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Q U I N T E S S E N C E I N T E R N AT I O N A L

Treatment of bruxism in children: A systematic review

Claudia Restrepo, DDS1/Sandra Gómez, DDS2/Ruben Manrique, MSc3

Objective: To conduct a systematic review to assess and analyze the scientific evidence about the available therapies for bruxism in children. Method and Materials: The literature was searched using Medline, PubMed, Ovid, Biomed Central, EBSCOhost, ISI, Cochrane Library, Embase, LILACS, Scielo, Scirus, the Internet at large, and databases of universities from March 1985 to the end of September 2007. Studies had to be intervention studies for bruxism in children, and the children included in the studies had to be 3 to 10 years old. Results: From 52 records found, 2 fulfilled the inclusion criteria. In 1 study, bruxism was treated by widening the upper airway through adenoidectomy, and the other study proposed to treat bruxism in children with psychologic techniques. When analyzed, the 2 considered studies did not fully accomplish the requirements to treat the etiology of bruxism in children. Conclusion: The available literature does not provide adequate support to treat bruxism in children, as the diagnosis methods in the studies are insufficient and are not comparable to confirm the presence of bruxism. Very few studies about therapies for bruxism in children meet the quality criteria required for the evidence-based practice. Treatment for bruxism in children requires further study. (Quintessence Int 2009;40:849­855)

Key words: adenoids, bruxism, children, pharmacology, psychology, physiotherapy, tonsil, treatment

The etiology of bruxism has been defined as multifactorial.1 It is mainly regulated centrally and influenced peripherally.2 This means that oral habits, temporomandibular disorders (TMDs),3 malocclusions,4 hypopnea,5 high anxiety levels,6 and stress,7 among others,8 could influence the peripheral occurrence of bruxism. These factors act as a motion stimulus to the central nervous system, which

reacts with an alteration in the neurotransmission of dopamine,9 and the answer is the clenching or grinding of the teeth. Strong controversy exists concerning the treatment of bruxism in children. Whether to treat bruxism during childhood is still a matter of debate.10 There is no agreement regarding the effectiveness of therapeutic options, and the available scientific studies are not comparable to evaluate efficacy. When there is bruxism in children, an abnormal modulation of the central catecholaminergic neurotransmission occurs.9 These alterations could cause permanent damage in the stomatognathic system, such as dental wear, TMD, or alterations in head posture.11 Longitudinal studies12 showed that bruxing habits persist from childhood to adulthood. Thus, it is useful to search for strategies to reduce bruxism13 in children.

1

Pediatric dentist; Professor, CES University; Director, CES-LPH Research Group, Medellín, Colombia.

2

Pediatric dentist, CES University; CES-LPH Research Group, Medellín, Colombia.

3

Director, Investigation Department, CES University, Medellín, Colombia.

Correspondence: Dr Claudia Restrepo, Calle 10 A No 22-- 04 Medellín, Colombia. Fax: (574) 268 44 13. Email: martinez [email protected]

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Identified citations that met the requirements for the study (n = 52)

Citations excluded as clearly not relevant based on titles (n = 11)

Potentially relevant citations retrieved in abstracts (n = 41)

Citations excluded as clearly not relevant based on abstracts (n = 27) Abstracts that did not meet the inclusion criteria (n = 11)

Potentially relevant abstracts (n = 14)

Citations studied in detail and selection on basis of inclusion criteria according to Chalmers et al (n = 3)

Citation excluded because the Chalmers score was below 70 (n = 1)

2 articles assessed Fig 1 Selection of studies.

Any type of intervention designed to reduce the signs and symptoms of bruxism was acceptable for evaluation. Pharmacologic, psychologic, physical, and surgical therapies were considered. The use of any occlusal device and alternative treatments were evaluated, as well. Types of outcome measure included formal standardized tests, parents'/guardians' reports of grinding or clenching, and clinical measures of dental wear or TMD. Outcomes for analysis were considered on 2 levels: (1) at the level of the target for intervention, eg, reducing anxiety or dental wear; (2) at the level of reducing signs and symptoms of bruxism as a whole. Outcomes used in the review were dependent on the focus of the intervention; eg, for studies about psychologic techniques aiming to reduce anxiety, the outcome measure was a specific test to evaluate anxiety in children.

