Journal of Dentistry 111 (2021) 103711

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Review article

Sleep bruxism and temporomandibular disorders: A scoping review of

the literature
Daniele Manfredini a, *, **, Frank Lobbezoo b
a
Professor, School of Dentistry, Department of Medical Biotechnologies, University of Siena, Italy
b
Professor and Chair, Department of Orofacial pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit
Amsterdam, Amsterdam, the Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: : To provide a scoping review of the literature by assessing all the English-language papers that
Sleep bruxism investigated the relationship between sleep bruxism (SB) and temporomandibular disorders (TMDs).
Bruxism Study data and sources: : A search was performed in the National Library of Medicine (PubMed) and Scopus
Temporomandibular disorders
databases, in order to identify all the articles published assessing the relationship between SB and TMDs, by
TMD
several different approaches. The selected articles were then structurally read and summarized in PICO tables.
The articles were selected independently by the two authors.
Study selection: : Out of 185 references that were initially retrieved, 47 articles met the inclusion criteria and were
thus included in the review. The studies were divided into four categories based on the type of SB assessment: 1.
questionnaire/self-report (n = 26), 2. clinical examination (n = 7), 3. electromyography (EMG) (n = 5), and 4.
polysomnography (PSG) (n = 9).
Conclusions: : Studies based on questionnaire/self-report SB featured a low specificity for SB assessment, and in
general they found a positive association with TMD pain. On the contrary, instrumental studies (i.e., electro­
myography, polysomnography) found a lower level of association or even a negative relationship between SB and
TMD pain. Findings from this updated review confirmed the conclusions of a previous review by Manfredini &
Lobbezoo, suggesting that literature findings on the relationship between SB and TMDs are dependent on the
assessment strategies that are adopted for SB. Future studies should consider SB as a multifaceted motor behavior
that must be evaluated in its continuum spectrum, rather than using a simplified dichotomous approach of
presence/absence.

Introduction After the publication of that paper, knowledge in the bruxism field
has progressively evolved. Based on emerging evidence that bruxism is
The association between sleep bruxism (SB) and temporomandibular an umbrella term including different motor behaviors, expert consensus
disorders (TMDs) is a controversial topic, which has been addressed by efforts were made to provide a bruxism definition that reflects the
several systematic literature reviews. In particular, a previous paper by complexity of the activity spectrum (i.e., teeth grinding, teeth clenching,
Manfredini and Lobbezoo [1], that was published a decade ago and built mandible bracing, mandible thrusting) and to specify that bruxism may
on an earlier review by Lobbezoo and Lavigne [2], concluded that have different circadian manifestations [3]. A successive consensus
findings are influenced by the strategy adopted to assess bruxism. In paper further clarified this distinction, providing two separate defini­
general, studies based on a self-reported or questionnaire-based tions for sleep and awake bruxism [4]. Within this premise, sleep
approach to bruxism found an association with TMD, which was how­ bruxism (SB) was defined a masticatory muscle activity (MMA) that
ever not replicated by the few investigations on occurs during sleep, characterized as rhythmic (phasic) or non-rhythmic
instrumentally-measured sleep bruxism (i.e., electromyography [EMG], (tonic) and not as a movement disorder or sleep disorder in otherwise
polysomnography [PSG]). healthy individuals [4].

* Corresponding author at: Daniele Manfredini, c/o Policlinico Le ScotteViale Bracci – 53100 Siena, Italy.
** Office: Via Ingolstadt 3, 54033 Marina di Carrara, Italy.
E-mail address: daniele.manfredini75@gmail.com (D. Manfredini).

https://doi.org/10.1016/j.jdent.2021.103711
Received 2 January 2021; Received in revised form 26 May 2021; Accepted 29 May 2021
Available online 6 June 2021
0300-5712/© 2021 Elsevier Ltd. All rights reserved.
D. Manfredini and F. Lobbezoo Journal of Dentistry 111 (2021) 103711

Different instrumental and non-instrumental approaches have been
suggested as possible strategies for the assessment of SB, without
necessarily having an unquestionable standard of reference [5]. Indeed,
PSG is the ideal strategy to evaluate SB correlates, but, as far as the jaw
muscle activity is concerned, it just provides a count of the events.
Because of the lack of information on the amount of muscle work, PSG
may not be the ideal approach to evaluate the relationship between
sleep bruxism and signs and symptoms of temporomandibular disorders
[6]. On the other hand, the self-reported (e.g., interviews, question­
naires) and clinical (e.g., tooth wear, shiny spots on restorations, linea
alba, tongue scalloping) approaches for the assessment of SB, which still
remain the most adopted assessment strategies in large-sample studies,
have well-known limits of differential diagnosis between different
circadian bruxism activities as well as with respect to other conditions
[7,8]. Thus, it is not surprising that findings on the relationship between
bruxism and TMDs is not clear yet and can be influenced by the
assessment strategies that are adopted for the two conditions, as
emerged from the previous reviews by Lobbezoo and Lavigne [2] and by
Manfredini and Lobbezoo [1].
Within these premises, an updated literature review has been per­
formed and discussed in this manuscript to evaluate if the new bruxism
definitions and distinction between bruxism activities based on their
circadian rhythm has led to an improved knowledge on this issue. The
present manuscript focused on papers dealing with the relationship
between SB and TMDs, and covers also the decades of literature
reviewed by the previous works, with the aim to summarize findings and
provide a scoping review with suggestions for the future researches on
the topic.
The population (“P”) is described in terms of sample size, inclusion
criteria, and demographic characteristics. The intervention (“I”) con­
cerns information on the study design, the assessment approach, the
number and qualification of examiners, and the statistical analysis. The
comparison (“C”) includes data on the control group depending on the
study design (i.e., individuals without SB; individuals without TMDs).
The outcome (“O”) is reported in terms of the possible relationship be­
tween TMD and SB. The main conclusions of each study’s authors were
also included.
The studies were assessed independently by the two reviewers.
Results
The search query identified 185 citation hits. Title and abstract
reading led to the exclusion of 138 articles, which were clearly not
relevant, and the full text was retrieved of the remaining 46 articles. Of
these, 27 were excluded for not fulfilling the inclusion criteria, so that 19
articles were selected for inclusion in the review. In addition, 28 papers
were added to the review by browsing the reference lists of the two
previous reviews. Thus, a total of 47 articles were included in the review
[9-55]. Table 1 provides the list of articles that were excluded after
reading the full text, along with the reason for exclusion from the review
[56-82]. Based on the criteria adopted for SB assessment, the selected
articles were then divided into four categories: questionnaire/self-report
(n = 26) [9-34], clinical assessment (n = 7) [35-41], electromyographic
recordings (n = 5) [42-46], polysomonographic recordings (n = 9)
[47-55].

