Accepted: 23 November 2020

DOI: 10.1111/joor.13130

ORIGINAL ARTICLE

Frequency of awake bruxism behaviour in orthodontic

patients: Randomised clinical trial: Awake bruxism behaviour in
orthodontic patients

Nayara C. Pereira1 | Paula V. P. Oltramari1 | Paulo C. R. Conti2 | Leonardo

3 1
R. Bonjardim | Renata R. de Almeida-Pedrin | Thaís M. F. Fernandes1 | Marcio
1 1
R. de Almeida | Ana C. C. F. Conti

1
Department of Orthodontics, University
of North Paraná (UNOPAR), Londrina-PR, Abstract
Brazil Introduction: The influence of aligners on the activity of the masticatory muscles is
2
Department of Prosthodontics, Bauru
still controversial, especially regarding the behaviour associated with awake bruxism
School of Dentistry, University of São Paulo,
Bauru Orofacial Pain Group, Bauru, Brazil (AB).
Objective: To compare the frequency of AB behaviours between patients treated
3
Section of Head and Face Physiology,
Department of Biological Sciences, Bauru
School of Dentistry, University of São Paulo,
with aligners and fixed appliances.
Bauru Orofacial Pain Group, Bauru, Brazil Methods: The sample comprised 38 Class I patients (mean age 22.08 years), divided

Correspondence:
Ana Cláudia de Castro Ferreira Conti,
Department of Orthodontics, University
of North Paraná (UNOPAR), Londrina-PR,
Brazil.
Email: accfconti@uol.com.br
by simple randomisation into two groups: OA group; orthodontic aligners (n 19) and
FA group; fixed appliance (n 19). The frequency of AB was investigated by the eco-
logical momentary assessment using an online device (mentimeter), during 7 follow-
ing days at different timepoints, before and after appliance placement and in the 2nd,
3rd, 4th and 6th months of orthodontic treatment. These variables were also evalu-
ated: level of anxiety by the State-Trait Anxiety Inventory, stress by the Perceived
Stress Scale, catastrophising related to pain and degree of hypervigilance by the Pain
Vigilance and Awareness Questionnaire, and the presence of facial pain evaluated by
the DC/TMD.
Results: There was no difference between groups in the frequency of AB behaviours,
with mean of 53.5% for group OA and 51.3% for FA. The most frequent behaviour
was slightly touching the teeth, and in FA group, there was a significant reduction in
this behaviour soon after appliance placement. The groups did not differ concerning
the degree of anxiety, stress, catastrophising, hypervigilance and facial pain.
Conclusion: The orthodontic treatment performed with aligners or fixed appliances
did not influence the frequency of AB during the 6 months of treatment.
Registry of Clinical Trials: (REBEC): RBR-9zytwf.