Search strategy for identification of studies

Studies were identified from the following sources: Medline, PubMed, Biomed Central, Ovid, Embase, EBSCOhost, ISI, Cochrane Library, LILACS, Scielo, Scrius, the Internet, and the databases of CES University, Universidad de Antioquia, El Bosque University, University of Michigan, and Baylor University. The literature was searched for articles published between March 1985 and the end of September 2007. The selection method is summarized in Fig 1. The first limits introduced were all kinds of intervention studies and the age of the children, as follows: (1) all children 0 to 18 years; (2) preschool children 2 to 5 years. The following search terms were used to identify articles. MESH terms were adapted to suit the fields of each of the databases: singl*, doubl*, tripl*, clin*, trial*, crossover, random*, allocate*, exp META ANALYSIS, "Child"[Mesh], "Bruxism"[Mesh] OR "Sleep Bruxism"[Mesh], "Occlusal Splints"[Mesh], "Therapeutics"[Mesh], "Physical Therapy Modalities"[Mesh], "Cognitive Therapy" [Mesh], "Psychoanalytic Therapy"[Mesh]), "Homeopathy"[Mesh], "Relaxation Techniques"[Mesh], "Psychotherapy, Group"

The aim of this investigation was to review the literature to evaluate and analyze the studies that could provide clinicians with strong, evidence-based recommendations for the treatment of bruxism in 3- to 10-yearold children.

METHOD AND MATERIALS

Criteria for considering studies for this review

Studies on interventions for bruxism in children were included. Investigations written in Spanish or English were considered. To be included in the evaluation, children had to be 3 to 10 years of age and have a multiple-axes diagnosis of bruxism. The children were required to have normal facial morphology and absence of syndromes or other type of neural incapacity. Questionnaires, an oral history taking (including a parent or guardian's report of grinding sounds), and extraoral and intraoral inspections for clinical signs of bruxism were required.

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Ta b l e 1

Studies about treatment of bruxism published between 1980 and 2007 that met initial requirements

Author and year of publication Subjects' age (y)

18

Source

Design

Cochrane, EBSCOhost, LILACS, Ovid, Medline, PubMed, Scielo, SCIRUS EBSCO host EBSCO host PubMed, Metacrawler

Hachmann et al, 1999 Malki et al, 200425 DiFrancesco, 200417 Restrepo, 200116

3­5 5­15 2­12 3­6

Controlled clinical trial Randomized clinical trial Randomized clinical trial Quasiexperimental

Ta b l e 2

Quality of selected abstracts

Description of methods Statistical analysis

Objective

Results

Conclusions

DiFrancesco et al Restrepo et al16 Hachmann et al18 Malki et al25

17

Yes Yes Yes Yes

Yes Yes No No

Yes Yes No No

Yes Yes No No

Yes Yes No No

[Mesh], "Socioenvironmental Therapy"[Mesh], "Exercise Therapy"[Mesh], "Myofunctional Therapy"[Mesh], "Respiratory Therapy"[Mesh], "Behavior Therapy"[Mesh], "pharmacology" [Subheading], "Pharmacology, Clinical" [Mesh], "Drug Therapy"[Mesh], "Dopamine" [Mesh], "Continuous Positive Airway Pressure" [Mesh], "Airway Resistance"[Mesh], "Sleep Apnea, Obstructive"[Mesh], "Adenoids" [Mesh], "Head"[Mesh], "Posture"[Mesh], ("surgery" [Subheading] OR "Surgical Procedures, Operative"[Mesh]). Various combinations of the above terms were used. The Internet was explored using the following search engines: Metacrawler, Academic Google, dogpile, Looksmart, and Journal Sede. The words were generic. The search terms for the Internet were "Bruxism in children," "Bruxism therapy and children," "Bruxism pharmacology children," "Bruxism dopamine inhibitor children," "Bruxism psychologic techniques children," "Bruxism cognitive therapeutics children," "Bite plates bruxism," "Occlusal plates bruxism," "Airway bruxism," "Tonsils bruxism," "Adenoids bruxism."