Material and methods

2.1 Search strategy

Table 1
Studies retrieved in full text but not included in the review.
On April 15th, 2021, a search of the literature was performed to
Study’s first Author and Reason for Exclusion
identify all peer-reviewed English-language citations that were relevant
Year
to the review topic, viz., the relationship between sleep bruxism and
temporomandibular disorders. Emodi- Perlman 2020 No information about the TMD-SB association itself
[56]
As a first step, the query “sleep bruxism AND temporomandibular
Somay 2020 [57] Study performed on a particular population
disorders” was searched in the National Library of Medicine Medline (hemodialysis)
(PubMed) and Scopus databases. The literature search was limited to all Wieckiewicz 2020 [58] Study included only TMD patients
the articles on adult populations (>18 years) that were added to the two Osiewicz 2020 [59] Study included only TMD patients
Poluha 2020 [60] Study included only patients with click
databases during the time span from January 1st, 2009 to April 15th,
Yadav 2020 [61] Study included only TMD patients
2021. Search expansion strategies were adopted to identify any addi­ Khayat 2019 [62] Pediatric patients included in the study group
tional potentially relevant citations (i.e., related articles, hands-on Wagner 2019 [63] Study included only TMD patients
search in private libraries, reference lists of included articles). The two Thymi 2019 [64] Study included only probable sleep bruxers
previous reviews by Lobbezoo and Lavigne [2] and Manfredini and Muzalev 2018 [65] Study included only TMD patients
Muzalev 2018 [66] Clinical case series
Lobbezoo [1] served as references to screen for the titles published
Demirkol 2018 [67] No information about the TMD-SB association itself
before 2008. Su 2018 [68] No information about the TMD-SB association itself
Criteria for inclusion in the review were based on the type of study. Magalhães 2017 [69] The sample includes adolescents < 18 y
Inclusion was limited to articles presenting clinical research data on: 1) Tavarez 2016 [70] No information about the TMD-SB association itself
Blasco-Bonora 2016 No information about the TMD-SB association itself
the relationship between SB and TMDs, as assessed by the use of ques­
[71]
tionnaires, or 2) the relationship between SB and TMDs, as assessed by de Siqueira 2016 [72] No information about the TMD-SB association itself
clinical assessment, or 3) the relationship between SB and TMDs, as Yu 2015 [73] Study performed on a particular population (pilots)
assessed by electromyography (EMG), or 4) the relationship between SB Dias 2015 [74] Study included only TMD patients
and TMDs, as assessed by polysomnography (PSG). Articles including Raphael 2015 [75] Study based on PSG-assessed SB vs self-reported SB
Blanco 2014 [76] Study included only TMD patients
populations with other conditions/diseases that are known for their
Paesani 2013 [77] Study on correlation between clinically-assessed SB vs
relationship with SB and/or TMDs were excluded from the review. Ar­ self-reported SB
ticles that were potentially satisfying the inclusion criteria for the review Piementel 2013 [78] Study performed on a particular population with
were retrieved in full text. Finally, consensus between the two reviewers fibromyalgia
Alajbeg 2012 [79] Study performed on a particular population (navy
(DM and FL) was reached in order to include/exclude the articles from
employees)
the review. Manfredini 2012 [80] Study focused on evaluation method of self-reported SB
in TMD patients
2.2 Assessment of papers Marklund 2010 [81] No information about the TMD-SB association
Smith 2009 [82] Study included only TMD patients

The selected articles were read according to a PICO-like structured Footnotes: TMD, Temporomandibular Disorders; SB, Sleep Bruxism; y, years;
strategy, viz., Population/Intervention/Comparison/Outcome. PSG, polysomnography.

