Association of Possible Sleep Bruxism with Oral Health-Related Quality of Life in AdolescentsABSTRACT
Objective: To evaluate the impact of possible sleep bruxism on oral health-related quality of life (OHRQoL) in adolescents.
Material and Methods: This is a cross-sectional study nested within a cohort study initiated in 2010 with a sample of preschool children from Santa Maria, Brazil. Subsequently, individuals were re-evaluated in 2020, totaling 10 years of follow-up. The sample used in this study is a follow-up sample, comprising 429 adolescents aged 11 to 15 years. OHRQoL was assessed using the CPQ11-14. Possible sleep bruxism was assessed by self-report using the question "Do you grind your teeth while sleeping?" Demographic, socioeconomic, and clinical variables were also taken into account. An adjusted multilevel Poisson regression analysis was conducted to evaluate the association between sleep bruxism and OHRQoL.
Results: The mean age of the individuals followed was 12.6 years (standard deviation [SD] 1.6). The mean CPQ11-14 scores were 10.6 (SD 8.4), and the prevalence of sleep bruxism was 14.4%. Adolescents who presented possible sleep bruxism had scores 30% higher on the CPQ11-14, indicating a greater impact on OHRQoL.
Conclusion: Individuals with sleep bruxism experience a lower OHRQoL compared to those without sleep bruxism.
Keywords:
Sleep Bruxism; Adolescent; Oral Health; Quality of Life.
Introduction
In recent decades, there has been a notable change in the prevalence of various oral diseases within populations, particularly dental caries and gingivitis. Conversely, there has been an increase in the number of individuals diagnosed with harmful parafunctional habits that impact the stomatognathic system [1,2]. Especially in the child and adolescent population, there has been a growing detection of signs and symptoms of bruxism, causing concern among health professionals, facing a problem of difficult diagnosis and treatment that can often affect aesthetics, function, and quality of life [3].
Sleep bruxism is a repetitive activity of the jaw muscles characterized by grinding or clenching of the teeth or by pushing the jaw during sleep. It can be described as either rhythmic (phasic) or non-rhythmic (tonic) muscle activity. Importantly, sleep bruxism is not classified as a movement disorder or a sleep disorder in healthy individuals [4]. Bruxism has two classifications and definitions based on its circadian phenotype: awake bruxism or sleep bruxism. Similarly, it can be defined as possible (self-report), probable (clinical examination), or definitive (polysomnography) [4]. The literature shows that the prevalence of bruxism varies between 3 to 49% in the adolescent population [5,6], being an essential factor to consider in this age group.
It is known that the occurrence of bruxism has the potential to negatively affect individuals' daily lives, as it can bring episodes of pain, discomfort during chewing, and aesthetic impairments [7-9]. Thus, considering its multiple harms and consequences, the occurrence of bruxism in adolescence can affect the well-being and oral health-related quality of life (OHRQoL) of affected individuals. OHRQoL is a construct encompassing self-esteem and self-perception, and that impacts daily life regarding individuals' oral health. It also reflects individuals' comfort when eating, sleeping, and engaging in social interactions, as well as their self-esteem and satisfaction with their oral health [10,11].
Previous literature has shown the potential effects of bruxism across different domains of OHRQoL [7-9]. However, although previous studies have evaluated the association between sleep bruxism and OHRQoL, most have investigated it among children [9,12,13] or adults [14,15]. Therefore, this relationship has not yet been thoroughly explored, and its effects are not well understood among adolescent populations in the Southern region of Brazil. Thus, this study aims to assess the association between sleep bruxism and OHRQoL in adolescents. We hypothesize that adolescents with this condition have worse levels of OHRQoL.
Material and Methods
This study follows the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines [16].
Population and Sample
This cross-sectional study is part of a 10-year cohort conducted in Santa Maria, a city located in southern Brazil. According to the Brazilian Institute of Geography and Statistics, the city's estimated population in 2021 was 285,159, including 29,893 adolescents aged 5 to 14 years.
The baseline data collection for this cohort began in 2010 (T1) during the National Children's Multivaccination Day. We included all health centres with a dental chair (n=15), distributed across various neighbourhoods and administrative regions of the city. Children were systematically selected from the vaccination queue to participate in the study. In total, 639 children aged 1 to 5 years were evaluated. Additional methodological details regarding this phase of the study have been published beforehand [17].
Subsequently, individuals were re-evaluated in 2020, for a total of 10 years of follow-up (T2). All participants from the first stage were invited to the follow-up (n = 639). Some search strategies were used to locate adolescents at follow-up, such as telephone calls, school visits, and social networks. Examinations and questionnaires for adolescents were administered either at their schools or at their residences. During this revaluation stage, the data considered in this study were obtained.
