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

Effects of orthodontic aligners on the ecological report of awake bruxism

BACKGROUND

The demand for orthodontic treatment with aligners has recently increased, but their effects on awake bruxism (AB) behaviours have to be evaluated yet.

OBJECTIVES

This investigation assessed if aligners can affect oral behaviours (i.e. tooth contact, teeth clenching, teeth grinding and mandible bracing) that are related with the AB spectrum.

METHODS

The investigation was performed in a sample of 32 consecutively recruited healthy adult patients who required orthodontic treatment. The study protocol involved three different sessions of 1-week monitoring without aligners, with passive aligners and with active aligners, respectively. All patients underwent an orthodontic treatment with aligners and used a smartphone-based application for a real-time report (i.e. ecological momentary assessment [EMA]) of their AB behaviours. Recording time was set from 8.00 to 12.30 and from 14.30 to 22.00. Analysis of variance (ANOVA) was used to compare the average reported frequency for each activity within and between the different sessions. The coefficient of variation (CV) was assessed to evaluate daily fluctuations within the 7 days monitoring periods.

RESULTS

The average reported frequency of the relaxed condition was 64.9%, 63.0% and 60.0% during the sessions without aligners, with passive aligners and with active aligners, respectively. ANOVA showed no significant differences in any of the AB behaviours within (i.e. between 7 days of evaluation) and between the monitoring sessions (i.e. before orthodontic treatment, with passive aligners, with active aligners). No sex differences were detected, except for the 'tooth contact' report that showed a higher frequency in females.

CONCLUSION

The impact of our results in the orthodontic field is not negligible; clinicians can find support for the hypothesis that from a global point of view, wearing or not wearing aligners (passive and/or active) does not influence the frequency of AB behaviours at the short term.

Actual state of the diurnal masseteric electromyogram: Differences between awareness and non-awareness of awake bruxism

PURPOSE

This study aimed to elucidate the relationship between diurnal masseter muscle activity and awareness of diurnal awake bruxism (d-AB) by conducting a comparative analysis of electromyographic (EMG) data from individuals with and without awareness of diurnal awake bruxism (d-AB), utilizing EMG data gathered from multiple subjects.

METHODS

Unilateral masseter electromyography (EMG) recordings were performed during the daytime using an ultraminiature wearable EMG device. A total of 119 participants (59 with awareness of diurnal tooth clenching [d-TC] and 60 without awareness of d-TC) were included. Waveforms longer than 0.25 s with the two amplitude conditions, exceeding twice the baseline and >5% of maximum voluntary clenching, were extracted. In addition, the number of bursts and episodes (groups of bursts), burst duration, and burst peak amplitude were calculated for each participant.

RESULTS

There were no significant differences in the EMG parameters between the groups with and without awareness of d-TC. Additionally, the frequency distribution of the number of EMG waveforms exhibited wide ranges and substantial overlap between the two groups.

CONCLUSIONS

The variability in the number of bursts and episodes, burst peak amplitude, and burst duration among subjects suggests the need for an objective classification of d-AB severity based on EMG values. The absence of significant differences and large overlap in frequency distributions between the groups with and without awareness of d-TC indicate difficulty in predicting muscle activity solely based on awareness of d-AB.

Awake bruxism report in a population of dental students with and without ecological momentary assessment monitorization-A randomised trial

OBJECTIVE

The Ecological Momentary Assessment (EMA) concept was the basis for developing a smartphone application for the real-time report of awake bruxism (AB) activities. The aim of this study was to assess the effects of the EMA with a randomised controlled trial designed to compare the frequency of AB reported in two separate single observation points between a group of students monitored over time with an EMA smartphone application and a non-EMA monitored group.

METHODS

Sixty-four (N = 64) dental students (22.3 YO [±2.6]; 52F; 12 M) answered the Oral Behaviour Checklist (OBC-1) and were randomised into an EMA-group (EG) and control group (CG). EG were monitored with a smartphone application for AB report during seven consecutive days and completed three EMA monitoring periods (EMA-1, 2 and 3) at one-month intervals. After the third period (EMA-3), both EG and CG answered again the OBC (OBC-2). Descriptive statistics were performed to characterise the sample. Pearson's chi-squared test, Fixer Exact test and post hoc Z test with Bonferroni correction were performed. The study hypothesis was that EMA could influence the AB reported by the participants because it implies an increase in the awareness, self-recognition, and self-control of bruxism behaviours. The level of significance was set at p < .05.

RESULT

The percentage of participants who changed the report of the activity of clenching their teeth while awake between OBC-1 and OBC-2 was significantly higher among participants in EG, when compared to CG (p = .027). For all other behaviours reported the within- and between-group differences from OBC-1 to OBC-2 were not significant. Clenching and bracing were the most frequently reported, whilst grinding was the less frequent behaviour.

CONCLUSION

A smartphone-based EMA approach demonstrated be useful to monitor AB over time, increasing individual's awareness, particularly to bracing and clenching behaviours.

Is there a relationship between the presence of external root resorption in second molars adjacent to impacted mandibular third molars with awake bruxism and masticatory muscle activity?

OBJECTIVES

This study aimed to assess whether awake bruxism and masticatory muscle activity could be related to external root resorption (ERR) in second molars adjacent to impacted mandibular third molars.