Selection of trials

All references found using the search strategy were introduced in a database made in Microsoft Excel (Table 1). The titles and abstracts were screened against the inclusion criteria by 2 of the authors to identify relevant articles. Then the quality of the selected abstract was evaluated and registered in another database (Table 2). If it was unclear whether an article met the inclusion criteria, the full text version was obtained and the article more fully assessed. Once all potentially appropriate studies had been obtained, each study was evaluated independently by 2 reviewers for final inclusion, according to a standardized checklist that considered internal (scientific) validity and external (generalizable) validity. If there was a question as to the possible inclusion or exclusion of any individual study, a final consensus was reached by 2 authors. If the primary reviewers could not come to a consensus, the full article was submitted to the third reviewer. Reviewers were not blinded to the name(s) of the author(s), institution(s), or publication source at any level of review. Initially, the studies were judged on the basis of their quality, according to Chalmers et al.14 This scale was used because it contains

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Ta b l e 3

Categories

Chalmers scoring system

Total possible points

Unblinded evaluation 1. Study design 2. Selection criteria 3. Reject log 4. Withdrawals 5. Intervention definition 6. Placebo and drug presentation 7. Randomization blinding 8. Blinding of physicians to therapy 9. Blinding of patients to therapy 10. Blinding of physicians and patients to results 11. Prior estimate of sample size 12. Testing randomization (pretreatment variables) 13. Testing blinding 14. Acceptance of treatment 15. Biologic equivalent Methods total Unblinded analysis data 1. On major end points 2. Estimate for negative trials 3. Statistical inference: Confidence limits 4. Statistical inference: Life table (when applicable) 5. Statistical inference: Regression analysis 6. Proper retrospective analysis 7. Withdrawals were adequately analyzed 8. Adverse effects are described and statistically analyzed 9. Group analysis 10. Blinding of statistician 11. Multiple looks considered Statistical analysis total Data presentation 1. Dates of starting and ending 2. Results of prerandomization: Data analysis 3. Tabulation of events employed as end point for each treatment 4. Timing of events Data presentation total TOTAL

3 3 3 3 3 3 10 10 4 3 3 3 3 3 3 60 3 3 2 2 2 4 4 3 2 2 3 30 2 2 2 4 10 100

in Table 3. Each item in the Chalmers instrument is weighted arbitrarily according to its putative relative contribution to overall quality of the trial. The overall quality score for a trial equals the total number of points obtained by the trial divided by the total possible points for the trial. Items not applicable to a particular trial were not counted in the points scored (numerator) or the total possible points (denominator), and therefore did not affect the overall quality score for that trial.15 For instance, in a patient-education trial in which blinding of subjects to the intervention might be impossible, item 9 is scored as not applicable, and the 4 points assigned to that item are not included in either the numerator or denominator. If an item were applicable to a trial but the article provided either insufficient or no information on that item, the trial received no points in the numerator for that item. The overall score for each trial represents the ratio of points obtained by the trial to the total possible points for that trial. Because the overall score is a proportion, the maximum is 1.00 and the minimum is 0. Two reviewers independently assigned the values for each item to each investigation. The articles that received a Chalmers score of 70 or above were included in the present systematic review.

Error of method

The reviewers were standardized to use the Chalmers scale with a third expert reviewer.

