UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4284
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Braz Dent Sci 2024 Apr/June;27 (2): e4284
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Level of knowledge of pediatric dentists on awake and sleep
bruxism in children
Nível de conhecimento de odontopediatras sobre bruxismo em vigília e do sono em crianças
Juliana Araújo Oliveira BUOSI1 , Maria Alice Vale de LIMA1 , Adriana Oliveira LIRA2 , Lívia Maria Sales PINTO FIAMENGUI1 ,
Carolina Ortigosa CUNHA3 , Paulo César Rodrigues CONTI4 , Juliana STUGINSKI BARBOSA5
1 - Universidade Federal do Ceará, Faculdade de Farmácia, Odontologia e Enfermagem, Departamento de Odontologia Restauradora.
Fortaleza, CE, Brazil.
2 - Universidade Cruzeiro do Sul, Faculdade de Odontologia. São Paulo, SP, Brazil.
3 - Centro Universitário Sagrado Coração, Faculdade de Odontologia. Bauru, SP, Brazil.
4 - Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Prótese. Bauru, SP, Brazil.
5 - Universidade de São Paulo, Faculdade de Odontologia de Bauru, Grupo de Dor Orofacial. Bauru, SP, Brazil.
How to cite: Buosi JAO, Lima MAV, Lira AO, Pinto Fiamengui LMS, Cunha CO, Conti PCR, et al. Level of knowledge of pediatric dentists
on awake and sleep bruxism in children. Braz Dent Sci. 2024;27(2):e4284. https://doi.org/10.4322/bds.2024.e4284
ABSTRACT
Objective: To evaluate the knowledge of pediatric dentists concerning bruxism in children and explore the subject
according to the latest scientic evidence. Material and Methods: Four hundred and twenty-ve pediatric dentists
lled out an online form comprising 17 statements regarding awake and sleep bruxism in children. Data was
analyzed in two distinct ways: participant’s knowledge and statements knowledge. Participant´s knowledge was
considered acceptable when at least 10 out of 17 statements were correctly answered. Statements knowledge was
considered satisfactory when correctly answered by, at least, 70% of the participants. Results: The average of
correct answers was 9.73 (±3.41). Fifty-two percent of the participants showed acceptable knowledge and only
4 statements obtained a percentage of answers considered satisfactory. Conclusion: The knowledge of pediatric
dentists regarding awake and sleep bruxism in children is decient, and continuous education concerning this
topic is suggested to avoid misdiagnosis and inadequate management.
KEYWORDS
Bruxism; Education; Knowledge; Pediatric dentistry; Surveys and questionnaires.
RESUMO
Objetivo: Avaliar o conhecimento dos odontopediatras sobre o bruxismo em crianças e discutir o tema de acordo
com as evidências cientícas atuais. Material e Métodos: 425 odontopediatras preencheram um formulário online
composto por 17 armações sobre bruxismo em crianças durante a vigília e o sono. Os dados foram interpretados
de duas formas distintas: conhecimento do participante e conhecimento das armações. O conhecimento do
participante foi considerado aceitável quando pelo menos 10 das 17 armações foram respondidas corretamente.
O conhecimento das armações foi considerado satisfatório quando foi respondido corretamente por, pelo menos,
70% dos participantes. Resultados: O número médio de respostas corretas foi de 9,73 (±3,41). Cinquenta e
dois por cento dos participantes demonstraram conhecimentos aceitáveis e apenas 4 armações obtiveram uma
percentagem de respostas consideradas satisfatórias. Conclusão: O conhecimento dos odontopediatras sobre
o bruxismo em crianças em vigília e durante o sono é deciente, sugerindo-se a educação continuada sobre o
tema, a m de evitar diagnósticos equivocados e condutas inadequadas.
PALAVRAS-CHAVE
Bruxismo; Educação; Conhecimento; Odontopediatria; Inquéritos e questionários.
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Buosi JAO et al.
Level of kno wledge of pediatric dentists on awake and sleep bruxism in children
Buosi JAO et al. Level of knowledge of pediatric dentists on awake and sleep
bruxism in children
INTRODUCTION
Bruxism is a repetitive jaw-muscle activity
characterized by clenching or grinding of the teeth
and/ or by bracing or thrusting of the mandible.
