Sleep

Sleep bruxism associated with obstructive sleep apnea syndrome in children Nata´lia Maria Ribeiro Ferreira1, Jarbas Francisco Fernandes dos Santos1, Mateus Bertolini Fernandes dos Santos2, Leonardo Marchini3 1

School of Dentistry, University of Taubate´, Brazil, 2School of Dentistry, Federal University of Pelotas, Brazil, Department of Preventive and Community Dentistry, University of Iowa, USA

3

Aims: Sleep bruxism (SB) and obstructive sleep apnea syndrome (OSAS) are often observed in children and may have several health implications. The aim of this paper is to evaluate their prevalence and to test for possible associations between these two conditions. Methodology: The sample consisted of 496 children randomly selected among the preschoolers of Taubate´, Brazil; 249 (50.2%) were boys and 247 (49.8%) were girls. Diagnoses of SB and OSAS were made by clinical examinations and questionnaires filled out by the children’s parents in a cross-sectional design. Analysis of variance and Chi-square tests were applied to verify possible association among the variables in question. Results: The average age was 4.49 years (SD: 61.04 years). A total of 25.6% were diagnosed with SB, while 4.83% were diagnosed with OSAS, and only 2.82% presented both conditions. A statistical association was found between SB and OSAS (P,0.001; Chi-square test): 11.03% of subjects with SB also presented with OSAS, and 97.18% of subjects without SB did not present with OSAS. No association was found among children’s gender and age and the presence of SB or OSAS. Conclusions: Within the limits of this study, SB was associated with OSAS. Keywords: Children, Obstructive sleep apnea syndrome, Parafunction, Parasomnia, Sleep bruxism

Introduction Sleep bruxism (SB) is an involuntary, parafunctional, rhythmic spasmodic action of the masticatory system produced by contraction of the masticatory muscles. It is clinically characterized by tooth grinding or clenching during sleep.1 The absence of standard criteria in the diagnosis and evaluation of SB has generated variations in the observed prevalence in epidemiological data regarding this parafunction, ranging between 8.4% and 32.3%.2–4 The signs and symptoms of SB reported in the literature are wear facets on anterior or posterior teeth where the borders of teeth fit the antagonist in excursive movements, hyperkeratotic ridges in the cheeks, tongue scalloping and/or incisal impressions in the lips, and history of frequent noises of tooth grinding during sleep.5,6 Also, pulp hypersensitivity, mobility, cusp fractures, temporomandibular dysfunction, masseter hypertrophy, and headaches may

Correspondence to: M. B. F. dos Santos, Rua Conc¸alves Chaves, 457, Pelotas, RS, Brazil. Email: [email protected] ß W. S. Maney & Son Ltd DOI 10.1179/2151090314Y.0000000025

be observed as a result of the SB condition. The most accurate way to diagnose SB is using polysomnography, which is considered the gold standard.7 However, clinical diagnosis is also considered a reliable method,8 where the professional should look for clinical findings and then ask about noises of tooth grinding during the night. SB may occur in children and adults and is considered to have a multifactorial etiology9 involving local and systemic factors,5 use of drugs, and psychological factors such as anxiety, restless sleep, and others.10 Although the precise etiology of SB is still unknown,11 some studies12,13 report evidence that suggests that SB is a movement disorder related to micro-arousals during sleep. Parasomnias are physical events that occur during sleep, which may also have a varied etiology, involving psychological and psychiatric factors and different behavioral comorbidities.14 Nocturnal enuresis, sleepwalking, and restless sleep are examples of parasomnias, which may be related to a more severe form of SB.15 Obstructive sleep apnea syndrome

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(OSAS) is characterized by partial or complete intermittent airway obstruction,16 which can cause serious long-term health consequences, such as cardio- and cerebrovascular diseases and reduced quality of life.17 In children, neurocognitive deficits can occur with a high frequency of OSAS.18 The prevalence of OSAS in children ranges from 0.7% to 10.3%.19 As the etiology of SB is unknown, there is no specific treatment.20,21 The management of this disorder consists of a multidisciplinary approach, including dentistry, medicine, and psychology.22 Among children, SB does not seem to cause major damage to the masticatory system, and it is usually asymptomatic. Therefore, it does not require therapeutic intervention, just periodic review to follow its progress since it can also present with spontaneous remission. However, if this condition persists during adolescence and young adulthood, major damage can be caused to the masticatory system.23 In children, its etiology appears to be closely related with other parasomnias, OSAS in particular, as suggested by previous studies.6,23 Considering the high prevalence of SB in children, its unknown etiology, and the possibility of etiological relation with OSAS as suggested by previous studies,6,23 the hypothesis tested in the present study was that there is an association between SB and OSAS in children.