Data analysis

The studies were initially categorized on the basis of the treatment given to the children with bruxism. Five main therapeutic regimens were made: (1) psychologic therapy; (2) pharmacology; (3) occlusal devices; (4) physical therapy; and (5) surgical therapies. Data of the studies were not found to be comparable. The diagnostic criteria to evaluate bruxism in children and the treatment assigned to the experimental groups were not the same in across investigations. Some of the analyzed studies presented adequate objective and design, but there was no correspondence regarding the methodology and related results.

those elements relevant to trials that are missing in other guide scales. Specifically, it examines the randomization of subjects, how withdrawals are dealt with, and blinding. The purpose of the Chalmers instrument is to evaluate the quality of published clinical trials based on the adequacy and appropriateness of reporting, design, and analysis.15 The Chalmers instrument is designed to be flexible enough to evaluate clinical trials with any type of content or intervention. The items included in the current evaluation are shown

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Missing data

Authors were contacted and asked to supply missing data. Where authors could not be contacted or data could not be supplied, missing data and dropouts were assessed for each study. The number of studies in the final analysis is reported in Table 2 concerning methodological quality.

criteria for the participants and quality according to Chalmers, so it was included in this systematic review. The other included survey was the article by DiFrancesco et al.17 Sixty-nine 2- to 12year-old children were included. The children presented bruxism and respiratory difficulties. The efficacy of the adenotonsillectomy to reduce the signs and symptoms of bruxism was evaluated. This investigation had a randomized clinical trial design. The article gave information about the selection of the children, and the blinding methods were clear. The statistical management was adequate and coherent with the objectives and methodology. There was an explanation of why children withdrew and how the data from these children were used. Baseline characteristics for the participants were described and tested using significance tests. The cited study by DiFrancesco et al17 failed in different parameters: First, the beginning and ending dates of the informed consent were not reported. The observed differences in the surveys with negative results lacked a power recalculation. The classification of the children as bruxist was performed by a phonoaudiologist, whose training to do so was not described in the article. The diagnostic criteria or instruments to perform the diagnosis are not related.

RESULTS

In total, 52 citations were found from the searches. On the basis of the titles, 14 abstracts were judged to be potentially relevant. Eleven did not accomplish the quality criteria to be included in the study, so only 3 full text articles were obtained. After the articles were read, 2 were judged to have met the inclusion criteria and the quality criteria according to Chalmers et al. Reasons for excluding articles generally concerned the research design or nature of the difficulties of the participants. The studies that were finally included in this systematic review, which accomplished the inclusion and quality criteria, were Restrepo et al,16 Chalmers score: 85; and DiFrancesco et al,17 Chalmers score: 76. The study that was excluded, due to its quality, was Hachmann et al,18 Chalmers score: 12. The study reported by Restrepo et al16 is a quasiexperimental survey that aimed to determine the efficiency of psychologic techniques to reduce the symptoms of bruxism in children. The selection of the subjects was well-described. The therapeutic procedure and its acceptance by the patients and parents was defined and strictly described. However, power calculation was not completed to ensure there were adequate participants to see a significant effect. The authors16 reported a range of baseline characteristics for the participants, and the eligibility criteria was adequately defined. There were no withdrawals. Collateral effects or damage and its statistical management were not presented in the article. The investigation could not be considered a randomized clinical trial, but it accomplished all the inclusion

DISCUSSION

When the first search was performed, it was noted that there is more available evidence to support the treatment of bruxism in adults than in children (n = 73). However, when the search was limited according to the inclusion criteria of this systematic review, it was observed that the available abstracts were not enough to support any kind of therapy for the parafunction in children. The most common treatment for bruxism in dentistry is the rigid occlusal splint, which has not been proved in the primary dentition because of the paradigm about the restriction over the growth of the maxillary alveolar process. However, if the classic studies about growth and development of the jaws