MATERIALS AND METHODS

Sixty patients, with requests for a cone-beam, computed tomography, were divided into two groups: ERR (patients with ERR in the second molar, n = 30), and control group (n = 30). Awake bruxism was assessed through the Oral Behaviors Checklist (OBC) and an ecological momentary assessment (EMA). Surface electromyography (EMG) was used to assess the masseter and anterior temporal muscle function. Normality and homogeneity of variances were demonstrated. Descriptive analysis was performed, using the T-test and Chi-square test to compare the characteristics of the groups. A multiple regression model was performed.

RESULTS

The ERR group presented more non-functional oral activities related to awake bruxism than the control group, according to OBC (p = 0.027) and EMA (p = 0.035). In addition, the ERR group had higher EMG activity than the control group in rest and isotonic protocols (p < 0.05).

CONCLUSIONS

Awake bruxism and greater masticatory muscle activity seem to be related to the presence of ERR in second molars adjacent to impacted mandibular third molars.

CLINICAL RELEVANCE

The results of the present study can reinforce the theory that triggering ERR in the second molars adjacent to impacted mandibular third molars may be related to mechanical forces coming from the masticatory function.

Awake bruxism behaviors frequency in a group of healthy young adults with different psychological scores

OBJECTIVE

To assess the frequency of awake bruxism (AB) behaviors in a group of undergraduate dentistry students and correlate it with the status of anxiety and depression.

MATERIALS AND METHODS

The frequency of five oral behaviors (i.e., relaxed jaw muscle, teeth contact, mandible bracing, teeth clenching, teeth grinding) was evaluated using a smartphone-based ecological momentary assessment (EMA) approach. The anxiety and depression status was investigated with the four-item patient health questionnaire for anxiety and depression (PHQ-4). ANOVA with Tukey post-hoc test was used to assess the difference in frequency of AB behaviors among the four PHQ-4 groups.

RESULTS

Among the four groups, there was a statistically significant difference in the frequency of relaxed jaw muscle, teeth contact, mandible bracing, and teeth clenching, but not for teeth grinding.

CONCLUSION

Based on this cross-sectional study's findings, psyche seems to have a determinant impact on AB behaviors, which is significantly higher in individuals with anxiety and depression traits.

Benefits of the combination of digital and analogic tools as a strategy to control possible awake bruxism: A randomised clinical trial

BACKGROUND

Awake Bruxism (AB) management includes cognitive and behavioural changes. Digital and analogic tools can be used to remind the individual to control/avoid AB behaviours. However, no study addressed both tools together.

OBJECTIVE

To compare the efficacy of the combination of digital (smartphone application) and analogic (adhesive reminders) tools versus digital tool alone for AB management.

METHODS

Seventy-two individuals diagnosed with probable AB were divided into 3 groups: Group 1 (n = 24), used both digital and analogic tools during 30 days; Group 2 (n = 24), used only a digital tool during 30 days and Group 3 (n = 24), used only a digital tool for the first 15 days and then added the analogic tool for 15 days. The AB frequency was measured in real-time with a smartphone app, which sent alerts asking the individuals if they were doing any AB behaviours (bracing, teeth contact, clenching or grinding). Groups were compared using one-way ANOVA and before-after adding an analogic tool (group 3) by paired t-test, considering α = 0.05.

RESULTS

All groups showed a decrease in AB behaviours at the end of the evaluation period. Group 1 (digital and analogic tools) showed the lowest average of AB behaviours among all groups; however, statistically significant differences were found only for the comparison between groups 1 and 2. In group 3, a significantly greater reduction in AB behaviours was found after combining both approaches.

CONCLUSION

The combination of digital and analogic tools showed the greatest reduction of AB frequency and can be recommended for AB control.

Examination of the relationship between masseter muscle activity during sleep and wakefulness measured by using a wearable electromyographic device

Purpose This study aimed to measure masseter muscle activity throughout the day in outpatients suspected of having awake bruxism (AB) and/or sleep bruxism (SB) and examine the relationship between AB and SB by comparing muscle activity during daytime wakefulness and nighttime sleep.Methods Fifty outpatients with suspected SB and/or AB participated in this study. A single-channel wearable electromyogram (EMG) device was used for EMG recording. The selected EMG bursts were divided into bursts during sleep (S-bursts) and bursts during awake state (A-bursts). The number of bursts per hour, average burst duration, and ratio of burst peak value to maximum voluntary contraction were calculated for both the S- and A-bursts. These values of the S- and A-bursts were then compared, and the correlations between them were analyzed. Additionally, the ratios of phasic and tonic bursts in the S- and A-bursts were compared.Results The number of bursts per hour was significantly higher for A-bursts than for S-bursts. No significant correlation was found between the numbers of S- and A-bursts. The ratio of phasic bursts was large and that of tonic bursts was small in both the S- and A-bursts. A comparison of the S- and A-bursts showed that the S-bursts had a significantly lower ratio of phasic bursts and higher ratio of tonic bursts than the A-bursts.Conclusions The number of masseteric EMG bursts during wakefulness did not show any association with that during sleep. It became clear that sustained muscle activity was not dominant in AB.

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.

Predicting Completion of Ecological Momentary Assessments Among Substance-Using Women Experiencing Intimate Partner Violence

Noncompletion of ecological momentary assessment (EMA) surveys is a common issue and may yield bias in results if not properly handled. Using data observed at scheduled times as well as data retrieved later to fill missing responses, this study aims to investigate predictors of EMA completion, including demographic characteristics, time-related factors, and momentary experiences/behaviors. Data were from a 30-day EMA study including 145 women currently experiencing intimate partner violence (IPV) and using substances. The average rate of EMA completion was initially 51.4% at the scheduled times and increased to 72.6% after incorporating data from later-retrieved surveys. Participants who were younger, had more children, or had lower mean levels of negative affect dysregulation showed lower completion rates. At the momentary survey level, more days into the study and afternoon/evening reports (vs. morning reports) were associated with lower completion; lower levels of negative affect dysregulation, less smoking or alcohol use, and experiencing IPV were linked to lower momentary completion. Implications of the results for handling missing data in EMA are discussed and have important ramifications for future research, practice, and theory.

