Daniele Manfredini, Jari Ahlberg, Ghizlane Aarab, Steven Bender, Alessandro Bracci, Peter A. Cistulli, Paulo Cesar Conti, Reny De Leeuw, Justin Durham, Alona Emodi-Perlman … See all authors
First published: 03 January 2023
Abstract
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.
1 INTRODUCTION
The definition of bruxism has evolved over the past few years, progressively going beyond the old belief that bruxism is synonymous with grinding the teeth while asleep.1, 2 With the increase in knowledge concerning the sleep correlates and the muscle activities that may equally be present also during wakefulness,3, 4 the bruxism construct has shifted from a pathology or disorder to a motor activity that may be a sign of underlying conditions and may even have possible physiological or protective relevance.5-8
In the 2018 consensus paper, sleep bruxism (SB) is defined as a masticatory muscle activity (MMA) during sleep that is characterised as rhythmic (phasic) or non-rhythmic (tonic) and is not a movement disorder or a sleep disorder in otherwise healthy individuals. Awake bruxism (AB) is defined as a masticatory muscle activity during wakefulness that is characterised by repetitive or sustained tooth contact and/or by bracing or trusting of the mandible and is not a movement disorder in otherwise healthy individuals.2
Within these premises, while preparing the Standardised Tool for the Assessment of Bruxism (STAB), the need emerged for the identification of the best strategy to define the bruxism status, comorbidities, aetiology and consequences. As muscle activities, both sleep and awake bruxism require a thorough assessment that could be based on a combination of subject-based, clinically based and instrumentally based information.
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.9, 10 This paper presents the first STAB version for on-field testing together with the user's guide (Appendix S1), the full STAB instrument with the list of items included in each specific axis and domain (Appendix S2) and a ToolKit version listing the original sources to the full versions of the questionnaires included in the STAB (Appendix S3).
2 AXIS A—ASSESSMENT OF BRUXISM STATUS AND CONSEQUENCES
Axis A includes the self-reported information on bruxism status and possible consequences (subject-based report), as well as the clinical (examiner report) and instrumental assessment (technology report).
2.1 Subject-based assessment—self-report
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. As a general rule, whenever possible, all items and questions are taken from existing instruments, and the original source is indicated as a reference for administration and scoring. When instruments did not exist for any specific item, new questions have been formulated and indicated as ‘additional question’.
For the Sleep Bruxism domain (A1), two items are proposed, with questions selected from the Oral Behaviour Checklist (OBC)11 to report on the current/last month habit of clenching or grinding the teeth when asleep, based on the information the patient has. The same reports were also asked for history. To assess the Awake Bruxism domain (A2), four items are proposed, with questions selected from the OBC to report on the current/last month habits of teeth grinding, teeth clenching, teeth contact and mandible bracing. The same conditions are investigated also as for history, by using questions based on the same formulation of the history of the SB report. Amongst the possible Patient's Complaints included in the A3 domain, the reports of Temporomandibular Disorders (TMD) and jaw-muscle symptoms (TMD pain screener and other Diagnostic Criteria for Temporomandibular Disorders [DC/TMD] items, items on non-painful symptoms),12-15 headache (item from the DC/TMD Symptoms Questionnaire),13 tooth wear (item from the Tooth Wear Evaluation System [TWES]),16 tinnitus (item from the Research Diagnostic Criteria for Temporomandibular Disorders [RDC/TMD] History Questionnaire),17 xerostomia (item from the Xerostomia Inventory)18 and drooling (Radboud Oral Motor inventory for Parkinson—ROMP)19 are investigated.
2.2 Clinically based assessment (for examiner's use)—examiner 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. Whenever possible, existing instruments and procedures have been included, to which the examiner should refer for administering, scoring and interpreting the results of the examination. When instruments did not exist, new items have been formulated and indicated as ‘additional item’.