Methods Subjects All the parents/guardians signed an informed consent form to participate in the study, which was previously approved by the Committee for Ethics in Research of the University of Taubate´ (protocol number CEP/ UNITAU 122/12). The inclusion criteria for this sample were children of preschool age (3–6 years old) who live in the city of Taubate´. According to Taubate´’s Department of Education, 11 474 children fit this criterion. The exclusion criteria were: patients’ parents who did not provide consent, children with neurological compromise, children medicated with psychotropic drugs, and esophageal reflux. A total of 762 children (a sample size with a power of 91.68% to represent the preschoolers of Taubate´, as calculated using Minitab v15 software) who were registered as preschoolers in the city of Taubate´ were randomly selected, and 266 refused to participate and/or did not return the questionnaires. A final number of 496 individuals completed all the research steps. The final sample had a power of 79.36% to represent the whole population of children of preschool age in the city of Taubate´ (Minitab v15). 2

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SB evaluation Diagnosis of SB was made by clinical examinations as well as by the application of a questionnaire to be answered by the parents. A single professional performed all of the examinations. Clinical examinations evaluated the presence of wear facets on canines and incisors where the worn borders of the teeth fit the wear facet of the antagonist tooth during excursive movements. On those children who did not present complete primary dentition, only the teeth present were analyzed. The questionnaire given to the children’s parents contained the following question: 1. Does your child grind his/her teeth at night? ( ) Yes ( ) No.

Those participants who presented with clinical signs of SB and whose parents answered ‘Yes’ to the question about grinding teeth at night were diagnosed with SB.

OSAS evaluation OSAS evaluation was also made by clinical examinations and by the application of a questionnaire to be answered by the parents, based on a modified version of the Mallampati questionnaire.17 During the clinical examination, the posterior oropharynx wall was evaluated, including the lower pole of the palatine tonsils, uvula, and soft and hard palates. The questionnaire contained the following questions: 1. During sleep, does your child snore? ( ) Yes ( ) No. If yes, is it frequent? 2. During sleep, have you noticed the child not breathing for a few seconds, as if choking? ( ) Yes ( ) No. 3. Upon waking does your child complain of tiredness? ( ) Yes ( ) No.

Those participants who had a Mallampati score of III or IV and whose parents answered ‘Yes’ for all the questions on the OSAS questionnaire were diagnosed with sleep apnea. All clinical examinations were done by a single examiner.

Statistical analysis The data was analyzed using descriptive statistics, and possible associations were tested using a Chisquare test. ANOVA was used to compare the average age among children who were and were not diagnosed with SB and OSAS. All the tests were performed using an alpha level of 5% (P50.05).

Results A total of 496 subjects were included in the sample: 247 girls (49.8%) and 249 boys (50.2%). The average age of the sample was 4.49 years (SD: 61.04 years). A total of 127 subjects (25.61%) were diagnosed with VOL .

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SB, while only 24 (4.83%) were diagnosed with OSAS. Only 14 subjects (2.82%) presented both conditions. Using the Chi-square test, there was a statistical association between SB and OSAS (P, 0.001; Chi-square test), as shown in Table 1. No statistical association was found among children’s gender and age and the presence of SB or OSAS, as shown in Tables 2 and 3.

Discussion In the present study, both SB and OSAS presented prevalence that is in agreement with previous studies. In regard to SB, 25.61% of the children were diagnosed with this condition, while the prevalence reported by previous studies ranges from 8.4% to 32.3%.2–4,6 The number of children diagnosed with OSAS (4.83%) was lower compared to SB prevalence. However, the prevalence of OSAS was also in agreement with previous reports, in which OSAS prevalence ranges from 0.7% to 10.3% in children.19 The hypothesis tested in this study — that there is an association between SB and OSAS in children — was confirmed by the results. An association was found between the presence of SB and OSAS, where 11.03% of subjects with SB also exhibit OSAS, and 97% of subjects without SB did not present OSAS. A general reduction in the upper airway is observed during sleep, due to a reduction of activity of muscles that maintain its patency.11 The upper airway seems to be important in both SB and OSAS conditions. In the SB condition, it was suggested that the rhythmic masticatory muscle activity during sleep has a role in lubricating the upper alimentary tract and increasing

