Efficacy of biofeedback therapy on sleep bruxism: A systematic review and meta-analysis

Effects of different interventions on bruxism: an overview of systematic reviews

OBJECTIVE

This study aimed to evaluate, qualify, and summarize evidence presented in systematic reviews (SR) on treatments for bruxism.

METHODS

The overview was conducted using the PICO strategy: children, adolescents, and adults with bruxism (P) were submitted to different treatments (I) compared to other treatments, placebo, or no treatment (C) in order to evaluate incidence, prevalence, and number of episodes of bruxism (O). The search was carried out in six databases and gray literature up to July 2023. Data were extracted, and the ROBS tool was used, followed by a descriptive synthesis of the results.

RESULTS

A total of 31 SR were included. Sixteen showed a positive effect on episodes of bruxism (BE), while two had negative, one had neutral, and nine had inconclusive effects. Using the risk of bias in systematic reviews tool (ROBIS), risk of bias varied from low (n = 23) to high (n = 5) among the SR. Pharmacological treatment, oral rehabilitation, and other therapeutic approaches presented inconclusive or negative effects on BE, while oral appliances showed controversial effects. Biofeedback, physical therapy, laser therapy, and botulinum toxin showed positive effects on the reduction of BE.

CONCLUSION

Biofeedback, physical therapy, laser therapy, and botulinum toxin showed positive effects on the reduction of BE; there is still a lack of studies to support the safe and long-term use of these therapies.

REGISTRATION NUMBER

PROSPERO CRD42021273905.

Publication performance and trends in bruxism research: A bibliometric analysis

BACKGROUND

Bruxism is an umbrella term that encompass a multidimensional spectrum of masticatory muscle activities.

OBJECTIVE

The purpose of this study was to do a bibliometric analysis including citation performance in the research topic of bruxism, by using an innovative method including details of article title, author keyword, KeyWords Plus and abstracts.

METHODS

The data were retrieved 2022-12-19 from the Clarivate Analytics Web of Science Core Collection, and the online version of the Science Citation Index Expanded (SCI-EXPANDED) for studies published 1992 to 2021. To evaluate research trends, the distribution of keywords in the article title and author-selected keywords were used.

RESULTS

The search yielded 3233 documents in SCI-EXPANDED, of which 2598 were of the document-type 'articles' published in 676 journals. The analysis of the articles revealed that "bruxism/sleep bruxism," "electromyography," "temporomandibular disorders" and "masticatory muscles" are the most used keywords by the authors. Further, the most frequently cited study was published 9 years ago and handles the present definition of bruxism.

CONCLUSION

The most productive authors and those with the highest performance have some common features; they have several national and international collaborations; and they have published articles about the definition, aetiology/pathophysiology and prevalence of bruxism, all senior researchers in the field of TMD. Hopefully, based on this study, researchers and clinicians will have information to be stimulated to outline future research projects on bruxism-related aspects, and to initiate new international or multinational collaborations.

Training of the lateral pterygoid muscle in the treatment of temporomandibular joint disc displacement with reduction: A randomised clinical trial

BACKGROUND

Disc displacement with reduction (DDwR) therapy should be performed only when pain or discomfort is presented. Data on treatment options for painful DDwR are very limited.

OBJECTIVE

The aim was to investigate whether isometric training of the lateral pterygoid muscle (LPM) is equivalent to stabilisation appliance therapy with regard to the treatment of painful DDwR. The training program is based on the science of Janda.

METHODS

This was a prospective, randomised study with a comparative treatment group. Sixty patients (≥18 years) with DDwR and pain were randomly assigned to two groups: (1) muscle training and (2) stabilisation appliance. The following variables were recorded at baseline examination and after 2, 4 and 6 months: changes in orofacial pain, clicking sounds of the temporomandibular joint (TMJ), force degrees for the lateral movement of the mandible and interincisal opening distance. p values of <.05 were considered statistically significant but 95% confidence intervals were also presented.

RESULTS

A decrease in orofacial pain intensity was seen in both groups (p < .0001). Registered TMJ clicking disappeared after 6 months of treatment in 37% (n = 11) of the patients in the training group and in 27% (n = 8) of the appliance group (p = .0009 and p = .0047). Muscle training showed 27 improvements in Janda force degrees at the end of the study (p < .0001).