Smartphone application to report awake bruxism: Development and testing of the Swedish version and a pilot study to evaluate family history in young adults and their parents

BACKGROUND

Together with psychosocial and hereditary factors, bruxism is a possible risk factor for orofacial pain. Bruxism is defined as a masticatory muscle activity characterized by repetitive or sustained tooth contact, or by bracing or thrusting of the mandible. A smartphone application to report awake bruxism (AB) has been developed and translated into more than 25 languages.

OBJECTIVE(S)

To translate the application into Swedish, adapt it to Swedish culture and conduct a study to evaluate the usability of the application for studies on family history and associated risk factors.

METHODS

Translation and cultural adaption of the Swedish version of the application (BruxApp) was carried out in a four-step sequential process. Ten young adults (22-30 years) were recruited together with ten parents (42-67 years) and reported their AB with the application over two seven-day periods. Pain, stress and parafunctional behaviours were assessed by questionnaires.

RESULTS

The back translation check showed minimal discrepancies between the translation and the English version. Participants did not report any problems with the application. Response rates for both groups were 65%. A difference in frequency of AB was shown between young adults and parents (22.0% vs. 12.5%, p < .001). A positive moderate correlation was found between AB and stress (r = 0.54, p = .017).

CONCLUSION

The use of application strategies enables data collection on AB which can be used in both clinical and research settings. The results suggest that the Swedish version is ready for implementation and for studies on the relationships between AB, family history and psychosocial factors.

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.

Research routes on awake bruxism metrics: Implications of the updated bruxism definition and evaluation strategies

BACKGROUND

With time, due to the poor knowledge on it epidemiology, the need to focus on awake bruxism as a complement of sleep studies emerged.

OBJECTIVE

In line with a similar recent proposal for sleep bruxism (SB), defining clinically oriented research routes to implement knowledge on awake bruxism (AB) metrics is important for an enhanced comprehension of the full bruxism spectrum, that is better assessment and more efficient management.

METHODS

We summarised current strategies for AB assessment and proposed a research route for improving its metrics.

RESULTS

Most of the literature focuses on bruxism in general or SB in particular, whilst knowledge on AB is generally fragmental. Assessment can be based on non-instrumental or instrumental approaches. The former include self-report (questionnaires, oral history) and clinical examination, whilst the latter include electromyography (EMG) of jaw muscles during wakefulness as well as the technology-enhanced ecological momentary assesment (EMA). Phenotyping of different AB activities should be the target of a research task force. In the absence of available data on the frequency and intensity of wake-time bruxism-type masticatory muscle activity, any speculation about the identification of thresholds and criteria to identify bruxers is premature. Research routes in the field must focus on the improvement of data reliability and validity.

CONCLUSIONS

Probing deeper into the study of AB metrics is a fundamental step to assist clinicians in preventing and managing the putative consequences at the individual level. The present manuscript proposes some possible research routes to advance current knowledge. At different levels, instrumentally based and subject-based information must be gathered in a universally accepted standardised approach.

The development of the Standardised Tool for the Assessment of Bruxism (STAB): An international road map

This paper summarises the background reasoning and work that led to the selection of the items included in the Standardised Tool for the Assessment of Bruxism (STAB), also introducing the list of items. The instrument is currently being tested for face validity and on-field comprehension. The underlying premise is that the different motor activities included in the bruxism spectrum (e.g. clenching vs. grinding, with or without teeth contact) potentially need to be discriminated from each other, based on their purportedly different aetiology, comorbidities and potential consequences. Focus should be on a valid impression of the activities' frequency, intensity and duration. The methods that can be used for the above purposes can be grouped into strategies that collect information from the patient's history (subject-based), from the clinical assessment performed by an examiner (clinically based) or from the use of instruments to measure certain outcomes (instrumentally based). The three strategies can apply to all aspects of bruxism (i.e. status, comorbid conditions, aetiology and consequences). The STAB will help gathering information on many aspects, factors and conditions that are currently poorly investigated in the field of bruxism. To this purpose, it is divided into two axes. Axis A includes the self-reported information on bruxism status and potential consequences (subject-based report) together with the clinical (examiner report) and instrumental assessment (technology report). Axis B includes the self-reported information (subject-based report) on factors and conditions that may have an etiological or comorbid role for bruxism. This comprehensive multidimensional assessment system will allow building predictive model for clinical and research purposes.

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.

A worldwide bibliometric analysis of the research trends and hotspots of bruxism in adults during 1991-2021

BACKGROUND AND OBJECTIVES

With the increasing attention to bruxism, the research on bruxism is increasing rapidly. However, there is still a lack of systematic bibliometric analysis in the field of bruxism in adults. This study aimed to comprehensively explore and visualize the global trends and research hotspots in the field of bruxism in adults during 1991-2021.

METHODS

The study searched the literature published during 1991-2021 in the Web of Science Core Collection database without language restrictions. VOSviewer, CiteSpace and Microsoft Excel were applied to analyse the authors, institutions, journals, countries, cited references, keywords and other information of the included publications, and construct visualized cooperation networks.