KEYWORDS

Aligners, Awake bruxism, Fixed appliance, Orthodontics

422 | © 2020 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/joor J Oral Rehabil. 2021;48:422–429.
CALDAS PEREIRA et al
1 | BAC KG RO U N D
Bruxism is defined as the activity of masticatory muscles occurring
during sleep (characterised as rhythmic or non-rhythmic) or awake
(characterised by repetitive or sustained contact of teeth), which
1
should be considered separately. Awake bruxism (AB) may be asso-
ciated with several psychosocial factors, such as anxiety, 2,3 stress3,4
and hypervigilance,5 and its most important effects are tooth wear,
orofacial pain symptoms, periodontal disease, tooth fracture and/or
2
breakage of dentures.
Most studies have focused on the study of sleep bruxism (SB),6,7
while knowledge about awake bruxism is still fragmented.6 The
prevalence of AB in adults varies from 22% to 30% and SB from 1%
7
to 15%. This high prevalence of AB affects more than one-third of
the population, especially young adult individuals, which is consid-
ered an age group frequently present in orthodontic practices.8
It should be noted that, in recent years, the use of orthodontic
aligners (OA) has increased significantly mainly to meet the demand
of young adult patients with great aesthetic needs. The clinical ef-
ficiency of these appliances associated with comfort in relation to
traditional fixed appliances (FA) has been identified as contributing
9,10
factors for their large-scale use.
Studies have investigated the clinical efficacy of aligners and
11 12
their effects on root resorption, periodontal health, perception
of pain and discomfort.10 It has been reported that orthodontic
aligners could be an alternative option for orthodontic treatment in
patients with temporomandibular disorder (TMD)13 and sleep brux-
ism.9 Its possible effects on bruxism are still unknown, and evidence
on the possible effects of aligners on the activity of masticatory
14
muscles is still limited and controversial. There is still lack of sci-
entific evidence demonstrating the effects of aligners on intraoral
perception and AB behaviour.
Thus, this clinical study had as primary objective to compare the
frequency of bruxism behaviour while awake, during the initial stages
of orthodontic treatment, comparing two types of orthodontic ap-
pliances (fixed and aligners). The levels of anxiety, stress, degree of
hypervigilance and catastrophising related to pain and presence of
facial pain symptoms were also compared.
2 | M E TH O DS
2.1 | Participants
Overall, from 2,662 individuals, 40 patients were selected in this
randomised parallel clinical trial study meeting the criteria: (1) age
between 13 and 35 years; (2) both genders; (3) Angle Class I mal-
occlusion; (4) moderate lower anterior crowding (3 to 6 mm); and
(5) treatment without extraction. The exclusion criteria were as fol-
lows: (1) missing permanent teeth, except for the third molars; (2)
anterior or posterior open bite; (3) anterior or posterior crossbite; (4)
history of orthodontic treatment; and (5) signs or symptoms of TMD
or other painful chronic disorder based on the recommendations of
| 423
the ‘Diagnostic Criteria for TMD (DC/TMD)’.15 Written consent was
obtained from all patients before the study. This study was approved
by the Institutional Review Board of University of North Paraná
(UNOPAR) under CAAE n. 12 088 219.0.0000.0108 and received
the number (RBR-9zytwf) in the Brazilian Registry of Clinical Trials
(REBEC).
2.2 | Interventions
For all patients included in the sample, initial orthodontic records
were obtained including intra- and extraoral photographs; den-
tal casts; periapical radiographs of upper and lower incisors; cone
beam computed tomography (CBCT); and digital intraoral scanning
(3D model) using an intraoral scanner (iTero® Intraoral Element
Scanner).
The participants were randomly divided into 2 groups by sim-
ple randomisation for the factors gender, age, amount of crowding
(Little's irregularity index) and severity of malocclusion (PAR index):
− Group OA (n = 20) treated with Invisalign orthodontic aligners
from Align Technology (Santa Clara, California, USA). The 3D
planning was performed using the software ClinCheckTM Pro
version 5,6 following the patients’ needs and manufacturer's
guidelines, and the aligners were changed at every 10 days.
− Group (FA) was also composed of 20 patients treated with fixed
appliances (slot 0.022 x 0.030”, 3M Unitek, Monrovia, Calif). The
appliances were placed up to the second molars following the
same sequence of Nitinol wires (0.014”, 0.016”, 0.016x.022”),
respecting the individual needs of each patient. Orthodontic
appointments were performed once a month by 2 orthodontic
master program students at the post-graduate clinics under super-
vision of an orthodontist with more than 15 years of experience.
2.3 | Outcome measurement
To allow real-time evaluation of the frequency of awake bruxism
behaviour, the ecological momentary assessment (EMA) was used
collecting self-reports of episodes of this parafunction, in their
natural environment.16 Each participant was instructed to recognise
various AB-related behaviours by links sent by WhatsApp using a
web-based survey program called Mentimeter®. Aiming to allow the
study participants to get used to this assessment, test links were
sent for training how to use the research instrument one day before
the study beginning.
The link directed the patient to the question about the contact
condition between teeth suggesting some behaviour related to
bruxism during wakefulness, based on previous studies: ‘Which op-
tion below best describes the contact of your teeth?’. The possible
responses were as follows: a) I am not touching my teeth; b) I am
not touching my teeth, but I feel my muscles are contracted; c) I am
slightly touching my teeth; d) I am clenching my teeth; or e) I am
424 | CALDAS PEREIRA et al
grinding my teeth. Each link was available for response for 5 min-
utes from the moment of the alert sound. After this period, the sys-
tem was blocked to record responses. A total of 10 links were sent
per day, for 7 consecutive days in the following periods: baseline,
soon after appliance placement, in the first, second, third and sixth
17,18
months after appliance placement.
The questions were sent by the researcher at random times to
avoid the risk that individuals modify their behaviour based on the