As part of the optional clinical assessment of the Joints and Muscles domain (A4), the examiner may assess the presence of one or multiple DC/TMD diagnoses13 and evaluate masseter hypertrophy. As for the Intra- and Extra-oral Tissues domain (A5), the evaluation of the presence of several signs (i.e. linea alba, lip impression, tongue scalloping, tongue traumatic lesion, alveolar bone exostosis) is required. As part of this evaluation domain, tongue position is also evaluated based on the modified Friedman score.20 Skeletal class (Class 1, 2, 3) and profile (hypo-, normo- and hyper-divergent) are optional items that may be included for selected research purposes. Concerning the Teeth and Restorations domain (A6), the evaluation of tooth wear from both a quantitative and qualitative perspective is suggested based on the TWES.16 Also, periodontal screening and dental examination as well as an evaluation of restorations are suggested to evaluate mobility, thermal sensitivity, discomfort on biting and/or teeth fractures as well as the presence of lost/broken fillings, scratched restorations, ceramic fractures, mobile implants, implant fractures and/or implant screw loosening.21 The evaluation of marks and/or perforations on oral appliances (if hard resin splint is worn by the patient) is also suggested.
2.3 Instrumentally based assessment—technology report
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 biosignal-recording devices (i.e. technology report).
As part of the Sleep Bruxism domain (A7), sleep-time electromyography (EMG) should be interpreted based on parameters concerning masseter events and work, such as the number of events exceeding 10% of the maximum voluntary contraction (MVC), the bruxism index, the bruxism time index and bruxism work index, if available.22, 23 The use of polysomnography (PSG) should be optionally evaluated based on the number of arousal-related and -unrelated SB events.24 The same bruxism indices described for EMG should be used, if available. Refinement of these outcome measures will be provided based on the proposals of a Sleep Bruxism Task Force.25, 26 Other optional methods (e.g. smartphone application scores for grinding sounds; appliances with sensors) can also be adopted. As part of the Awake Bruxism domain (A8), an evaluation with technological Ecological Momentary Assessment (EMA) strategies is required, by the adoption of data collection over one week.27 Patients' compliance and comprehension should be considered to enhance the validity of the data.28, 29 Wake-time EMG is also included in this domain.30 The same interpretation strategies as for sleep-time EMG scoring are recommended.25 Further outcome measures for the interpretation of wake-time EMG and other methods will be suggested based on the proposals of an Awake Bruxism Task Force.31 For the Additional Instrument domain (A9), intraoral acidity evaluation is included as an optional item as a possible marker of stress-related or gastroesophageal reflux-induced salivary changes.
3 AXIS B—RISK AND ETIOLOGICAL FACTORS AND COMORBID CONDITIONS
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 (i.e. specific subscales) form are included.
As part of the Psychosocial Assessment domain (B1), four anxiety and depression screening items are included based on the Patient Health Questionnaire-4,32 along with the four-item Brief Resilient Coping Scale as a coping evaluation instrument.33 For the Concurrent sleep-related conditions assessment (B2), screening questions on possible sleep-related conditions that are associated with bruxism are proposed. The eight-item STOP-BANG questionnaire is included for sleep apnea screening.34 The seven items of the insomnia scale and the seven items of the periodic limb movement disorders and restless leg syndrome scale of the Sleep Disorder Questionnaire are added.35 An item on sleep position is also included in the OBC.11 Within the concurrent non-sleep conditions assessment domain (B3), all the remaining OBC items investigating the report of oral behaviours during waking hours (i.e. Q7-21) are included.11 As an optional item, the time of smartphone use can be indicated. Based on the International Network for Orofacial pain and Related disorders Methodology (INOfRM) recommendations, concurrent diagnoses of motor disorders should be indicated.36 The six-item GERD-Q instrument is included to screen for gastroesophageal reflux disease (GERD-Q).37 The report of known diagnoses of autoimmune diseases and/or attention deficit hyperactive disorder is also required. The domain on prescribed medications and use of substances assessment (B4) is based on the collection of information about the patient's report of the use of drugs, medications and substances that are known for their possible exacerbating or attenuating role on bruxism and its possible consequences. This list is based on literature suggestions about the bruxism-enhancing and attenuating substances.38 In the final Additional Factors Assessment domain (B5), the patient is asked to report a known history of bruxism and other related conditions (i.e. tooth wear, obstructive sleep apnea, orofacial pain, gastroesophageal reflux disease) in the family.
