Journal Pre-proof

Determinants of Probable Sleep Bruxism in a Pediatric Mixed Dentition Population: A

Multivariate Analysis of Mouth vs. Nasal Breathing, Tongue Mobility, and Tonsil Size

James S. Oh, DDS, Soroush Zaghi, MD, Nora Ghodousi, DDS, Cynthia Peterson, PT,
Daniela Silva, DDS MS, Gilles Lavigne, DMD MSc PhD FRCD, Audrey J. Yoon, DDS
MS
PII: S1389-9457(20)30499-8
DOI: https://doi.org/10.1016/j.sleep.2020.11.007
Reference: SLEEP 4634

To appear in: Sleep Medicine

Received Date: 2 November 2020

Accepted Date: 5 November 2020

Please cite this article as: Oh JS, Zaghi S, Ghodousi N, Peterson C, Silva D, Lavigne G, Yoon AJ,
Determinants of Probable Sleep Bruxism in a Pediatric Mixed Dentition Population: A Multivariate
Analysis of Mouth vs. Nasal Breathing, Tongue Mobility, and Tonsil Size, Sleep Medicine, https://
doi.org/10.1016/j.sleep.2020.11.007.

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© 2020 Published by Elsevier B.V.

Determinants of Probable Sleep Bruxism in a Pediatric Mixed Dentition Population: A
Multivariate Analysis of Mouth vs. Nasal Breathing, Tongue Mobility, and Tonsil Size

James S Oh DDS1, Soroush Zaghi MD2,3, Nora Ghodousi DDS2, Cynthia Peterson PT2, Daniela
Silva DDS MS1, Gilles Lavigne DMD MSc PhD FRCD4, Audrey J Yoon DDS MS1

Affiliation
1. Section of Pediatric Dentistry and Orthodontics, Division of Growth and
Development, UCLA School of Dentistry, Los Angeles, CA, USA

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2. The Breathe Institute, Los Angeles, CA, USA

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3. UCLA Health, Santa Monica, CA, USA
4. Department of Oral Health, Université de Montréal, Montreal, Canada
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Corresponding Author:
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Audrey Jung-Sun Yoon DDS, MS

Section of Pediatric Dentistry and Orthodontics
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Division of Growth and Development

UCLA School of Dentistry
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10833 Le Conte Ave. CHS 20-137

Los Angeles, CA 90095
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Email: [email protected]

Highlights
• Probable sleep bruxism was associated with impaired nasal breathing, habitual mouth
breathing, restricted tongue mobility, and tonsillar hypertrophy
• Restricted tongue mobility was found to be an independent risk factor for bruxism.
• Tonsil hypertrophy, restricted tongue mobility, and nasal obstruction may have a
synergistic association on the presentation of sleep bruxism.
Abstract

Objectives:
This study aims to identify structural and functional craniofacial characteristics that correlate
with higher incidence of ‘probable’ sleep bruxism in children.

Methods:
From March 2018 until March 2019, a cross-sectional clinical study was performed with ninety-
six healthy children ages 6-12 years who presented for routine dental examination at the UCLA

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pediatric dental clinic. Variables of interest included: (1) assessment of probable bruxism based

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on parental awareness on the frequency of tooth grinding during sleep and clinical signs of
bruxism based on tooth wear; (2) parental reports of mouth breathing while awake and asleep,
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snoring during sleep, difficulty breathing and/or gasping for air during sleep; (3) parental reports
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of psychosocial distress; (4) assessment of tonsil hypertrophy, tongue mobility, and nasal
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obstruction. Three pediatric dental residents were calibrated to perform the clinical data
collection. All dental residents were graduated dentists with licensure and at least one year of
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experience examining children. The methodology to take the specific measurements

administered in the manuscript were calibrated between the data-collectors under the supervision
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of a board-certified pediatric dentist and orthodontist (AY).