2
D. Manfredini and F. Lobbezoo
3.1 Summary of studies based on questionnaire/self-report
Twenty-six studies investigated the association between SB and
TMDs by means of a questionnaire or self-reported assessment (Table 2).
The study populations accounted for a total of more than 42 thousands
subjects.
Study designs were strongly heterogeneous, based on the evaluation
of the SB-TMD association either in non-patient populations (e.g., gen­
eral population, university students, patients attending dental clinics for
conservative care) or in case-control groups of TMD vs non-TMD in­
dividuals. Methodological differences were evident also from the num­
ber and formulation of bruxism assessment items as well as from the
TMD diagnosis strategy [83-86]. All the studies were based on a
cross-sectional assessment of the association at a single assessment
point.
As for the results, all papers found a statistically significant associ­
ation between SB and TMD. However, two articles reported an associ­
ation between bruxism and TMD only if awake bruxism and sleep
bruxism were considered together [12,15], and another study showed
that the concurrent report of AB and SB increases the odds ratio for
TMDs more than the sum of the two behaviors [17]. Yet another paper
found an association only for patients who are told by their dentist to be
bruxers [33], whilst others reported an association with clenching
[26-28,30] or grinding report [18, 31].
3.2 Summary of studies based on clinical assessment
Seven studies assessed sleep bruxism by means of a clinical exami­
nation [35-41]. They accounted for a total of 1869 subjects. All studies
except one [37] were based on a case-control design, with comparison
groups of TMD vs non-TMD patients. The authors used either the
American Academy of Sleep Medicine (AASM) diagnostic criteria (i.e., a
combination of patient self-report and clinical signs) [35], a compre­
hensive clinical assessment [40], or just the presence of tooth wear
[36-39, 41] to evaluate bruxism. TMDs were diagnosed based on the
RDC/TMD.
Findings of the five studies based on tooth wear assessment did not
support an association with TMDs, with minor exceptions [39] con­
cerning the possible value of attrition to discriminate between different
TMD diagnoses. The other two studies reported that SB patients have a
higher odds for myofascial pain and arthralgia (Odds ratio=6.9) than
individuals not fulfilling AASM criteria for sleep bruxism [35] and that
an association exists between clinically-assessed bruxism and myofascial
pain [40].
3.3 Summary of studies based on electromyography
Five studies used a portable EMG device [42–46]. They accounted for
a total of 401 subjects, recruited either among attendants of a general
dental clinic [42], university students [43,46], or belonging to a
case-control investigation comparing TMD vs non-TMD patients [44,
45]. Different portable EMG devices for in-home recording were used,
all based on single-channel recording except for one study that gathered
data from bilateral masseter and temporals muscles [42]. In two studies,
the researchers placed the EMG surface electrode on the masseter
muscle for two or six nights (the first night was for adaptation) [43,46].
The other two studies consisted of four recording nights with surface
electrodes placed on the temporalis muscle [44,45]. All studies were
based on a dichotomous assessment of presence/absence of bruxism,
based on a cutoff threshold of two or four EMG episodes per hour of
sleep.
As for the findings, three studies did not retrieve any significant as­
sociations between sleep bruxism and TMDs [42,43, 45], one study
found an association with unspecific TMDs [44], and another one found
an association with clicking sounds from the temporomandibular joints
[46].
3
Journal of Dentistry 111 (2021) 103711
3.4 Summary of studies based on polysomnography
Nine studies assessed the relationship between SB and temporo­
mandibular disorders by means of PSG recordings [47-55]. Four of them
came from the same group of researchers [47,49-51] and have been
included in this review because of the different data they presented on
the same populations. The studies involved a total of 516 subjects. All
studies had a case-control design, with either bruxism vs non-bruxism
groups [48,54] or TMD vs non-TMD groups [47,49-51,52,53,55]. TMD
diagnoses was based on the RDC/TMD in all studies except one, which
adopted the INfORM TMD Pain Screener [48]. The RDC/SB criteria for
the number of arousal-related events were adopted to categorize the
presence or absence of SB, with the cutoff threshold set as either two or
four episodes/hr. Three studies recorded one night [48,53,55], whilst
the others recorded PSG for two nights, even if the first was considered
only for accommodation.
As for the findings, no association between SB and TMDs was re­
ported, with some minor exceptions. One study reported an association
with myofascial pain [52], whilst two articles on the same study popu­
lation described an increased background/baseline EMG activity for
TMD patients than controls [47,50]. Another article reported a higher
prevalence of TMD pain in individuals with low frequency SB than high
frequency SB [54].
Discussion
The relationship between sleep bruxism and TMDs is still a contro­
versial topic in dentistry.
In the past two decades, two successive reviews tried to summarize
all the findings on this topic, pointing out the difficulties to reach con­
clusions [1,2]. In particular, a 2010 review by Manfredini and Lobbezoo
on the literature published between 1998 and 2008 showed an incon­
sistency of findings between studies adopting different approaches to
bruxism assessment. The same inconsistency has been observed in this
updated review, limited to sleep bruxism, which confirmed that an as­
sociation with TMDs is generally found in studies relying on
self-reported or clinically-based SB evaluation and is not confirmed in
studies using instrumental approaches to its assessment (i.e., PSG, EMG).
Some of the weak points underlined in 2010 are still present in the
literature produced during the past decade, thus not allowing a real
progress in knowledge with respect to the previous conclusions. In
particular, despite the very focused clinical research question that was
adopted to select and structurally read the articles [87], several articles
did not focus on the TMD-SB association as their primary outcome. A
total of almost forty-five thousands individuals took part to the 47
reviewed articles, which had different study designs and inclusion
criteria that renders any attempts of performing a meta-analysis of data
impossible. Most instrumental studies had a control group of individuals
not fulfilling PSG criteria for SB. With respect to such studies, the
questionnaire-based investigations have a lower level of specificity for
sleep bruxism, as a result of the frequently adopted single-item self-­
report (e.g., RDC/TMD question for sleep bruxism). This can be recog­
nized as a potential bias for the study of the bruxism-pain association,
since patient might associate their pain in the morning to their bruxism
activity at night. In addition to that, population-based surveys are hardly
useful to discriminate between individuals with clinically relevant
symptoms and subjects who are just reporting an ancillary finding.
As a general remark, all studies on self-reported evaluation of sleep
bruxism reported its association with TMD symptoms. The same
happened for studies on clinically-based evaluation of sleep bruxism,
with the exception of investigations adopting tooth wear as a SB indi­
cator. A couple of those investigations suggested a synergistic effect of
reported SB and AB. In contrast, researches on the instrumental assess­
ment (i.e., EMG, PSG) failed to show an association between SB and
TMDs, with minor exceptions. None of the PSG studies found a rela­
tionship between sleep bruxism and TMDs. Based on the assumption that
D. Manfredini and F. Lobbezoo
Table 2
PICO-like structured reading of reviewed articles divided per category of sleep bruxism assessment strategies.
Study’s first Population (patients/
author and problem)
year
Questionnaire/Self Report studies
Ekman 2020 1962 subjects born in 1966
[9] and living in Oulu (1050
women)
Nogueira 600 undergraduate
2020 [10] students (63.8% females;
60.7% under 23 years old)
Ahlberg 2019 1005 musicians from 19
[11] orchestras, (52.3% men m.
a. 47.7 ys SD 10.3, 47,7%
women m.a. 43.4 ys SD
9.8)
Reissmann, 705 patients, recruited
2017 [12] from community cases and
controls and clinic cases
Huhtela, 4403 Finnish students,
2016 [13] (1628 M m.a. 24.9 ± 3.6 ys
and 2775 F m.a. 24.2 ± 3.6
ys, randomly selected in
university)
Yeler, 2016 519 university students,
[14] (223 M m.a. 21.57 ± 2.3y,
296 F m.a. 21.02 ± 2y)
admitted for dental care,
randomly selected