Bruxism and apnea in children

airway patency.11 In regard to the OSAS condition, partial or complete intermittent airway obstruction results in apnea or hypopneic breathing.16 The occurrence of OSAS seems to be related to alterations in consciousness during sleep, in addition to genetic, neuromuscular, and anatomic factors, such as adenotonsillar hypertrophy and inflammatory responses, both systemically and locally within the upper airway.16 A possible explanation of the association between SB and OSAS in children observed in this study could be the hypothesis suggested by Fonseca et al.6 that young children grind their teeth as a physiological response to increase the airway patency because they have OSAS. Further associations were checked to evaluate possible association with SB and/or OSAS. No association between children’s gender and SB was observed in the present study, which is in agreement with previous studies that also verified no gender association with SB.6,11 No association was observed between gender and OSAS, either, which is in agreement with a previous study.24 Table 3 Comparison among children’s age and sleep bruxism and obstructive sleep apnea syndrome (one-way ANOVA)

Age Average SD N P-value

Sleep bruxism

Sleep apnea

No

No

Yes

4.49 1.03 472 0.946

4.50 1.14 24

Yes

4.50 1.02 369 0.506

4.43 1.07 127

Table 1 Sleep bruxism and obstructive sleep apnea syndrome association (Chi-square test) Sleep bruxism No

Sleep apnea

No Yes Total

Yes

Total

n

%

n

%

n

%

359 10 369

97.18% 2.82% 74.39%

113 14 127

88.97% 11.03% 25.61%

472 24 496

95.17% 4.83% 100%

Note: P,0.001. Table 2 Relationship among children’s gender with sleep bruxism and obstructive sleep apnea syndrome (Chi-square test) Girls

Sleep bruxism Sleep apnea

No Yes No Yes

Boys

Total

n

%

n

%

n

%

P-value

180 67 232 15

72.87% 27.13% 93.92% 6.08%

189 60 240 9

75.90% 24.10% 96.38% 3.62%

369 127 472 24

74.39% 25.61% 95.16% 4.84%

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No associations were observed between the diagnosis of SB and age. Although no association was found, previous studies suggest that SB occurrence decreases with age.11,23 Also, no association was observed between the diagnosis of OSAS and age. This finding is in contrast with a recent literature review about pediatric OSAS,16 which suggested that the prevalence of this condition increases with age. A possible explanation for this difference may be the sample size and the strict age limits of the present sample (3–6 years-old), which may have overshadowed this relationship between age and prevalence of OSAS. As stated earlier, the polysomnography test is considered the gold standard for SB and OSAS diagnosis.7 However, polysomnography presents some limitations, since it requires the children’s hospitalization, which may be stressful for the children and their parents.25 One may also consider that the use of polysomnography in large samples is unviable due to economical limitations. Thus, clinical diagnosis and questionnaire application were used to evaluate the presence of SB and OSAS in the present study. A recent systematic review by Brockmann et al.25 addressed the diagnosis of obstructive sleep apnea in children. Among the 33 studies included in this systematic review, only six used clinical examinations in the diagnosis of OSAS, where the tonsil size evaluation was mentioned in three of them. On the other hand, 10 studies used questionnaires in the diagnosis of OSAS. A previous study also stated that some questionnaires could have high sensitivity but low specificity for OSA diagnosis,26 which may compromise the results. In order to obtain reliable results, the authors decided to use the Mallampati score system in this study, which is based on clinical examinations and also a questionnaire that is answered by the parents. This is a non-invasive test that can be rapidly used to assess the presence and severity of OSAS, as previously reported.17 It is important to state that both SB and OSAS could be under-reported in this study, due to the limitations inherent to the use of clinical plus questionnaires methods for diagnosing these conditions. Thus, further studies using more reliable tests, such as polysomnography, should be made to shed more light on this topic. Another limitation of the present study is the fact that Body Mass Index of the children was not recorded, since obesity is frequently associated with OSAS.16 Further investigations could be made to control the influence of obesity. Also, further studies should be made to verify the validity of the hypotheses raised by Fonseca et al.6 and corroborated by the association between SB and 4

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OSAS observed in the present study. This verification is very important since a statistical association among the variables does not indicate a direct cause-andeffect relationship.

Disclaimer Statements Contributors All the listed authors made valuable contributions to this manuscript. The authors also thank Ms Anna Okulist for her native English proofreading of this manuscript. Funding The authors would like to thank CNPq (a Brazilian governmental research agency) and the University of Taubate´ for the grant received by the first author (NMRF) to develop this study (PIBIC #072/12). Conflicts of interest The authors deny any conflict of interest. Ethics approval This study was approved by the Committee for Ethics in Research of the University of Taubate (protocol number CEP/UNITAU 122/ 12).

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Sleep bruxism associated with obstructive sleep apnea syndrome in children.

Aims: Sleep bruxism (SB) and obstructive sleep apnea syndrome (OSAS) are often observed in children and may have several health implications. The aim ...
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