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Results:
The mean age of individuals was 8.9 (SD=1.9) years with a gender distribution of 46 males and
50 females. There were 23 out of the 96 (24%) individuals who met the diagnostic criteria for
probable sleep bruxism (PSB). Sleep Disturbance Scale for Children (SDSC) scores were
significantly elevated among children positive for PSB, indicating that they are at higher risk for
sleep disturbances (PSB-positive: 45.1+/-13.0, PSB-negative: 34.8+/-5.5; p<0.0001). Impaired
nasal breathing, parental reports of mouth breathing when awake or asleep, restricted tongue
mobility, and tonsillar hypertrophy were found to be significant risk factors for PSB. Exploratory
analysis further suggests a synergistic effect between tonsil hypertrophy, restricted tongue
mobility, and nasal obstruction. The incidence of probable sleep bruxism among individuals
without any of the exam findings of tonsillar hypertrophy, restricted tongue mobility, and nasal
obstruction was 5/58 (8.6%), whereas the incidence of PSB among individuals with all three
exam findings was 10/11 (90.9%), p<0.0001. Among the 23 individuals with PSB, however,
there were n=5 (21.7%) who did not have any of the three exam findings, suggesting an
additional role of psychosocial distress, postural maladaptation, malocclusion, or other factors in
the etiology of sleep bruxism.

Conclusion:
This study shows that tonsil hypertrophy, restricted tongue mobility, and nasal obstruction may
have a synergistic association on the presentation of PSB. Dentists should evaluate for tonsillar

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hypertrophy, restricted tongue mobility, and nasal obstruction in the evaluation of PSB, as these

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exam findings are highly prevalent in the majority of cases.

Keywords:
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Bruxism, dental wear, restricted tongue mobility, sleep disordered breathing, pediatric dentistry,
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nasal breathing, tonsillar hypertrophy.

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Funding
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No funding was received for this study.

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Conflict of interest statement

The authors declare they have no conflicts of interest.
1. INTRODUCTION

Bruxism is defined as a repetitive jaw-muscle activity characterized by clenching or grinding of

the teeth and/or by bracing or thrusting of the mandible which may occur during sleep (sleep
bruxism), during wakefulness (awake bruxism), or both. A diagnostic grading system of bruxism
has been proposed for clinical and research purposes. ‘Possible’ bruxism is based on self-
reported, ‘probable’ is based on self-reported plus the inspection part of clinical examination and
‘definite’ bruxism is based on self-reported, a clinical examination, and a polysomnographic
recording preferably along with audio/video recording.1

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The prevalence of bruxism in children is highly variable with a range of 3.5-40.6%.2 Identifying
bruxism at an early age is crucial as it is a clinical risk factor for tooth wear, dental damage and
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fractures, jaw muscle fatigue, and pain.3
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Evolutionarily, keeping teeth sharp by bruxing has importance for food retrieval and defense. In
humans, remnants of this mechanism is believed to may have remained in some individuals as a
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maladaptive, inherited behavior.4 Whereas clenching and grinding of teeth may sometimes be
associated with normal teething and play a fundamental role in dental health and maxillofacial
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development, bruxism is considered clinically maladaptive and pathologic when associated with
excessive dental wear. Risk factors for pathologic bruxism include psychological or physical
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distress, behavioral abnormalities, and sleep disturbances.5 Current treatment modalities in

pediatric dentistry are often limited to focusing on the consequences of bruxism (as with occlusal
splints) or dental restoration as opposed to understanding and addressing associated factors that
may predispose to repetitive masticatory-muscle activity.6,7

The primary aim of this study was to identify parent-reported measures and clinical findings
associated with probable sleep bruxism (PSB) among children. The secondary objective of this
study was to determine the association between the various factors through multivariate
exploratory analysis.

