RESEARCH AND EDUCATION

Bruxism definition: Past, present, and future e What should a

prosthodontist know?
Daniele Manfredini, DDS, PhD,a Jari Ahlberg, DDS, PhD,b and Frank Lobbezoo, DDS, PhDc

Bruxism is an important cur- ABSTRACT

rent topic in dentistry and Statement of problem. The definition of bruxism has evolved, and the dental profession needs to
other medical fields, as shown align with the terminologies adopted in the current literature of sleep and orofacial pain medicine.
by the number of congresses
Purpose. The purpose of this review was to discuss the recent evolution of bruxism concepts and
and events that have focused
the implications for changing the definition that is currently used by the prosthodontic community.
on it recently and by the
increase in peer-reviewed Material and methods. A historical perspective on the evolution of the definition of bruxism, as
publications, with 30% more well as a systematic literature review on the validity of polysomnography (PSG)-based criteria for
sleep bruxism diagnosis to detect the presence of clinical consequences, is presented. Selected
citation hits retrieved with articles were read in a structured Population, Intervention, Comparison, Outcome (PICO) format
the MedLine/PubMed search to answer the question “If a target population with conditions such as tooth wear, dental
term “bruxism” during the implant complications, and temporomandibular disorders (P) is diagnosed with sleep bruxism by
2015-2019 year span than for means of PSG (I) and compared with a population of nonbruxers (C), is the occurrence of the
the preceding 5 years. condition under investigation (that is, the possible pathologic consequences of sleep bruxism)
However, more clinical be different between the 2 groups (O)?”
research is required into the Results. Eight studies were eligible for the review, 6 of which assessed the relationship between
known (or believed) context PSG-diagnosed sleep bruxism and temporomandibular disorder pain, while the other 2 articles
of the phenomenon. In evaluated the predictive value of tooth wear for ongoing PSG-diagnosed sleep bruxism and the
particular, the bruxism potential role of sleep bruxism in a population of patients with failed dental implants. Findings
were contradictory and not supportive of a clear-cut relationship between sleep bruxism
construct has shifted from
assessed based on available PSG criteria and any clinical consequence. The literature providing
pathology to motor activity definitions of bruxism as a motor behavior and not pathology has been discussed.
with possibly even physio-
logical or protective rele- Conclusions. The bruxism construct has shifted from pathology to motor activity with possibly
1,2 even physiological or protective relevance. An expert panel including professionals from different
vance. For the average
medical fields published 2 consecutive articles focusing on the definition of bruxism, as well as
dental practitioner, as well as an overview article presenting the ongoing work to prepare a Standardized Tool for the
for prosthodontists, this Assessment of Bruxism (STAB) to reflect the current bruxism paradigm shift from pathology
means that bruxism can no to behavior (that is, muscle activity). As such, dental practitioners working in the field of
longer viewed as a “paraf- restorative dentistry and prosthodontics are encouraged to appraise this evolution. (J Prosthet
unctional” act of grinding the Dent 2021;-:---)
teeth while asleep that leads
to tooth wear or other damage. discussed critically in the present study, which focuses on
The dental profession would benefit from the inclu- the evolution of bruxism concepts.
sion of the most recent changes in the definition of
bruxism in the Glossary of Prosthodontic Terms3 to align THE PAST
with the current terminology adopted in the fields of From the perspective of the dental practitioner, bruxism
sleep and orofacial pain medicine.4,5 This will be has always been considered the act of grinding the teeth

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
a
Professor, School of Dentistry, Department of Medical Biotechnologies, University of Siena, Siena, Italy.
b
Professor, Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland.
c
Professor and Head, Department of Orofacial pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit
Amsterdam, Amsterdam, the Netherlands.

