
sufficiently limit potential bias
Study
Important potential confounders
confounding
are appropriately accounted for,
limiting potential bias with respect
to the relationship between PF and
outcome
The statistical analysis is appropriate
Statistical
for the design of the study, limiting
analysis and
potential for presentation of invalid
presentation
or spurious results
Ferreira-Bacci Herrera
et al21
et al25
Katayoun
et al23
Kuch
et al22
Restrepo
et al24
Türkoğlu
et al17
Vanderas
et al8
High
High
Low
High
Moderate
Moderate
Low
Moderate
High
Low
High
Low
High
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Moderate
Low
Low
Low
High
High
Moderate
Low
Low
Low
Low
Abbreviations: QUIPS, quality in prognosis studies tool; PF, prognostic factor.
a
Ratings: High, moderate, and low indicate high, moderate, and low risk of bias, respectively.
Türkoğlu et al17 analyzed children and adolescents
between 8 and 17 years old and found that state anxiety,
anxiety sensitivity, and the severity of depression symptoms were higher in the SB group (P< .05). Finally, one
study21 conducted in 5- to 15-year-old children suggested that SB could be associated with attention-behavior problems, based on the higher number of arousals
detected in SB (66% of the cases). In this study, arousals
from sleep were associated with parental reports of
somatic or physical complaints and externalizing and
internalizing behaviors, as well as with attention problems in this small group of children. Although there was
a trend, the statistical significance for these correlations
(P = 0.07-0.1) was not achieved.
Discussion
Summary of Evidence
In this systematic review, we investigated the potential
associations between SB and psychosocial factors in
children and adolescents. The role of psychosocial
factors in the etiology of bruxism is probably one of the
most debated issues concerning this disorder, with stress
being clearly considered as a significant trigger.2 This
assumption is reliant on reports by adult patients who
usually describe increases in their nighttime teeth grinding during stressful life periods. In addition, a large proportion of clinicians, will often attribute a patient’s
bruxing behavior to underlying increased stress.2
Although the first study supporting this argument for
children26 dates back more than 40 years ago, definitive
conclusions are yet to be confirmed.
Several methodological inadequacies may have contributed significantly to the current lack of clarity. Many
of the studies that have reported a possible association
between pediatric SB and psychosocial factors9-16 did not
use a homogeneous set of diagnostic criteria for both
psychosocial factors and SB. Furthermore, the most
striking limitations of these studies are represented by
the subjectivity of the self-reported diagnosis of bruxism,
and by the lack of information on whether the studies
address sleep or awake bruxism. Standardized definition
and a diagnostic grading system are prerequisites for
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8
Clinical Pediatrics
evidence-based practice management.1 SB diagnosis
based on overnight polysomnographic recordings is very
well documented and accepted by most clinicians and
researchers as the gold standard.27 Unfortunately, overnight polysomno-graphic sleep studies are onerous,
labor-intensive, impose substantial discomfort on the
children and their families, and are relatively inaccessible to children.28 In our study, because of the lack of a
consensus in the literature regarding a definitive tool to
SB diagnosis, the one proposed by the AASM was used.7
In fact, we selected only articles that met this classification criterion regardless of whether the authors actually
mentioned the use of this classification system. In the
second phase of the selection process, 23 articles were
excluded because they failed to meet the AASM diagnosis criteria.7 Furthermore, the instruments employed to
measure psychological factors associated with SB examined a broad range of psychological traits and constructs,
although not all of them have been validated for use with
children (Appendix C, available online at http://cpj.sagepub.com/content/by/supplemental-data). Of note, many
of the psychological measures chosen used tests with
outdated normative data, tested populations for which
the normative data were potentially invalid, and/or had
questionable psychometric properties. Kuch et al22 used
a measure that targets aggression and hyperactivity with
weak psychometric properties. We would therefore be
hesitant to draw any firm conclusions based on the findings of this particular study. We decided against excluding this study,22 but rather outlined the limitations of the
instrument used. Most of the other selected studies generally used improved psychological instruments.
However, the Rutter Scale used by Ferreira-Bacci et al25
is also problematic as far as its validity, even if a Brazilian
verison of the test was employed. The questionnaire used
by Restrepo et al24 was also an outdated test, and appears
to have been used in a culturally inappropriate setting,
which could weaken the validity of the conclusions from
the study. However, the authors24 also included the
Conners’s scale, an approach that appears to reinforce
their findings. Considering that there exist a large body
of literature on the gold standard measures of stress, anxiety, and other psychological factors in children and adolescents,29 there is no doubt that such considerations need
to be incorporated when researchers select the measures
that will be used to evaluate the target population during
the research planning and design phase.