2. METHODS
2.1 Design
From March 2018 until March 2019, a prospective cohort study was conducted of ninety-six
healthy children (mean age, 8.86 years; range, 6-12 years; 46 male, 50 female), who presented
for routine dental examination at the University of California, Los Angeles (UCLA). Exclusion
criteria were as follows: respiratory disease, known comorbidities, prescribed medications for
chronic disease, premature birth, craniofacial defect, prior orthodontic therapy, prior
tonsillectomy, prior oral or maxillofacial surgery. We assessed the impact of parent-reported
measures based on parent report as well as clinical findings based on examination by three

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pediatric dental residents on the outcome measure of probable sleep bruxism. Clinical examiners

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were blinded to the subjective survey and SDSC tool administered. To test inter-examiner
agreement, 10 individuals were selected at random and measured by all three residents. Intraclass
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correlation coefficient (ICC) in a mixed model was used to assess inter-rater agreement among
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the three residents for clinical item measurements. All showed excellent agreement (ICC>0.85)
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according to Cicchetti’s guideline.

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2.2 Sleep Disturbance Scale for Children (SDSC)

SDSC, developed in 1996 by Bruni et al., is a screening tool for parent-reported symptoms of
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sleep disorders in children that has been validated in previous studies. It comprises 26 items in a
Likert-type scale with values 1-5, with higher numerical values reflecting a greater clinical
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severity of symptoms. The sum of the scores was calculated to be the individual’s sleep index
score (range 26-130). Scores ranging from 26-35 are considered to be within normal range; 36-
44, 45-51, >52 are considered to be at mildly, moderately, severely, increased risk for sleep
disturbances, respectively.

2.3 Clinical assessment tool

In addition, the FAIREST-15 clinical examination screening tool also includes six questions
regarding breathing route, posture, concentration, and anxiety measures. Parents were asked to
rate on a scale of 1-4 the extent to which their child breathes through their mouth when awake
and when asleep; difficulty with concentration; anxiety measures (see appendix A). The
FAIREST-15 tool was adapted from FAIREST-21 tool which has been established in previous
literature.10

2.4 Clinical Findings

The clinical findings included in this study were the assessment of tonsillar hypertrophy based on
the Brodsky scale [Grade 1 (<25%); Grade 2 (26-50%); Grade 3 (51-75%); Grade 4 (>75%)]8,
tongue mobility based on the tongue range of motion ratio (TRMR) scale [Grade 1 (>80%);
Grade 2 (50-80%); Grade 3 (<50%); Grade 4 (<25%)]9, and nasal obstruction based on the nasal
breathing test [<1 min; 1-2 min; 2-3 min; 3+ min] (see appendix A). Nasal breathing test was

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administered by sealing lips and mouth of the subject with gentle MicroPore paper tape. A timer

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was used to assess how long the subject could comfortably breathe through the nose for up to
180 seconds with the lips and mouth taped. Subjects were deemed to pass the test if they could
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successfully breathe through the nose for three minutes.10
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2.5 Assessment of Bruxism

Bruxism has two distinct circadian manifestations: it can occur during sleep (indicated as sleep
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bruxism) or during wakefulness (indicated as awake bruxism).” A diagnostic grading system of

‘possible’, ‘probable’, and ‘definite’ sleep or awake bruxism has been developed for clinical and
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research purposes.1 In this manuscript, assessment of bruxism was based on parent-report as well
as clinical examination which meets the criteria for ‘probable’ sleep bruxism. Parent-report of
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sleep bruxism in this study was based on question #19 of the SDSC which asks the frequency to
which “the child grinds teeth during sleep” rated on an ordinal scale: never, occasionally,
sometimes, often, always. Clinical examination for the presence of dental wear was assessed on
an ordinal scale: none, mild, moderate - severe. The assessment of probable bruxism was
conferred if individuals met both criteria: affirmatory parent reports (occasional-always teeth
grinding during sleep) and presence of clinical dental wear (mild-severe) on exam findings.

2.6 Statistical Analysis

Analysis of variance (ANOVA) was performed to assess for statistically significant differences
in probable sleep bruxism outcomes among the parent-reported and clinical findings.
Significance for all statistical tests was predetermined at p<0.05. Associations of tonsil size,
TRMR, and nasal breathing to probable sleep bruxism were assessed by Chi-square test. All
analyses were done using JMP-14 (SAS Institute, Inc.) and p-value <0.05 was considered to be
statistically significant.