RESULTS

A total of 878 articles were finally included. The top two most productive authors in the past 30 years were Lobbezoo F and Manfredini D. ACTA-Amsterdam, Univ Sao Paulo, Univ Helsinki, Univ Padua, Univ Montreal, et al. were prominent institutions in this field. Journal of Oral Rehabilitation made outstanding contributions in this field. The United States produced the most documents in this field, followed by Brazil. Both countries and authors cooperated closely around the world. The two most cited articles focused on the definition, assessment and classification of bruxism. In recent years, diagnostic criteria and stress have begun to receive a lot of attention.

CONCLUSION

From 1991 to 2021, the attention to bruxism in adults continued to increase. Diagnostic criteria and stress may be potential research hotspots in this field. This study references relevant scholars on development trends and research hotspots.

Smartphone Applications in Dentistry: A Scoping Review

This scoping review aims to investigate the latest literature concerning the use of smartphone applications (apps) in the prevention, management, and monitoring of oral diseases. Smartphone applications are software programs that are designed to run on smartphones. Nowadays, smartphones are regularly used by people of all ages, and mobile health apps (MHAs) represent an important means of spreading information related to oral health, which is the state of the mouth and teeth, including the gums and other tissues. Several apps have been designed to promote prevention, diagnosis, and therapeutic adherence monitoring. This scoping review considered randomized clinical trials, cross-sectional studies, before-after (pre-post) studies with no control group, and observational studies. Once the inclusion and exclusion criteria had been defined, a preliminary confined search was performed on PubMed and Scopus; key terms from the collected articles were selected to design a search strategy, and then a search of all the included articles' reference lists was run for further research. Studies were excluded if they did not fulfill the inclusion criteria. The preferred reporting items for scoping reviews (PRISMA-ScR) consensus was followed. The risk of bias was evaluated by providing a qualitative analysis of the clinical studies via the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment of Controlled Intervention Studies, Observational Cohort Studies, and Cross-Sectional Studies (NHLBI, NIH). A total of 21 studies were included in this review. As it is clear from the studies selected, the literature indicates that MHAs are effective in improving oral hygiene in adolescents and children and reducing the dental plaque index, including in patients undergoing orthodontic treatment. MHAs are also able to reduce the symptoms of patients affected by obstructive sleep apnea-hypopnea syndrome (OSAHS) and improve the swallowing-related quality of life of elderly patients. MHAs are furthermore recommended to decrease dental anxiety among patients, both during dental procedures and the post-operative period. MHAs are useful to spread knowledge about traumatic dental injuries among non-oral health professionals and to monitor dental erosion and awake bruxism. MHAs' clinical outcomes might have been influenced by the demographic features of the subjects involved. Further studies considering a longer follow-up period and larger samples are needed. In conclusion, MHAs can be considered a useful tool to monitor oral disease and increase patients' quality of life related to oral health.

Explicating the role of amygdala substructure alterations in the link between hypoleptinemia and rumination in anorexia nervosa

OBJECTIVE

The amygdaloid complex plays a pivotal role in emotion processing and has been associated with rumination transdiagnostically. In anorexia nervosa (AN), we previously observed differential reductions of amygdala nuclei volumes (rostral-medial cluster substantially affected) and, in another study, elevated food-/weight-related rumination. Both amygdala volumes and rumination frequency correlated with characteristically suppressed leptin levels in AN. Thus, we hypothesized that amygdala nuclei alterations might be associated with AN-related rumination and potentially mediate the leptin-rumination relationship in AN.

METHODS

Rumination (food-/weight-related) was assessed using ecological momentary assessment for a 14-day period. We employed frequentist and Bayesian linear mixed effects models in females with AN (n = 51, 12-29 years, majority admitted to inpatient treatment) and age-matched healthy females (n = 51) to investigate associations between rostral-medial amygdala nuclei volume alterations (accessory basal, cortical, medial nuclei, corticoamygdaloid transitions) and rumination. We analyzed mediation effects using multi-level structural equation models.

RESULTS

Reduced right accessory basal and cortical nuclei volumes predicted more frequent weight-related rumination in AN; both nuclei fully mediated the effect of leptin on weight-related rumination. In contrast, we found robust evidence for the absence of amygdala nuclei volume effects on rumination in healthy females.

CONCLUSION

This study provides first evidence for the relevance of specific amygdala substructure reductions regarding cognitive symptom severity in AN and points toward novel mechanistic insight into the relationship between hypoleptinemia and rumination, which might involve the amygdaloid complex. Our findings in AN may have important clinical value with respect to understanding the beneficial neuropsychiatric effects of leptin (treatment) in AN and potentially other psychiatric conditions such as depression.

Influence of awake bruxism behaviors on fatigue of the masticatory muscles in healthy young adults

The present cross-sectional study aimed to analyze the relationship between awake bruxism and fatigue of masticatory muscles in healthy young adults. For this purpose, 121 graduate students participated in this study. Frequency of awake bruxism was collected for 7 consecutive days by ecological momentary assessment (EMA) using an online survey (mentimeter). Muscle fatigue was tested one day after EMA assessment, which consisted of voluntarily and continuously clenching at 30% (kgf/cm2) of maximum bite force (MBF) until exhaustion. The percentage of change in MBF after the clenching task, as compared to the MBF before the clenching task was measured. The average frequency of awake bruxism was 45.5% during 7 days. Sustained clenching resulted in a significant reduction in MBF values in the total sample (p < 0.05). Nevertheless, no significant correlation was found between frequency of awake bruxism behaviors and percent of change in MBF and endurance time during the fatigue test. Therefore, it can be concluded that young healthy adults present a relatively high frequency of awake bruxism behaviors that do not seem to impact the degree of masticatory muscle fatigue.