To calculate the sample size, a standard error of 5% was considered, a confidence interval of 95%, and a mean difference in CPQ11-14 of 14.0 (SD 8.4) in exposed individuals (with sleep bruxism) and 11.4 (SD 7.8) in those not exposed (without sleep bruxism) [18]. Considering a power of 80% and a 1:1 ratio of exposed to unexposed individuals, the calculation resulted in a total of 302 individuals. To account for potential losses, we determined that a minimum sample size of 393 individuals was required, with a 30% allowance.
Collection of Data and Variables
OHRQoL was assessed using the short version of the Child Perception Questionnaire (CPQ11-14) [19], completed by the students. This questionnaire consists of 16 questions divided into four domains: oral symptoms, functional limitations, emotional well-being, and social well-being. Participants respond to each question using a Likert scale that ranges from 0 to 4 points, with the following options: (0) never; (1) once or twice; (2) sometimes; (3) frequently; and (4) every day or almost every day. The total score is calculated by adding the points for all items, yielding a score ranging from 0 to 64. A higher score indicates a greater impact of oral health conditions on the individual's quality of life.
Possible sleep bruxism was diagnosed through self-reporting by the participating adolescents or through reports from parents or guardians about audible grinding sounds during the adolescents’ sleep. Sleep bruxism was collected through the question: "Do you grind your teeth while sleeping?", with response options: (0) no and (1) yes, based on previous literature on the topic [20].
Demographic and socioeconomic variables were gathered using a structured questionnaire, which served as adjustment variables in the study. Demographic characteristics included sex (male and female); age (reported in years and dichotomized by the sample mean); and skin color, which was assessed according to criteria proposed by the Brazilian Institute of Geography and Statistics (IBGE), using the question “What race do you consider yourself to be?”, subsequently dichotomized into “white” and “non-white” (mixed-race, black, yellow, or indigenous). The socioeconomic variable included household income, collected in Brazilian reais and categorized according to the Brazilian minimum wage (MW) into: > 1MW and < 1MW. One Brazilian minimum wage is approximately equivalent to 200 US dollars.
Dental caries was assessed according to the International Caries Detection and Assessment System (ICDAS) criteria [21]. The examiners underwent prior training and calibration, achieving interand intra-examiner Kappa coefficients ranging from 0.70 to 0.96. Each individual was evaluated separately, utilizing gauze, a CPI probe (commonly referred to as a "ball point"), and a dental mirror. Adolescents were assessed either at home or at school, with evaluations conducted using natural light. For data analysis, dental caries was classified based on the presence (ICDAS scores of 3, 5, and 6) or absence (ICDAS scores of 0, 1, 2, and 4) of cavitated carious lesions.
Data Analysis
Data analysis was carried out using Stata 17.0 (StataCorp, College Station, TX, USA). We conducted a descriptive study to characterize the sample. A comparison between participants who were followed up and those who dropped out was made to confirm the representativeness of our sample after ten years. This was evaluated using chi-square tests and t-tests. All analyses accounted for sample weights using the “svy" command. The study's outcome was measured using the total scores of the CPQ11-14.
We employed adjusted and unadjusted multilevel Poisson regression models to examine the relationship between sample characteristics and overall CPQ11-14 scores. Predictor variables that demonstrated a p-value of less than 0.20 in the unadjusted analysis were included in the adjusted model. Results are presented as Rate Ratio (RR) and 95% confidence intervals (95% CI). A significance level of 0.05 was established.
Results
Of the 639 children assessed at the beginning of the study, 429 were evaluated during follow-up, yielding a retention rate of 67.1%. The reasons for losses to follow-up included the inability to locate the adolescent (n = 184), relocation to another city (n = 19), and refusal by either the adolescent or their guardian (n = 7).
Table 1 shows the general sample characteristics. The sample was comparable for girls and boys, and the mean age of the individuals followed was 12.5 years (SD = 1.3). Regarding socioeconomic variables, the majority of adolescents had household incomes higher than the minimum wage. Regarding oral health-related characteristics, 14.3% of adolescents reported sleep bruxism, and 30.6% had untreated dental caries. Additionally, the mean CPQ11-14 scores were 10.6 (SD = 8.4).
Sample characteristics according to demographic, socioeconomic, and oral health-related characteristics.
Table 2 presents the association analysis between sleep bruxism and overall CPQ11-14 scores. In the unadjusted analysis, sex, skin color, household income, presence of sleep bruxism, and dental caries were associated with poorer OHRQoL (p<0.05). In the adjusted analysis, adolescents who presented possible sleep bruxism had CPQ11-14 scores 30% higher than their equivalents (RR 1.30; 95% CI 1.19-1.41), indicating a greater impact on OHRQoL. Additionally, girls (RR 1.19; 95% CI 1.12-1.27), those from low-income households (RR 1.22; 95% CI 1.13-1.30), and those with cavitated dental caries (RR 1.14; 95% CI 1.07-1.23) also had poorer OHRQoL.