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2 Volume
Clinical Implications
The bruxism construct has gone through an
evolution over the past years, and the
prosthodontist should appraise the new definition
and conceptualization to embrace a more medically
oriented approach to the phenomenon.
while asleep; it was linked to the presence of tooth wear
and, more in general, to some occlusal traits such as
interferences that were considered to be possible
etiologic factors. It is thanks to early sleep-laboratory
studies in the mid-1990s that sleep bruxism has been
described as a phenomenon that is part of an arousal
during sleep.6 Sleep architecture has been progressively
elucidated, and a peculiar type of electromyographic
activation in the masseter muscles, called rhythmic
masticatory muscles activity (RMMA), has been
described as the final neurovegetative sign of a cascade of
events defined as arousal response.7 Such RMMA events,
which have been assessed with polysomnography (PSG),
were adopted as markers of sleep bruxism (SB) episodes.
During the past 2 decades, research has increasingly
focused on the neurologic and central correlates of such
SB/RMMA events. Findings from pathophysiological
studies support a shift from occlusal beliefs to new
models that may explain the generation of SB.8 This has
important implications for the dental practitioner, who
should no longer view bruxism as an activity arising from
occlusal interferences.9-11
Based on those observations, PSG criteria for SB were
established by assessing the most accurate cutoff
threshold to identify individuals with clinical signs such
as tooth wear, pain in the morning, shiny contacts on
restorations, or a reported history of tooth grinding.12
Since then, PSG has become the standard of reference
for SB diagnosis, and PSG/SB criteria continue to be
refined. Individuals who have more than 4 SB episodes
per hour of sleep have been labeled as severe sleep
bruxers.13
Over the years, in parallel with the progressive
diffusion of PSG/SB criteria in the laboratory research
setting, observations have emerged from clinical in-
vestigations. First, several dental and nondental re-
searchers started to consider bruxism as a masticatory
muscle activity that may also occur during wakefulness.
Such awake bruxism (AB) is mainly performed in the
form of tooth clenching or mandible bracing, which is the
analog of clenching without tooth contact. Clenching and
bracing represent prolonged, isometric contractions of
masticatory muscles, different from the motor activity
with respect to the phasic, isotonic, sudden-onset
contraction of RMMA/SB episodes. Suggestions then
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emerged that SB criteria should consider a more
comprehensive spectrum of motor activities to gain
conceptual homogeneity between SB and AB definitions.
Different strategies could be adopted to pursue that goal,
encompassing the need for an overall measurement of
the sleep-time electromyography (EMG) activity of
masticatory muscles.1,14,15
Second, the use of PSG/SB criteria for bruxism has
gone far beyond the original intentions.16 Indeed, while
the criteria were drawn from a superselected sample of
individuals and were basically validated by self-reported
SB in the attempt to screen for individuals with a
higher frequency of episodes for research purposes, many
clinicians seemed to overlook the specific origin and aim.
PSG was used in many investigations to categorize SB as
a dichotomous condition (present or absent) based on
those criteria, thus forcing an oversimplification of an
overly complex biologic model. Almost inevitably, con-
tradictory results were reported from PSG/SB studies as
for the clinical correlates of SB with respect to patient
perception of self-reported bruxism,17 and the associa-
tions of “bruxism” with its possible clinical markers were
put in doubt.18
To determine the clinical relevance of currently
adopted PSG-based cutoffs for SB assessment in terms of
their suitability as thresholds to detect any possible
pathologic consequences of bruxism, a systematic litera-
ture review was performed on November 13, 2020, as
part of the preparation for this manuscript. The PubMed/
MEDLINE database was browsed and searched for all
articles dealing with the clinical consequences of sleep
bruxism as assessed with PSG.
Inclusion was restricted to clinical studies on humans,
assessing the role of PSG-diagnosed SB as a risk factor
for the following possible clinical consequences: tooth
wear; biologic outcomes such as implant failure, implant
mobility, and marginal bone loss; or mechanical out-
comes such as complications or failures of either pre-
fabricated components or laboratory-fabricated
suprastructures of dental implants and dental implant-
supported rehabilitations; and temporomandibular dis-
orders (TMDs) by comparing the rate of such complica-
tions in individuals with and without bruxing behaviors.