4 DISCUSSION
This paper aimed 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. The tool consists of two axes, specifically dedicated to the evaluation of bruxism status and consequences (Axis A) and bruxism risk and etiological factors and comorbid conditions (Axis B). It includes 14 domains, accounting for a total of 66 items. A combination of self-reported, clinically based and instrumentally gathered data is provided to collect information on the above topics. A user's guide to the instrument is available in Appendix S1, and the full instrument is presented in Appendix S2.
The process that led to the development of the instrument, which started in 2018, after the publication of the ‘work in progress’ consensus paper on bruxism definition,2 was described in two separate papers providing an introductory overview9 and describing the road map to STAB finalisation, respectively.10 In parallel, a screening instrument, viz., the Bruxism Screener (BruxScreen) has been prepared by the core group of STAB developers to be used in large-scale epidemiological research projects and, especially, in general, dental practices.39 The screening instrument is particularly important to fit with the need to satisfy the A4 principle of Applicability, Affordability, Accessibility and Accuracy2 that are prevented by the comprehensiveness of the STAB.
Concerning the STAB, the face validity of the tool, i.e. the degree to which the instrument looks as though it is an adequate reflection of the construct to be measured, was assessed subjectively by collecting feedback on the tool from amongst all authors of this paper. In the absence of any standards regarding how to assess face validity,40 the outcomes could not be quantified. Rather, after several rounds of in-person and online meetings and exchanges, the discussants agreed that the STAB will likely yield a valid assessment of the frequency of the various awake and sleep bruxism-related jaw-muscle activities (i.e. teeth clenching, teeth grinding, teeth contact and mandible bracing),2 as well as of its most common clinical signs, risk and etiological factors, comorbid conditions and consequences. However, clearly, the validation process of the STAB is far from completed yet, but the tool is now ready for on-field testing.
Depending on the specific clinical and/or research needs of the users, some sections of the STAB might specifically be picked up. For this purpose, the list of instruments that can be selected for specific uses is provided as a ToolKit in Appendix S3. The inclusion of already existing tools and items, with special concern for the self-reported domains, should ease data collection and comparison with existing literature findings. Nonetheless, the presence of some additional items, some minor modifications to a few of the existing items and the lack of homogeneity between the answer options between the various instruments will be a challenging issue to design studies and provide proper statistical analysis and interpretation. For this reason, the STAB should be viewed as an open project, which will be reviewed from time to time by the core group of authors based on the emerging feedback from its on-field application. Researchers are free to use any additional tool that fits the needs of their specific projects, and in case of broad applicability, they can suggest their tools for possible future inclusion in the ToolKit of the STAB.
Within the above premises, there is no doubt that the STAB covers a much-needed gap in the dental and medical literature. From its use in the research and clinical settings, artificial intelligence models can be created to predict diseases based on the presence of certain bruxism phenotypes. The inputs drawn from the bruxism field might be an important step to upgrade other classification systems within the areas of orofacial pain and dental sleep medicine with some further information concerning the aetiology and inter-relationship of the various conditions.
5 CONCLUSIONS
After a long development process that started in 2018, a consensus approach amongst multidisciplinary experts has refined the first multidimensional system for the evaluation of bruxism, viz., the Standardised Tool for the Assessment of Bruxism (STAB). The instrument is now ready for on-field testing and further refinement, and 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.
AUTHOR CONTRIBUTIONS
D.M. co-chaired all sessions and meetings leading to this paper, drafted the STAB and drafted this paper; F.L. conceptualised the STAB project, co-chaired all sessions and meetings leading to this paper, and revised the STAB and this paper; J.A. co-chaired all sessions and meetings leading to this paper, and revised the STAB and this paper; G.A., A.B., J.D., D.E., L.M.G., M.K., I.P., P.S. and P.W. took part to the sessions and meetings leading to this paper, and revised the STAB and this paper; S.B., P.A.C., P.C.C., R.D.L., A.E.-P., B.H.-H., C.H., T.K., G.K., G.J.L. and D.P. revised the STAB and this paper.
ACKNOWLEDGEMENTS
The authors express their gratitude to Dr Alan Glaros, Department of Dental Public Health and Behavioural Science, University of Missouri-Kansas City, School of Dentistry, Kansas City, MO, USA, for his precious inputs during the review phases of the STAB questionnaire. Open Access Funding provided by Universita degli Studi di Siena within the CRUI-CARE Agreement. Open Access Funding provided by Universita degli Studi di Siena within the CRUI-CARE Agreement.