We identified 7 articles that met our inclusion criteria. Only 1 of the 7 selected studies22 reported on the
absence of an association between SB and psychosocial
variables (conformity, masculinity/femininity, maturity,
aggression, inhibition, activity levels, sleep disturbance,
and somatization). This study was conducted in younger
children ranging between 5 and 6 years of age. Thus, the
younger characteristics of their cohort might have influenced the results. Furthermore, the psychological measure used may have also hampered the conclusions,
given the questionable psychometric properties of the
instrument selected and employed for this study. The
authors22 concluded that although bruxism in children
aged 5 to 6 years may be a relatively common childhood
habit, no psychological associations are obviously present. These findings agree with those of Rodríguez et al30
who did not find an association between dental wear and
emotional state in 5-year-old children. However, this
study did not meet our review inclusion criteria.
In contrast, 3 of the selected studies8,24,25 reported an
association between SB and psychosocial factors in children between 6 and 11 years old, especially between SB
and stress, anxiety and tension personality traits. Two of
these studies24,25 used 2 different questionnaires, one for
children and another for parents, which likely added
increased reliability to its findings. The convergent
validity that can be gained from measuring both of these
participant groups undoubtedly strengthens the conclusions. The other study8 used urinary tests to assess catecholamine levels as a measure of underlying stress,
since the main objective of the investigators was to test
the hypothesis that emotionally stressful states as measured by urinary catecholamines may affect the development of bruxism. Others studies in the same age group
that had to be excluded from the final analyses10,12,13 also
reported a positive association between SB and anxiety/
stress. These latter studies, however, did not meet our
inclusion criteria, because they failed to consistently use
the AASM diagnostic tool.7
Using a case–control approach, Katayoun et al23
reported a significant association between SB and psychosocial disorders (thought, conduct, and antisocial
disorders) among 12- to 14-year-old adolescents.
Similarly, Türkoğlu et al17 conducted a study in patients
aged 8 to 17 years and reported that SB is associated
with anxiety sensitivity. These results agree with those
of Lindqvist26 who reported a positive association
between atypical facets and nervous disorders in
12-year-old children.
Finally, one study21 surveying small pediatric cohort
(5- to 15-year-old children and adolescents; n = 10 for
SB and no SB groups) evaluated the association of SB
with attention-behaviour problems, and explored the
potential contribution of arousals in sleep bruxers.
Although arousals were correlated with attention problems, bruxer children trended toward more behavior
problems.
In summary, although SB is common in preschool
children,15we did not identify any published studies
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9
De Luca Canto et al
evaluating the association between SB and psychosocial
factors in younger children, that is, <5 years old. In children between 5 and 6 years old it seems that bruxism is
a relatively common childhood habit that does not
appear to exhibit significant psychological correlates.22
In older children (6-11 years old) and in adolescents (1217 years old), the available evidence supports a positive
association between SB and psychosocial factors.
However, we should caution that these portrayed and a
priori valid associations could reflect normal developmental processes rather than represent causal inferences.
Methodologically stronger research studies in these
populations are, however, warranted.
Assuming the face validity of the current systematic
review, our findings can be rationalized if we consider
that in most places, school begins after 5 years of age.
From the developmental standpoint, children will gradually become less egocentric and, henceforth, new experiences, particularly in social settings will increase their
effects. Thus, the period ranging from 7 to approximately 12 to 14 years of age will be characterized by
transition from syncretism to objectivity, whereby experiences and self gradually lose their quality of being
fragments of an absolute and undivided experience to
become interdependently coordinated with intuition.31
In this context, the effects of anxiety and stress in children and adolescents are similar to the reported findings
in the general population.32 Ultimately, SB is a dynamic
behavior that concerns medical, dental, and psychological health care domains, and may be an important behavior to consider within a multidisciplinary health care
context.15Multidisciplinary teams should be constituted
to develop research and clinical strategies to diagnose
and treat SB in children and adolescents, and thus
unravel in a more mechanistic fashion the emerging
interdependencies between psychosocial conditions and
phenotypic behaviors during sleep such as SB.
Limitations
Some methodological limitations of this review should
be considered. First, there was no standardization
regarding the survey instrument used to quantify psychological factors. Different psychological variables
were considered with overlapping confusing definitions,
all of which may obscure the actual findings. Also, the
questionnaires were applied by different professionals,
and the tools employed may very well be at the root of
the inconsistent results because of psychometric and
sampling issues. Additionally, 1 of the 7 articles had a
very small sample21 and another25 did not include a control group.
Conclusions
Based on the available evidence, there is no evidence
to support or dispel the presence of an association
between SB and psychosocial factors in children
younger than 5 years; a significant association between
SB and stressful, anxious, and tense personality traits
emerged in children between 6 and 11 years of age;
similarly, a significant association between SB and
psychosocial disorders (anxiety thought, conduct, and
antisocial disorders) was present in adolescents (12-17
years old).
Considering that pediatricians are the first professional to which the parents and the children complain
about bruxism, increased knowledge regarding SB in
general, and the association between SB and psychosocial factors may aid in the diagnostic process, formulation of the initial treatment plan, and ultimately assist
in timely referral to the appropriate specialist as
needed.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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