Berger, 2016 508 adult patients,
[15] attending dental clinic,
(296 F and 212 M, a.r.
18–64 y, m. a. 34 ± 12y)
Emodi, 2015 140 F > 18y with 3ys of
[16] professional life
Sierwald, 1623, adult population,
2015 [17] admitted at university
clinic
Marklund, 308 dental students
2008 [18] followed up for one year
(196F, 112 M; m.a. 23 yrs.,
a.r. 18–48)
Intervention (features of
study design)
Q: 1 items for SB report + 1
item for AB report CA:
modified DC/TMD protocol
Q: anamnestic index of
Fonseca, with item on teeth
grinding/clenching Q: RDC/
TMD
Q: 9 items for assesing sleep
related problems and
Orofacial pain. One-way
ANOVA and Chi-square test,
Somers’s d test. Logistic
regression Model
Q: SR-SB + SR-AB 2 items
(RDC/TMD Axis I&II) Q+CA:
TMD diagnosis and interview
by 6 experts ANOVA,
Kruskal-Wallis and non-
parametric test (Chi-square
test) Logistic regression
Q: 186 items, of which 5
items on TMD/Facial Pain
and bruxism Chi-square test
and Logistic regression
model
Q: 1 item for SB assessment
+ 10 items for TMD
assessment Chi-square test
Q: 2 items on SB and AB + 1
item on TMD (RDC/TMD
Axis I) x^2 test
Q: 5 items cervical pain + 9
items SR-SB (AASM) CA:
cervical muscle sensitivity
evaluation, TMD evaluation
(RDC/TMD Axis Tukey test
Logistic regression
Q: 2 items on SR-AB and SR-
SB (RDC/TMD) CA: TMD
examination, (RDC/TMD
Axis I&II) Logistic regression
analyses and other
nonparametric statistical
tests
Q: TMD symptoms and
awareness of parafunctions
Standardized CA by two
expert examiners Loading
test (MVC for 30 s) to
provoke fatigue and pain
RDC/TMD diagnosis of MP
Comparison (control group)
Presence of TMD signs and
symptoms in subjects with and
without self-reported SB or AB
Presence of TMD (unclear
evaluation) in subjects with
self-reported sleep bruxism vs
subjects without self-reported
bruxism
Subgroups of musicians
according to the played
instrument with unspecified
demographic features
500 TMD (434F, 66 M, m.a.
34.6 ys, SD 13.1) vs 114 pain-
free TMD (88F, 26 M, m.a. 39.3
ys SD 13.1) and 91 without
TMD (57F, 34 M, m.a. 35.8 ys
SD 12.7) 0.4% patients exluded
due to incompelte data
21% F + 12.5% M with SB, 2%
F + 2.8% M with AB, 7.2% F +
3.2% M with both and 25.9% F
+ 11.4% M with TMD-pain,
9.6% F + 4.2% M with TMJ
pain on movement
147 bruxers, 373 non bruxers,
344 TMD paitents, 185 non-
TMD patients
Sleep bruxism group (TMD
pain 42.6% vs no TMD pain
57.4%), awake bruxism group
(TMD pain 56.1% vs No TMD
pain 43.9%), mixed bruxism
group (TMD pain 60% vs no
TMD pain 40%)
48 Dentists (m.a 39.2 ± 9.4 y;
a.r. 28–62 y) vs High-tech
workers 44 (m.a 39.9 ± 7.7 y;
a.r.: 27–56 y vs general group
48, (40.5 ± 8.6 y, a.r. 27–65 y)
733 TMD patients (mean age ±
SD: 41.4 ± 16.3 years; 82% F,
18% M) vs 890 healthy subjects
(mean age ± SD: 40.4 ± 11.8
years; 57% F, 43% M)
No “patients” control group
Three partially overlapping
cohorts: no signs and
symptoms during the one-year
interval (N = 140); reports of
jaw muscle signs or symptoms
during the interval (N = 196);
4
Journal of Dentistry 111 (2021) 103711
Outcome
Subjects who reported SB or
AB (pain in the masticatory
muscles, pain in the TMJ) had
significantly more TMD signs
than those not reporting
bruxism (p<.001)
Of the 233 students who
reported sleep bruxism, 82%
had TMD - sig. association
between report of sleep
bruxism and TMD (p<.001)
Orofacial pain experience
significantly associated with
disrupted sleep (p=.001),
frequent sleep bruxism
(p<.001), and frequent stress
(p=.002)
SB (OR 5.1 95% CI: 3.1 to 8.3)
and AB (OR 6.7 95% CI: 3.4 to
12.9) indpendently associated
with painful TMD. SB+AB
multiplicative interaction (OR
= 0.57; 95% CI: 0.24 to 1.4)
was not signicant, but results
indicated a signicant positive
additive interaction (RERI =
8.6; 95% CI: 1.0 to 19.7)
SR-SB and/or AB associated
with TMD pain (Odds Ratio
[OR] = 5.71; 95% [CI] =
4.86–6.70), TMJ pain on jaw
movement (OR = 4.49; 95%
CI = 3.54–5.69), and TMJ
locking (OR = 2.98; 95% CI =
2.17–4.10)
Bruxism was present in 42% of
students with TMD, the
relationship was signicant (p
< .05) TMD was found in
96.6% of bruxers. Probable SB
was most prevalent (61.50%)
among subjects with severe
TMD (p < .05)
No statistically significant
association between SB only
and TMD pain Occurence of
TMD lower in patient with SB
rather than AB and mixed
bruxism (AB+SB) (p<.0.05)
A positive statistical
association between MFP and
sleep bruxism (P < .005).
TMD pain did not
substantially increased in
reports of AB (OR 1.7; CI
1.0–2.7) or SB (OR 1.8; CI
1.4–2.4) but TMD pain
significantly increased in cases
of simultaneous presence of
AB+SB (OR 7.7; CI 5.4–11.1)
Grinding associated with
myofascial symptoms
(p=.001) and MP RDC/TMD
diagnosis (p=.04) at baseline
and 1 year Reported clenching
habits increased from 38% at
baseline to 48% at 1 year
Conclusions
Bruxism should be
considered as a background
factor of TMD and should be
taken into account in the
diagnostics and treatment of
TMD patients
Individuals who have
reported sleep bruxism are
more susceptible to having
TMD
Among symphony orchestra
musicians, orofacial pain
experience seems to be
related to sleep bruxism
rather than the belonging
instrument group
SB and AB are both
associated with an increased
presence of painful TMD, but
are not independent factor
and interact additively
SR-SB is associated with TMD
symptoms
Self reported sleep bruxism is
signicantly associated with
TMD
Interaction between SB and
AB may increase TMD pain,
but SB alone is not
significantly associated with
TMD
Significant associations of
MFP with both SB and AB
AB and SB are associated
with an increased presence of
painful TMD, both are
interactive in a negative
synergism that increases
TMD risk in an unclear way
Hypothesis of a positive
relationship between
awareness of bruxism and MP
not rejected TMD signs and
symptoms only in a minor
proportion of subjects with
awareness of bruxism
(continued on next page)
D. Manfredini and F. Lobbezoo
Table 2 (continued )
Study’s first Population (patients/
author and problem)
year
Osterberg, Two cohorts of 70-yrs.
2007 [19] subjects (N = 904; 481F,
425 M) representative of
the general population
Chen, 2007 9 patients with MFP (6F,
[20] 3M: med.a. 35 yrs.; a.r.
18–67)
Johansson, Two cohorts of 50 yrs. (N
2006 [21] = 12,468) and 60 yrs.-old
(N = 6232) subjects
representative of the
general population (50.6%
M, 49.4%F)
Kobs, 2005 307 population
[22] representatives subjects
(140 M, 167F; m.a. 35.4
yrs.; a.r. 20–54)
Ahlberg, 750 subjects with irregular
2005 [23] shift-work and 750 with
regular work in a
broadcasting company
(46.3%F, 53.7% M; 41.9%
aged> 45 yrs.)
Mundt, 2005 2963 subjects from a
[24] population based survey
(1493F, 1470 M; a.r.
35–74)
Glaros, 2005 96 subjects recruited at a
[25] TMD clinic or in the
general population
Gesch, 2005 4290 representative
[26] randomly selected subjects
from the general
population (original
sample: N = 7008) (2181F,
2109 M; a.r. 20–79 yrs.)
Equal distribution per each
five-year age strata
Velly, 2003
[27]
Intervention (features of
study design)
Chi-square analysis
(presence/absence of
symptoms) Logistic
regression
Q: 5 item TMD index Q: other
health problems, among
which bruxism Logistic
regression analysis
RDC/TMD 43 alerts/day
(wrist vibrator) On alerts,
subjects checked for their
teeth contact 10-day protocol
Frequency of NTC (non-
parametric test)
Q: 123 items on general and
oral health CA in a randomly
selected subgroup of 961
subjects (for purposes of Q
validation as for number of
remaining teeth and MO)
Logistic regression
Abbreviated CA for TMD
Unspecified “clenching”
assessment (self-report) 299
subjects examined for
clenching-muscle sensitivity
to palpation relationship Chi-
square test
Q: work-related aspects and
health problems Self-
assessed frequency of tooth
grinding and clenching
Perceived current orofacial
pain severity (RDC/TMD axis
II: GCPS) Logistic regression
analysis
Assessment of TMJ or jaw
muscle pain Assessment of
occlusal support Dental
interview with a question on
bruxism Chi-square and
logistic regression models
RDC/TMD Two calibrated
examiners Pagers to be filled
out at each alert by a wrist
vibrator (every 120 ± 20
min) Pagers: pain and stress
VAS, yes/no question on
teeth contacts Linear
regression to predict jaw pain
Dental interview: TMD signs
and symptoms (AAOP
questions) Q: frequency of
parafunctions (clenching and
grinding) Calibration of
interviewers and dental
examiners (occlusion)
Blinded operators Logistic
regression analysis
RDC/TMD SCL-90R Q:
bruxism (no clenching-
Comparison (control group)
RDC/TMD MP diagnosis at
baseline or at FU (N = 56)
Comparison of subjects with
different TMD severity Only
1% high scores (3–5 points) in
the 5-item TMD index
15 MAP-free controls (10F, 5
M; med.a. 30 yrs.; a.r. 19–49)
Comparison of subjects with
and without TMD
Stomatognathic dysfunction
(N = 114) vs. no dysfunction
(N = 193)
19.6% of the study sample with