Given their methodological heterogeneity, the studies
were assessed in a Population, Intervention, Comparison,
Outcome (PICO) format. For each article, the data were
extracted to answer the question, “If a target population of
individuals with a certain condition such as tooth wear,
dental implant complications, and TMDs (P) is diagnosed
with sleep bruxism by means of PSG (I) and compared
with a population of nonbruxers (C), is the occurrence of
the condition under investigation (that is, the possible
pathologic consequences of sleep bruxism) be different
between the 2 groups (O)?” The PICO format did not
perfectly fit all the included studies because of the different
Manfredini et al
- 2021
study designs, especially concerning the selection of the
target population and the comparison group. Neverthe-
less, it was the best possible approach to a systematic
assessment of the current literature. The pertinent details
of the included studies are presented in Table 1, which also
includes some critical considerations of the strengths and
weaknesses of the examined studies. Table 1 also reports a
response to the question, “Are the currently adopted
PSG-based cutoffs for SB diagnosis suitable as thresholds
to detect the pathologic consequences of bruxism?” based
on the data of each individual study. All studies were
assessed separately by the 3 review authors, and in cases
of divergent assessments with regard to the assignment of
strengths and weaknesses, consensus was reached by
discussion.
After excluding the citations that were clearly not
pertinent to the clinical research question, 11 articles
were retrieved in full text. A consensus decision was to
exclude 3 further articles because they were studies that
either adopted single-channel EMG as the only recording
method to detect pain symptoms (N=2) or assessed tooth
wear with an SB force detection method (N=1).
Six of the 8 included studies assessed the relationship
between PSG-diagnosed SB and TMD pain,13,19,23-25,27
while the other 2 articles evaluated the predictive value
of tooth wear for ongoing PSG-diagnosed SB20 and the
potential role of SB, as diagnosed with PSG recordings, in
a population with failed dental implants.26 The included
studies had different designs in terms of population
recruitment and size, ranging from 19 participants in the
investigation on dental implants to a maximum of 86
participants for the SB-TMD studies and up to 130 par-
ticipants for the SB-tooth wear study. Two studies had
problems of redundancy owing to duplication of the
study population,13,20 but they were included in the re-
view because different kinds of data were presented in
the 2 publications. In addition, 2 other articles 21,24 came
from the same research group but presented data on
different sample sizes.
From a methodological viewpoint, the SB-TMD
studies had different design characteristics, which pre-
vented a direct comparison or a meta-analysis of data. A
standardized Research Diagnostic Criteria for TMD
(RDC/TMD) diagnostic assessment was performed in 3 of
the 6 studies, and a control group was selected in 5 in-
vestigations, accounting for 103 participants (62 TMD-
free individuals from the 3 studies comparing the prev-
alence of PSG-diagnosed SB in TMD and non-TMD
participants; 34 non-SB participants in 1 study
comparing the prevalence of TMD in PSG-diagnosed SB
and non-SB; and 7 SB participants without pain in 1
preliminary study comparing the features of SB with and
without pain). In 2 articles, the study sample was split to
compare bruxers with TMD pain and bruxers without
TMD pain, while the other investigations were
Manfredini et al
3
performed on patients with TMD and were designed to
assess the prevalence of PSG-diagnosed SB. Three
studies based their findings on a single night of PSG
recordings, while in the other 3 studies an additional
preliminary adaptation night was part of the protocol.
Consistent with the criteria for inclusion in the review, all
studies adopted standardized criteria for PSG-SB diag-
nosis. There were only minor inconsistencies in the cri-
terion adopted to diagnose the so-called RMMA because
EMG activity greater than 20% of maximum voluntary
contraction level was selected as the cutoff in all studies
except 1 in which it was set at 10% of maximum
voluntary contraction.
