Sleep bruxism in children main methods of treatment: a systematic review with meta-analysis

1. Introduction

Sleep bruxism and conscious bruxism are masticatory muscle activities characterized by repeated or prolonged tooth contact and bracing or thrusting of the jaw [1, 2]. Although there is a lot of variation due to the various assessment techniques (self-report, clinical inspection, electromyography, or polysomnography), the literature reports that children and adolescents with sleep bruxism range from 3.5% to 49.6%, and those with fully conscious bruxism range from 4.1% to 7.1% [2]. There are no gender differences in Sleep Bruxism (SB) prevalence, according to the literature. Although bruxism was once viewed as a set of coordinated activities that did not contribute to a functional objective or a parafunctional activity, it now seems that the definition is more by a biological continuum that ranges from physiological to pathological function [3]. As a result, among healthy people, bruxism is no longer regarded as a disorder but rather as a practice that might have both dangerous and beneficial effects on dental health [4]. Given its involvement in the preservation of tissue homeostasis, stress management, and developing alveoli, it appears that bruxism is physiological, especially in children [5, 6, 7, 8, 9, 10]. Therefore, extreme bruxism qualifies as abnormal. Therefore, controlling excessive and physiological bruxism is critical when weak structures are nearby. Additionally, it was said that in otherwise healthy people, bruxism shouldn’t be viewed as a condition but rather as a behaviour that can increase (or decrease) the risk of certain health outcomes. It is stated that bruxism can be a risk factor with potentially adverse effects on oral health, including significant mechanical tooth wear, broken teeth, prosthodontic difficulties, and/or pain in the masticatory muscles or temporomandibular joint [11, 12, 13, 14]. The main indicators and signs of bruxism are tooth erosion, sounds during the night, shattered teeth, tooth sensitivity, masseter muscle hypertrophy, tongue indentation, lip or cheek biting, and headaches [15, 16, 17]. Numerous risk variables are associated with the aetiology, including biological (such as genetics, sleep problems, and neurochemicals), psychologic (such as personality, anxiety, and stress, today also increased due to the 2019-nCoV acute respiratory disease (Covid-19)) [18, 19, 20, 21, 22], and exogenous factors (such as specific medications, alcohol, tobacco, caffeine, and illegal narcotics) [23, 24, 25]. Therefore, various specialists and treatment methods treat both sleep and awake bruxism. Certain sleeping habits have been recognized as significant risk factors for bruxism. The risk factors for irregular tooth wear and the emergence of temporomandibular joint (TMJ) dysfunction are unknown to someone with SB. According to recent research findings, SB may also contribute to primary headaches, which are thought to be primarily controlled by the central nervous system and may be correlated with abnormalities in the brain’s GABAergic and glutamatergic systems. In addition to bodily motions, respiratory issues, increased muscular activity, and heart rate irregularities, bruxism may also be accompanied by sleep disruptions [26, 27]. Occupation sleep apnoea, parasomnias, restless legs syndrome, mandibular myoclonus, and rapid eye movement disorders are among the sleep conditions that coexist with bruxism. The literature highlights sleep bruxism-related problems with falling asleep, interrupted sleep, and sleeping for fewer hours than is essential [28]. Sleep characteristics like nocturnal agitation, nightmares, night terrors, snoring, somniloquy, mouth breathing, and prone position are all linked to sleep bruxism. Sleep problems such as poor sleep quality and attention problems are also linked to conscious bruxism. The diagnosis of bruxism might be difficult [29]. Despite the illness being acknowledged, no universally acknowledged diagnostic criteria for AB were published in the literature. The American Academy of Sleep Medicine (AASM) proposed one of the most widely accepted criteria for the diagnosis of SB, which includes the presence of tooth grinding or clenching sounds during sleep and one or more of the following concurrent signs and symptoms: abnormal tooth wear, jaw muscle discomfort, fatigue, or pain and jaw lock on awakening, or masseter muscle hypertrophy on voluntary forceful clenching [30]. The therapeutic therapy of SB is a topic of debate among doctors. The medical professional, the child’s parents, and the youngster must work together to treat bruxism successfully. SB is currently receiving physiotherapy treatment. Kinesiotherapy, massage, infrared therapy, and low-level laser therapy are typical treatment modalities for treating SB in pediatric patients (LLLT). Occlusal appliances are used as part of the dental bruxism treatment to guard the teeth against pathological abrasion while you sleep. Also, according to reports, youngsters with orthodontic procedures aimed at expanding their jaw are less likely to develop SB [31]. The primary purpose of this meta-analysis is to analyze which treatment methods are most effective in treating bruxism. A secondary purpose is to assess the average age of bruxism patients.

