Received: 17 February 2023 | Revised: 13 June 2023 | Accepted: 6 July 2023

DOI: 10.1111/joor.13559

ORIGINAL ARTICLE

Awake bruxism in temporomandibular disorders patients

referred to tertiary care: A retrospective study on its
assessment and TMD management

Laura Nykänen1,2 | Frank Lobbezoo3 | Antti Kämppi1 | Daniele Manfredini4 |

Jari Ahlberg1,2

1
Department of Oral and Maxillofacial
Diseases, University of Helsinki, Helsinki, Abstract
Finland
Background: Bruxism is defined as a repetitive jaw-­muscle activity characterised by
2
Head and Neck Center, Department of
Oral and Maxillofacial Diseases, Helsinki
clenching or grinding of the teeth and/or by bracing or thrusting of the mandible.
University Central Hospital, Helsinki, Bruxism can occur during sleep (sleep bruxism, SB) or during wakefulness (awake
Finland
3
bruxism, AB). To date, the effect of AB on the purported negative consequences of
Department of Orofacial Pain and
Dysfunction, Academic Centre for bruxism has remained unclear.
Dentistry Amsterdam (ACTA), University Objectives: The assessment of AB, its relation to temporomandibular disorders (TMD)
of Amsterdam and Vrije Universiteit
Amsterdam, Amsterdam, The Netherlands treatment modalities, and their possible outcomes were investigated among TMD pa-
4
Department of Biomedical Technologies, tients resistant to treatment in primary care and referred to a tertiary care clinic.
School of Dentistry, University of Siena,
Methods: The records of 115 patients were studied. Patients were referred to the
Siena, Italy
Head and Neck Centre, Department of Oral and Maxillofacial Diseases, Helsinki
Correspondence
University Central Hospital, for TMD treatment between 2017 and 2020. The data
Laura Nykänen, Department of Oral and
Maxillofacial Diseases, University of derived from the eligible patients' records included the following: background data
Helsinki, 00100 Helsinki, Finland.
(age and sex), referral data (reason and previous treatment), medical background (so-
Email: [email protected]
matic and psychiatric), clinical and possible radiological diagnoses at a tertiary care
clinic, treatment modalities for masticatory muscle myalgia, bruxism assessment, its
possible treatment modalities and their outcomes, and overall management outcome.
We analysed the outcomes of single treatment modalities and combined groups of
modalities. For the demographic data, the Chi-­squared test and Fischer's Exact test
were used to determine the associations between the categorical variables. A Sankey-­
diagram was used to describe the flow of treatment.
Results: Temporomandibular joint-­pain-­dysfunction syndrome (K07.60) was the most
frequent single reason to refer a patient to tertiary care (17.4%). At referral, men had
myalgia (M79.1) significantly more often (p = .034) than women. Similarly, men had
depression (p = .002) more often and other psychiatric diagnoses (p = .034). At tertiary
care, the presence of AB was assessed in 53.9%, and self-­reported AB was recorded
in 48.7%. In patients with possible AB, those who were prescribed neuropathic pain
medication showed significantly less improvement in symptoms (p = .021) than those

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Journal of Oral Rehabilitation published by John Wiley & Sons Ltd.

J Oral Rehabil. 2024;51:181–187.  wileyonlinelibrary.com/journal/joor | 181

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182 NYKÄNEN et al.

who underwent splint therapy (p = .009). Overall, half of the patients showed overall
improvement in their TMD symptoms from the treatment combinations.
Conclusion: Despite several treatment modalities, only half of the patients showed
improvement in their symptoms in the present study. A standardised assessment
method encompassing all factors contributing to bruxism behaviours and their conse-
quences is suggested.