2.7 Ethics
This study was approved by the Institutional Review Board of the University of California, Los
Angeles (Protocol ID: 18-000810)

3. RESULTS

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96 participants enrolled in this study (mean age, 8.86 years; range, 6-12 years; 46 male, 50
female) were evaluated for the items described in the clinical exam tool. There were n=47
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subjects with no dental wear, n=37 subjects with mild dental wear, and n=12 subjects with
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moderate to severe dental wear. 23 participants were found to have probable sleep bruxism based
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on clinical reports as well as exam findings. SDSC scores were significantly elevated among
children positive for PSB for whom the diagnostic criteria were present (PSB-positive: 45.1+/-
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13.0 vs. PSB-negative: 34.8+/-5.5; p<0.0001). There were no significant effects of gender or age
differences on outcome measures.
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Parental reports of mouth breathing while awake, mouth breathing during sleep, snoring during
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sleep, and difficulty breathing and/or gasping for air during sleep were all associated with
increased odds of probable sleep bruxism. In addition, difficulty with concentration/focus was
also associated with increased odds of probable sleep bruxism, and stress/anxiety demonstrated a
trend to significance. See table 1.

Increased tonsil size (according to the Brodsky scale) was associated with a greater odds of
probable sleep bruxism. Pearson ChiSquare (n=96, df 3) = 20.0, p<0.0001. See figure 1.
Functional ankyloglossia (according to the TRMR scale) was associated with a greater odds of
probable sleep bruxism. Pearson ChiSquare (n=96, df 3) = 31.4, p<0.0001. See figure 2. Inability
to breathe through the nose for at least 3 min was associated with a greater odds of probable
sleep bruxism. Pearson ChiSquare (n=96, df 1) = 16.2, p<0.0001. See figure 3. Multivariate
analysis suggests that restricted tongue mobility was an independent risk factor for bruxism
when controlling for nasal breathing and tonsil size. See table 2.

Of the 96 participants, 25 had tonsil hypertrophy (Brodsky grade 3-4), 18 had restricted tongue
mobility (TRMR grade 3-4), and 30 had nasal obstruction (Nasal Breathing Test <3 min). There
were 58 participants without any of the above factors, 10 participants with one of the above
exam findings, 17 participants with two of the above findings, and 11 participants with all three
of the factors above. Although tonsil hypertrophy, restricted tongue mobility, and nasal
obstruction were each found to be statistically significant for an association with probable sleep

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bruxism, there was a synergistic effect in the study among individuals who were affected by all

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three factors. The incidence of probable sleep bruxism among individuals without any of exam
findings of tonsil hypertrophy, restricted tongue mobility, and nasal obstruction was 5/58 (8.6%),
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whereas the incidence of probable sleep bruxism among individuals with all three exam findings
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was 10/11 (90.9%), p<0.0001. See figure 4.
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4. DISCUSSION
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Bruxism is a clinical risk factor for tooth wear, dental damage and fractures, jaw muscle fatigue,
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and pain.3 Identifying the clinical signs of bruxism at an early age is crucial in order to prevent
the pathologic consequences that may occur. While the pathophysiology of bruxism remains
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poorly understood, the prevalence of bruxism appears to be significantly increased in participants

with sleep and breathing disorders.2,11 Bruxism has been associated with fragmented sleep12,13,
arousals during sleep leading to increase in parafunctional activity14,15, and activation of upper
airway muscles as a compensation for narrowed airway passages.16 Prior studies have shown
there is a positive correlation between the burden of sleep-disordered breathing due to
adenotonsillar hypertrophy with bruxism in children and significant improvement of bruxism
after adenotonsillectomy.13 Among adult individuals with obstructive sleep apnea, successful
treatment of breathing abnormalities with CPAP has been shown to eliminate bruxism during
sleep.17 Nevertheless, there are many individuals without sleep-disordered breathing who still
present with reports of teeth grinding and signs of moderate to severe signs of dental wear. Other
known risk factors for pathologic bruxism include psychological or physical distress, in addition
to non-breathing related sources of sleep disturbances.5