Real time evaluation of awake bruxism behaviors in young asymptomatic students and its impact on the masticatory muscles

STATEMENT OF PROBLEM

The relationship of awake bruxism with pain is still unclear.

PURPOSE

The purpose of this clinical study was to evaluate awake bruxism behavior for 1 week in healthy young adults with ecological momentary assessment, assess its relationship with masticatory muscle tenderness, and the participation of endogenous analgesia.

MATERIAL AND METHODS

A total of 150 healthy participants were provided with a smartphone application that sent 10 alerts at random intervals every day. The participants were instructed to report in real time which of the following awake bruxism behaviors best represented their current condition: relaxed jaw muscles, tooth contact, tooth clenching, tooth grinding, or jaw bracing. At baseline, participants underwent recordings of the pressure pain threshold and conditioned pain modulation of the masticatory muscles. Pressure pain threshold recording was also repeated on the last day of the study. A t test was used to compare the first and the last pressure pain threshold recording after 1 week with an ecological momentary assessment evaluation. The Pearson correlation test was performed to evaluate the correlation between variables (α=.05).

RESULTS

Overall compliance was 75.9%. The average frequency of relaxed jaw muscles was 54.5%, tooth contact 29.4%, jaw bracing 5.8%, tooth clenching 9.7%, and tooth grinding 0.6%. The average frequency of a distinct awake bruxism behavior was 45.5%. A statistically significant increase in pressure pain threshold values was found (P=.001; P=.001; P=.045 for right and left anterior temporalis and left masseter, respectively). No significant correlation was found between the frequency of awake bruxism behaviors, the pressure pain threshold, and conditioned pain modulation (P>.05).

CONCLUSIONS

The most prevalent behavior was tooth contact (29.4%). No relationship was found between awake bruxism behaviors and masticatory muscle tenderness or endogenous analgesia.

Ecological Momentary Assessment of Awake Bruxism Behaviors: A Scoping Review of Findings from Smartphone-Based Studies in Healthy Young Adults

BACKGROUND

The recent introduction of ecological momentary assessment (EMA) smartphone-based strategies has allowed achieving some interesting data on the frequency of different awake bruxism (AB) behaviors reported by an individual in the natural environment.

OBJECTIVE

The present paper aims to review the literature on the reported frequency of AB based on data gathered via smartphone EMA technology.

METHODS

On September 2022, a systematic search in the Pubmed, Scopus and Google Scholar databases was performed to identify all peer-reviewed English-language studies assessing awake bruxism behaviors using a smartphone-based Ecological Momentary Assessment. The selected articles were assessed independently by two authors according to a structured reading of the articles' format (PICO).

RESULTS

A literature search, for which the search terms "Awake Bruxism" and "Ecological Momentary Assessment" were used, identified 15 articles. Of them, eight fulfilled the inclusion criteria. The results of seven studies using the same smartphone-based app reported a frequency of AB behaviors in the range between 28.3 and 40% over one week, while another investigation adopted a different smartphone-based EMA approach via WhatsApp using a web-based survey program and reported an AB frequency of 58.6%. Most included studies were based on convenience samples with limited age range, highlighting the need for more studies on other population samples.

CONCLUSIONS

Despite the methodological limits, the results of the reviewed studies provide a standpoint for comparison for future studies on the epidemiology of awake bruxism behaviors.

Ecological Momentary Assessment of Awake Bruxism Frequency in Patients with Different Temporomandibular Disorders

Self-reported awake bruxism (AB) has been associated with temporomandibular disorders (TMD). However, the daily amount of AB behavior has not been quantified in pain patients. Therefore, this study aimed to assess AB frequency in patients with myofascial pain and temporomandibular joint (TMJ) pain and compare it to a group of pain-free individuals. Eighty-four individuals belonging to either a TMD group (n = 54) or a healthy control group (n = 30) were selected. AB frequency was obtained by ecological momentary assessment with a dedicated smartphone application that sent sound alerts at random intervals during the day for one week. Upon receiving the alert, the volunteer reported the current muscular condition and/or the teeth position, i.e., relaxed jaw muscle, jaw bracing, teeth contact, teeth clenching, or teeth grinding. Data were evaluated by independent t-test (α = 0.05). During the seven days, AB frequency was 62.1% ± 26.8% for TMD patients and 36.2% ± 27.3% for pain-free subjects (p < 0.001). Mandible bracing was most common in the TMD group (p < 0.001), while teeth contact, clenching, and grinding did not differ between groups. Moreover, no differences were found in AB frequency between myofascial pain and TMJ pain patients. Therefore, TMD patients have higher AB frequency characterized by jaw bracing, irrespective of pain location.

Electromyographic Assessment of Masseter Muscle Activity: A Proposal for a 24 h Recording Device with Preliminary Data

OBJECTIVE

The instrumental measurement of electromyographic (EMG) activity in the natural environment is the best strategy available to collect information on bruxism. The twofold aim of this study was to (1) introduce and discuss a novel EMG device for the assessment of awake (AB) and sleep bruxism (SB) in the home environment over 24 h and (2) present some preliminary data.