KEYWORDS
awake bruxism, bruxism, orofacial pain, TMD

1 | I NTRO D U C TI O N symptoms were found to be more prevalent in subjects with awake

tooth clenching. 28,29
An international expert group defined bruxism as a “repetitive jaw-­ Bearing this in mind, the assessment of AB, its management
muscle activity characterized by clenching or grinding of the teeth modalities and their possible outcome were studied among TMD
and/or by bracing or thrusting of the mandible. Bruxism has two patients resistant to treatment in primary care and referred to a
distinct circadian manifestations: it can occur during sleep (defined tertiary care clinic. Since AB may not be well recognised by dental
as sleep bruxism (SB) or during wakefulness (defined as awake professionals, our aim was to investigate whether the TMD manage-
bruxism [AB])”.1 Masticatory muscle activity (MMA) associated with ment results are better among patients assessed with possible AB.
bruxism can be divided into three different behaviours: teeth grind-
ing (rhythmic), teeth clenching (tonic), or bracing or thrusting of the
mandible without tooth contact. Since the 2013 definition and the 2 | M ATE R I A L S A N D M E TH O DS
2018 update, 2 studies on bruxism have been shifting their focus
from rhythmic masticatory muscle activity (RMMA) during sleep to This study was conducted as a retrospective study using patient
including other MMA as well, including during wakefulness. The re- records at the Head and Neck Centre, Department of Oral and
ported prevalence of bruxism in a Western adult population is 8%–­ Maxillofacial Diseases, Helsinki University Central Hospital. The clinic
31.4% for AB and 12.8 ± 3.1% for SB, depending on the assessment is a public health tertiary care unit, receiving referrals from both public
method used.3 and private sector physicians and dental professionals at the Helsinki
At present, the construct of bruxism also involves a more varied and Uusimaa Hospital District. Referred patients report with oral can-
perspective on aetiology, assessment and consequences. The aeti- cers, maxillofacial traumas or severe malocclusions need a hospital
ology of bruxism, according to current knowledge, is multifactorial environment for their dental treatment because of their general illness
and can be divided into internal (genetic),4,5 external (medications or suffer from complicated TMD, for example. The intake criteria at
and substances)6 and psychosocial factors (i.e. personality traits, the hospital for TMD patients are persistent severe TMD symptoms
7–­12
stress). The consequences of bruxism may be either neutral, that are resistant to conservative treatment according to the Finnish
which causes no harm for the individual's health; negative, such as National Guidelines of TMD.30 Among other things, the guidelines in-
muscle symptoms, possible temporomandibular disorders (TMD), clude patient information, stabilisation appliances, self-­instructed ex-
damage to teeth or restorations13–­15; or even potentially positive, ercises, physiotherapy and medication.
such as an increase in salivary flow rate in gastric oesophageal reflux A search was conducted on the patient records of the clinic, and
disease or increased airway flow in obstructive sleep apnea.16–­19 patients at least 18 years old referred in 2017–­2020 were included
The grading system of bruxism assessment is “possible” (self-­ in the search whenever the term “bruxism” was mentioned in the
report), “probable” (self-­report and/or clinical findings) and “defi- patient record. Patients with temporomandibular joint arthritis were
nite” (self-­report and/or clinical findings, and polysomnography for excluded. In addition, only patients whose treatment was initiated
SB or electromyography for AB).1 The assessment of AB is a rather and completed within the indicated time range were included in the
new concept in bruxism research. So far, according to the cur- analyses. The search yielded 115 patients eligible for the present
rent definition,1,2 an expert consensus20 and the newly published study. The data search was performed by a professional informati-
21
Standardised Tool of the Assessment of Bruxism, the most feasible cist, and each patient record gathered was controlled for suitability
instruments are self-­reports in the form of single-­point question- by a dentist specialising in oral physiology (LN).
naires and ecological momentary assessment, 22–­24 with or without The data derived from the eligible patients' records included
electromyography. the following: background data (age and sex), referral data (reason
Despite some earlier studies on factors associated with AB, 25–­27 and previous treatment), medical background (somatic and psychi-
its effect on bruxism's purported negative consequences has re- atric), clinical (ICD-­10) and possible radiological diagnoses at a ter-
mained unclear. This may be a result of the lack of standardised as- tiary care clinic, treatment modalities for TMD, bruxism assessment,
sessment methods thus far. 21 However, in two recent studies, TMD its possible treatment modalities and their outcome, and overall
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NYKÄNEN et al. 183