In this study, parental report of psychological distress, mouth breathing while awake, mouth
breathing while asleep, snoring, gasping for air and/or difficulty breathing were all associated
with increased odds of probable sleep bruxism. In addition, clinical findings of tonsil
hypertrophy, nasal obstruction, and restricted tongue mobility were found to have a synergistic
association with the incidence of probable sleep bruxism. Individuals without tonsil hypertrophy,
nasal obstruction, or restricted tongue mobility were unlikely to present with probable sleep

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bruxism (8.6%), whereas individuals with all three above factors were very likely to present with

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probable sleep bruxism (90.9%). It appears that in this population, breathing and tongue mobility
were the major determinants of probable sleep bruxism, however, it is important to note that
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there were n=5 individuals without any of these findings that still persisted with probable sleep
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bruxism likely attributable to other psychological or physical distress. On the other hand, there
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were n=1 individual with all three factors that did not present with PSB; it is important to note
that this individual had symptoms of anxiety/depression, snoring, and poor sleep despite the
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absence of parental recognition and physical exam findings of PSB.

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TONSILLAR HYPERTROPHY
This study shows tonsillar hypertrophy with a Brodsky scale grade 3+ to have a statistically
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significant association to increased odds of moderate-severe signs of probable sleep bruxism

(Table 2, Figure 1). Previous studies have shown a significantly higher incidence of bruxism
occurring in children with tonsil hypertrophy.18 In a study comparing the incidence of bruxism
before and after adenotonsillectomy, it was found that 45.6% of the individuals studied that
presented with tonsillar hyperplasia and sleep disordered breathing from 2-12 years old presented
with bruxism. Three months after adenotonsillectomy, just 11.8% of those individuals presented
with bruxism10. Children with airway obstruction pull the jaw forward to mechanically maintain
better airway patency. This may stimulate receptors in the upper airway to increased airway tone,
leading to bruxism.16 This draws researchers to conclude that the correction of the airway
obstruction decreases the arousals during sleep, leading to a decrease in the parafunctional
activity of bruxism.
TRMR
The results of this study showed a statistically significant association between ankyloglossia
(TRMR: Grade 3+) and increased odds of PSB (Table 2, Figure 2). We hypothesize that
ankyloglossia may lead to altered resting oral posture (low tongue position) contributing to oral
myofascial dysfunction.19

IMPAIRED NASAL BREATHING

Mouth breathing while asleep as well as mouth breathing while awake were significantly

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associated with bruxism in our study. Bruxism is a common complaint of parents of mouth-

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breathing children.13 Previous studies have explained the association of mouth breathing to
bruxism by the theory that bruxism increases salivary excretion for oral lubrication and the
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esophagus, and excess of saliva may drain out of the mouth that would be open, based on mouth
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breathing.20,21 Another explanation may be that mouth breathing interferes with the sleep cycle
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and affects cerebral oxygenation, bringing about somniloquy and involuntary muscle
contractions of the facial muscles, triggering sleep bruxism.21,22 Mouth breathing leading to oral
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dryness has also been associated with increased dental wear.23

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This study shows impaired nasal breathing statistically significantly associated with increased
odds of PSB (Table 2, Figure 3). In a previous study of children diagnosed with nasal obstruction
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from 2-13 years of age, 65.2% of those individuals presented with bruxism.24 Intragroup analysis
revealed a prevalence of allergic rhinitis associated with other airway diseases in the group with
bruxism, confirming the fact that allergic children are more predisposed to bruxism than non-
allergic children.25 Hypotheses related to the occurrence of bruxism amongst individuals with
nasal obstructions may include: altered saliva flow, changes to pressure in the eustachian tube,
and altered resting oral posture (low tongue position, lips apart, mouth breathing) contributing to
oral myofascial dysfunction.24