It has two distinct circadian manifestations: during
sleep (sleep bruxism - SB) and wakefulness (awake
bruxism - AB) [1]. Over the years, several efforts
have been made to clarify bruxism physiology,
classication, and diagnosis [1-3]. Recently, the rst
steps towards the creation of a Standardized Tool
for the Assessment of Bruxism (STAB) have been
introduced, which will facilitate the assessment of
bruxism patients by providing a comprehensive
examination of the clinical implications of various
bruxism activities and etiologies [3].
Despite concerted efforts by task forces,
one challenge persists: bruxism exhibits a higher
prevalence among children, ranging globally
from 3.5% to 40.6% between the ages of two and
twelve years. Furthermore, the bulk of available
research on bruxism has been centered on adults.
Notably, the prevalence of bruxism tends to
decline progressively around the ages of 9 and 10,
underscoring that a signicant portion of children
do not persist with bruxism into adulthood [4].
The pediatric dentist typically is often
the initial point of contact for parents and
children reporting bruxism symptoms. Identifying
potential deciencies in professional education in
this domain and improving comprehension of this
condition can optimize the diagnostic process,
treatment planning, and prognostic outcomes.
In this context, the current study sought to assess
the knowledge of pediatric dentists regarding
both SB and AB in children.
MATERIAL AND METHODS
Study design and ethical considerations
The present study was an observational,
cross-sectional, descriptive study, approved by
the Human Research Ethics Committee (protocol
number: 2.812.303). All enrolled participants
signed a written informed consent form before
entering the study.
Participant screening and eligibility assess-
ment
Participants were recruited from August to
December 2018 through social media. Eligible
participants were pediatric dentists, residing
in Brazil, registered in the Federal Council of
Dentistry, without the restriction of age, gender,
or time since dental school graduation.
Survey form
The survey was carried out by using an
online form (Google Forms app from Google™).
The survey Google Forms link was distributed
through authors’ personal Instagram® (Kevin
Systrom, Mike Krieger, Burbn, Inc., USA),
WhatsApp® (WhatsApp LLC, Meta Inc., USA),
and Facebook® (Meta Inc., USA). The survey
comprised two sections. The rst one included
data regarding age, gender, time (years) since
dental school graduation, and time (years)
since completion of pediatric dentistry training.
In the second section, volunteers were asked
to indicate their opinions regarding SB and AB
in children. The survey form was developed
based on a preexisting form used to evaluate
Temporomandibular Disorders (TMD) knowledge
among dentists [5,6] since there were no
published studies with this kind of questionnaire.
The survey form was developed and revised by
two professionals with years of experience in
the eld.
The form comprised 17 statements divided
into three domains: (1) Classification and
Diagnosis (composed of 6 statements: 1, 2, 3,
8, 9, 10); (2) Etiology and Pathophysiology
(composed of 6 statements: 4, 5, 6, 7, 11,17); and
(3) Treatment (composed by 5 statements: 12,
13, 14, 15, 16). These statements were created
as affirmations, ones with correct and others
with incorrect information. Each statement was
followed by an 11-point numerical scale ranging
from “0” to “10”, where “0” represented “strongly
disagreed” and “10” represented “strongly agree”.
The number “5” represented a “neutral” opinion.
The answers were classied as “agree” (scored
7 to 10), “disagree” (scored 0 to 3) or “neutral”
(scored 4 to 6) [5,6].
The survey´s form data was interpreted
in two distinct ways: participant’s knowledge
and statements knowledge. Participant´s
knowledge was considered acceptable when
at least 10 out of 17 statements were correctly
answered. Statements knowledge was considered
“satisfactory” when it was correctly answered by
at least 70% of the participants, “intermediate”
when it was correctly answered between 50%
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Buosi JAO et al.
Level of kno wledge of pediatric dentists on awake and sleep bruxism in children
Buosi JAO et al. Level of knowledge of pediatric dentists on awake and sleep
bruxism in children
and 69% of the participants, and “unsatisfactory”
when it was correctly answered by 50% of
participants or under.
For statistical analysis, the score obtained for
each statement was transformed into an ordinal
variable: (1) for correctly answered; (2), for a
neutral answer, and (3), for wrong answer.