expectation of alert. The recording time was set between 8:00 and
20:00. A minimum of 70% of responses was considered necessary
to validate them; in case of failure to reach this percentage, an addi-
tional recording day was defined to complete this protocol.
The variables that might impact the AB behaviour were also as-
sessed at baseline as anxiety by the State-Trait Anxiety Inventory
(STAI-T),19 stress by the Perceived Stress Scale (PSS 14), 20 and cata-
strophising by the pain catastrophizing scale (PCS)21 and the degree
of hypervigilance by the Pain Vigilance and Awareness Questionnaire
22
(PVAQ). The presence of facial pain was also investigated using the
DC/TMD symptoms questionnaire.15 Additionally, stress and the
presence of pain were also investigated in the first, second, third and
sixth months after appliance placement.
2.3.1 | Sample Size
An analysis of the power of the test showed that based on the aver-
age standard deviation of the AB frequency variation (32.1), a sample
of at least 19 patients would have an 80% probability of detecting a
real difference of 30 percentage points between the groups, with a
significance level of 5%.
2.3.2 | Randomisation
Simple randomisation was performed by an external investiga-
tor, using a software (Excel 2007, Microsoft Windows, Microsoft,
Chicago, IL, USA), at a ratio of 1:1. This investigator inserted the ran-
domisation codes in numbered, sealed and opaque envelopes, con-
secutively, assuring blinded allocation into 2 groups.
2.3.3 | Blinding
The blinding of patient and operator was not possible in this study.
However, the results were analysed in a blind manner, assigning a
code number to the patients and group with aligners as OA Group,
and fixed appliances as FA Group.
2.4 | Statistical analysis
Statistical analysis was performed by an investigator not related to
the study. All quantitative measurements were analysed using the
Kolmogorov-Smirnov normality test. Comparison between the OA
and FA groups in the quantitative variables was performed by the
t test for independent groups, and the proportion of occurrence of
pain was analysed by the Fisher exact test. Regarding the frequency
of AB, comparison between the six periods, within each group, was
performed by the Friedman test, and comparison between the two
groups in each period was performed by the Mann-Whitney test.
All tests were performed at a significance level of 5% (P < .05). All
statistical procedures were performed on the software SPSS version
26.
3 | R E S U LT S
3.1 | Participants flow and baseline data
Figure 1 shows the flowchart of patients evaluated for study eli-
gibility, randomisation, allocation, treatment and follow-up on the
first 6 months of orthodontic treatment. Participants who met the
established criteria were recruited from August 2018 to February
2019. Forty individuals were recruited, divided into 2 groups of 20
patients. One participant from each group was excluded from the
sample due to non-compliance in answering the questions (group
FA) and due to a trip abroad at baseline (group OA). Thus, data from
a total of 38 patients were analysed. According to Table 1, the two
groups matched for gender (P = 1.000), age (P = .0681), PAR index
(P = .8751) and Little's irregularity index (P = .5705). At baseline, the
groups did not differ regarding anxiety, catastrophising, hypervigi-
lance, stress and facial pain.
3.2 | Outcome data
Evaluation of frequency of awake bruxism.
The mean percentage of valid responses in the study was 71.52%,
being 72.88% for group OA and 70.16% for group FA.
Regarding the mean frequency of AB, considering all types of
behaviour, group OA maintained a more constant frequency, with
55.9% at T0, 56% T1, 50.2% at T2, 52.2% at T3, 52.4% at T4 and
in 54.1% at T5. Conversely, group FA had a mean frequency at T0
(baseline) of 61.4%, and then, this frequency showed a decrease,
namely 44.4% at T1, 47.7% at T2, 46.1% at T3 and 46.3% at T4, rising
again at T5 to 61.8% (Table 2 and Figure 2).
Concerning the different habits that comprised the diagnosis of
AB, the most prevalent in groups OA and FA was to slightly touch the
teeth (40.1% and 38.4%), clenching the teeth (9.5% and 7.6%), with-
out dental contact but with contracted muscles with 3.2% and 4.9%,
and grinding the teeth with 0.7% and 0.4%, respectively (Table 2).
With regard to the variation in the frequency of AB in each eval-
uation period compared to the baseline (T0), there was no statisti-
cally significant difference between the groups (P < .05) (Table 3).
Regarding the most frequent behaviour (slightly touching the
teeth), an increase was observed right after appliance placement
CALDAS PEREIRA et al
F I G U R E 1 Flowchart of patients
[Colour figure can be viewed at
wileyonlinelibrary.com]
(T1) from 36.6% to 42.7% in group OA, gradually decreasing in the
following periods. In group FA, a statistically significant decreasing
shortly after placement (T1) from 45.1% to 25.6% was observed, ris-
ing in the following periods (Table 4).
3.2.1 | Harms
There were no harms during the follow-up of the two groups be-
tween time points.
4 | D I S CU S S I O N
The AB has higher prevalence in the adult population than SB6,7;
however, much of the scientific evidence obtained so far is related
to SB. Among the strategies to control the activity of masticatory
| 425
muscles during sleep, the use of interocclusal devices has been indi-
cated, even though this remains controversial in the literature. 23 In
this context, appliances made of different material than rigid or re-
silient occlusal plates, such as orthodontic aligners, called the atten-
tion of researchers.14,24 Although the use of these appliances does
not seem to influence the SB,14 no study has investigated the effect
of these aligners in relation to AB. Thus, this study compared the fre-
quency of AB behaviour among patients starting orthodontic treat-
ment with aligners and conventional fixed appliances. Our results
showed that the type of orthodontic appliance does not seem to
influence the activity levels of awake bruxism, considering all differ-
ent types of parafunctional behaviour. However, the ‘light contact’
behaviours presented significant different frequencies between
groups after appliance placement.
The groups were matched at baseline for age, gender, amount
of crowding and severity of malocclusion. Also, at baseline, the
intergroup results concerning the degree of anxiety, stress,
426 | CALDAS PEREIRA et al