Unadjusted and adjusted analysis of the association between sleep bruxism and overall CPQ11-14 scores.
Discussion
This study's results confirm the hypothesis that sleep bruxism may harm OHRQoL among adolescents. Our findings also suggest that girls, those from low-income households, and those with cavitated dental caries also presented poorer OHRQoL. Although the literature has already assessed this association, studies exploring the disorder during adolescence in the Southern region of Brazil have not yet been conducted.
Our results demonstrated a prevalence of possible sleep bruxism of 14.4% among adolescents. The prevalence was lower than that reported in studies carried out in other regions of Brazil, which ranged from 22.2% to 31% [22, 23]. This divergence can be explained by the fact that in our study, the report of possible sleep bruxism was given by the adolescent himself, which may underestimate the results since the adolescent himself is sleeping while carrying out the activity, and, at this age, parents start to visit their children's rooms less frequently [22].
The results indicated that individuals with possible sleep bruxism experienced a more significant impact on their OHRQoL. This can be attributed to the connection between emotional factors, such as stress and anxiety, as well as certain personality traits, and sleep bruxism. It is believed that this condition serves as a mechanism for releasing the tension that has built up throughout the day. Therefore, individuals who experience episodes of bruxism have worse sleep quality [15] and, consequently, are more tired when carrying out their daily activities, which affects how they perceive their oral health. Furthermore, symptoms of masticatory muscle pain and wear from grinding and clenching can compromise individuals' quality of life. Additionally, aesthetics can be affected by wear, which can influence adolescents' perceived oral health [24].
The findings also show that girls had a greater impact on OHRQoL, in line with previous studies [25-27]. This result can be attributed to women’s greater awareness and concern regarding their oral health care, as reported in previous literature [26]. Additionally, it is important to consider psychosocial factors, such as gender roles and aesthetic pressures, which influence adolescents' perceptions and self-esteem regarding their oral health [28], thereby playing a crucial role in determining OHRQoL.
It is well established in the literature that socioeconomic factors are associated with OHRQoL, meaning that individuals with lower socioeconomic backgrounds exhibit poorer health and quality of life [29]. Our findings also demonstrated this association, as lower household income was associated with worse OHRQoL among adolescents. Household income was used as a proxy for socioeconomic status, as it has been widely used in previous studies [29]. In this sense, this finding can be explained by the susceptibility of these individuals to various risk factors that influence oral health [30], such as material and psychosocial factors [29], which can affect individuals' perceived oral health and OHRQoL.
Adolescents with cavitated dental caries lesions had a greater impact on OHRQoL, in line with previous studies [31-34]. This can be explained by the fact that individuals with untreated caries lesions experience more episodes of toothache, leading to functional limitations and difficulties in performing daily activities such as eating and sleeping [32]. Furthermore, the consequences of untreated lesions also extend to individuals' psychosocial domains. Some authors demonstrated that verbal bullying related to the oral condition of adolescents was mainly associated with untreated dental caries lesions [35]. Besides, victims of school bullying and verbal bullying related to oral conditions are more likely to have bruxism associated with poor sleep quality [36].
Several limitations of the study should be noted. The data are cross-sectional, which may constrain causal inferences regarding the findings. Nevertheless, no prior research has investigated the relationship between potential sleep bruxism and oral health-related quality of life (OHRQoL) during adolescence in this region. Therefore, it is suggested that future longitudinal investigations be conducted to better understand the effects of sleep bruxism on individuals' quality of life. Additionally, possible sleep bruxism was measured through self-reporting by the adolescent, which may not be as accurate as clinical evaluation or polysomnography [4]. However, this form of assessment is valid in previous studies [37], even though polysomnography is a complex and costly method to apply in population-based studies. It is important to note that this study did not consider several significant variables related to bruxism that could affect the outcome, such as sleep disorders. Therefore, future research incorporating these factors may be required.
Despite limitations, our study also has strengths that warrant emphasis. This study assessed the occurrence of possible sleep bruxism and its impact on an important patient-reported outcome during adolescence. Evaluating these factors during this phase is highly relevant, as it is a critical period of transition in individuals' lives, subject to changes and impacts that can persist throughout life [38].
Conclusion
Adolescents with possible sleep bruxism presented poorer OHRQoL compared to their counterparts without bruxism. Nonetheless, the effect of bruxism on OHRQoL was even greater than that of dental caries in this sample. Thus, in the context of clinical care for adolescents, our results suggest the importance of evaluating parafunctional habits, an increasing oral health problem in this age group.
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Financial SupportThis study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES)-Finance Code 001 and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS - process 21/2551-0002006-7).
Acknowledgements
The authors thank all the children, their parents, and schools for their cooperation, as well as the Health and Education Authorities of Santa Maria, Rio Grande do Sul, for their information and authorization.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alessandro Leite Cavalcanti