2. Materials and methods

2.2 Search strategy

A literature search was performed on PubMed, Lilacs, Web of Science and Scopus, and articles published from 2000 to 2022 were considered according to the keywords entered. The term “Bruxism” has been combined with “Children” using the boolean connector AND. The web search was assisted using MESH (Medical Subjects Headings) (Table 1). The criteria for this review are described in the Preferred Reporting Items for Systematic Reviews (PRISMA) and by the following flowchart (Fig. 1). Furthermore, a manual search of the references of previous systematic reviews on a similar topic was conducted as well. In addition, a manual search was performed through the bibliography of studies and via google solar. However, they were not found. In addition, to further complete, non-English articles were also selected and viewed through the LILACS search engine. This systematic review was conducted according to (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The systematic review protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) with CRD42022377415, recorded on 30 November 2022.

Table 1.Search strategy.

PubMed
	(“bruxism”) AND (“children”)
Web of Science
	(ALL = (bruxism)) AND (ALL = (children))
Lilacs
	bruxism (Palavras) AND children (Palavras)
Scopus
	TITLE-ABSTRACT (ABS)-KEY (bruxism AND children)

Fig. 1.Prisma flowchart. PECO: Population (including animal species). *: Records evaluates from the database; **: Studies removed because they are systematic reviews of the literature.

3. Results

3.3 Metanalysis

The meta-analysis was conducted by random model effect because of the medium heterogeneity (I² = 53%) between the four included studies. The overall effect, reported in the forest plot (Fig. 2), the Forrest plot found that photo biomodulation therapy has a higher efficacy (OR 0.10; 95% CI from 0.02 to 0.43), followed by treatment with hydroxyzine (OR 0.19; 95% CI from 0.03 to 1.04). The average between girls and boys with bruxism is 18.5 for boys and 19. 5 for girls (Fig. 2) with a p-value < 0.05.

Fig. 2.Forest plot of the meta-analysis. CI: confidence interval.

3.4 Quality assessment and risk of bias

Using RoB 2, the risk of bias was estimated and reported in Fig. 3. Regarding the randomization process, 100% of the studies ensured a low risk of bias. However, 50% of the studies excluded a performance bias, but 100% reported all outcome data, and 100% of the included studies adequately excluded bias in the selection of reported outcomes, while 75% excluded bias in self-reported outcomes. Overall, only 3 of the four studies were shown to have a low risk of experiencing bias.

Fig. 3.Risk of bias domains of the included studies.

4. Discussion

This meta-analysis aimed to put the different studies on treating bruxism in children. All the analysed studies evaluated new therapies’ effects on treating bruxism and compared them with either occlusal splint or placebo. The most effective treatment in this study is photobiomodulation, followed by hydroxyzine. There is proof that photobiomodulation (PBM) prevents delicate nerves from moving along their axons, which lowers the potential of their mitochondria and, in turn, reduces the amount of adenosine triphosphate (ATP) available for nerve activity. The principal purpose of using photobiomodulation on the head and neck muscles is to relieve pain brought on by temporomandibular disorders. The first generation of potent H1 receptor antagonists includes hydroxyzine. It contains anti-dopaminergic and anti-histaminergic properties. The pharmaco-pathological link between hydroxyzine’s anti-dopaminergic action and the problem in the dopaminergic area of the brain can be used to explain how the drug may help treat bruxism. The emotional condition is most frequently mentioned, with stress and worry being risk factors for temporomandibular disorders (TMD). Oliveira et al. [36] demonstrated that patients with bruxism are more likely to experience anxiety and distress. Neuroticism-prone personality traits have also been linked to an increased risk of SB in young people. Therefore, the clinician needs a multidisciplinary approach in treating bruxism in children since, in addition to drug or laser therapy, it also needs behavioural therapy since stress is one of the leading etiological causes [36]. Although dealing with children, this meta-analysis considered only one study by Ghanizadeh et al. [34], whose study population is between the ages of 4 and 17. The remaining studies have as their maximum age range 12 years. However, the final results were not biased since they are still a residual number compared to the total population in this meta-analysis. In this study, according to the literature that defines 14 years as the age of transition, we used this criterion, which is respected by almost all studies except Ghanizadeh et al. [34, 36].