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are taken into account,19­21 it can be concluded that transverse or sagittal changes do not appear until the beginning of the mixed dentition. Only 1 study18 reported the treatment of bruxism in children with occlusal splints. Indeed, physiologic or radiographic studies to establish the effect of occlusal splints to reduce the signs and symptoms of bruxism or analyze the effects of the splints on the growth of the dental arches during the primary dentition were not found. Hachmann et al18 evaluated the effect of occlusal splints to reduce the symptoms of bruxism in 3- to 5-year-old children. The diagnosis of bruxism was performed through the presence of dental wear. Physiologic abrasion occurs during normal function such as mastication and affects the canine ridges, supporting cusps, molar fossae, and pits. It is difficult to determine whether the wear found in children is caused by bruxism or other variables such as diet or endogenous factors. The evidence is now pointing to the rise in soft drink consumption as the most significant factor in the development of tooth wear, causing dental erosion in young people. Nowadays, studies have increased the controversy. A survey22 that included 356 children (aged 6 years) was performed to evaluate the prevalence and etiologic factors involved with wear of primary teeth. The authors found no significant association between gastroesophageal reflux, toothbrushing habits, or consumption of citrus fruits/soft drinks and the presence of tooth wear for all groups of teeth. The wear showed a relation with the presence of bruxism for canines and the habit of holding drinks in the mouth before swallowing for incisors, concluding that the wear of incisors could be considered physiologic for this age. This kind of evidence was not considered in the study by Hachmann et al,18 is not even discussed as a possible limitation of the study, and could be considered a selection bias. Additionally, the treatment time was only 2 months, which is not long enough to perform the changes in the muscles proclaimed in the article. The statistical analysis was not explicit, and there were no tables or graphs with the results. The investigation by Hachmann et al does not accomplish the criteria to be considered a randomized clinical trial.

There is evidence16 for the positive effect of a combined technique of induced muscular relaxation and competence reaction in 3to 6-year-old children with bruxism. However, in the study by Restrepo et al,16 bruxism was determined by indirect measurements, which hampers an unequivocal interpretation of the outcome. The mentioned study used the Bernal and Tsamtsouris23 test to detect temporomandibular disorders, from which data about confidence and validity is not available, but no other scientific instrument had been validated to use in 3- to 6-year-old children. Other therapeutic alternatives for the treatment of bruxism were explored. DiFrancesco et al17 reported the results of a study on a group of children with sleep-disordered breathing and bruxism, of whom a significant proportion of parents ceased to report bruxism after adenotonsillectomy. Although the survey met the inclusion criteria for this systematic review, the scientific strength of the investigation was low, and the authors failed to provide a significant explanation for their findings, as they did not give any information about the signs and symptoms of bruxism that were supposed to be reduced. Still, there is not enough evidence to prove that reduced widths of the airway could be associated with the dopaminergic alteration involved in the generation of bruxism. However, more recent studies24 have also shown that adenotonsillectomy could improve bruxism significantly in children who have obstructive symptoms due to adenotonsillar hypertrophy. However, this final investigation was not considered for the present systematic review, as it was published in 2008 and the present review accepted articles published through September 2007. Bruxism cannot be considered normal, even during the beginning of the mixed dentition. However, there is little evidence about the treatment of bruxism in children, even when effects in the permanent dentition were reported.12 Further randomized clinical trials are necessary to assure strong evidence for the treatment of bruxism in children. According to the present systematic review, evidence is inadequate to support the treatment of bruxism in children.

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CONCLUSIONS

Most of the articles considered in this review are inconclusive: None had an appropriate randomized clinical trial study design. Comparative studies, impact studies, case reports, and reviews were the most commonly used study designs in the initial literature search. Clinicians should be aware of this scarcity of evidence regarding the management of bruxism. There is a vast need for welldesigned studies on the management of bruxism in children.

10. Molina OF, dos Santos Júnior J, Nelson SJ, Nowlin T. Profile of TMD and bruxer compared to TMD and nonbruxer patients regarding chief complaint, previous consultations, modes of therapy, and chronicity. Cranio 2000;18:205­219. 11. Velez AL, Restrepo CC, Peláez A, et al. Head posture and dental wear evaluation of bruxist children with primary teeth. J Oral Rehabil 2007;34:663­670. 12. Egermark I, Carlsson GE, Magnusson T. A 20-year longitudinal study of subjective symptoms of temporomandibular disorders from childhood to adulthood. Acta Odontol Scand 2001;59:40­48. 13. Magnusson T, Egermark I, Carlsson GE. A prospective investigation over two decades on signs and symptoms of temporomandibular disorders and associated variables. A final summary. Acta Odontol Scand 2005;63:99­109. 14. Chalmers TC, Smith H Jr, Blackburn B, et al. A method

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