perceived orofacial pain vs.
80.4% without
Cases (subjects with jaw
muscle and/or TMJ pain) vs.
controls
MP (N = 24) vs. MP+A (N =
21) vs. DD (N = 24) vs. no TMD
(N = 27) m.a: 35.4–44.9 yrs.; F:
60.7%− 87.0% of the samples
No control group Low
frequency of positive
endorsements to TMD-related
items (10.7%)
100 TMD-free selected among
outpatients at a dental clinic
5
Journal of Dentistry 111 (2021) 103711
Outcome Conclusions
Clenching associated with
myofascial symptoms and the
MP RDC/TMD diagnosis at
baseline and 1 year (p<.001)
Sex differences for bruxism TMD symptoms associated
(20%F, 15% M, p <0.01) with bruxism Uncertainty in
Correlation between TMD self-reported bruxism,
index and bruxism (p<.001) caution in interpretation of
Bruxism: 2.23 OR (95% C. results
I.:1.48–3.35) for severe TMD
(more than two symptoms)
MFP more NTC than controls MFP nearly 4 times more
(med. 34.9% vs. 8.9%, NTC during wake time and
p<.001) NTC frequency not higher stress levels than
different between genders controls NTC frequency not
(med. F13.5%, M11.1%) FTC correlated with stress levels
frequency (chewing or
swallowing) similar in MFP
and controls (med. 10.9% vs.
9.2%) MFP higher stress
scores, not correlated with
NTC frequency
TMD pain: 12.1%; MO Association between bruxism
difficulty: 11.1% Bruxism: and TMD signs and symptoms
79.9% of TMD pain; 78.3% of
MO difficulty Bruxism: highest
odds ratio for TMD pain
(OR=4.2) and MO difficulty
(OR=2.0)
Clenching: 81 yes vs. 218 no “Solid relationship” between
Bilateral muscle sensitivity: “incidence of clenching" and
53.1% of “clenchers”vs. 31.2% muscle palpation findings
of “non-clenchers” (p=.001)
No subjects with GCPS grade Association between
III or IV scores Frequent perceived orofacial pain and
bruxism: 10.6% of study self-reported bruxism
sample vs. 37.6% of subjects
with GCPS grade II scores
(p<.001) Probability of
current orofacial pain
positively associated with
frequent bruxism (p<.001).
Bruxers: more TMJ tenderness Significant associations
(F: 26.1% vs. 39.4%, p=.003; between bruxism and TMD
M: 28.7% vs. 44.0%, p=.026) signs in females and males
Female bruxers: more muscle
tenderness (25.2% vs. 35.1%,
p=.001) Logistic regression
confirmed associations:
muscle tenderness in F (OR
1.7), TMJ tenderness in F (OR
2.0) and M (OR 1.9)
MP+A highest scores of Parafunctional behaviors
intensity in teeth contacts MP related with jaw pain levels
subjects higher levels of teeth in subjects with TMD and
contact intensity vs. DD and controls
controls Correlation between
muscle tension and jaw pain
Univariate analysis: “TMD “Frequent clenching”
symptoms” associated with significantly and clinically
parafunctions (p<.01) connected with subjective
Multivariate analysis: frequent TMD symptoms
clenching 3.4 OR, wear facets
0.7 OR for TMD symptoms
Clenching-only (OR 2.50) or
clenching–grinding (OR 6.79)
(continued on next page)
D. Manfredini and F. Lobbezoo
Table 2 (continued )
Study’s first Population (patients/
author and problem)
year
83 MFP patients from more
than six months (81%F,
med.a. 35 yrs., a.r.19–59)
Velly, 2002 152 TMD patients (derived
[28] from tables; unspecified
demographic features)
Celic, 2002 230 M needing for dental
[29] treatment (m.a. 21.3 ± 2.1
yrs.; a.r. 19–28)
Huang, 2002 261 patients seeking for
[30] TMD treatment (Clinic
Cases) 1016 age- and sex-
matched subjects from a
health cooperative, of
which 121 were
Community Cases and 210
(randomly selected)
Community Controls
McFarlane 131 consecutive PDS
2001 [31] patients (111F, 20 M; med.
a. 36 yrs.; a.r. 18–65)
Ciancaglini, 483 subjects at general
2001 [32] population level (300F,
183 M; m.a. 44.9 ± 14.8
yrs.; a.r. 18–75)
Marbach, 151 female TMD patients
1988 [33] (cases) - aged 38.0 yrs (s.d.
11.7)
Locker, 1988 677 general population
[34] subjects (55.7%F), no data
about mean age or range
(from 18 yrs to over 65)
Clinically Based Diagnosis
Fernandes, 272 subjects (87.5% F m.a.
2012 [35] 36.9, 12.5% M m.a. 38.7)
Intervention (features of
study design)
grinding; clenching only;
grinding only; clenching-
grinding) Logistic regression
RDC/TMD Q: putative
factors related to TMD Single
examiner Cluster analysis
and logistic regression
CA: occlusion, TMJ and
masticatory muscles Q:
perceived severity of
symptoms and other health
problems (awareness of
parafunctions) Interobserver
reliability test on 10
randomly selected subjects
Logistic regression analysis
RDC/TMD Q: specific risk
factors for TMD (clenching)
MP, A, MP+A groups
Exclusion of subjects with
missing data or without MP
or A Logistic regression
analysis
Q (postal): demographic and
health-related questions (one
question on tooth grinding)
GHQ, IBQ A priori sample
size calculation (power
analysis with recruited
patients: 93% to detect a 2.5
OR) Logistic regression
analysis
Questionnaire-based
interviews Standardization
of interviewing dentists Q:
masticatory disturbances
(Helkimo Index) Single
question for bruxism Test-
retest reliability of
questionnaire on 40 random
subjects Multiple logistic
regression
Q: item on parafunctional
habits (unspecific)
Q: items on TMJ and jaw
muscle symptoms + 2 item
on nocturnal grinding and
habitual clenching during the
day
CA: SB combination of signs
and self report (AASM). TMD
diagnostic examination
Comparison (control group)
(64%F, significantly different
from cases)
100 subjects (data derived
from tables; unspecified
demographic features; 17
subjects with TMJ click and no
pain)
Presence vs. absence of specific
clinical signs and symptoms
195 Controls 97 MP 20 A 157
MP + A
196 sex- and age-matched
TMD-free controls
consecutively selected at a
clinic for conservative care
No control group Bruxism
taken as independent variable
(152 bruxers vs. 331 non-
bruxers)
139 age and sex matched
controls without any TMD
signs and symptoms
Presence of nocturnal grinding
and/or daytime clenching in
individuals reporting or not
reporting temporomandibular
disorders
58 no painful TMD (of which
42 w/o SB) vs 214 painful TMD
(155 assesed with SB)
6
Journal of Dentistry 111 (2021) 103711
Outcome Conclusions
positively associated with Clenching alone or combined
chronic MFP in the univariate with grinding, contributing
and in the logistic regression factors to chronic MFP
Grinding-only not associated
with MFP
Four clusters of patients Generalized TMD groups
Clenching plus grinding (“dysfunctionals”) strongly
related to recurrent pain with related to clenching-grinding
short duration and low and depression
frequency (cluster 1, 7% of
sample, OR 7.8) Clenching
plus grinding related to
intense pain with high
frequency (cluster 3, 43% of
sample, OR 4.7)
Awareness of parafunctions: Clinical TMD signs and
15% of sample Awareness of symptoms weak association
parafunctional habits (teeth with awareness of
grinding and teeth clenching) parafunctional habits and
largest influence on the odds with some occlusal
of clinical signs of TMD parameters Caution to not
(3.6–6.7 OR for TMJ pain, overestimate findings in the
4.2–7.0 for muscle pain) clinical setting
About 80% of MP (with or Clenching identified as a risk
without A) reported clenching factor for subjects with MP
along with other risk factors and MP+A
(vs. 55%A 49% controls)
Clenching associated with an
increased risk of MP (OR 4.8)
and MP+A (OR 3.3) (p<.01)
Univariate analysis: diurnal PDS patients characterized
(OR 2.6), nocturnal (OR 2.5) by frequent headaches,
and combined diurnal/ history of facial trauma, teeth
nocturnal (OR 6.0) grinding grinding, sleep problems,
associated with PDS. Logistic pain elsewhere in the body
regression: five variables and high levels of
independently associated with psychological distress
PDS (among which teeth
grinding during the day and/
or night)
Univariate analysis: Bruxism potentially harmful
association of bruxism with to the masticatory system
several signs and symptoms of Bruxism likely to have a
masticatory disturbances direct relation with TMD and
Logistic regression: TMJ play an etiologic role
sounds (OR=1.64) and
difficulty in closing the mouth
(OR=2.84) associated with
bruxism Bruxism: SE
43.5–53.5%, SP 73.3–74.5%
for the presence of
craniofacial pain and
difficulty in closing the mouth
Tooth grinding or clenching, Bruxism told by dentist
as “told by dentist”, was different than bruxism
reported by 39.3% of cases reported by patients
and 23.0% of controls
(p<.005) No difference
between cases and controls in
their report of oral habits
Significant associations were Grinding and clenching
observed between the hypothesised as risk factors
reporting of one or more for symptoms
symptoms and grinding at
night (p<.0001) and habitual
clenching during the day
(p<.0001)
Risk of myofacial pain and SB patients presented
arthralgia increased in SR-SB increased odds for myofascial
patients with TMD pain than pain and arthralgia
(continued on next page)
D. Manfredini and F. Lobbezoo Journal of Dentistry 111 (2021) 103711