CONCLUSION

Muscle training and appliance therapy improved mouth opening and reduced pain intensity in both patient groups. Muscle training might be a promising option in the treatment of patients suffering from painful DDwR.

Effectiveness of Different Electrical Stimulation Modalities for Pain and Masticatory Function in Temporomandibular Disorders: A Systematic Review and Meta-Analysis

Temporomandibular disorders comprise a set of conditions that include alterations of the temporomandibular joint and masticatory muscles. Although different modalities of electric currents are widely used for treating temporomandibular disorders, previous reviews have suggested these are ineffective. This systematic review and meta-analysis aimed to determine the effectiveness of different electrical stimulation modalities in patients with temporomandibular disorders for reducing musculoskeletal pain, increasing the range of movement, and improving muscle activity. An electronic search was conducted of randomized controlled trials published until March of 2022 that compared the application of an electrical stimulation therapy versus a sham or control group. The main outcome measure was pain intensity. Seven studies were included in the qualitative analysis and in the quantitative analysis (n = 184 subjects). The overall effect of electrical stimulation on pain reduction was statistically superior to sham/control (MD = -1.12 cm; CI 95%: -1.5 to -0.8), showing moderate heterogeneity of results (I2 = 57%, P = .04). The overall effect on range of movement of the joint (MD = 0.97 mm; CI 95%: -0.3 to 2.2) and muscle activity (SMD = -2.9; CI 95%: -8.1 to 2.3) were not significant. Transcutaneous electrical nerve stimulation (TENS) and high-voltage current stimulation reduces pain intensity clinically in people with temporomandibular disorders with a moderate quality of evidence. On the other hand, there is no evidence of the effect of different electrical stimulation modalities on range of movement and muscle activity in people with temporomandibular disorders with a moderate and low quality of evidence respectively. PERSPECTIVE: TENS and high voltage currents are valid options for the control of pain intensity in patients suffering from temporomandibular disorder. Data suggest clinically relevant changes compared to sham. Healthcare professionals should take this into account as it is inexpensive therapy, has no adverse effects and can be self-administered by patients.

Effectiveness of Biofeedback in Individuals with Awake Bruxism Compared to Other Types of Treatment: A Systematic Review

Excessive masticatory muscle activity is generally present in awake bruxism, which is related to increased anxiety and stress. It has been hypothesized that biofeedback could potentially manage awake bruxism, however, its effectiveness has not been empirically analyzed in a systematic manner. Therefore, this systematic review was designed to determine the effectiveness of biofeedback compared to other therapies in adults with awake bruxism. Extensive searches in five databases looking for randomized controlled trials (RCTs) that included biofeedback to manage awake bruxism were targeted. The risk of bias (RoB) assessment was conducted using the Cochrane RoB-2 tool. Overall, four studies were included in this systematic review, all of which used the electromyographic activity of the masticatory muscles during the day and night as the main endpoint. Auditory and visual biofeedback could reduce the excessive level of masticatory muscle activity in a few days of intervention. The majority of the included studies had a high RoB and only one study had a low RoB. The standardization of the biofeedback protocols was also inconsistent, which makes it difficult to establish the ideal protocol for the use of biofeedback in awake bruxism. Thus, it is proposed that future studies seek to reduce methodological risks and obtain more robust samples.

Shear Wave Elastography in Bruxism-Not Yet Ready for Clinical Routine

Ultrasound shear wave elastography (SWE) is an emerging modality for the estimation of stiffness, but it has not been studied in relation to common disorders with altered stiffness, such as bruxism, which affects almost one-third of adults. Because this condition could lead to an increased stiffness of masticatory muscles, we investigated SWE in bruxism according to a proof-of-principle and feasibility study with 10 patients with known bruxism and an age- and gender-matched control group. SWE of the left and right masseter muscles was estimated under three conditions: relaxed jaw, 50% of the subjective maximal bite force, and maximal jaw opening. Rejecting the null hypothesis, SWE was significantly increased during relaxed jaw (bruxism 1.92 m/s ± 0.44; controls 1.66 m/s ± 0.24), whereas for maximal mouth opening, the result was vice versa increased with 2.89 m/s ± 0.93 for bruxism patients compared with 3.53 m/s ± 0.95 in the healthy control, which could be due to limited jaw movement in chronic bruxism patients (bruxism 4.46 m/s ± 1.17; controls 5.23 m/s ± 0.43). We show that SWE in bruxism is feasible and could be of potential use for diagnostics and monitoring, though we also highlight important limitations and necessary methodological considerations for future studies.