Sample calculation and statistical analysis
It was estimated that a minimum
of 383 participants from a total amount of
8,546 pediatric dentists registered at the
Brazilian Federal Council of Dentistry, was
adequate for the present study. A sampling
error of 5% and a condence level of 95% were
considered. For statistical analysis, a qualitative
and quantitative description was performed.
RESULTS
Sample description and main ndings are
presented in Table I. A total of 425 pediatric
dentists completed the survey form. The frequency
of agreements, disagreements, and neutralities
for each statement is described in Table II.
The average number of correct answers
was 9.73 (±3.41). Approximately half of the
participants (52%) showed acceptable knowledge.
Only 2% (n=9) answered all statements correctly
and none answered all incorrectly.
Statements with the highest percentage of
correct answers were items 7 (81%) and 8 (91%),
and statements with the lowest percentage of
correct answers were items 9 (39%) and 11 (31%).
Only 4 statements were correctly answered by at
least 70% of the participants (Table II).
DISCUSSION
This cross-sectional study aimed to evaluate
pediatric dentists’ knowledge regarding SB
and AB in children. In general, the sample was
mainly composed of women, with a mean age of
39.7 years, and a mean time since dental school
graduation and completion of pediatric dentistry
training of 16.6 years and 11.9 years, respectively.
Fifty-two percent of the sample showed acceptable
knowledge and only four statements obtained a
percentage of answers considered as satisfactory.
The ndings are of concern and are discussed
below.
Classication and diagnosis domain (state-
ments 1, 2, 3, 8, 9 and 10)
There seems to be a satisfactory level of
understanding by pediatric dentists regarding
the denition of SB and the fact that bruxism is
related to other systemic alterations (statements
1 and 2) [1]. However, only 40% of the sample
agreed that bruxism is more prevalent during
childhood (statement 3). In a previous study,
Guillot et al. [7] found that 90.6% of the
participants considered SB to be more prevalent
among adults.
Table I - Sample description and main findings
Mean ± SD age, y 39.7 ± 9.8
Gender, %
Female 95.29%
Male 4.71%
Mean ± SD Time since graduation completion, y 16.6 ± 9.9
Mean ± SD Time since completion of the pediatric dentistry specialization, y 11.9 ± 9.8
Participants Knowledge (n, %)
Acceptable 221; 52%
Unacceptable 204; 48%
Brazilian regional division (n, %)*
Southeast 209; 49.2%
Northeast 71; 16.7%
South 101; 23.8%
Central-West 34; 8.00%
North 7; 1.6%
*3 volunteers did not answer the question. SD = standard deviation; % = percentage; y = years.
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Level of kno wledge of pediatric dentists on awake and sleep bruxism in children
Buosi JAO et al. Level of knowledge of pediatric dentists on awake and sleep
bruxism in children
Statement 8 showed the highest percentage
of correct answers (90.82%). There is a common
opinion, especially among patients and clinicians,
that bruxism is related to stress [7]. AB is
probably a result of a prolonged contraction of the
masticatory muscles after emotional tension [8]
and children with a high level of responsibility
and neuroticism are more likely to present SB [9].
AB definition was partially addressed
in statement 9, which showed the highest
percentage of neutral responses. Although the
term bruxism derives from the Greek term
“brychein”, meaning grinding of the teeth, the
current consensus on bruxism states that AB is
characterized by tooth-contacting behaviors or
mandible bracing, without the need for tooth
contact [10].
Statement 10 refers to dental attrition as a
denitive sign of bruxism requiring immediate
treatment, and almost half of the sample agreed
or remained neutral regarding this statement.
Canine wear, dental wear, headache [11], and
non-carious cervical lesions [12] are the most
prevalent signs and symptoms of SB in children,
Table II - Survey’s form statements; answers for each statement
Statement Correct
Answer
Dentists Answers Statement’s
knowledge
Agree Disagree Neutral
1. Concerning the definition of sleep bruxism, it is an activity of
the masticatory muscles during sleep, which is characterized as
rhythmic (phasic) or non-rhythmic (tonic).
Agree 69.18% 8.94% 21.88% Intermediate
2. Bruxism can be considered a protective or signaling activity
associated with other systemic alterations. Agree 79.29% 11.29% 9.41% Satisfactory
3. Sleep bruxism is more prevalent among children and its
occurrence reduces during adulthood. Agree 40.00% 44.71% 15.29% Unsatisfactory
4. Occlusal problems, such as premature contact, may cause child
bruxism. Disagree 33.18% 53.88% 12.94% Intermediate
5. Attention Deficit Hyperactivity Disorder (ADHD) may be
associated with child bruxism. Agree 80.00% 7.53% 12.47% Satisfactory
6. Drugs used in ADHD therapy, such as Ritalin, can be associated
with the presence
of child bruxism.