TA B L E 1 Comparison between the two groups regarding age, Little's irregularity index, Par index, degree of anxiety, stress,
hypervigilance, catastrophising and facial pain, before appliance placement

Variables OA (n = 20) FA (n = 20) P

Age (years) mean/sda 23.60 5.65 20.56 4.51 0.0681ns

b
Gender
Male n(%) 11 60.0 12 (65.0) 1.0000 ns
Female n (%) 8 40.0 7 35.0
a
Little's irregularity index mean/sd 4.69 1.35 4.99 1.88 0.5705 ns
a
PAR index mean/sd 7.70 4.66 7.50 3.18 0.8751 ns

Variables OA (n = 19) FA (n = 19) P

a
Anxiety mean/sd 36.3 6.1 37.4 6.9 .622ns
Catastrophising mean/sda 1.4 1.1 1.9 0.9 .077ns
a
Hypervigilance mean/sd 50.8 13.5 49.9 11.2 .825ns
Stress mean/sda 19.4 6.9 21.8 7.4 .302ns
c
Facial pain n(%) 6 31.6 6 31.6 1.000 ns

ns, non-significant
a
(Independent t test)
b
(Chi-square test with Yates’ correction)
c
(Fisher exact test)

TA B L E 2 Description of the proportion of each response related to EMA during the evaluation periods for both groups, mean (m) and
standard deviation (sd)

T0 T1 T2 T3 T4 T5 Total

Response m sd m sd m sd m sd m sd m sd m sd

OA a 44.1 30.9 44.0 28.3 49.8 33.5 47.8 34.8 47.6 35.2 45.9 39.0 46.5 30.4
b 5.9 15.6 2.7 8.1 2.7 10.4 2.8 11.8 2.8 11.2 2.6 11.2 3.2 11.2
c 36.6 26.1 42.7 27.5 41.6 31.5 40.6 29.4 39.8 29.7 39.5 33.6 40.1 26.8
d 12.4 19.1 10.4 14.9 6.0 9.3 8.4 12.7 9.7 16.9 9.8 17.4 9.5 12.6
e 1.0 4.3 0.2 1.0 0.0 0.0 0.4 0.9 0.2 0.7 2.2 9.6 0.7 1.8
b + c+ 55.9 30.9 56.0 28.3 50.2 33.5 52.2 34.8 52.4 35.2 54.1 39.0 53.5 30.4
d+e
FA a 38.6 31.2 55.6 35.4 52.3 34.7 53.9 33.2 53.7 37.4 38.2 36.7 48.7 30.3
b 6.0 11.6 10.3 17.4 4.4 11.4 4.2 10.9 2.1 5.5 2.3 6.5 4.9 10.0
c 45.1 28.0 25.6 26.7 37.4 33.2 35.1 30.8 33.4 33.0 54.2 34.6 38.4 25.7
d 10.0 9.8 8.0 13.8 6.0 7.4 6.8 14.2 10.4 23.5 4.3 7.3 7.6 9.5
e 0.3 0.9 0.5 1.7 0.0 0.0 0.1 0.4 0.4 0.9 0.9 3.1 0.4 1.0
b + c+ 61.4 31.2 44.4 35.4 47.7 34.7 46.1 33.2 46.3 37.4 61.8 36.7 51.3 30.3
d+e