Managements of sleep bruxism in adult: A systematic review

This systematic review aimed to update the management of sleep bruxism (SB) in adults, as diagnosed using polysomnography (PSG) and/or electromyography (EMG). Management methods covered were oral appliance therapy (OAT) with stabilization splints, cognitive-behavioral therapy (CBT), biofeedback therapy (BFT), and pharmacological therapy. A comprehensive search was conducted on MEDLINE, Cochrane Library, and Web of Science up to October 1st, 2021. Reference list searches and hand searches were also performed by an external organization. Two reviewers for each therapy independently performed article selection, data extraction, and risk of bias assessment. The reviewers resolved any disagreements concerning the assortment of the articles by discussion. Finally, 11, 3, 14, and 22 articles were selected for each therapy. The results suggested that OAT tended to reduce the number of SB events, although there was no significant difference compared to other types of splints, that the potential benefits of CBT were not well supported, and that BFT, rabeprazole, clonazepam, clonidine, and botulinum toxin type A injection showed significant reductions in specific SB parameters, although several side effects were reported. It can be concluded that more methodologically rigorous randomized large-sample long-term follow-up clinical trials are needed to clarify the efficacy and safety of management for SB.

Customized Appliance Device for Force Detection in Bruxism Individuals: An Observational Study

Objective

This study aims to test a customised device for detecting contact-related sleep bruxism in adult patients and to show the efficacy of an established biofeedback method incorporated within the device.

Methods

Four volunteers, three of whom suffered from bruxism and one did not, underwent four tests to assess bruxism-related force detection during sleep with concurrent electromyographic recording and to compare SB activity with and without biofeedback stimuli.

Results

The device detected sleep bruxism in bruxer individuals, whilst no activity emerged in the control individual. A correlation between EMG and device signals for bruxism-related events emerged. Moreover, bruxism activity showed a significant decrease on the nights when the biofeedback treatment was applied.

Conclusion

The force-based device can detect appliance-contacting SB events as reliably as EMG recording. Finally, biofeedback stimuli allowed achieving a reduction in the severity and frequency of SB events.

The dental demolition derby: bruxism and its impact - part 2: early management of bruxism

Bruxism is a term that encompasses a range of presentations of rhythmic and repetitive muscular activity. For many, this is not a significant problem but for some, the behaviour leads to significant problems and extensive tissue damage. This is different to temporomandibular disorders. This paper will review methods of managing cases where bruxism is destructive, or potentially destructive, before needing to resort to full reconstruction.

Bruxism is challenging to control. The aim for early management is to limit tissue damage at an early stage rather than await extensive destruction that is then difficult to manage.

There is also a significant financial burden to delaying intervention.

Interventions at this stage range from pharmacological to splint therapy. Guidance on splint choice and design is provided.

Paroxysmal dyskinesia and electrodermal volatility: The role of mindfulness, self-compassion and psychophysiological interventions

To date, there are no behavioral or psychophysiological treatment studies on paroxysmal dyskinesia (PD). PD is a group of debilitating movement disorders that present with severe episodes of dystonia, chorea, and/or ballistic like movements. This is a first case report of a 50-year-old male who received behavioral interventions (e.g., mindfulness, CBT, and biofeedback interventions) to manage his PD episodes in tandem with multidisciplinary treatments (e.g., neurology, psychiatry, etc.). The paper primarily discusses the serendipitous observation of galvanic skin response (GSR) elevations and spikes immediately before and after the onset of PD episodes. GSR volatility was noted in wave amplitude and wave morphology. Graphs are presented to illustrate GSR volatility associate with PD episodes and the reduction of GSR volatility in response to behavioral approaches. The discussion highlights the feasibility of using GSR biofeedback as an adjunct to mindfulness and CBT to manage PD as part of a multidisciplinary treatment approach. Peripherally, issues that related to misclassification of somatic symptoms and related disorders (e.g., psychogenic non-epileptic seizures) and aspects of neurocognitive disorders are discussed. The paper reviews neurological findings, MRI, neuropsychological data, and psychiatric assessment to highlight the dilemma clinician's face and clarify behavioral practices to further the management of PD.