CONFLICT OF INTEREST STATEMENT
The authors declare they do not have any conflicts of interest.
APPENDICES
REFERENCES
· 1Lobbezoo F, Ahlberg J, Glaros AG, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil. 2013; 40: 2-4.
o View
· 2Lobbezoo F, Ahlberg J, Wetselaar P, et al. International consensus on the assessment of bruxism: report of a work in progress. J Oral Rehabil. 2018; 45: 837-844.
o View
· 3Manfredini D, Ahlberg J, Wetselaar P, Svensson P, Lobbezoo F. The bruxism construct: from cut-off points to a continuum spectrum. J Oral Rehabil. 2019; 46: 991-997.
o View
· 4Manfredini D, Ahlberg J, Lobbezoo F. Bruxism definition: past, present, and future - what should a prosthodontist know? J Prosthet Dent. 2021; 128(5): 905-912.
o View
· 5Raphael KG, Santiago V, Lobbezoo F. Is bruxism a disorder or a behavior? Rethinking the international consensus on defining and grading of bruxism. J Oral Rehabil. 2016; 43: 791-798.
o View
· 6Manfredini D, De Laat A, Winocur E, Ahlberg J. Why not stop looking at bruxism as a black/white condition? Aetiology could be unrelated to clinical consequences. J Oral Rehabil. 2016; 43: 799-801.
o View
· 7Svensson P, Lavigne G. Clinical bruxism semantics beyond academic debates: normo- and patho-bruxism as a new proposal. J Oral Rehabil. 2020; 47: 547-548.
o View
· 8Lobbezoo F, Ahlberg J, Aarab G, Manfredini D. Why using ‘harmless behaviour’, ‘risk factor’ and ‘protective factor’ as terms describing the various possible consequences of bruxism is still the best option. J Oral Rehabil. 2021; 48: 762-763.
o View
· 9Manfredini D, Ahlberg J, Aarab G, et al. Towards a Standardized Tool for the Assessment of Bruxism (STAB)-overview and general remarks of a multidimensional bruxism evaluation system. J Oral Rehabil. 2020; 47(5): 549-556.
o View
· 10Manfredini D, Ahlberg J, Aarab G, et al. The development of the Standardized Tool for the Assessment of Bruxism (STAB): an international road map. J Oral Rehabil. doi:10.1111/joor.13380. Online ahead of print.
o View
· 11Markiewicz MR, Ohrbach R, McCall WD Jr. Oral behaviors checklist: reliability of performance in targeted waking-state behaviors. J Orofac Pain. 2006; 20(4): 306-316.
· 12van Grootel RJ, van der Glas HW, Buchner R, de Leeuw JR, Passchier J. Patterns of pain variation related to myogenous temporomandibular disorders. Clin J Pain. 2005; 21(2): 154-165.
o View
· 13Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortium network and orofacial pain special interest group. J Oral Facial Pain Headache. 2014; 28(1): 6-27.
o View
· 14Gonzalez YM, Schiffman E, Gordon G, et al. Development of a brief and effective temporomandibular disorder pain screening questionnaire: reliability and validity. J Am Dent Assoc. 2011; 142: 1183-1191.
o View
· 15 American Academy of Sleep Disorders. International Classification of Sleep Disorders. 3rd ed. American Sleep Disorders Association; 2017.
· 16Wetselaar P, Lobbezoo F. The tooth wear evaluation system: a modular clinical guideline for the diagnosis and management planning of worn dentitions. J Oral Rehabil. 2016; 43(1): 69-80.
o View
· 17Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992; 6(4): 301-355.
· 18Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The xerostomia inventory: a multi-item approach to measuring dry mouth. Community Dent Health. 1999; 16(1): 12-17.