SPECTRUM OF BREATHING DYSFUNCTION

This study shows snoring, gasping for air and/or difficulty breathing are all associated with
increased odds of PSB (Table 1). Individuals with sleep bruxism have reported a 2–3 times
higher prevalence of obstructive sleep apnea.26 A significant correlation between sleep bruxism
and snoring has been supported by the previous studies in children.27,28 Although studies have
suggested the concomitant occurrence of tooth grinding in individuals with OSA, a limited upper
airway, rather than upper airway obstruction, could be a factor contributing to the relationship
between snoring and SB in children and adolescents.29 OSA and its relationship to sleep bruxism
is related to an arousal response that is often provoked by hypoxemia and breathing difficulty.26
The termination of the apneic event is often accompanied with a variety of oral phenomena such
as snoring, gasping, mumbling, and tooth grinding.26,30,31 Sleep-related problems are commonly
reported in 25– 40% of preschoolers and school children (e.g. insomnia, obstructive sleep apnea

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(OSA), restless legs syndrome (RLS), somniloquy, enuresis, rhythmic movements, and disorders

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of arousal).32,33 It is imperative to recognize these pathologies early, as children with sleep
bruxism can have a high likelihood of showing problematic daytime behavior which can also be
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frequently associated with sleep problems.27,32,34 This can therefore impair children’s learning
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ability throughout the day and effectiveness to perform well in school.
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PSYCHOLOGICAL DISTRESS
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This study shows parental reports of the child’s psychological distress as significantly associated
with bruxism (Table 1). Previous studies have shown that individuals with bruxism had elevated
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levels of catecholamines in their urine in comparison to non- bruxism participants; such findings
support a link between emotional stress and bruxism.35–37 Elevations of catecholamines may
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explain the body’s response to stress, as the sympathetic nervous system is activated, therefore
elevating catecholamine levels of the body.38 In addition, studies show individuals report that
they clench their teeth in periods of intense or frequent familial duties or increased workload.7
Children may also learn to clench by watching a parent react to stress, anger or frustration,
therefore mimicking their behaviors.7,19

Recommendations in previous studies have identified bruxism as a clinical risk factor in

recognizing psychological or psychiatric disorders, such as severe or pathological anxiety, mood,
and personality disorders.7 The expertise of a psychologist may be useful in those cases and
dentists may be integral in providing referral services to facilitate patient treatment and education.
In addition, sleep hygiene measures aim to reduce any influence of psychological stress on sleep
bruxism.11 This includes avoidance of caffeine close to bedtime, keeping the bedroom well-
ventilated and quiet, relaxing close to bedtime, and relaxation techniques before sleep.39

The results of this study suggest that altered resting oral posture (low tongue position due to
mouth breathing and/or ankyloglossia) may predispose to bruxism in the pediatric dental
population. Dentists are encouraged to look for signs of psychosocial stress, nasal obstruction,
mouth breathing, tonsillar hypertrophy, and restricted tongue mobility among individuals with
moderate to severe dental wear prior to restorative work as a potential underlying cause of the
individual’s recurrent poor dentition. Future studies from our group will investigate methods to

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reliably measure low tongue position: ranging from the whole tongue resting high in the roof of

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the mouth to the whole tongue lying low in the floor of mouth, and variations in between.

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Limitations include the single institute study, practitioner experience, and limited sample size.
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Also, our assessment for sleep bruxism is limited by classification on parent-report and clinical
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inspection only, as ‘definite’ sleep bruxism requires audio/video or polysomnographic

recordings. Future research designs would include a larger sample size, polysomnographic
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findings, and preferably combine ecological momentary assessment/experience sampling

methodology (EMA/ESM).
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5. CONCLUSION

In our study, probable sleep bruxism was found to be significantly associated with impaired
nasal breathing, habitual mouth breathing, restricted tongue mobility, and/or tonsillar
hypertrophy. Restricted tongue mobility was found to be an independent risk factor for bruxism
among individuals with normal nasal breathing. This study further shows that tonsillar
hypertrophy, restricted tongue mobility, and nasal obstruction may have a synergistic association
on the presentation of PSB.
Dentists should evaluate for tonsillar hypertrophy, restricted tongue mobility, and nasal
obstruction in the evaluation of PSB, as these exam findings are highly prevalent in the majority
of cases.

