Siddharth Bandodkar, Shuchi Tripathi, [...], and Adarsh Tripathi
Abstract
Purpose
To evaluate the role of anxiety/depression and occlusal factors in bruxism using Hospital Anxiety and Depression Scale and T-Scan III respectively.
Methods
The present case control study was comprising of a group of thirty patients with bruxism (Group Br) and 30 healthy individuals as control group (Group NBr). Subjects were selected from outdoor patients visiting the dental unit with the chief complaint of wearing off/sensitivity of all the teeth due to habitual grinding. The cases were selected by using the diagnostic criteria as given by the American Academy of Sleep Medicine (AASM). Further based on similarities of age and gender, controls were selected. Tooth wear index was recorded using an index given by Ekfeldt et al. Hospital Anxiety and Depression Scale (HADS) questionnaire was administered to both the groups to evaluate anxiety and depression. Recording of occlusal parameters in both the groups was done digitally by using T-Scan III. Statistical analysis was done by using student's t-test, chi square test and Mann Whitney U test.
Results
Group Br had significantly greater mean tooth wear index (22.24 ± 11.5) than group NBr (5.17 ± 3.30). Group Br had significantly higher anxiety (9.03 + 1.87/7.17 + 1.82) and depression scores (8 + 1.93/6.17 + 1.23) as compared to NBr. The disclusion time of group Br was 0.652 ± 0.749 and that of group NBr was 0.247 ± 0.289 (p = 0.008).
Conclusions
Subjects with higher level of anxiety, depression and increased disclusion time may have greater predilection towards suffering from bruxism (p < 0.05).
Keywords: Anxiety, Bruxism, Depression, Digital occlusal analysis, Tooth wear
Graphical abstract
1. Introduction
The Glossary of Prosthodontic Terms-9 has defined ‘bruxism’ as ‘parafunctional grinding of teeth or an oral habit consisting of involuntary, rhythmic or spasmodic nonfunctional gnashing, grinding, or clenching of teeth, in other than chewing movement of the mandible which may lead to occlusal trauma’.1
Authors have reported prevalence of bruxism range widely from 4 to 96%.2 Prevalence has been calculated to be present in 10% of the population during sleeping hours and the prevalence of bruxism during day hours has been calculated to be 20%.3,4 Prevalence of bruxism might be affected by variables such as age, gender and location demographics of the patient.5, 6, 7, 8
Etiology of bruxism has been thought to be because of multitude of factors like central or pathophysiological factors involving brain neurotransmitters or basal ganglia, psychosocial influences causing emotional stress or anxiety and peripheral factors such as tooth interference in dental occlusion.9, 10, 11, 12, 13, 14 For evaluating the psychological status of the patient, various tests have been used such as Hospital Anxiety Depression Scale (HADS), Beck Depression Inventory (BDI) and Hamilton Anxiety Rating Scale (HAMA).12 Traditionally, articulating paper has been used to discern points of contact between the maxillary and mandibular dentition during centric and eccentric movements of natural tooth and dental prosthesis. But using these papers have certain drawbacks like the size of the mark may not represent the amount of load15 and the paper markings gets smudged in saliva.16 Computerized occlusal analyzers have been used to overcome such shortcomings during evaluation of occlusion.17, 18, 19
Regrettably no clear data has been available on the cause and effect of bruxism.12 Available studies have shown that possible relationship between bruxism and various psychosocial and occlusal factors is still in the progress but no conclusive report has yet been reported.9,21,22 Bruxism have severely influenced the quality of human life leading to depression and other oro-facial problems like damage to supporting structures of teeth, tooth wear, frequent fractures/wear of dental restorations/implants and temporomandibular and musculoskeletal disorders.23, 24, 25, 26, 27, 28, 29 The present study was conducted to find an association between anxiety/depression and occlusal parameters in bruxism as there is no clear direction in the existing literature in this regard.
In the present study, null hypothesis was that there is no significant correlation between anxiety/depression and occlusal parameters in patients with bruxism.
2. Material and methods
The present study was conducted from January 2017 to October 2018 in the ‘Department of Prosthodontics and Crown & Bridge’ of the institution. The study was a ‘case control study’ comprising of a group of patients with bruxism as cases (Group Br: Bruxers) and a group of age and sex matched control group (Group NBr: Non Bruxers). The sample size was calculated using the following formula:
n = 2X(Zα/2 + Zβ)2 SD2/d
2
· n: Sample size per group
·
· SD: Pooled standard deviation being 3 in this.
·
· d: Difference in the means (effect size)
·
· Zα/2: Significance level (1.96), Zβ: Power of the study (0.84)
·
Assuming 80% power, 5% significance level with 95% confidence interval as well as assuming standard 4, the required sample size per group was 30. Ethical approval from the institutional ethics committee (1450/Ethics/R.cell-16) was obtained and the informed consent was taken from each subject included in the study. Thirty patients were selected in ‘Group Br’ as cases, using the diagnostic screening criteria of bruxism as given by the American Academy of Sleep Medicine (AASM).30 Inclusion criteria for group Br were knowledge or awareness of bruxism either by the subject or by a bed partner (Clenching or grinding of the teeth during sleeping), healthy individuals with no systemic disorders, completely dentate subjects (Third molars were not evaluated) with absence of any restorations and prosthesis, no history of chronic diseases, migraine, neuralgia, trauma, tumours or temporomandibular joint disorders/surgeries in the head and neck region and no history of orthodontic treatment. Thirty healthy individuals were selected as ‘Group NBr’ based on similarities of age and gender with the ‘Group Br’.