METHODS

Fifteen healthy volunteers (eight males and seven females; mean age: 48.2 ± 4.1 years) underwent 24 h EMG recording trials of their masseter muscle activity (MMA) with a miniaturized wireless device. This device allowed us to measure the durations of the different phases of the recordings (total duration, awake time, sleep time, and electrode dislodgement time) as well as the bruxism time index (BTI) and bruxism work index (BWI) for both the waking and sleeping hours.

RESULTS

For the healthy volunteers, on average, the bruxism work index (BWI) values were 0.4 ± 0.2 and 0.1 ± 0.1 for awake and sleep, respectively, while the mean bruxism time index (BTI) values were 0.9 ± 0.5 for awake and 0.3 ± 0.1 for sleep.

CONCLUSIONS

This investigation describes the technical features of a novel EMG recording device that permits the evaluation of masseter muscle activity in the home environment over 24 h. For the first time, a dedicated elaboration of the EMG signal allowed an assessment of muscle work and not just a count of purported SB/EMG events.

CLINICAL SIGNIFICANCE

Based on the multidisciplinary approach in the study of bruxism, such a methodology, thanks to its peculiar features, will allow researchers and clinicians to monitor the epidemiology of MMA and delve deeper into the awake and sleep bruxism correlates for tailored management in clinical settings.

Monitoring of awake bruxism by intelligent app

Background. Bruxism is a topic of much controversy and is continually debated in the field of dentistry due to the multifaceted clinical relationship that results in painful conditions and consequences to patients. The aim of this review was to determine the effectiveness of a smartphones app in monitoring awake bruxism. Methods. PROSPERO (registration number: CRD42021271190). The eligibility criteria were as followed: observational studies, case-control studies, studies that reported odds ratios, and studies on awake bruxism. The following keywords were searched: [smartphones apps] AND [apps] AND [awake bruxism], OR [sleep bruxism], OR [sleep hygiene], OR [parasomnias], AND [habits]. Results. All the included studies found that the use of the smartphone app allows controlled awake bruxism monitoring. The results also show that the slepp bruxism and awake bruxism  are interactive, having negative synergism and substantially increasing the risks of temporomandibular joint pain and temporomandibular disorders. Discussion. In the awake bruxims it was possible to identify 70% symptoms through the different frequencies of behavior provided by the App, within the present technological tools have become daily in young and adult population. The app is effective and easy to use by patients, effectively limiting biases the time of evaluation.

Impact of Confinement by COVID-19 in Awake and Sleep Bruxism Reported by Portuguese Dental Students

Confinement by COVID-19 was a stressful period that could potentially trigger awake bruxism (AB) and/or sleep bruxism (SB) behaviors. This study aims to characterize the AB and SB behaviors reported by Portuguese dental students before the pandemic and during the first period of mandatory confinement by COVID-19. Dental students were included in this longitudinal study. They answered the Portuguese validated version of the Oral Behavior Checklist (OBC) before the COVID-19 pandemic emerged (T1) and one month after mandatory confinement started in Portugal (T2). Descriptive statistics and the linear-by-linear association test were performed to assess changes over time (p ≤ 0.05). Sixty-four dental students (mean age 22.5 ± 2.8 years; 81.5% females) completed the study protocol. Considering AB, there was a general increase of the behavior from T1 to T2. The percentage of participants who reported to “grind their teeth when waking up” just few times decreased (p < 0.001) and the percentage of participants who reported “feeling discomfort/tension in the facial muscles when waking up just few times” increased (p = 0.019). Considering SB, there was a significant decrease of the behavior in all samples. The number of “None” report to grinding teeth during sleep or when waking up increased (p = 0.012). An increase in the self-reporting of feeling discomfort in masticatory muscles when awake or sleeping was observed (p = 0.028). The percentage of participants who did “not remember” any AB or SB activity decreased (p < 0.050). The confinement due to COVID-19 resulted in a forced change in dental students’ lifestyles that resulted in an increase of reported AB and a decrease of reported SB. Clinical Significance: In case of confinement periods, students should be encouraged to try normalizing their daily life by creating healthy routines and, by doing so, reducing the possible predisposition to bruxism and its consequences.

Comparison between Ecological Momentary Assessment and Questionnaire for Assessing the Frequency of Waking-Time Non-Functional Oral Behaviours

Over the years, several tools have been proposed to measure oral behaviours (OB). Recently, a smartphone-based application for ecological momentary assessment (EMA) has been introduced to collect real-time data on waking-time OB. The aim of this study was to compare the self-reported frequency of OB by means of a standardised questionnaire with that recorded with a smartphone-based application for EMA. A total of 151 participants, recruited from the general population, were invited to fill in the Oral Behaviour Checklist (OBC). Scores for four questions concerning grinding, clenching, tooth contact, and mandible bracing were computed. Afterwards, participants were provided with a smartphone application for prolonged real-time reporting of OB. One-way analysis of variance (ANOVA) and a general linear mixed model (GLMM) were used to compare the responses to each OBC question with the frequencies of the same condition recorded with the EMA. Results showed significant association between OBC responses and the EMA recordings. In particular, increased frequencies of clenching, grinding, and teeth contact were recorded by individuals who provided higher OBC scores. On the other hand, a nonlinear association was observed for “mandible bracing”, pointing out difficulties in the comprehension of this condition.