management outcome. Five patients had no ICD-­10 diagnosis. Of We analysed the outcomes of the single treatment modalities
the rest, the following ICD-­10 diagnoses were included: for TMDs (shown in Table 2), as well as combining groups of them
(shown in Figure 1 by their Roman numerals) as follows:
• K07.60 Temporomandibular joint-­pain-­dysfunction syndrome
• M79.1 Myalgia • I: Conservative treatment*
• K07.63 Temporomandibular joint arthralgia • II: Conservative treatment and BonT-­A (Botulinum toxin A)
• G44.8 Other specified headache syndrome (headache attributed • III: Conservative treatment and arthrocentesis
to TMD) • IV: Conservative treatment and chronic pain medication
• K07.61 Clicking temporomandibular joint • V: Conservative treatment, BonT-­A and chronic pain medication
• S03.0 Dislocation of temporomandibular disc • VI: Conservative treatment, arthrocentesis and chronic pain
• K07.65 Degenerative joint disease of TMJ medication
• F45.8 Other somatoform disorder (bruxism) • VII: Conservative treatment, BonT-­A and arthrocentesis
• G47.8 Other sleep disorder (sleep bruxism) • VIII: BonT-­A
• IX: Conservative treatment, BonT-­A , arthrocentesis and chronic
We combined and labelled the diagnoses (shown in Figure 1 by pain medication
their Arabic numerals) as follows:
*Conservative treatment consists of counselling, splint therapy,
• 1: Bruxism (F45.8, G47.8) jaw exercises and NSAID medication.
• 2: TMJ internal derangement (K07.63, K07.61, S03.0, K07.65, K07.60) To get access to the data, the study received a permit from the
• 3: Muscle disorder (M79.1, G44.8, K07.60) Helsinki University Head and Neck Center (permit no HUS148/2022).
• 4: Muscle disorder and TMJ internal derangement (diagnoses According to the local bylaws, no medical ethical approval was
from both 2 & 3) needed for a retrospective study on patient records.
• 5: No ICD-­10 diagnosis

The diagnosis K07.60 was considered as a general TMD diag- 2.1 | Statistical methods
nosis without any specific definition of muscle or TMJ internal de-
rangement disorder. All patient records were manually checked for For the demographic data, the Chi-­squared test and Fischer's
their complaint and allocated to the groups above accordingly. Exact test were used to determine the associations between the

1: Bruxism: 18
I: 37

Possible AB: 56
2: TMJ internal Improvement in
derangement: 20 symptoms:57
II: 33

III: 2
3: Muscle
disorder: 50 IV: 5

V: 9
Bruxism not No improvement
defined: 59 VI: 5 in symptoms:58
4: Muscle disorder
and TMJ internal VII: 8
derangment: 22 VIII: 1
5: No ICD-10 diagnosis: 5 IX: 15

I: Conservave treatment; II: Conservave treatment and BonT-A; III: Conservave treatment and arthrocentesis; IV: Conservave treatment and chronic pain medicaon; V: Conservave
treatment, BonT-A and chronic pain medicaon; VI: Conservave treatment, arthrocentesis and chronic pain medicaon; VII: Conservave treatment, BonT-A and arthrocentesis; VIII: BonT-A;
IX: Conservave treatment, BonT-A, arthrocentesis and chronic pain medicaon

F I G U R E 1 A Sankey diagram describing patient diagnoses, possible awake bruxism, management and outcome of management in the
tertiary clinic.
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184 NYKÄNEN et al.

TA B L E 1 Descriptive data on study population at referral and TA B L E 1 (Continued)

tertiary care by sex: frequencies and percentages (chi-­squared test).
Women, n = 97 Men, n = 18
Women, n = 97 Men, n = 18
n = 115 n % n %
n = 115 n % n % Muscle relaxant 12 12.4 3 16.7
Primary care Neuropathic pain 31 32.0 3 16.7
Prior treatment in primary dental care medication

Medication 45 46.4 6 33.3 Non-­pharmacological treatment

Jaw exercises 7 7.2 1 5.6 Jaw exercises 81 83.5 14 77.8

Splint therapy 55 56.7 12 66.7 Splint therapy 80 82.5 15 83.3

Physiotherapy 14 14.4 1 5.6 BoNT-­A 52 53.6 14 77.8*

BoNT 12 12.4 1 5.6 Arthrocentesis 28 28.9 2 11.1

Counselling 8 8.3 0 0.0 Counselling 76 78.4 13 72.2

ICD-­10 diagnosis for referral *p < .05; **p < .01.