Table 2 (continued )
Study’s first Population (patients/ Intervention (features of Comparison (control group) Outcome Conclusions
author and problem) study design)
year

(Orofacial Pain Clinic no pain TMD group (P < .0001

Janal, 2007 51 F with MP (m.a. 34.5 ±
[36] 11.0 yrs)
Schierz, 2007 646 population
[37] representative subjects
(341F, 305 M; a.r. 35–44
yrs)
Storm, 2007 22 F with SR TMD pain
[38] lasting from 1 year
(collected from
participants to a previous
study)
Seligman, 52 patients with unilateral
2006 [39] TMJ DD (m.a. 32.2 ± 9.6
yrs; a.r.: 17–63) 73 patients
with TMJ OST (m.a. 40.7
± 13.2 yrs; a.r. 21–72) 43
patients with MP only (m.
a. 30.5 ± 8.6 yrs; a.r.
13–54)
Manfredini, 212 TMD patients (144 F,
2003 [40] 68 M; m.a. 34.7)
John, 2002 154 consecutive TMD
[41] patients (115F, m.a. 32.8
± 14.8 yrs, a.r. 13–76; 39
M, m.a. 28.7 ± 9.8 yrs; a.r.
13–58)
Electromyography (EMG)
Ohlmann 110 individuals in need of a
2020 [42] dental crown (65F, m.a. 50,
s.d. 12.8 yrs; 45 M, m.a.
54yrs, s.d. 11.9 yrs)
Mude, 2017 29 students, 10 M and 19 F;
[43] m.a. 24.1
Protocol) and (RDC/TMD
Axis I&II) Chi-square test,
non parametric Kruskal-
Wallis
Changes in TW over two
weeks (blind examination of
dental casts) Diary booklet
each night (SCL-90 R, life
stressors, daiyly stressors,
self-report bruxism,
spontaneous and widespread
pain severity) RDC/TMD
diagnosis of MP (good inter-
examiner reliability) Control
of diet influence on TW T-test
for continuous variables and
correlation test
Outcome variable: SR TMD
pain (RDC/TMD question or
Helkimo Index) Exposure
variable: anterior TW on a
four-point ordinal scale
Three calibrated dentists
(ICC=0.89) Chi-square plus
logistic regression to control
for age and sex
Longitudinal FU of a group of
participants to a previous
study Single blind and
trained examiner RDC/TMD
Q: parafunctions awareness
Loading test (MVC for 30 s)
to provoke fatigue and pain
Chi-square, parametric and
non-parametric tests
Retrospective recruitment on
the basis of RDC/TMD
diagnoses No group overlap
of diagnoses Dental casts
(attrition severity) Attrition
rate: attrition severity/years
of age Single blind examiner
Comparison of the severity
and rates of dental attrition
Classification tree method
RDC/TMD Set of clinical
criteria for bruxism (blind
examiner with respect to
TMD) Cross-sectional study
Chi-square test
Patients grouped under the
collective term TMD TW
index on dental casts (single
blinded examiner) Good
intra- and inter-rater
reliability Logistic regression
Nocturnal EMG (Bruxoff), 5
nights. (RDC/TMD Axis I&II)
same examiner Q+CA: AASM
criteria medical, social,
grinding history, sleep
quality, SB Chi-square test
EMG 2 days (1◦ for
acclimatization) on weekend
from 9 a.m. Q: OFP and
headache (RDC/TMD) to
differentiate pain history
12 matched control F
TMD pain (N = 31) vs. non-
TMD subjects (N = 615)
46 F without TMD
132 asymptomatic controls (m.
a. 37.3 ± 15.4 yrs; a.r. 20–78)
77 age- and sex-matched TMD-
free subjects (52F, 25 M; m.a.
33.6)
120 TMD-free patients in need
for prosthodontic treatment
(76F, m.a. 30.9 ± 13.7 yrs, a.r.
16–75; 44 M, m.a. 30.0 ± 11.1
yrs, a.r. 17–64)
58 bruxers (at least one
recording night with more than
2 episodes/hr) vs 52 non-
bruxers
Pain history group (PHG) vs
non Pain history group (non-
PHG)
Risk for myofascial pain and
arthralgia increased in SB
individuals (OR=6.9 95% CI P
< .0001)
(Dis)Appearance of similar
proportion of old/new
features appeared over 2
weeks (index WT creation)
Greater WT index in controls
than MFP patients (1.34 vs.
1.23) Higher TW levels
associated with lower reports
of pain o muscle paplation
Tooth grinding related to
palpation pain reports only in
those with unilateral pain
No trend between increased
TW and risk of TMD pain (OR
1.0–1.11)
Positive loading test: 45%
cases vs. 15% controls
(p=.007). TMJ pain in 26% of
cases (p=.002) Awareness of
clenching: 6.60 OR for
inclusion among “cases”
(p=.002) Awareness of
grinding: 1.35 OR for
inclusion among “cases”
(p=.60)
Model for the asymptomatic
controls vs all the TMD
patients: SE 74%, SP 86.4%
Prediction of osteoarthrosis:
SE 89.2%, SP 67.4% DD: SE
53.8% to 71.2% Nearly perfect
models on the attrition
characteristics of MP patients
Bruxism: 58% vs. 44.1%
(p<.05) Prevalence of bruxism
in the different RDC/TMD
subgroups between 38.5%−
87.5% Strong associations
with MP alone (p<.05) or
combined with other
diagnoses (p<.01)
TW related to age in both
groups Controls more TW
(index severity > 2.5) than
TMD patients (51.7% vs.
37.6%) Odds of TMD: 24%
decrease for each additional
unit of the mean TW score
Significant differences
between bruxers and
nonbruxers for RDC/TMD
group I diagnosis (myofascial
pain) (p=.011)
No significant difference in
number of episodes per hours
in phasic, tonic, and mixed
events) between the PHG and
Failure to show more tooth
grinding in MP than control
subjects Failure to support a
model of MP maintenance by
tooth grinding (no
information on clenching or
on the role of grinding in pain
initiation)
Exclusion of a clinically
relevant increased risk for
TMD from anterior TW
Muscle and TMJ pain elicited
with loading test as a
discriminant between cases
and controls Association
between parafunctions and
TMD
Suggestion for a peculiar
attrition pattern in MP
Anterior attrition as a
differentiating factor in the
intracapsular models vs with
the asymptomatic controls
Asymptomatics: low anterior
attrition severity and some
mediotrusive wear
Bruxism more strongly
associated muscle disorders
than with DD and joint
pathologies Association
independent from other
concurrent RDC/TMD
Incisal TW not associated
with TMD Exclusion of a
clinically relevant increased
risk for TMD from incisal TW
TMD symptoms cannot be
explained only by the
number of bruxism episodes
Sustained TE activity higher
in PHG compared to non-
PHG during waking hours,
but not during sleep.
(continued on next page)