A world panorama of bruxism in children and adolescents with emphasis on associated sleep features: A bibliometric analysis

BACKGROUND AND OBJECTIVES

To present a world panorama of the published papers on bruxism in children and adolescents, emphasising the characteristics of studies related to the sleep features of these patients.

METHODS

Literature searches were conducted in six databases without language or date restrictions. Data on the titles, types of study, main subjects, countries of origin, keywords, years of publication, authors and their network collaborations, journals and sleep studies were extracted and analysed using VantagePoint™ software.

RESULTS

A total of 725 studies met the eligibility criteria. Most included only children (75.31%), with observational design (66.34%), and risk or aetiology (53.93%) as the main subject. Brazil (18.06%) and Brazilian authors (54.84%) had the largest number of studies, with a low amount of network collaboration. The Journal of Oral Rehabilitation published most of the studies (6.2%); publications in this field have grown considerably from 2000 to 2020. Of the studies, 123 (16.96%) included sleep studies; night sweating, restless sleep, sleep talking, mouth breathing, snoring, obstructive sleep apnoea syndrome, sleep-disordered breathing, nightmares, poor sleep quality and duration, and daytime naps were significantly associated with bruxism in most.

CONCLUSION

Studies on bruxism in children and adolescents have increased in the past 20 years, with most being observational, and risk or aetiology as the main subject. Brazil and the Journal of Oral Rehabilitation have published most in the field. Sleep studies have shown some features associated with bruxism, such as night sweating, restless sleep, somniloquy, snoring, breathing problems, nightmares, daytime naps, and poor sleep quality and duration.

Bruxism: Best Evidence Consensus Statement

PURPOSE

The purpose of this Best Evidence Consensus Statement is to report on the prevalence, potential causes or association, treatment and cure of bruxism.

MATERIALS AND METHODS

A literature search limited to Clinical Trials, Randomized Controlled Trials, Systematic Reviews and Meta Analyses, with the key words bruxism, and prevalence identified 22 references, bruxism and causation 21, bruxism, and treatment 117, and bruxism and cure none.

RESULTS

Prevalence received 5 references which were relevant to the question researched. Causation received 11 relevant references, treatment 34 relevant references and cure none. Eighteen additional references were culled from the reference lists in the aforementioned articles.

CONCLUSIONS

Due to variations in demographics and the dependence on anamnestic data, the true prevalence of bruxism in any specific population is unknown. There is moderate evidence that psychosocial factors such as stress, mood, distress, nervousness, and feeling blue are associated with sleep bruxism (SB) as well as caffeine, alcohol, and smoking. There is no consensus on what symptoms of SB or awake bruxism (AB) should be treated. There is some evidence that occlusal devices and bio feedback therapies can be utilized in SB treatment. There is conflicting evidence in the use of Botulinum toxin A and no compelling evidence for the use of drug therapy to treat SB. There is not an established cure for bruxism. The clinician is best served in using caution in the dental rehabilitation of patients with severe occlusal wear.

The Current Trend in Management of Bruxism and Chronic Pain: An Overview of Systematic Reviews

Bruxism, specifically sleep bruxism (SB), is a worldwide discussed topic in the literature; however, there is insufficient evidence to define and support a standard approach for the treatment of SB. The purpose of this overview was to map the evidence from systematic reviews (SR), examining the effects of interventions to improve chronic pain related to bruxism. The methodological quality of SRs was assessed using the AMSTAR-2 tool. We conducted a comprehensive literature search in April 2020, in the following databases: Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, LILACS, BBO, and Epistemonikos. Nine SRs with critically low to high methodological quality were included. Considering the main findings, botulinum toxin type A (BTX-A) showed a significant pain and sleep bruxism frequency reduction when compared to placebo or conventional treatment (behavioral therapy, occlusal splints, and drugs), after 6 and 12 months. Occlusal splints combined to muscle massage showed some benefit in pain reduction. There was no difference in pain and bruxism frequency between biofeedback therapy and an inactive control group. Regarding drug therapy, there is no difference when amitriptyline, bromocriptine, clonidine, propranolol, and levodopa were compared to placebo. In conclusion, there is some evidence to support the use of occlusal splints plus massage, and BTX-A to reduce chronic pain related to SB. No evidence was provided to support the recommendation of biofeedback therapy and drug therapy. There is still a need for more methodologically rigorous randomized clinical trials (RCT) to be conducted on the efficacy and safety of different therapies for SB.