K07.60 18 18.6 2 11.1
M79.1 4 4.1 4 22.2*
categorical variables. A Sankey diagram (http://sanke​ymatic.com/
K07.63 8 8.3 2 11.1
build/) was used to describe the flow of treatment. For the analyses,
G44.8 0 0.0 0 0.0
SPSS (version 27.0; SPSS, Inc.) was used.
K07.61 3 3.1 1 5.6
S03.0 3 3.1 1 5.6
K07.65 5 5.2 0 0.0 3 | R E S U LT S
F45.8 6 6.2 3 16.7
G47.8 0 0.0 0 0.0 Of the patients eligible for the study, 84.3% were women and
Anxiety 9 9.3 4 22.2 15.7% men. The mean ages were 45.0 (SD 13.9) and 41.2 (SD 13.9),
Additional diagnosed state at referral respectively.
Depression 11 11.3 8 44.4** Prior to referral, splint therapy (58.3%) and medication (44.3%)
Psychiatric illness 12 12.4 6 33.3* were the two most commonly recorded treatment modalities among
Referred from all patients. Temporomandibular joint-­pain-­dysfunction syndrome
Public primary care 28 28.9 6 33.3 (K07.60) was the most frequent single reason to refer a patient on
Private practice 15 15.5 4 22.2 (17.4%), without a difference between the sexes. At referral, men
Other tertiary 43 44.3 7 38.9 had myalgia significantly more often (M79.1; p = .034) than women.
department Similarly, regarding other diagnoses than TMD, men had more de-
Tertiary clinic pression (p = .002) and other psychiatric diagnoses (p = .034). Nearly
Allocated to half (43.5%) of the patients were referred from another tertiary
Oral physiology 57 58.8 13 72.2 clinic (Table 1).
Oral & maxillofacial 11 11.3 2 11.1 At the tertiary clinic, a majority of the patients (60.9%) was al-
surgery
located to oral physiology for treatment. Temporomandibular joint-­
Orthodontics 2 2.1 0 0.0
pain-­dysfunction syndrome (K07.60) was the diagnosis most often
ICD-­10 diagnosis
recorded; in all 47.0%. Degenerative joint disease of TMJ (K07.65)
K07.60 47 48.5 7 38.9
was diagnosed in 19.6% in women and none in men (p = .035). The
M79.1 27 27.8 4 22.2
presence of AB was assessed in 53.9%, and self-­reported awake
K07.63 12 12.4 3 16.7
bruxism was recorded in 48.7% altogether (Table 1).
G44.8 0 0.0 0 0.0 Of the treatment modalities provided, jaw exercises (84.3%) and
K07.61 6 6.2 1 5.6 splint therapy (84.3%) were most common. In patients with possi-
S03.0 2 2.1 1 5.6 ble AB, neuropathic pain medication (p = .021) and splint therapy
K07.65 19 19.6 0 0.0* (p = .009) produced significantly less improvement in symptoms.
F45.8 21 21.6 2 11.1 Similarly, in patients without self-­reported AB, splint therapy ap-
G47.8 2 2.1 0 0.0 peared ineffective (p = .080) as a single treatment modality (Table 2).
Awake bruxism assessed 52 53.6 10 55.6 The Sankey diagram revealed that patients with muscle disorder
Possible awake bruxism 48 49.5 8 38.9 had possible AB more often. Patients with temporomandibular joint di-
Management agnoses seemed to have more bruxism behaviour that was not defined
Medication than those with possible AB. Half the patients showed improvement in
NSAID 34 35.1 3 16.7 their symptoms, and about half had received conservative treatment,
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NYKÄNEN et al. 185

TA B L E 2 Provided treatment modalities (total) and outcome (positive/no effect) in patients with possible awake bruxism or bruxism not
defined: frequencies and percentages (chi-­squared test and Fischer's Exact test).