As for the findings, the tooth weareSB investigation
showed that the pooled assessment of tooth wear had
high sensitivity (94%), specificity (87%), and negative
predictive values (99%), with unacceptable positive pre-
dictive values (26% to 71%%),20 thus suggesting that
PSG-diagnosed SB is mainly useful to exclude individuals
without tooth wear but that other potential causes of
tooth wear should be considered for differential diagnosis
whenever tooth wear is present. In the study on patients
with failed dental implants, 6 of 19 (31.5%) participants
were diagnosed as bruxers,26 but the external validity of
the findings is hard to determine because of the absence
of data about the percentage of individuals with and
without SB diagnosis in the whole target population
receiving dental implants. Studies on the relationship of
PSG-diagnosed SB with TMD symptoms also yielded
results that are difficult to interpret because some in-
consistencies of findings were present even between the
studies performed by the same group of researchers. In
summary, PSG-diagnosed SB was found to be associated
with myofascial pain in 1 article,23 no association was
detected in another article,24 and a negative association
(that is, those with pain exhibited fewer SB episodes with
respect to those without pain) was described in 2
studies.13,25 The other 2 studies reported that individuals
with TMD had only a slightly higher rate of SB episodes/
hour of sleep with respect to those without TMD (8.0
versus 6.2 episodes/hour)27 and that the prevalence of
PSG-diagnosed SB in a population of patients with TMD
was much lower than hypothesized (17.3%).19
In brief, the misuse of PSG/SB criteria as a possible
indicator to measure the role of SB as a risk factor for
clinical consequences has paradoxically led to the pro-
gressive diminution and dismantling of “old beliefs” in
terms of linear SBetooth wear and SB-pain relationship,
thus paving the way for conceptualizing bruxism as a
motor behavior.
THE PRESENT
To overcome these issues and based on the emerging
evidence concerning the vicious circle between
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Table 1. PICO-like summary of findings from reviewed studies investigating validity of currently adopted PSG-based cutoffs for SB diagnosis suitable as
thresholds to detect pathologic consequences of bruxism
Validity of
PSG-SB Cutoffs
First to Detect
Author, Intervention Comparison (Control Pathologic
year Population (Study design) group) Outcome Reviewers’ Comments Consequences
Smith, 53 patients with PSG for 2 Assessment of % of PSG PSG-SB diagnosis in Weakness: Absence of Unclear
200919 TMD (RDC/TMD consecutive nights bruxers in the study 17.3% of patients true control group of
myofascial pain) (one for adaptation) sample patients without TMD
(43F, m.a. Recordings of Main finding: “Active”
33.6±12.4 y) episodes of EMG PSG-SB has low
activity >10% of prevalence in myofascial
MVC pain patients
Abe, Same sample by PSG for 2 Sample split into 3 Significant difference in Weaknesses: - Yes
200920 Rompré et al. consecutive nights groups for comparison TW scores in both Unmatched sex
(2007)21, with (one for adaptation) of tooth wear scores: moderate to high and distribution between
different analysis of Clinical tooth wear Moderate-to-high SB low RMMA versus groups
data scoring according to (N=59; 36F, 23M; m.a. control group (P<.001) - Report of tooth
130 participants Johansson et al. 25.5 ±0.6 yrs.) No difference in TW grinding was criterion
(58%F; m.a. 26.6 (1993)22 (0-4 Low SB (N=48; 32F, 16M; scores between the 2 SB for splitting group (risk
±0.6 y., range 19-44) ratings) m.a. 27.9 ±0.9 yrs.) groups (P>.05) for circular reasoning
without TMD as No SB (N=23; 8F, 15M; Pooled TW scores when evaluating TW)
primary complaint m.a. 26.6 ±1.5 yrs.) highest value to Main findings: - TW plus
discriminate individuals history of tooth grinding
with SB from controls seems helpful to
(ROC=0.945) discriminate SB patients
from individuals without
tooth grinding history
- TW cutoff values low
and variable (difficult
clinical application)
Rossetti, 30 patients with TMD index 30 healthy controls (24F, No association between Strengths: - Calibrated Yes
200823 MFP (24F, 6M; m.a. PSG for 2 6M; m.a. 26±4.5 y; a.r. SB and report of worst examiners
26.6±5 y; a.r. 19-39) consecutive nights 20-42) pain in morning (P=.76) - Presence of true
without sleep (one for adaptation) SB: 63.3% of MFP control group
disorders and other Recordings of patients vs 33.3% of Weakness: No
TMD symptoms episodes of EMG controls (P=.04) adjustment for sex
activity >20% of Main finding: RMMA
MVC during sleep associated
Parametric and with MFP and risk factor