The demographic data was collected from both the groups regarding the age, sex and address. Clinically, the tooth wear was recorded using the Index given by Ekfeldt et al.31 for both the groups. The participants of both the groups were administered “Hospital Anxiety and Depression Scale” (HADS) to record anxiety and depression. HADS is a fourteen item scale that generates ordinal data.32 Seven items of which relate to anxiety and seven relate to depression. Each item on the questionnaire is scored from 0 to 3 meaning a person anxiety/depression score may vary between 0 and 21. A cut-off point of 8 was used to categorize anxiety or depression scale separately.
Occlusal contact data was evaluated digitally using T-Scan III for Windows (Tekscan Inc, Boston, MA, USA). Same examiner performed all routine clinical examinations and T-Scan measurements to reduce biasness. Appropriate sized T‐scan sensor was fitted to a rigid, autoclavable, fork-shaped plastic holder and inserted into the oral cavity aligned with the midline of the participants. For each individual, a new T‐scan III sensor was used and if the sensor got perforated while handling in the same individual, it was replaced with a new sensor to decrease chances of false readings caused by salivary leakage into the sensor. The individuals were instructed to bite down sensor stably and the real‐time force movie of occlusion generated was recorded on a computer monitor. Prior to measurement, T-scan sensor was recalibrated between participants to compensate individual variations in bite force. The same sensitivity value was maintained across all recordings for each participant. Based on individual recordings, following occlusal parameters were measured: a) occlusion time (time from the first contact of teeth to maximal intercuspation); b) disclusion time (time from maximal intercuspation to the last contact of teeth); c) left-right occlusal contact area distribution ratios and d) anterior-posterior occlusal contact area distribution ratios.
The data was summarized as mean ± SD (Standard deviation) and statistical analysis was done using the SPSS software 24.0 (Statistical Package for Social Sciences, Chicago, Illinois, USA). For parametric analysis, unpaired t-test and for non-parametric analysis, Mann Whitney U test were used.
3. Results
No significant difference in gender proportions between the groups Br (53.3% males, 46.7% females) and NBr (56.7% males and 43.3% females) [p = 0.795] was found (Table 1). Age group under 30 years (56.7%) had higher prevalence for bruxism than other age groups (Table 1). Bruxism was more common in patients belonging to urban areas (60%) as depicted in Table 1. Group Br had a significantly greater mean tooth wear index (mean = 22.24) as compared to the Group NBr (Table 2). A higher anxiety scores was found in Group Br (mean = 9.03) as compared to Group NBr (mean = 7.17) (Table 3). Similarly Group Br (mean = 8) had significantly higher depression scores than Group NBr (mean = 6.17) as shown in Table 4. When occlusal parameters were compared (Table 5), disclusion time of Group Br (0.652 ± 0.749) was more than Group NBr (0.247 ± 0.289).
Percentage distribution of subjects in Group Br and NBr according to Demographic profile.
Comparison of mean Tooth wear index in groups Br and NBr.
Mean anxiety scores for comparing groups Br and NBr using the HADS-A scale.
Mean depression scores for groups Br and NBr using the HADS-D scale.
Mean Occlusion time, disclusion time, anteroposterior and left right stress distribution of groups Br and NBr using the T scan occlusal analyzer.
4. Discussion
The diagnosis of bruxism whether subjective or objective have been found to be a challenging task.33 No universally accepted criteria for diagnosis of awake bruxism have been reported in the literature yet. One of the best description for the diagnostic of sleep bruxism was proposed by American Academy of Sleep Medicine (AASM) for both research and clinical intentions.30 Hence, in our study we have used the diagnostic criteria given by the AASM in the International Classification for Sleep disorders.
In the present study, 53.3% of the bruxers were males and 46.7% bruxers were females (Table 1) and it was found to be statistically not significant. Difference in level of anxiety, extent of statement of the problem in questionnaires in males and females,11 variation in masticatory force and the time of detection of bruxism could account for the variation in prevalence of bruxism in males and females.5 Finding of this study corroborate with those conducted by Manfredini D et al.7 and Lavigne GJ et al.,8 who concluded that there was no gender based predilection for bruxism. However, findings opposed studies done by Al Zarea et al.5 and Hegde et al.6 who found higher predilection for bruxism in males. American Sleep Disorder Association though did find that there was a tendency for females to have a higher predilection for bruxism.34
A higher prevalence for bruxism in patients under the age of 30(56.7%) than the patients in the age group of 31–35 years (26.7%) and patients above the age of 35 years (16.7%)was seen in the present study (Table 1). The prevalence of bruxism has usually been found to be higher in the younger generation due to higher amount of stress resulting from sedentary lifestyle, job constraints and inability to cope up with adverse circumstances.9 Manfredini D et al.7 concluded that bruxism tend to decrease with age.