[Bruxism: Classification, Diagnostics and Treatment]

Bruxism: Classification, Diagnostics and Treatment Abstract. Bruxism, the grinding or clenching of teeth, is common in the population. Stress, anxiety syndromes and genetic disposition seem to be dominant factors that lead to increased muscle tension. A distinction is made between two circadian manifestations, sleep and wake bruxism. Bruxism is a major risk factor for tooth structure and dentures. The diagnosis is based on a targeted medical history and examination. Sleep bruxism can be demonstrated by electromyography and video recording in the sleep laboratory. The treatment aims to protect the hard tooth substance and preserve the denture using occlusal splints. Relaxation exercises can improve bruxism. Specialized physiotherapy can improve tension, pain and restricted movement. Botulinum toxin treatment reduces the subjective complaints during the period of action.

Intelligent Occlusion Stabilization Splint with Stress-Sensor System for Bruxism Diagnosis and Treatment

Bruxism is a masticatory muscle activity characterized by high prevalence, widespread complications, and serious consequences but without specific guidelines for its diagnosis and treatment. Although occlusal force-based biofeedback therapy is proven to be safe, effective, and with few side effects in improving bruxism, its mechanism and key technologies remain unclear. The purpose of this study was to research a real-time, quantitative, intelligent, and precise force-based biofeedback detection device based on artificial intelligence (AI) algorithms for the diagnosis and treatment of bruxism. Stress sensors were integrated and embedded into a resin-based occlusion stabilization splint by using a layering technique (sandwich method). The sensor system mainly consisted of a pressure signal acquisition module, a main control module, and a server terminal. A machine learning algorithm was leveraged for occlusal force data processing and parameter configuration. This study implemented a sensor prototype system from scratch to fully evaluate each component of the intelligent splint. Experiment results showed reasonable parameter metrics for the sensors system and demonstrated the feasibility of the proposed scheme for bruxism treatment. The intelligent occlusion stabilization splint with a stress sensor system is a promising approach to bruxism diagnosis and treatment.

Efficacy of Biofeedback for Medical Conditions: an Evidence Map

BACKGROUND

Biofeedback is increasingly used to treat clinical conditions in a wide range of settings; however, evidence supporting its use remains unclear. The purpose of this evidence map is to illustrate the conditions supported by controlled trials, those that are not, and those in need of more research.

METHODS

We searched multiple data sources (MEDLINE, PsycINFO, CINAHL, Epistemonikos, and EBM Reviews through September 2018) for good-quality systematic reviews examining biofeedback for clinical conditions. We included the highest quality, most recent review representing each condition and included only controlled trials from those reviews. We relied on quality ratings reported in included reviews. Outcomes of interest were condition-specific, secondary, and global health outcomes, and harms. For each review, we computed confidence ratings and categorized reported findings as no effect, unclear, or insufficient; evidence of a potential positive effect; or evidence of a positive effect. We present our findings in the form of evidence maps.

RESULTS

We included 16 good-quality systematic reviews examining biofeedback alone or as an adjunctive intervention. We found clear, consistent evidence across a large number of trials that biofeedback can reduce headache pain and can provide benefit as adjunctive therapy to men experiencing urinary incontinence after a prostatectomy. Consistent evidence across fewer trials suggests biofeedback may improve fecal incontinence and stroke recovery. There is insufficient evidence to draw conclusions about effects for most conditions including bruxism, labor pain, and Raynaud's. Biofeedback was not beneficial for urinary incontinence in women, nor for hypertension management, but these conclusions are limited by small sample sizes and methodologic limitations of these studies.

DISCUSSION

Available evidence suggests that biofeedback is effective for improving urinary incontinence after prostatectomy and headache, and may provide benefit for fecal incontinence and balance and stroke recovery. Further controlled trials across a wide range of conditions are indicated.