Possible awake bruxism, n = 56 Bruxism not defined, n = 59

Positive Positive
outcome No effect outcome No effect

n = 115 Total % n= % n= % p-­value n= % n= % p-­value

Medications
NSAID 37 32.2 10 58.8 7 41.2 .294 11 55.0 9 45.0 .428
Muscle relaxant 15 13.0 7 58.3 5 41.7 .429 1 33.3 2 66.6 .487
Neuropathic pain 34 29.6 3 21.4 11 78.6 .021 10 50.0 10 50.0 .962
medication
Other
Jaw exercises 97 84.3 24 49.0 25 51.0 .762 23 47.9 25 52.1 .347
Splint therapy 97 84.3 19 40.4 28 59.6 .009 23 46.0 27 54.0 .080
BoNT-­A 66 57.4 14 45.2 17 58.4 .611 18 51.4 17 48.6 .956
Arthrocentesis 30 26.1 6 42.9 8 57.1 .643 10 62.9 6 37.5 .273
Counselling 90 78.3 21 46.7 24 53.3 .330 24 53.3 21 46.7 .837

or conservative treatment combined with botulinum toxin injections. frequency and intensity of awake bruxism-­t ype masticatory muscle
Other treatment combinations also showed improvement in those activity, any speculation about the identification of thresholds and
with possible AB and temporomandibular joint problems (Figure 1). criteria to identify bruxers is premature. Probing deeper into the
study of AB metrics is a fundamental step to assist clinicians in pre-
venting and managing the putative consequences at the individual
4 | DISCUSSION level”.34 The results of the present study underscore that view.
In our study, we saw that psychiatric diagnoses were present in
In the present study, among patients referred to tertiary care who almost half the patients. A recent large-­scale study also reported
were resistant to TMD treatment provided in primary care, we found that SB and AB share several psychological correlates.4 However, it
that AB was assessed only in half, nearly of half who were defined should also be noted that the patients were referred to tertiary care
as having self-­reported AB. This can be considered the first main with complicated TMD problems.
finding of the study. As the inclusion criterion was that the word In general, many pitfalls were noted in the patient records. The
“bruxism” was mentioned in the search, recorded without any stand- most notable were the negligible use of ICD-­10 code for bruxism,
ardised method for its assessment, it also means that the patients and no assessment of bruxism behaviours in half the patients.
other than those with defined and graded “possible” AB may also Notably, half of the patients were just “bruxers”. However, it must be
have other bruxism behaviour. The second main finding was that underscored that all personnel in the clinic are experienced special-
those with possible AB had a better outcome overall with different ists in oral physiology so that pitfalls cannot be explained by inexpe-
treatment combinations than the other patients. rience or lack of knowledge of personnel but merely by the lack of
Since the 2013 bruxism definition,1 new insight in bruxism be- standardised assessment methods available when the patients were
haviours have been recognised. AB has been one of emerging inter- examined and treated.
est. Its aetiology, epidemiology, pathophysiology and role in bruxism The limitation of the present study may be the specific study
consequences, both positive and negative, have remained unknown. population, namely, TMD patients referred to tertiary care because
Therefore, a group of bruxism research experts worked on develop- of insufficient response for conservative management in primary
ing the recently published Standardised Tool for the Assessment of care. Thus, the results cannot be compared to the general popula-
Bruxism (STAB)18,31,32 and the Bruxism Screening tool (BruxScreen)33 tion. Many TMD patients respond well to conservative management
to better assess all bruxism behaviours. modalities in primary care or even experience spontaneous allevia-
Two recent studies found that AB behaviours are significantly tion of symptoms.35 Another limitation may be the relatively small
28,29
more frequent in TMD patients than in asymptomatic controls. sample size of the patients here. However, it should be noted that
Most of the existing literature focuses on bruxism in general or on from all patients referred to the Head and Neck Centre, only some
SB in particular, while knowledge on AB is generally fragmental. are allocated as TMD patients, and of these, only those whose treat-
However, a group of bruxism experts recently wrote in their in-­depth ment was initiated and completed within the time range from 2017
review that “Phenotyping of different AB activities should be the tar- to 2020 were eligible for the study. However, it should be noted that
get of a research task force. In the absence of available data on the to our best knowledge, no corresponding study exists.
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186 NYKÄNEN et al.

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