7
D. Manfredini and F. Lobbezoo
Table 2 (continued )
Study’s first Population (patients/
author and problem)
year
Schmitter, 44 F participants screened
2015 [44] by examiner, (a.r. 18–65)
Yachida, 115 individuals—39 M m.a
2012 [45] 36.8 ± 14.0 y and 76 F m.a
32.8 ± 10.2 y, >18 y
Baba, 2005 103 consecutive healthy
[46] subjects (51 F, 23.7 ± 2.6
yrs.; 52 M, 24.7 ± 2.0 yrs.)
recruited among university
students
Polysomnography (PSG)
Santiago 170 F from university clinic
2019 [47] and also recruited
volunteers
Smardz, 77 patients (56 F and 21 M
2019 [48] 18–63 y, m. a. 34.8 ± 10.8)
Muzalev, 170 F recruited among
2017 [49] patients seeking treatment
at University clinic
Raphael, 170 F recruited at
2013 [50] University Clinic
Intervention (features of
study design)
group (PHG) and non pain
history group (non-PHG)
Non parametric tests
(Mann–Whitney U test,
Kolgomorov-Smirnov)
CA: Myofacial (RDC/TMD
Axis I&II) same examiner
Tooth wear (alginate
impression) Q: medical,
social, grinding history, sleep
quality, SB Noctunal EMG
(GrindCare), 4 nights. Non-
parametric tests
(Kruskal–Wallis test and
Mann–Whitney U test)
Q+CA: three trained
examiners TMD and self
reported SB (RDC/TMD)
Portable EMG, 4 nights
during 1wk (GrandCare3)
ANOVA,Tukey test,
Spearman correlation tests
6 nights (no analysis on first
night) Q: TMD-related
symptoms and awareness of
bruxing behavior CA: jaw
function and TMD symptoms
(calibrated operators)
Nocturnal EMG Single-
channel right masseter
ambulatory device NMMA
events (20% MVC)
Multivariate statistical
analysis
CA: facial examination by
oro-facial specialists (RDC/
TMD) Group I. Patients
divided into 2 groups (M-
pain) with pain on muscle or
only one TMJ site, and
‘muscle and joint pain’ (MJ-
pain), with pain on both TMJ
sites; pain intensity scale
1–10, fibromyalgia
assesment (ACR 1990
criteria); PSG: 2 nights, the
first for acclimation, the
second for data (RDC/SB);
Logistic regression models
PSG + Q: ICD-10-CM (AASM)
and One-night video-PSG
(between 10.00 p.m.- 6.00 a.
m.) Patients divided in BEI 〈
2 and BEI 〉 2 Q: TMD Pain
Screener (Short and Long
screener) Paramentric (T-
test) and Non-parametric test
(Mann–Whitney U test)
Myofacial Pain (RDC/TMD),
2 raters PSG of 2 consecutive
nights, (1 for
adaptation),10:30 pm to
07:00 am, RMMA (RDC/SB)
Non parametric tests
(Median test, chi-square test)
and parametric test (t-test)
PSG for 2 consecutive nights
(1◦ for adaptation) 10:30 pm
and 7:00 am, RMMA (RDC/
SB) Myofacial pain (RDC/
TMD) Parametric tests
Multiple linear regression
Comparison (control group)
22 with TMD, 86.1% with SR-
SB (m.a. 45.0 ± 13.6 y) vs 22
without TMD, 31.8% with SR-
SB (m.a. 45.2 ± 9.0 y)
30 individuals without TMD-
pain nor SB vs 22 no-TMD with
SB vs 13 with TMD without SB
vs 50 with TMD-pain and SB
No control group
124 patients mTMD, of which
34 with muscle pain only (m.a.
40.3 y SD 15.5) and 90 with
muscle and joint pain MJ-pain
(m.a. 40.3 y SD 14.7) vs 46
controls (m.a. 36.1, SD 13.5).
17 Patient classified as non-
bruxers, (BEI < 2), vs 58
bruxers (BEI > 2), m.a 34.8 ±
10.8
86F with TMD (m.a. 37.8, SD
13.4) vs 37F non-TMD (m.a
34.7 SD 12.9) both with at least
2 SB episodes per night
124 with myopfacial pain vs 46
non-TMD patients, a.r. 19–78
m.a. 39.2 y SD=14.6
8
Journal of Dentistry 111 (2021) 103711
Outcome Conclusions
non-PHG. (p = .232, p = .619,
and p = .351
According to EMG data, SB occurs more often among
significant difference in SB TMD patients
activity between TMD group
(95%) vs no-TMD group
(68%), (p = .02)
No significant differences in No major differences
EMG activity between TTH between patients with
patients and those without different craniofacial pain
self-reported SB (p = .294) conditions and pain-free
individuals in jaw-muscle
EMG activity recorded with a
single-channel EMG device
during sleep
Data on 93 subjects Average Association between
muscle activity duration for masseter muscle activity and
subjects with joint sounds click sounds
higher than that of sub.
without sounds
High background EMG was The results suggest that
significantly elevated among research with mixed TMD
the M-pain group compared to groups is biased in
controls, with nearly half the understading the relationship
subgroup experiencing high with SB. Future studies
background EMG (P = .00). should stratify mTMD by
Sleep bruxism was twice as joint pain.
frequent in the M-pain
subgroup compared to
controls although this do not
reach significance (P = .08).
However, SB appears to be less
frequent in TMD with muscle
and joint pain compared to
controls
Cases and Controls groups did TMD pain is not related to the
not differ significantly in intensity of SB.
terms of the results of TMD
Pain Screener (U = 253.0, p =
.08). No significant
relationship between BEI and
TMD Pain Screener (p = .55)
Similar number of SB episodes TMD pain cannot be
among controls mean [SD] = explained by increasing
2.2 [1.9] and cases 2.1 [2.0] number of SB episodes per
(p = .77). Also duration of hour of sleep or decreasing
interepisode intervals similar time between SB events.
in cases (mean 1137.7, SD
1975.8 s) and controls (mean
1192.0, SD 1972.0 s)
Sleep background EMG was SB event-related EMG was
significantly higher in TMD negatively associated with
cases than in controls, but not pain intensity ratings on post
because of SB events. sleep waking.
(continued on next page)
D. Manfredini and F. Lobbezoo Journal of Dentistry 111 (2021) 103711

Table 2 (continued )
Study’s first Population (patients/ Intervention (features of Comparison (control group) Outcome Conclusions
author and problem) study design)
year

Raphael, 170 F recruited at
2012 [51] University Clinic
Rossetti, 30 MFP patients (24F, 6 M;
2008 [52] m.a.26.6 ± 5 yrs.; a.r.
19–39) without sleep
disorders and other TMD
symptoms
Rossetti, 14 TMD patients (8F, 6 M;
2008 [53] m.a. 27.1 ± 7.4 yrs.; a.r.
17–40) without sleep
disorders
Rompré, 100 SB (60%F; m.a. 26.5 ±
2007 [54] 0.6 yrs.) without TMD as a
primary complaint
Camparis, 40 consecutive patients
2006 [55] with SR tooth grinding
(32F, 8 M; m.a. 36.1 ± 11.3
yrs.)
PSG for 2 consecutive nights
(1◦ for adaptation) 10:30 pm
and 7:00 am, RMMA (RDC/
SB) Myofacial pain (RDC/
TMD) Non-Parametric test
(Kruskal-Wallis) and
parametric tests Multiple
linear regression
Q + CA for MFP diagnosis
Single examiner RDC/TMD
assessment TMD index PSG
for 2 consecutive nights (one
for adaptation) Calibration of
EMG amplification
Recordings of episodes of
EMG activity >20% of MVC
Additional question (one
week later) to assess daytime
clenching Parametric and
non-parametric statistical
test
VAS scores at rest RDC/TMD
muscle and joint palpation
Single-night PSG Calibration
of EMG amplification
Recordings of episodes of
EMG activity >20% of MVC
Parametric and non-
parametric statistical test
PSG for 2 consecutive nights
(one for adaptation) Sleep
variables and SB episodes
scored according to
standardized criteria (blind
examiner) Q: SR pain
intensity and other factors
Chi-square, non-parametric
tets and cluster analysis
Preliminary interview RDC/
TMD PSG to confirm SB
(Single night) Recordings of
episodes of EMG activity
>20% of MVC RDC/TMD
questionnaire items for axis I
and II Univariate and non-
parametric test
124 with myopfacial pain vs 46
non-TMD patients, a.r. 19–78
m.a. 39.2 y SD=14.6
30 healthy controls (24F, 6 M;
m.a. 26.0 ± 4.5 yrs.; a.r 20–42)
12 non-TMD subjects (6F, 6 M;
m.a. 27.4 ± 5.2 yrs.; a.r.
22–40)
43 non-bruxers controls (68%
M; m.a. 24.5 ± 0.9 yrs.) Some
subjects excluded after the
second PSG night (no SB
confirmation/absence)
Comparison performed on 54
SB vs. 34 non-SB subjects
20 bruxers with TMD (Group
A) vs. 20 bruxers without TMD
(Group B)
Pain duration is similar for The belief that SB is a
patients with TMD, with and sufficient explanation for
without PSG evidence of SB myofascial TMD should be
abandoned
No association between SB RMMA during sleep
and report of worst pain in the associated with MFP and risk
morning (p=.76) SB: 63.3% of factor (although small) for
MFP patients vs. 33.3% of the MFP Daytime clenching
controls (p=.04) No potential risk factor for MFP
differences between MFP and
controls as for sleep variables
Association between SR
daytime clenching and MFP;
no association with report of
worst pain in the morning or
VAS levels in the evening
No association between SB neither associated with
bruxism and TMD (p=.976), general TMD nor pain on
neither between bruxism and palpation Pain only in some
pain on palpation (p = 1.000) SB individuals
No differences between
groups for sleep variables No
difference between RMMA in
bruxers with and without pain
on palpation (p>.05)
Excluded “bruxers” more SB-RDC: high level of
complain of clenching, painful discrimination between SB
jaw upon awakening and and controls Pain frequently
muscle fatigue than included reported among SB with low
SB (OR 3.9–4.9) Pain of frequencies of jaw muscle
excluded “bruxers” higher contractions
than that of included SB
(p=.06)
Group A: myofascial pain Inconclusive evidence for the
(100.0%), disk displacement association between facial
(10.0%) and arthralgia pain and SB
(85.0%) Difference between
groups A and B for non-
specific physical symptoms
(p=.001) and mandibular
impairment (p=.001); no
differences for depression SB
episodes/h: 20% more for
subjects without pain (8.0 vs.
6.2)