Agree 54.35% 16.24% 29.41% Intermediate
7. Mouth breathing, presence of allergic rhinitis, asthma, adenoid,
and tonsil hypertrophy may cause or perpetuate child bruxism. Agree 80.71% 12.71% 6.59% Satisfactory
8. Awake bruxism may be associated with moments of stress,
anxiety, and concentration. Agree 90.82% 4.00% 5.18% Satisfactory
9. Bracing/thruster the mandible during wakefulness, even without
tooth contact, is considered awake bruxism. Agree 39.29% 32.71% 28.00% Unsatisfactory
10. The presence of dental attrition is a clear sign of bruxism
demanding immediate treatment. Disagree 34.82% 50.59% 14.59% Intermediate
11. Episodes of sleep bruxism are common during childhood,
especially in the period of tooth eruption, characterizing
physiological bruxism.
Disagree 50.35% 31.06% 18.59% Unsatisfactory
12. Intraoral acrylic splints are not indicated in pediatric dentistry
as they limit mandibular growth. Disagree 27.53% 56.24% 16.24% Intermediate
13. The management of awake bruxism is based on patient
education through self-knowledge and behavior avoidance, without
the need for an occlusal appliance.
Agree 46.59% 25.41% 28.00% Unsatisfactory
14. To date, no therapy is effective in the cure or prevention of
primary bruxism. Agree 57.88% 23.53% 18.59% Intermediate
15. Restoring occlusal balance through occlusal adjustments, oral
rehabilitation, or orthodontic treatment are valid therapy options
for primary bruxism.
Disagree 42.59% 44.24% 13.18% Unsatisfactory
16. The prescription of muscle relaxants is indicated to reduce
episodes of bruxism, reducing its masticatory muscle overload and
pain.
Disagree 33.18% 42.35% 24.47% Unsatisfactory
17. The correction of malocclusions prevents the occurrence of sleep
bruxism. Disagree 28.94% 56.47% 14.59% Intermediate
% = percentage
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Buosi JAO et al.
Level of kno wledge of pediatric dentists on awake and sleep bruxism in children
Buosi JAO et al. Level of knowledge of pediatric dentists on awake and sleep
bruxism in children
however, dental attrition may indicate past
bruxism without current activity [1]. Besides,
dentists should be aware of several other factors
that may contribute to dental damage, such as
erosion, poor density of enamel, and certain
medication use [13].
Etiology and pathophysiology domain (state-
ments 4,5,6,7,11 and 17)
Pediatric dentists seem to be aware of
bruxism as a protective or signaling activity
associated with Attention Decit Hyperactivity
Disorder (ADHD) [14], mouth breathing, allergic
rhinitis [15], asthma [16], adenoid and tonsil
hypertrophy [17] (statement 5). However, only
54.35% of the sample agreed drugs administered
for ADHD management, such as Ritalin, may be
associated with child bruxism (statement 6).
Malki et al. [18] observed a positive relationship
between the use of Central Nervous System
stimulants and tooth wear. In addition, other
drugs may also be associated with higher chances
of SB, such as duloxetine, paroxetine, and
venlafaxine [19].
Statements 4, 11, and 17 refer to the
association between peripheral components
(premature contact, tooth eruption, and
malocclusion correction) as preventive for SB,
however, none of these factors were deemed
to possess an adequate level of knowledge
among the specialists evaluated. Only 31.06%
of participants did not correlate SB with tooth
eruption during childhood. Besides, the idea
that bruxism is physiological may be destructive.
Bruxism has been associated with sleep arousals,
autonomic sympathetic cardiac activation,
psychosocial components, exogenous factors, and
comorbidities [20]. As previously established,
bruxism is mainly regulated centrally - not caused
by anatomical factors [1], thus the inuence of
peripheral components on its pathophysiology is
not supported [21,22].