nonparametric (although small) for MFP
statistical tests to
compare groups
Rossetti, 14 patients with VAS scores plus 12 non-TMD No association between Strengths: - No
200824 TMD (8F, 6M; m.a. RDC/TMD muscle participants (6F, 6M; bruxism and TMD Standardized TMD
27.1±7.4 y; a.r. 17- and joint palpation m.a. 27.4±5.2 y; a.r. (P=.976), nor between diagnosis (RDC/TMD)
40) without sleep Single-night PSG 22-40) bruxism and pain on - Control group
disorders Recordings of palpation (P=1.000) Weaknesses: - Single-
episodes of EMG No difference between night PSG with no
activity >20% of RMMA in bruxers with adaptation
MVC and without pain on - Heterogeneous sample
Parametric and palpation (P>.05) of TMD patients
nonparametric - No adjustment for sex
statistical tests to Main findings: - SB
compare groups neither associated with
general TMD nor with
pain on palpation
- Pain only in some SB
individuals
Rompré, 100 SB (60%F; m.a. PSG for 2 43 non-bruxers controls Excluded “bruxers” more Strengths: - Large- No
200713 26.5±0.6 y) without consecutive nights (68%M; m.a. 24.5±0.9 y) often complain of sample PSG study
TMD as primary (one for adaptation) Some participants clenching, painful jaw - Presence of control
complaint Pain assessment by excluded after second upon awakening and group
questionnaire: SR PSG night (no SB muscle fatigue than Weaknesses: -
pain intensity and confirmation/absence) e included SB (OR 3.9-4.9) Nonstandardized TMD
other factors comparison performed Pain of excluded diagnosis
Chi-square, on 54 SB vs 34 non-SB “bruxers” higher than - Sex-unmatched groups
nonparametric tests participants that of included SB Main finding: Pain
and cluster analysis (P=.06) frequently reported
among SB with low
frequencies of jaw
muscle contractions
(continued on next page)

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Table 1. (Continued) PICO-like summary of findings from reviewed studies investigating validity of currently adopted PSG-based cutoffs for SB diagnosis
suitable as thresholds to detect pathologic consequences of bruxism
Validity of
PSG-SB Cutoffs
First to Detect
Author, Intervention Comparison (Control Pathologic
year Population (Study design) group) Outcome Reviewers’ Comments Consequences
Camparis, 40 consecutive RDC/TMD axis I and 20 bruxers with TMD SB episodes/h: 20% Strengths: - Standardized No
200625 patients with SR II (Group A e 100% more for participants TMD diagnosis (RDC/
tooth grinding PSG to confirm SB myofascial pain, 10% without pain (8.0 vs 6.2) TMD)
(32F, 8M; m.a. (single night) disc displacement, 85% Weaknesses: -Single-night
36.1±11.3 y) Recordings of arthralgia) vs 20 bruxers PSG with no adaptation
episodes of EMG without TMD (Group B) -No adjustment for sex
activity >20% of -Unclear aims with
MVC respect to conclusions
Single variable and Main finding:
nonparametric tests Inconclusive evidence for
association between
facial pain and SB
Tosun, 19 patients with Single-night PSG Assessment of % of PSG- 6 of 19 patients (31.5%) Weaknesses: - Absence Unclear
200326 dental implant Recordings of bruxers in study sample were diagnosed with SB of a true control group
complications (of episodes of EMG - Absence of absolute
368 who received activity >20% of frequency data (such as,
implant treatment) MVC SB with vs without
No statistical implant complications)
analysis - No statistical analysis on
different patterns of
complications in relation
to SB (no adjustments for
type of rehabilitation)
- No sex/age information
on study sample
Main finding: SB
potential risk factor for
dental implant
complications, with
inconclusive evidence
Lavigne, 6 bruxers with PSG for 2 7 bruxers without pain No significant differences Weakness: Preliminary No
199720 nonmyofascial jaw consecutive nights (2F,5M; m.a. 27.3±4.8 y) between 2 groups of study
muscle pain (3F, 3M; (one for adaptation) bruxers in number of Main finding: Less
m.a. 25.3±0.6 y) Recordings of bruxism bursts per bruxism episodes in
episodes of EMG episode and EMG level non-myofascial jaw
activity >20% of per bruxism burst muscle pain, but
MVC Nonmyofascial jaw contents of episodes
Comparison of PSG- muscle pain group unaffected by pain
SB frequency in 2 showed 40% less
groups episodes/hr (P=.037)

a.r., age range; EMG, electromyography; F, female; M, male; m.a., mean age; MFP, myofascial pain; MVC, maximum voluntary contraction level; PICO, Population, Intervention, Comparison,
Outcome; RDC/TMD, Research Diagnostic Criteria for TMD; RMMA, rhythmic masticatory muscle activity; ROC, receiver operating curve; SB, sleep bruxism; SR, self-reported; TMD,
temporomandibular disorders; TW, tooth wear; VAS, visual analog scale.