Note: a- I am not touching my teeth, b- I am not touching my teeth, but I feel my muscles are contracted, c- I am slightly touching my teeth, d- I am
clenching my teeth and e- I am grinding my teeth

hypervigilance, pain catastrophising and facial pain showed simi-
larity between groups. This ‘baseline’ facial pain was mostly mild in
both groups and did not meet the DC criteria for TMD. The similarity
between groups was preserved throughout the period of evalua-
tion and therefore did not interfere with the study's outcomes. The
control of these variables is fundamental, since several authors have
already related AB to anxiety, 2,3 stress3,4 and hypervigilance.5 The
combination of these factors seems to be additive, non-adaptive and
may lead to an increase in the individual's likelihood to develop oral
parafunctions and facial pain. 25
Most reports in the literature about the frequency of AB
were obtained by cross-sectional and retrospective self-re-
ports 8; however, due to the risk of memory bias of patients and
lack of information on their frequency, other diagnostic means
were developed.17,26 In order to minimise the risk of bias, we as-
sess AB frequency applying the EMA as reported in most recent
CALDAS PEREIRA et al | 427

F I G U R E 2 Evolution of responses b + c+d + e (b - I am not
touching my teeth, but I feel my muscles are contracted, c - I am
slightly touching my teeth, d - I am clenching my teeth and e - I am
grinding my teeth), that characterised the behaviour of AB in the
two groups during the evaluation period
The mean total response rate to the 10 alerts sent was 71.52%,
being similar between the two groups: 72.88% for group OA and
70.16% for group FA. These values were lower than the mean re-
sponse rate of 82.1 ± 9.2% from 15 alerts per day found in another
study,17 yet they are in agreement with the mean compliance rate
per day of 60% of alerts, with a minimum of 12 daily alerts.6
The evaluation of AB behaviours in this follow-up period of
6 months resulted in a mean total frequency of 53.5% and 51.3%
for groups OA and FA, respectively. It can be noticed that the fre-
quency was similar between groups, regardless of the type of or-
thodontic appliance used (Table 2). Other studies also reported the
mean frequency of AB in a sample of healthy young adults (non-or-
thodontic patients), dental students, and observed frequencies of
28.3%17 and 48%,18 both related to data collected for seven con-
secutive days using EMA strategy, applying the BruxAppR (BruxApp
Team, Pontedera, Italy). In the latter, that value of 48% at baseline

TA B L E 3 Comparison between groups of the variation of frequency of AB (responses b + c+d + e) between each evaluation period and
T0

OA Group FA Group
Responses
b + c+d + e mean SD CI 95% mean SD CI 95% P

T1-T0 0.1 26.3 −12.6 to 12.8 −17.0 31.0 −32.0 to −2.1 .075 ns
T2-T0 −5.7 26.6 −18.5 to 7.1 −13.7 36.4 −31.2 to 3.9 .445 ns
T3-T0 −3.7 33.6 −19.9 to 12.5 −15.3 33.1 −31.2 to 0.7 .291 ns
T4-T0 −3.5 34.7 −20.2 to 13.2 −15.1 35.4 −32.1 to 2.0 .313 ns
T5-T0 −1.8 36.9 −19.6 to 15.9 0.4 26.7 −12.5 to 13.3 .832ns

Note: ns – non-statistically significant difference (independent t test). (b)- I am not touching my teeth, but I feel my muscles are contracted, (c)- I am
slightly touching my teeth, (d)- I am clenching my teeth and (e)- I am grinding my teeth.