Treatment domain (12, 13, 14, 15 and 16)
In this domain, any statement was considered
as presenting a satisfactory level of knowledge,
thus showing professionals are not qualified
for bruxism management. Only 46.59% of the
participants agreed AB therapy is based on patient
education through self-awareness and control
without the need for a protective occlusal device
(Statement 13). Currently, SB management
consists of wearing occlusal splints while sleeping;
sleep hygiene, and other lifestyle behavioral
approaches [23]. AB management consists
of behavior identification, monitoring, and
avoidance [24]. In a preliminary study, ecological
momentary intervention for AB management has
been proposed for healthy young adults [25],
however, for children, psychological management
must be preferred [10,26,27].
Statement 12 concerns the use of acrylic
splints in pediatric dentistry, and 43.76% of
the sample agreed or was neutral on the belief
that those appliances limit mandibular growth.
The use of occlusal splints is a reversible, non-
invasive treatment and a previous study showed
it is effective in reducing symptoms of SB, such
as grinding sounds and headache [28]. To date,
no study associated using occlusal splints
with limited mandibular growth, however, its
indication should be constantly monitored by
the dentist [29].
Regarding statement 14, 57.88% of the
sample agreed no therapy is effective for the cure
or prevention of primary bruxism (Statement
14). Also, although some drugs are promising to
attenuate bruxism, such as hydroxyzine, there
is not enough scientic evidence to support the
use of any drug for bruxism management [19]
(Statement 16).
As discussed above, there is no scientific
support for the role of occlusion on AB or
SB pathophysiology [21,22], thus, restoring
occlusal balance through occlusal adjustments,
oral rehabilitation, or orthodontic alignment
(statement 15) must be avoided. Moreover, given
that most children do not maintain SB behavior
during adulthood, non-interventionist measures
are recommended for its control [4].
This study is relevant since it emphasizes
the need for continuing education programs
for pediatric dentists when it comes to bruxism
etiology, diagnosis, and treatment. One of the
study’s strengths was that it assessed participants
from different regions of Brazil, which could
guide the national education sector. However,
our study has some limitations, such as the
absence of a reference group formed by TMD
and Orofacial Pain specialists and other groups
for comparison, such as general dentists and
orthodontists [30]. Additionally, bias related
to online form application may have occurred.
Lastly, the ndings presented here should not be
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Level of kno wledge of pediatric dentists on awake and sleep bruxism in children
Buosi JAO et al. Level of knowledge of pediatric dentists on awake and sleep
bruxism in children
generalized and future studies conducted between
pediatric dentists from different nationalities are
suggested.
CONCLUSION
Based on the results of this observational,
cross-sectional, descriptive study, a high
percentage of pediatric dentists showed
unacceptable knowledge regarding child bruxism,
and only 4 statements obtained a percentage of
answers considered satisfactory. There is a lack of
knowledge of pediatric dentists regarding AB and
SP in children and continuous education about
this topic is necessary to avoid misdiagnosis and
insufcient management.
Acknowledgements
The authors extend their appreciation to the
participants of the study for their commitment to
responding to the questionnaires.
Author’s Contributions
JAOB: Conceptualization, Methodology,
Investigation, Writing – Original Draft Preparation,
Writing – Review & Editing. MAVL: Writing –
Original Draft Preparation, Writing – Review &
Editing. AOL: Conceptualization, Methodology.
LMSPF: Investigation, Writing – Original Draft
Preparation, Writing – Review & Editing,
Visualization, Supervision. COC: Formal Analysis,
Writing – Review & Editing, Visualization,
Supervision. PCRC: Conceptualization, Writing
– Review & Editing, Visualization, Supervision.
JSB: Conceptualization, Methodology, Writing
– Review & Editing, Visualization, Supervision.
Conict of Interest
The authors declare no conicts of interest.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-for-prot sectors.
Regulatory Statement
This study was approved and conducted
following all the Human Research Ethics
Committee of the Universidade Federal do
Ceará, Brazil, (Protocol number 2.812.303) and
under the 1964 Helsinki Declaration and its later
amendments.
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Lívia Maria Sales Pinto Fiamengui
(Corresponding address)
Universidade Federal do Ceará, Faculdade de Farmácia, Odontologia e Enfermagem,
Departamento de Odontologia Restauradora, Fortaleza, CE, Brazil.
Email: liviamspf@ufc.br
Date submitted: 2024 Mar 13
Accept submission: 2024 June 11