polysomnographically and self-reported or clinically
approached SB, a panel of experts from different med-
ical fields, including dentistry, sleep medicine, psychol-
ogy, and orofacial pain, was configured. In 2013, a
consensus definition of bruxism was published, which
also suggested the need for improved diagnostic
grading and a different conceptualization of bruxism as
follows28:
“Bruxism is a repetitive jaw-muscle activity characterized
by clenching or grinding of the teeth and/or by bracing or
thrusting of the mandible. Bruxism has two distinct circadian
manifestations: it can occur during sleep (indicated as sleep
bruxism) or during wakefulness (indicated as awake
bruxism).”
The umbrella term bruxism now includes the different
motor activities more clearly. Also considering that iso-
metric, clenching-type activities are an important part of
the bruxism continuum, criticism of the use for clinical
purposes of PSG/SB yes or no cutoff criteria based on the
identification of arousal events alone has been raised.1
The need to expand the bruxism taxonomy was also
evidenced by the poor quality of the literature on bruxism
management, which lacks clinically useful information on
the indications for treatment.21
The 2013 definition has been well-received by re-
searchers and clinicians; it has been highly cited (more
than 50 times per annum), and the definition has been
promptly adopted by several major organizations.
Indeed, the American Academy of Orofacial Pain has
already included the definition in the glossary of the fifth
edition of their Orofacial Pain Guidelines for Assessment,
Diagnosis, and Management (2013),29 and the American
Academy of Sleep Medicine has incorporated the defi-
nition into the third edition of their International Clas-
sification of Sleep Disorders (2014).5

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6 Volume
The consensus article, originally intended as an
important standpoint and confluence of viewpoints,
suddenly became a text that many experts perceived as a
document in need of an upgrade. This led to a series of
debates, both on the article and30,31 in congresses,32
and subsequently, a new consensus article was pub-
lished in 2018.33 The premises leading to the second
consensus article were that a report of the work in
progress to describe the ongoing paradigm shift in the
bruxism construct was needed. The core of the article was
that because research focused on the neurophysiological
correlates of RMMA-SB and the derived bruxism
generator model has been erroneously applied to un-
derstand the clinical correlates of unspecific “bruxism,”
attention should be shifted to the distinction between the
different motor activities. The main conclusions of this
effort were that:
- in otherwise healthy individuals, bruxism should not
be considered as a disorder but rather as a motor
behavior that can be a risk and/or protective factor
for certain clinical consequences, not to say just a
harmless activity;
- both noninstrumental approaches (notably self-
report) and instrumental approaches (notably elec-
tromyography) can be used to assess bruxism; and
- standard cutoff points for establishing the presence
or absence of bruxism should not be used in other-
wise healthy individuals; rather, bruxism-related
masticatory muscle activities should be assessed on
the behavior’s continuum.
Thus, the new consensus report developed separate
definitions for SB and AB; discussed the concept of
bruxism as a behavior that can be a risk factor for certain
clinical conditions, rather than a disorder per se; reex-
amined the 2013 diagnostic grading system; and elabo-
rated a research agenda. Among these, the decision to
split the definitions of SB and AB as well as the clear
statement on the conceptualization of bruxism as a motor
behavior (and not a pathology or a parafunction) was the
most clinically meaningful aspects for the dental
practitioners.