· 19Kalf JG, Borm GF, de Swart BJ, Bloem BR, Zwarts MJ, Munneke M. Reproducibility and validity of patient-rated assessment of speech, swallowing, and saliva control in Parkinson's disease. Arch Phys Med Rehabil. 2011; 92(7): 1152-1158.
o View
· 20Laharnar N, Herberger S, Prochnow LK, et al. Simple and unbiased OSA prescreening: introduction of a new morphologic OSA prediction score. Nat Sci Sleep. 2021; 13: 2039-2049.
o View
· 21Jepsen S, Caton JG, Albandar JM, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: consensus report of workgroup 3 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol. 2018; 89(Suppl 1): S237-S248.
o View
· 22Van Der Zaag J, Lobbezoo F, Visscher CM, Hamburger HL, Naeije M. Time-variant nature of sleep bruxism outcome variables using ambulatory polysomnography: implications for recognition and therapy evaluation. J Oral Rehabil. 2008; 35(8): 577-584.
o View
· 23Manfredini D, Fabbri A, Peretta R, Guarda-Nardini L, Lobbezoo F. Influence of psychological symptoms on home-recorded sleep-time masticatory muscle activity in healthy subjects. J Oral Rehabil. 2011; 38: 902-911.
o View
· 24Lavigne GJ, Rompré PH, Montplaisir JY. Sleep bruxism: validity of clinical research diagnostic criteria in a controlled polysomnographic study. J Dent Res. 1996; 75(1): 546-552.
o View
· 25Thymi M, Lobbezoo F, Aarab G, et al. Signal acquisition and analysis of ambulatory electromyographic recordings for the assessment of sleep bruxism: a scoping review. J Oral Rehabil. 2021; 48(7): 846-871.
o View
· 26Lavigne G, Kato T, Herrero Babiloni A, et al. Research routes on improved sleep bruxism metrics: toward a standardised approach. J Sleep Res. 2021; 30(5):e13320.
o View
· 27Bracci A, Djukic G, Favero L, Salmaso L, Guarda-Nardini L, Manfredini D. Frequency of awake bruxism behaviours in the natural environment. A 7-day, multiple-point observation of real-time report in healthy young adults. J Oral Rehabil. 2018; 45(6): 423-429.
o View
· 28Colonna A, Lombardo L, Siciliani G, et al. Smartphone-based application for EMA assessment of awake bruxism: compliance evaluation in a sample of healthy young adults. Clin Oral Investig. 2020; 24(4): 1395-1400.
o View
· 29Nykänen L, Manfredini D, Lobbezoo F, et al. A multi-center study on patient comprehension of awake bruxism terminology: prior patient education is advisable for a successful ecological momentary assessment (EMA) by smartphone application. J Clin Med. 2022; 11:3444. doi:10.3390/jcm11123444
o View
· 30Colonna A, Noveri L, Ferrari M, Bracci A, Manfredini D. Electromyographic assessment of masseter muscle activity: a proposal for a 24hr recording device with preliminary data. J Clin Med. 2022; 12(1): 247. doi:10.3390/jcm12010247
o View
· 31Bracci A, Lobbezoo F, Hangman-Henrikson B, et al. Awake bruxism assessment: an expert consensus recommendations. J Clin Med. 2022; 11(17): 5083.
o View
· 32Kroenke K, Spitzer RL, Williams JB, Lowe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009; 50: 613-621.
o View
· 33Sinclair VG, Wallston KA. The development and psychometric evaluation of the brief resilient coping scale. Assessment. 2004; 11: 94-101.
o View
· 34Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anaesthesiol. 2009; 22(3): 405-411.
o View
· 35Douglass AB, Bornstein R, Nino-Murcia G, et al. The sleep disorders questionnaire. I: creation and multivariate structure of SDQ. Sleep. 1994; 17(2): 160-167.
o View
· 36Peck CC, Goulet JP, Lobbezoo F, et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil. 2014; 41(1): 2-23.
o View
· 37Jones R, Junghard O, Dent J, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009; 30(10): 1030-1038.
o View
· 38de Baat C, Verhoeff M, Ahlberg J, et al. Medications and addictive substances potentially inducing or attenuating sleep bruxism and/or awake bruxism. J Oral Rehabil. 2021; 48(3): 343-354.
o View
· 39Lobbezoo F, Ahlberg J, Aarab G, et al. The bruxism screener (BruxScreen): development, pilot testing, and face validity. J Oral Rehabil. 2023; accepted for publication.
· 40de Vet HCW, Terwee CB, Mokkink LB, Knol DL. Measurement in Medicine. Cambridge University Press; 2011.
o View
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