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LEGENDS

Table 1.
Subjective Parental Reports Related to Spectrum of Breathing Dysfunction and Psychosocial
Distress: Association with Probable Sleep Bruxism

Table 2.
Objective Clinical Factors Related to PSB: Results of Univariate and Multivariate Analysis

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Figure 1.

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Increased tonsil size (according to the Brodsky scale) is associated with a greater odds of
probable sleep bruxism, Pearson Chi Square (n=96, df 3) = 20.0, p<0.0001.
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Figure 2.
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Functional ankyloglossia (according to the TRMR scale) is associated with a greater odds of
probable sleep bruxism, Pearson ChiSquare (n=96, df 3) = 31.4, p<0.0001.
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Figure 3.
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Inability to breathe through the nose for at least 3 min is associated with a greater odds of
probable sleep bruxism, Pearson ChiSquare (n=96, df 1) = 16.2, p<0.0001.
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Figure 4.
There were 5/58 patients with 0/3 factors with PSB, as compared to 10/11 patients with 3/3
factors with PSB (p<0.001) indicating a compound and synergistic effect between tonsil size,
tongue mobility, and nasal breathing on PSB.
Table 1. Subjective Parental Reports Related to Spectrum of Breathing Dysfunction and
Psychosocial Distress: Association with Probable Sleep Bruxism

Probable Sleep Univariate Analysis

Bruxism

Prognostic Factor Yes No Odds 95% P-value

Ratio Confidence (Pearson’s
Interval Chi Square)

f
Spectrum of Breathing Dysfunction

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Mouth Breathing while awake 70.0% 37.0% 3.9 1.4-10.7 p=0.04 *

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(16/23) (27/73)
Mouth Breathing during sleep 73.9% 42.5% 3.8 1.36-10.86 p=0.009 *

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(17/23) (31/73)

Pr
Snoring during sleep 78.3% 37.0% 6.1 2.0-18.4 p<0.0001 *
(18/23) (27/73)

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Difficulty breathing and/or gasping for 39.1% 6.8% 8.7 2.5-30.0 p<0.0001 *

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air during sleep (9/23) (5/73)
Psychosocial Distress
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Difficulty with concentration/focus 65.2% 17.8% 8.7 3.0-24.7 p=0.0002 *
(15/23) (13/73)
Almost always feels stressed/anxious 8.7% 1.4% 6.9 0.6-79.4 p=0.078
(2/23) (1/73)
 Table 2. Objective Clinical Factors Related to PSB: Results of Univariate and
Multivariate Analysis

Probable Sleep Univariate Analysis Multivariate Analysis

Bruxism

Yes No Odds 95% P-value Odds 95% P-value

Ratio Confidence (Pearson’s Ratio Confidence (Pearson’s
Interval Chi Interval Chi
Prognostic Factor

f
Square) Square)

oo
Ankyloglossia: TRMR Grade 3+ 56.5% 6.8% 21.2 6.2-72.8 p<0.0001 * 10.6 2.8-40.7 p=0.0006 *

pr
(13/23) (5/73)
Nasal Breathing Test: Unable to breathe 65.2% 20.5% 7.3 2.6-20.3 p<0.0001 * 2.1 0.5-8.5 p=0.2915

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through nose for >3 min at time of exam (15/23) (15/73)

Pr
Tonsil Size: Brodsky Grade 3+ 60.9% 15.1% 8.8 3.1-25.2 p<0.0001 * 2.7 0.7-11.2 p=0.1618
(14/23) (11/73)

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