The widespread acceptance of this new publishing
effort is evidenced by the fact that the article has already
been cited 128 times (data from CrossRef Wiley Pub-
lishing Website e accessed November 13, 2020). Since
2018, the international community of bruxism experts has
defined SB as “a masticatory muscle activity during sleep
that is characterized as rhythmic (phasic) or nonrhythmic
(tonic) and is not a movement disorder or a sleep disorder in
otherwise healthy individuals.” AB has been defined as “a
masticatory muscle activity during wakeful-ness that is
charcterized by repetitive or sustained tooth contact and/or by
bracing or thrusting of the mandible and is not a movement
disorder in otherwise healthy individuals.” This is a
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reminder that the dental community should adopt these
definitions as well so as to speak a common language
and implement cross-knowledge among the different
categories of professionals.
In addition to the definition, the comprehension of
the paradigm shift from pathology to behavior is a
further recommendation for the dental practitioner and
especially for those colleagues involved in restorative
dentistry and prosthodontics. Avoiding the use of terms
such as “parafunction,” in favor of the more generic
“muscle activity,” could help reduce improper or un-
necessary treatments. For instance, when facing an in-
dividual with a worn dentition, the dentist should be
aware that tooth wear may be an indirect sign of the
SBesleep apnea relationship.22 Thus, the proper path of
action by the dentist is to ask the appropriate questions
to screen and to refer for respiratory disturbances,
which are potentially life-threatening conditions that
could even worsen with the use of occlusal devices
because of the rotation of the mandible that may further
reduce airway patency.34,35
THE FUTURE
In the 2018 consensus article, it was noted that the
bruxism behaviors in children, the relationship of SB with
other sleep disorders such as obstructive sleep apnea, the
possible role of clenching (more than grinding) as an
overload factor for the temporomandibular joint and the
masticatory muscles, and the clinical relevance of tooth
wear as such and as a prosthetic and restorative chal-
lenge (also considering erosion from reflux disease) are
among many challenges that need to be considered
further in the future.
Importantly, the paucity of data on AB should be
corrected. Recent research approaches on the assessment
of AB seem promising: a smartphone application has
been introduced for that purpose.36 It was based on so
called ecological momentary assessment (EMA)
principles or experience sampling methodology, which
allows real-time evaluation of AB behaviors.
In brief, a challenging future is ahead of us, and the
main goals will be to assess and discriminate in a valid
and feasible way which motor activities included under
the umbrella term bruxism are physiological and which
activities represent additive bruxism that may mirror
some underlying conditions such as sleep apnea, psy-
chological disorders, side effects of medications, and
primary motor disorders. It is also important to find out
how these conditions relate to the clinical consequences
of bruxism behaviors. Therefore, quantification of jaw
muscle work during sleep and wakefulness and the
assessment of their time-related relationships with pain
and tooth wear will be the main goals of clinical research
on the topic.
Manfredini et al
- 2021
An overview manuscript has recently been published
by another group of international experts to present the
general structure of a Standardized Tool for the Assess-
ment of Bruxism (STAB).37 The idea behind the STAB
project is to gather as much data as possible on the
possible risk, comorbidity, and associated factors for
bruxism, as well as on the bruxism status and its clinical
consequences. Information drawn from the participant,
collected during a clinical assessment, and recorded with
instruments will be formatted into specific domains. The
STAB is currently under revision by a pool of invited
reviewers external to the expert panel. Furthermore, the
final version will be subjected to infield testing for
possible refinement. In brief, the goal of the STAB is to
identify relevant factors that are associated with brux-
ism’s etiology, status, and consequences. This informa-
tion can be used for various purposes in both clinical and
research settings. Clinical algorithms can be established
to predict the presence of bruxism, its causes, and its
consequences based on known factors along the
etiology-status-consequences trajectory. For clinicians,
an instrument on bruxism should be able to link the
different domains.