Current Knowledge and Future Perspectives on Awake Bruxism Assessment: Expert Consensus Recommendations

Awake bruxism (AB) is differentiated from sleep bruxism (SB) by the differences in etiology, comorbidities, and consequences related to the different spectrum of muscle activities exerted in relation to the different circadian manifestations. Furthermore, less literature data are available on AB than on SB. The introduction of ecological momentary assessment (EMA) strategies has allowed for collecting valuable data on the frequency of the different activities reported by an individual in his/her natural environment. This strategy has been further improved with the recent use of smartphone technologies. Recent studies have described an average frequency of AB behaviors, within the range of 23–40% for otherwise healthy young adults. An association between AB and some psychological traits has emerged, and the findings have indicated that patients with musculoskeletal symptoms (e.g., temporomandibular joint and/or muscle pain, muscle stiffness, and fatigue) report higher AB frequencies. Preliminary data suggest that muscle bracing and teeth contact are the most commonly reported behaviors, while teeth clenching is much less frequently reported than commonly believed previously. Report of teeth grinding during wakefulness is almost absent. This paper has critically reviewed the currently available approaches for the assessment of AB. In addition, some future perspectives and suggestions for further research have been provided.

Ecological Momentary Assessment of Awake Bruxism with a Smartphone Application Requires Prior Patient Instruction for Enhanced Terminology Comprehension: A Multi-Center Study

The prevalence of awake bruxism (AB) has been reported as being 30%, with sleep bruxism (SB) at 9−15%. Most studies have focused on SB, emphasizing the importance of AB research. For epidemiological evaluations of AB, a smartphone application based on ecological momentary assessment (EMA) was introduced. The aims of this multi-center study were: (1) to investigate how well lay subjects comprehend the AB terminology used in the smartphone application, and (2) to find out whether professional instruction improved their comprehension. The study population consisted of lay subjects from Italy, Portugal, and Finland comprising 307 individuals (156 men, 151 women; 18−86 years). Subjects first completed a five-item questionnaire about the meanings of the five AB terms used in the smartphone application. Each question offered four answer options, with one being correct. Immediately afterwards, the meanings of the terms were instructed. Lastly, the subjects were re-tested with the same questionnaire. In Finland and Italy, the re-tested correct answer scores for the single terms were at 89−97% per term. Improved comprehension was seen across sex, education, and age groups. In the Portuguese data, no improvement was found. Significant differences were found between countries in the improved scores for all terms that were correct following the instruction (Finland, 16.3% to 72.1%; Italy, 32.3% to 83.8%; Portugal, 23.1% to 33.7%) (p < 0.001). In conclusion, standardized instruction on AB terminology prior to EMA is recommended to improve the reliability of collected data.

Psychosocial and Behavioral Factors in Awake Bruxism-Self-Report versus Ecological Momentary Assessment

The issue of psychosocial factors and concurrent conditions associated with AB is a relatively new approach in the study of Awake Bruxism (AB). In the present study a population of 84 dental students were assessed for probable AB with two modes of AB assessment: Single point self-report (SR) and ecological momentary assessment through a designated smartphone application (BA). The two assessment modes were compared with regard to their ability to phenotype subjects as far as the following psychosocial and behavioral variables are concerned: Gender; depression; somatization; oral behaviors; chronic pain and associated pain symptoms in the head, neck and scapula. Two-way ANOVA showed main effect of SR for the following variables: Chronic Pain Intensity score (F_(1,49) = 6.441, p < 0.02), migraine/headache (F_(1,81) = 7.396, p < 0.01), pain in neck (F_(1,81) = 6.726, p < 0.05), pain in scapula (F_(1,81) = 8.546, p < 0.005) and the oral behaviors of pushing the tongue forcefully against the teeth (F_(1,81) = 5.222, p < 0.05) and inserting the tongue between the upper and lower teeth (F_(1,81) = 5.344, p < 0.03). The effect of SR on the habit of chewing gum was borderline (F_(1,81) = 3.369, p = 0.07). Main effect of BA was found for depression (F_(1,81) = 6.049, p < 0.05), while the effect of BA on somatization was borderline (F_(1,81) = 3.657, p = 0.059). An interaction between SR and BA groups could be observed for the behavior of biting, chewing or playing with the tongue, cheeks or lips (F_(1,81) = 4.117, p < 0.05). The results suggest that a combination of a single-point self-report referring to the past 30 days, and an ecological momentary assessment supplying information about the actual timing of the report, can help us to better assess AB, as well as increase our ability to define the phenotype of subjects with AB as far as psychosocial and behavioral factors are concerned.

Utility of Smartphone-based real-time report (Ecological Momentary Assessment) in the assessment and monitoring of awake bruxism: A multiple-week interval study in a Portuguese population of university students

PURPOSE

The Ecological Momentary Assessment (EMA) concept was the basis for developing a smartphone application for the on-time report of awake bruxism (AB) activities. This study aims to monitor AB report over time in a population of healthy young adults.

METHODS

A population of young adults recruited among dental students in good general health was recruited. All answered to a questionnaire, including the Oral Behavior Checklist (OBC-1). They were then monitored with a smartphone application for AB report during seven consecutive days and completed three further observation periods (EMA-1, 2 and 3) at one-month intervals. After the third period (EMA-3), participants answered again the OBC questionnaire (OBC-2). Changes over time were described, and Pearson Correlation test was performed to assess the correlation between EMA and OBC items reports. A significance level of p = .01 was set.

RESULTS

Thirty-one University students completed the study protocol. Answers to the OBC showed an increase in the prevalence of self-reported bracing and teeth clenching from the first to second report (38.7%-54.8% and 77.4%-90.3%, respectively). A slight increase in the 'relaxed' condition (62.5%-69.0%) was observed with EMA-based smartphone application over time. No correlation between OBC items and EMA was detected between OBC-1 and EMA-1. A moderate positive correlation in bracing report (+0.509, p = .01) and weak positive correlation in teeth contact report (+0.380, p = .05) were found between OBC-2 and EMA-3.