The prevalence of sleep bruxism reported in this systematic review is consistent with the previous two systematic reviews that estimated this subject and discovered around 30% prevalence of SB in youngsters. This finding demonstrates that most of the research included in both systematic reviews, which were chosen based on parental complaints of SB, used a similar technique for diagnosis [37]. Additionally, the authors’ classification in their works was used to determine the diagnosis of SB in the included research. However, given the cultural variations, varying socioeconomic levels, and unique aspects of the study’s methodology, the variation in incidence by continent can be considered understandable. The most common clinical symptom in children with SB was dental wear, which was to be expected. Typically, the dentist will ask parents whether their kids are clenching or grinding their teeth before the parents pay attention and report the problem [38]. Therefore, paying attention to canine primary wear is crucial and frequently linked to functional wear. As a result, it is advised that the diagnosis of the likely SB be assessed in a way that considers both pathological and physiological wear, considering each age group. It is crucial to agree on categorising the primary differences and dental wear in youngsters because this may have affected the study’s findings. Care must be given when determining the source of a child’s dental wear, which can also result from other factors, including erosion. Half of the children with SB reported headaches, the most common symptom. Only one study looked at headache frequency; the others only reported whether this symptom was present [39]. No study determined if this condition was a headache in the morning or occurred throughout the day. A kind of orofacial pain, this illness typically affects adults and children [40]. It is explained by the fact that sleep bruxism is thought to be a central nervous system behaviour and may be an etiological mechanism and a means of activating the muscles. The muscle alterations generated by SB also caused the trigeminal nociceptive neuron’s central sensitization. Additionally, this habit may impair sleep quality by prompting nocturnal awakenings. These sleep disorders are linked to SB and are especially prevalent in youngsters. Five studies showed a positive relationship between headaches and SB in the analysis. Although the prevalence could be estimated, there wasn’t enough research with the same design to analyse the relationship between sleep bruxism and most clinical signs and symptoms of the masticatory system examined. Following the most common clinical symptoms and indicators of headache, around 30% of the study participants experienced frontal muscular, TMJ, face, and masseter muscle pain. The least frequent symptom in kids was discomfort when moving their jaw. The children whose pain-related symptoms were evaluated ranged in age from 3 to 8 years. In a sample of 1263 kids, Tachibana et al. [41] discovered a prevalence rate of 21.0%, with a higher rate in the five to seven-year-old age range (27.4%). The high prevalence highlights the significance of an early, accurate diagnosis. Although polysomnography is the preferred method for diagnosing SB in adults, there is no standard procedure for doing this additional test on children. Therefore, a thorough clinical examination is crucial for correctly diagnosing childhood SB. A strong correlation between SB and bite marks on the buccal mucosa was discovered in the current investigation. Children with headaches were more common before and after therapy in G1 (photobiomodulation). One of the most typical symptoms is a headache, including tension and migraine headaches. Particularly tension headaches, brought on by hunched-over posture or stress, have been linked in the literature to SB. Muscle spasms brought on by ongoing stress are the source of tension headaches and SB. Most headache cases recorded did not go away with sleep, leading to restless nights. According to Herrera et al. [42], children with SB have more microarousals, which appear to be linked to increased behaviour and attention deficits. Following laser treatments, maximum muscular contraction increased in clinical investigations utilizing photobiomodulation. In a different study, individuals with mandibular fractures were treated with photobiomodulation, and that study likewise discovered a rise in BF. Lower BF in patients with SB appears to imply muscle relaxation, which could prevent tissue injury from severe muscle contraction, even though the study’s findings differ from those published in the literature. The literature lists several SB side effects, including connections with TMDs, headache, tooth deterioration, restricted mouth opening, and muscle exhaustion [32]. The World Health Organization advises using homoeopathic medicines due to their accessibility, low cost, lack of side effects, and ability to be used internally. Even though, regardless of the disease, healthcare practitioners do not typically recommend homoeopathy as a first line of treatment, its prescription has been rising due to its low toxicity. In the current trial, M. Officinalis was effective in treating potential SB in children, whether used in conjunction with P. decandra or not. Both medications are all-natural, and parents or guardians have not experienced any physical side effects [43]. Homoeopathic material medica recommends P. decandra to prevent teeth grinding and clenching, while M. Officinalis is recommended for anxiety. Since bruxism has been linked to anxiety and teeth grinding (Oliveira et al. [36], 2015), the current clinical investigation sought to determine how these drugs might affect potential sleep bruxism when taken singly and combined [44]. According to recent research, the regulation of SB is central rather than peripheral (Saletu et al. [45], 2005). To treat sleep bruxism, numerous Central nervous system acting medications have been administered to reduce the activity of the orofacial muscles while the patient is asleep (Macedo et al. [46], 2014). Only the CNS alpha agonist Clonidine, the dopamine precursor L-dopa, and the benzodiazepine Clonazepam has effectively lowered SB. SB should be diagnosed along several axes; both non-instrumental and instrumental diagnostic techniques are acceptable. Polysomnography is the standard gold method for identifying symptoms while you sleep (Bortoletto et al. [47], 2016). Iwasaki et al. [48] (2010) recommended against using this diagnosis approach on children since results could be affected by taking them out of their normal environments and placing them in a sleep lab. Clinical inspection is one of the non-instrumental procedures. In addition to self-reports, some questionnaires ask about sleep history. This experiment’s primary objective was to examine hydroxyzine’s efficacy in treating bruxism in children [48]. It’s likely that managing comorbid conditions also manages bruxism. Additionally, the efficacy and safety of hydroxyzine over the long term cannot be predicted by existing results. Children took part in this study as participants. The medical professional administering the drugs to the parents was aware of the allocation groups. It is unclear if hydroxyzine also reduces bruxism in older people. This study also used a scale and a symptom questionnaire before and after using the drug to treat bruxism [49]. A physiotherapeutic method to enhance head posture was evaluated for effectiveness. Although numerous therapies for child bruxism have been the subject of studies, there is still a shortage of data to back up these treatments. It was previously shown that the anterior head position is prevalent in children who grind their teeth and impacts the central nervous system’s oxygenation. Compared to the control group, whose position was poorer in the second measurement, the experimental group’s kids corrected their head postures more. This may imply that bruxism causes an anterior head tilt that may worsen over time. To be confirmed, additional research is required. Dopamine levels raised in low-oxygen environments are also linked to bruxism in youngsters. To increase the free airway and thereby lessen the incidence of bruxism, physiotherapeutic methods to alter head posture have not yet been documented. Higher anxiety levels have been observed when the airway pressure is decreased, linked to bruxism symptoms. Another advantage of altering the forward head posture in bruxism-prone youngsters is that higher airway pressure can lessen anxiety [50]. The studies in this meta-analysis evaluate photobiomodulation as an effective treatment method for bruxism followed by hydroxylysine. All this shows a psychological and emotional component in the aetiology of bruxism [51]. All of this might suggest clinicians’ direct treatment of the masticatory muscles by stimulating relaxation, or in more severe cases; action could be taken on the central nervous system. The limitation of this meta-analysis firstly, the inconsistency of the sample and, secondly, the lack of common methods for diagnosing bruxism. In addition, another important limitation is the lack of a common method to assess the improvement of bruxism. Some studies evaluate pre- and post-treatment by questionnaires given to parents or sitters, while others evaluate the effectiveness of therapy by electromyography or gnathodynamometer.