As possible examples of clinical scenarios, a dental
professional could “predict” that an individual with
myofascial pain (bruxism consequence) has AB behavior
(bruxism status) that is associated with a psychological
profile (etiology), or that an individual with a respiratory
disorder (bruxism etiology) may have a SB pattern
(bruxism status) that is associated with a degree of tooth
wear or rate of prosthodontic complications (bruxism
consequences).
Within this context, an impressive amount of
research, both cross-sectional and longitudinal, could be
performed. In addition, future research using cross-
sectional and especially longitudinal designs can be
performed to answer important questions such as “In
which patients is bruxism associated with certain con-
sequences and in which ones it is not?” and “In which
patients is bruxism associated with a known etiology?”
As a final remark, it is fundamental that this “new”
bruxism paradigm is also transferred to the management of
temporomandibular disorders, focusing on the interrelation
of the recognized bruxism-pain-psychosocial triangle. It
will also be by the virtue of adopting this conceptual
framework that dentistry as a profession will be brought out
of the muddy waters of the obsolete parafunction-centered
era. This is especially important in improving the dental
practitioners’ collaboration with physicians in the assess-
ment, prevention, and management of bruxism.
IMPLICATIONS FOR THE PROSTHODONTIST
The implications of the evolving bruxism construct for
prosthodontists are worthy of consideration. In the
Manfredini et al
7
most recent edition of the Glossary of Prosthodontic
Terms, bruxism is still defined as “1. The parafunc-
tional grinding of teeth; 2. An oral habit consisting of
involuntary rhythmic or spasmodic nonfunctional
gnashing, grinding, or clenching of teeth, in other
than chewing movements of the mandible, which
may lead to occlusal trauma.”3 Such a definition of
bruxism, although adequate, is unnecessarily compli-
cated because of ambiguous terms such as rhythmic,
spasmodic, and gnashing. It also lacks a link to the
commonly agreed-upon circadian nature of bruxism
(that is, sleep versus awake). In addition, the defini-
tion solely focuses on tooth contact conditions,
thereby excluding masticatory muscle activity that is
like that developed during tooth contact but without
the teeth touching, such as bracing and thrusting of
the mandible. Importantly, the term “parafunction”
implies a disordered function. Recent insights, how-
ever, suggest that bruxism cannot only be associated
with negative health outcomes but also with positive
ones, such as the possible role in preventing upper
airway collapse during sleep and thereby obstructive
sleep apnea. Likewise, the term “oral habit” implies
that bruxism is a fully conscious condition, which is
obviously not the case if one considers SB. Finally,
the addition that bruxism may lead to occlusal trauma
is problematic, not only because of the ongoing
debate on what exactly occlusal trauma is but also
because occlusal trauma is just 1 of the many possible
consequences of bruxism.
Based on these considerations, the international
consensus definition should be considered for inclusion
in Glossary of Prosthodontic Terms-10 to align with the
commonly used terminology at the bruxism expert
community level. Meanwhile, dentists are encouraged
to start using the updated definition and to conceptu-
alize bruxism as a motor behavior in their clinics or
when performing research projects on this intriguing
topic.
CONCLUSIONS
This manuscript provided an overview of the recent
evolution of the bruxism construct and discussed the
possible implications for changing the definition that is
still currently adopted by the prosthodontic community.
An expert panel including professionals from different
medical fields, including dentistry, sleep medicine, psy-
chology, and orofacial pain, published 2 consecutive ar-
ticles focusing on the bruxism definition,28,33 as well as
an overview article presenting the ongoing work to
prepare a Standardized Tool for the Assessment of
Bruxism (STAB),37 reflecting the current bruxism para-
digm shift from pathology to behavior (that is, muscle
activity).
THE JOURNAL OF PROSTHETIC DENTISTRY
8 Volume
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Corresponding author:
Dr Daniele Manfredini
School of Dentistry
University of Siena
c/o Policlinico Le Scotte
Viale Bracci e 53100 Siena
ITALY
Email: daniele.manfredini@unisi.it
Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2021.01.026
Manfredini et al