Footnotes: yrs, years; SD, standard deviation; Q, question; ANOVA, analysis of variance; SR, self report; SB, sleep bruxism; AB, awake bruxism; RDC/TMD, Research
Diagnostic Criteria for Temporomandibular Disorders; CA; clinical assessment; TMD, temporomandibular disorders; F, females; M, males; OR, odds ratio; CI, confi­
dence intervals; EMG, electromyography; PSG, polysomnography; AASM, American Academy of Sleep Medicine; ACR, American College of Rheumatology; TTH,
tension-type headache.

PSG is required to provide a definite assessment of sleep bruxism [3],
these findings have generally been interpreted as a proof of the absence
of any clear relationship with temporomandibular disorders as well as
an indirect proof of the fallacy of self-reported approaches. Nonetheless,
over the recent years, some criticism to the PSG/SB criteria emerged, as
also pointed out by recent confirmation that, based on the pain adap­
tation model, experimental pain causes a reduction in SB activity [88].
The 2018 update of the consensus panel works and a successive paper on
the misuse of SB cutoffs discussed the pitfalls of a dichotomous approach
to SB diagnosis based on currently adopted PSG criteria [4,6]. In
particular, it is now clear that, whilst PSG remains an essential tool, viz.,
the standard of reference, for assessing sleep correlates of masseter
muscle activities, a broader construct of bruxism as a complex group of
different muscle behaviors should be adopted. Within this framework,
all studies relying on PSG/SB criteria were actually reporting on the
association between pain and the amount of masseter muscle activity
associated with sleep arousals, viz., the activity that was taken as the
reference to count an SB event. Thus, they were not assessing the full
spectrum of bruxism activities unrelated with sleep arousals and/or
under the EMG threshold for being considered an SB event.
These considerations have important clinical implications for the
interpretation of the literature findings and for the design of future
studies. Indeed, a possible clinical hypothesis is that prolonged, tonic
muscle contractions or, more in general, the total amount of muscle
activity during sleep are the actual key factors to explain potential
consequences of bruxism from a musculoskeletal viewpoint. Strategies
to measure the muscle work [89] or to assess the Bruxism Time Index
[90] are just two examples of possible approaches to refine in the near

9
D. Manfredini and F. Lobbezoo
future. The importance of such findings has been confirmed by the
report of an increased background sleep-time masseter muscle activity
in patients with myofascial pain with respect to healthy controls [50].
Thus, paradoxically, until new algorithms and suggestions for the
interpretation of the EMG signal emerge [91], it seems not savvy to
discard all findings that are drawn from patients’ self-report as if they
are biased. Based on the current interpretation of the bruxism construct,
instrumental and non-instrumental approaches are just two different,
broad categories of strategies that can be adopted to collect data,
without any real hierarchical or stackable structure. The fact that tooth
wear (i.e., a potential sign of tooth grinding) is not clearly associated
with either psychological features or TMD symptoms [92-94], whilst
report of muscle clenching and teeth contact habits are [95,96], should
help to definitively understand the current limits of PSG to correlate
with clinical findings.
The ongoing project for a multidimensional system for the evaluation
of bruxism (i.e., the Standardized Tool for the Assessment of Bruxism
[STAB]) is indeed going into the direction of collecting as many data as
possible before building up any other hierarchical model for bruxism
assessment that could confirm or replace the status of instrumental ap­
proaches as the standard of reference [5]. To this aim, identifying the
best available approach to assess the bruxism status based on the 2018
definition is essential before getting into further speculations about the
possible relationships with any risk, etiological, and associated factors as
well as clinical consequences. The key message from current evidence
and preliminary STAB works is that bruxism as a muscle activity is not
suitable to be evaluated in terms of the simple dichotomy “present
versus absent”. Similarly, the suggestion of grading hierarchically
bruxism diagnosis as possible, probable, or definite based on the
self-reported, clinical, or instrumental evaluation, respectively, needs to
be re-appraised within the broader construct of bruxism as an umbrella
term for a spectrum of different muscle activities.
Studies on the self-reported ecological momentary assessment of
awake bruxism seem to support the possibility of collecting reliable
data, as usually accepted for psychological science metrics [97,98], and
offer promising perspectives for bridging the gap between psychological
factors and TMDs via bruxism mediation [99]. Of course, this could not
be easily transferred to the evaluation of sleep phenomena, but pro­
posals for revising sleep apnea metrics in favor of a more patient-report
oriented evaluation are examples of how this suggestion should be taken
into consideration for the sleep bruxism field as well [100,101]. In
addition to that, it must be borne in mind that SB consequences may
include also non-painful muscle symptoms, which are rarely considered
as an outcome variable in research studies, despite being a frequent
complaint in the clinical setting [64,102].
As a conclusive remark for this scoping review, it can be suggested
that, despite the seemingly identical conclusions of this review with
respect to the previous reviews by Lobbezoo and Lavigne [2] and by
Manfredini and Lobbezoo [1], something has changed. Indeed, thanks to
the evolution of bruxism construct over the past decade, the way to
interpret the findings derived from different assessment approaches is
no longer unbalanced in favor of PSG recordings. This could further
open up a new era in the bruxism literature, with strong influence on the
future research agenda for any investigations on the possible clinical
consequences of bruxism. The target of future instrumental research
should be sleep bruxism phenotyping for both quantitative (e.g.,
bruxism time index, bruxism work index) and qualitative evaluation (e.
g., arousal-related events, isolated short-lasting events, elevated back­
ground activity, tonic prolonged activity). Until then, investigators
adopting current PSG/SB criteria to study the bruxism-TMD relationship
should be aware that they are dealing with only a part (i.e.,
arousal-related SB events) of the complex SB puzzle.
Conclusions
Almost twenty-five years after the review by Lobbezoo and Lavigne
10
Journal of Dentistry 111 (2021) 103711
[2] and more than ten years after the review by Manfredini and Lob­
bezoo [1], the relationship between sleep bruxism and TMDs remains a
debated topic. As an update, the literature published during the
2009–2021 span was here reviewed, leading to confirm previous con­
clusions that association findings are strongly dependent on the assess­
ment strategy for sleep bruxism. Indeed, in general, questionnaire
studies reported an association between TMDs and sleep bruxism, whilst
instrumental studies did not. As part of this scoping review, some sug­
gestions to interpret this ongoing inconsistency have been suggested,
based on the current bruxism construct that requires a non-hierarchical,
comprehensive evaluation as proposed in the Standardized Tool for the
Assessment of Bruxism (STAB).
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
The authors are very grateful to Ovidio Saracutu, undergraduate
student at the School of Dentistry, University of Siena, for his invaluable
help with literature search and data extraction.
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