Urban population (60%) were relatively more affected with bruxism than in rural population (40%) in the study (Table 1). This difference in prevalence rate could be because of variation in diet and lifestyle in the urban and rural places as well as unawareness leading to non-reporting of disease condition seen in rural population.5,6
In the present study, tooth wear in Group Br was higher as compared to the Group NBr (Table 2). Seligman DA et al.26 and Knight DJ et al.27 found in their studies that tooth wear was increased in patients with bruxism. However, Pergamalian28 and Baba K et al.29 have not shown a positive correlation between tooth wear and bruxism in their study.
The relationship between anxiety/depression and bruxism has been studied in previous instances in the past. However, the jury is still out on this topic. Questionnaires like the Beck Depression Inventory (BDI), the Hospital Anxiety Depression Scale (HADS) and the Hamilton Anxiety Rating Scale (HAMA) have been used.12 In the current study Hospital Anxiety and Depression Scale (HADS) was used, developed by Zigmond and Snaith in 1983.32 This test has previously been used by Gungormus and Erciyas12 in their study and they found a positive correlation between stress and bruxism.
The findings of our study showed a significantly higher level of anxiety (9.03 ± 1.87) and depression (8 ± 1.93) in the group of bruxers (Table 3, Table 4). The findings of this study were corroborated by Z Gungormus and Erciyas,12 S. K. Rao et al.10 and Major et al.35 who found that the subjects with higher level of anxiety and depression have higher tendencies for bruxism. While Pierce et al. found no relation between stress and bruxism.36
Methods used for studying occlusion were evaluation of wear pattern of occlusal splints,37 detection of force applied to the device and interarch contacts,38 evaluation of occlusal marks using articulating papers and computerized occlusal analyzer.15 Saraçoğlu A and Ozpinar B16 found that the recording materials except the T-Scan were affected by the presence of saliva. Also, T scan considered the fourth dimension i.e. time while recording the patient's occlusion which helps to decipher the first point of contact.
In the current study T-Scan occlusal analyzer was used instead of a conventional articulating paper. While considering the occlusal factors in the subjects it was found that there was a significant increase in disclusion time (0.652 ± 0.749 s) in Group Br (Table 5). However no statistically significant difference was noted in occlusion time or disclusion time among the bruxism patients in previous study done by Gumus et al.18 A study done in military pilots affected with bruxism were characterized by a highly reduced occlusion time compared to healthy non-pilot subjects.39 Further no significant difference were found in left-right and anterior-posterior occlusal contact areas while Gumus et al.18 have reported that in bruxism patients a larger areas of posterior contact is seen as compared to healthy individuals. Carlsson et al.4 and Kerstein and Radke19 found that occlusal prematurities and other malocclusions could play a role in increased bruxism in the subjects. However, Adisen et al.20 and Manfredini et al.21 found that there was little correlation between occlusal factors and bruxism.
The purpose of this study was to evaluate the effects of occlusal and psychological factors in bruxism patients to decipher the possible causes of bruxism. This may help to formulate an effective treatment policy to prevent the harmful sequelae of bruxism like tooth wear and ensuing temporomandibular joint disorders. This study will help the dentist to formulate a clearer path to treat a patient with bruxism by treating not only the consequences but also the etiological factors. Limitation of this study was that the sample size was limited. Further long term longitudinal studies would be required to see the evolution pattern of bruxism and effect of long term treatment therapy on bruxism.
5. Conclusion
Within the limitations of the study, it was concluded that bruxism is related to multifactorial etiology with the presence of higher degree of tooth wear. Subjects with higher level of anxiety, depression and increased disclusion time have greater predilection towards suffering from bruxism (p < 0.05). Further long term studies are needed to formulate effective treatment planning of patients suffering with bruxism.
Article information
J Oral Biol Craniofac Res. 2022 Jan-Feb; 12(1): 38–41.
Published online 2021 Oct 14. doi: 10.1016/j.jobcr.2021.10.007
PMCID: PMC8556522
PMID: 34745863
Siddharth Bandodkar,a Shuchi Tripathi,b,∗ Pooran Chand,b Saumyendra V. Singh,b Deeksha Arya,b Lakshya Kumar,b Mayank Singh,b Rameshwari Singhal,c and Adarsh Tripathid
aPrivate Practitioner, Goa, India
bDepartment of Prosthodontics, King George's Medical University UP, Lucknow, India
cDepartment of Periodontics, King George's Medical University UP, Lucknow, India
dDepartment of Psychiatry, King George's Medical University UP, Lucknow, India
Shuchi Tripathi: ude.aidnicmgk@ihtapirtihcuhs
∗Corresponding author. Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India. ude.aidnicmgk@ihtapirtihcuhs
Received 2021 Jun 2; Revised 2021 Jul 23; Accepted 2021 Oct 6.
Copyright © 2021 Craniofacial Research Foundation. Published by Elsevier B.V. All rights reserved.
Articles from Journal of Oral Biology and Craniofacial Research are provided here courtesy of Elsevier
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