5. Conclusions

Therefore, given the different methods of treatment and evaluation of bruxism and therapy, further clinical trials and meta-analyses on a larger cohort of patients are needed to evaluate the effectiveness of other ways of bruxism treatment. The use of photobiomodulation and hydroxyzine therapy is a valuable means of being able to treat bruxism in children. Bite therapy needs compliance and, on the part of the child, is quite tricky and, therefore, not very predictable in outcome. Therefore either with photobiomodulation or hydroxyzine, there will be better results in decreasing bruxism since there is no need for patient compliance. Photobiomodulation obviously and still requires the patient to go to the office while as. At the same time, draisie therapy has o or at least very mild side effects, including fatigue. Therefore, this drug therapy should be limited in severe cases. However, further studies and an adequate sample are needed to evaluate the efficacy. Although this meta-analysis was conducted on studies that were very uneven in terms of therapy, we can say, albeit with the limitation of data and studies,that hydroxyzine and photobiomodulation are important aids in the treatment of growing bruxism patients. In fact, photobiomodulation has been used for a long time in the treatment of muscle disorders and therefore the meta-analysis performed confirms this effect. The pharmacological effects of hydroxyzine are central and therefore act on muscle contractility. Therefore the therapy of first choice, as studies in the literature using it in the treatment of orofacial pain, is photobiomodulation.

Availability of Data and Materials

Not applicable.

Author contributions

GM, RF, MMM, SC, LF, GC and MC—designed the research study. GM and RF—performed the research. MC, LF, SC, AB and GC—analyzed the data. GM, MMM and MC—wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest. Giuseppe Minervini is serving as one of the Editorial Board members of this journal. We declare that Giuseppe Minervini had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to PD.