CONCLUSION

Using a smartphone-based approach to AB report may be helpful to monitor AB over time and increase an individual's awareness to recognise actions such as bracing and teeth contact concerning the single-time report.

Awake Bruxism-Single-Point Self-Report versus Ecological Momentary Assessment

Assessment of awake bruxism (AB) is problematic due to the inability to use continuous recordings during daytime activities. Recently, a new semi-instrumental approach was suggested, namely, ecological momentary assessment (EMA), via the use of a smartphone application. With the application, subjects are requested to report, at least 12 times per day, the status of their masticatory muscle activity (relaxed muscles, muscle bracing without tooth contact, teeth contact, teeth clenching, or teeth grinding). The aim of the present study was to test the association between a single observation point self-report and EMA assessment of AB. The most frequent condition recorded by the EMA was relaxed muscles (ca. 60%) and the least frequent was teeth grinding (less than 1%). The relaxed muscle condition also showed the lowest coefficient of variance over a seven-day period of report. Additionally, only the relaxed muscles and the muscle bracing conditions presented an acceptable ability to assess AB-positive and AB-negative subjects, as defined by single-point self-report questions. The combination between self-report and EMA may have the potential to promote our ability to assess AB. We suggest to re-consider the conditions of teeth contact and teeth grinding while using EMA to evaluate AB.

Research routes on improved sleep bruxism metrics: Toward a standardised approach

A recent report from the European Sleep Research Society's task force "Beyond AHI" discussed an issue that has been a long-term subject of debate - what are the best metrics for obstructive sleep apnoea (OSA) diagnosis and treatment outcome assessments? In a similar way, sleep bruxism (SB) metrics have also been a recurrent issue for >30 years and there is still uncertainty in dentistry regarding their optimisation and clinical relevance. SB can occur alone or with comorbidities such as OSA, gastroesophageal reflux disorder, insomnia, headache, orofacial pain, periodic limb movement, rapid eye movement behaviour disorder, and sleep epilepsy. Classically, the diagnosis of SB is based on the patient's dental and medical history and clinical manifestations; electromyography is used in research and for complex cases. The emergence of new technologies, such as sensors and artificial intelligence, has opened new opportunities. The main objective of the present review is to stimulate the creation of a collaborative taskforce on SB metrics. Several examples are available in sleep medicine. The development of more homogenised metrics could improve the accuracy and refinement of SB assessment, while moving forward toward a personalised approach. It is time to develop SB metrics that are relevant to clinical outcomes and benefit patients who suffer from one or more possible negative consequences of SB.

Frequency of awake bruxism behaviour in orthodontic patients: Randomised clinical trial: Awake bruxism behaviour in orthodontic patients

INTRODUCTION

The influence of aligners on the activity of the masticatory muscles is still controversial, especially regarding the behaviour associated with awake bruxism (AB).

OBJECTIVE

To compare the frequency of AB behaviours between patients treated with aligners and fixed appliances.

METHODS

The sample comprised 38 Class I patients (mean age 22.08 years), divided by simple randomisation into two groups: OA group; orthodontic aligners (n 19) and FA group; fixed appliance (n 19). The frequency of AB was investigated by the ecological momentary assessment using an online device (mentimeter), during 7 following days at different timepoints, before and after appliance placement and in the 2nd, 3rd, 4th and 6th months of orthodontic treatment. These variables were also evaluated: level of anxiety by the State-Trait Anxiety Inventory, stress by the Perceived Stress Scale, catastrophising related to pain and degree of hypervigilance by the Pain Vigilance and Awareness Questionnaire, and the presence of facial pain evaluated by the DC/TMD.

RESULTS

There was no difference between groups in the frequency of AB behaviours, with mean of 53.5% for group OA and 51.3% for FA. The most frequent behaviour was slightly touching the teeth, and in FA group, there was a significant reduction in this behaviour soon after appliance placement. The groups did not differ concerning the degree of anxiety, stress, catastrophising, hypervigilance and facial pain.

CONCLUSION

The orthodontic treatment performed with aligners or fixed appliances did not influence the frequency of AB during the 6 months of treatment. REGISTRY OF CLINICAL TRIALS: (REBEC): RBR-9zytwf.

Awake bruxism frequency and psychosocial factors in college preparatory students

OBJECTIVE

To assess the frequency of reported masticatory muscles activity during wakefulness (i.e., awake bruxism [AB]), levels of anxiety, depression, stress, and the oral health-related quality of life (OHRQoL) in college preparatory students.

METHODS

Sixty-nine college preparatory students participated in the study. AB was evaluated by the Oral Behaviors Checklist (OBC) and a smartphone-based ecological momentary assessment (EMA; [Bruxapp®]). Anxiety and depression were measured by the Hospital Anxiety and Depression Scale, stress was evaluated by the Perceived Stress Scale, and OHRQoL was obtained by The Oral Health Impact Profile-14. Data were analyzed by Pearson's correlation coefficient (α = 0.05).

RESULTS

The average EMA-reported frequency of AB behaviors was 38.4%. Significant correlations were found between AB and the OBC, anxiety, depression, stress, and OHRQoL (p < 0.001).

CONCLUSION

College preparatory students demonstrated moderate frequency of AB, which was significantly correlated with psychosocial factors.