TA B L E 4 Intra- and intergroup comparison concerning the response ‘C’ between the 6 evaluation periods

OA Group FA Group
P
Period mean SD median mean SD median between groups

T0 36.6 26.1 37.9 45.1 28.0 44.4c 0.354

a
T1 42.7 27.5 35.8 25.6 26.7 18.4 0.025*
ab
T2 41.6 31.5 32.8 37.4 33.2 21.9 0.583
bc
T3 40.6 29.4 42.9 35.1 30.8 29.2 0.452
T4 39.8 29.7 31.0 33.4 33.0 27.2ab 0.563
c
T5 39.5 33.6 44.4 54.2 34.6 58.8 0.181
p between periods 0.912 0.001**

Note: Periods with similar letters are not statistically different from each other
Response C - I am slightly touching my teeth
*Statistically significant difference between groups (Mann-Whitney test)
**Statistically significant difference between periods (Friedman test)

studies. 6,17,18,26 Sending questions in links by WhatsApp allowed
checking the frequency of AB in real time for the two groups
during the first six months of the orthodontic treatment. The
association of the web-based survey program (mentimeter) with
popular social media is an interesting and easy way for the imple-
mentation of EMA in researches.
decreased to 26% after one month.18 A similar AB frequency was
found in another study, 49% of the sample (114 patients) beginning
orthodontic treatment self-reported awake bruxism behaviour. 27
When the frequency of AB behaviour was analysed between
groups, there was no significant variation in this frequency com-
paring each period to the baseline data (Table 3). Therefore, the
428 | CALDAS PEREIRA et al

frequency of AB did not differ, regardless of the type of appliance not seem to change the initial frequency of light touch behaviour
used. The paucity of the available literature regarding the influ- reported by EMA.
ence of the type of orthodontic treatment on the frequency of AB Considering that the groups did not differ in the initial levels of
make it impossible to have comparison parameters. Concerning anxiety, stress, hypervigilance, catastrophising and reports of fa-
the effects of aligners with episodes of SB, a tendency to increase cial pain, we can infer that possibly the awake bruxism behaviour
in SB after the first and third months of treatment has been re- in these patients could be influenced only by the presence of or-
ported,14 in contrast to another study which revealed that, after thodontic appliances. Thus, this pioneer study contributed to under-
the first month of treatment, the patients showed a significant re- stand a little more about the impact of orthodontic therapy over the
duction in the number of SB episodes, and after three months, the initial phase of treatment.
9
values returned to baseline levels. To date, there is no pre-es-
tablished standard or cut-off value to define who has or does not
have AB. In addition, many types of oral habits are part of this 4.1 | Limitations
behaviour, which complicates the analysis and interpretation of
data. As a limitation of our study, it should be highlighted that the sample
When considered a specific type of behaviour, the habit of was composed of young individuals, other age ranges might be in-
slightly touching the teeth and clenching the teeth were the con- vestigated as well.
ditions most frequently reported, with a total mean frequency of
40.1% and 9.5% in group OA, and 38.4% and 7.6% in group FA.
Lower prevalence values (14.5% for touching the teeth and 3.7% 4.2 | Generalisability
for clenching the teeth) were reported in samples of individuals
not undergoing orthodontic treatment.17 In another study, 20% of Generalisation of the outcomes should be performed with caution as
participants answered that the teeth were in contact, 14% with the patients were healthy and young.
mandibular clenching, 3% reported clenching the teeth, 1% grind-
ing the teeth, and a month later these values were 11%, 13%, 2%
and 1%, respectively.18 5 | CO N C LU S I O N
Although the methodology used to characterise the frequency of
AB in this study considered the frequency of four behaviours, higher The type of orthodontic appliance (orthodontic aligners or conven-
values were found for the ‘slightly touching the teeth’ from the base- tional fixed appliances) did not influence the frequency of awake
line, regardless of the type of appliance. Possibly, such differences bruxism behaviour during the initial stages of orthodontic treat-
can be explained by the use of an online evaluation technique and by ment, although the behaviour of slightly touching the teeth seems
directly sending the questions: ‘What option below best describes to be reduced right after placement of FA. Yet, the most common
the contact of your teeth?’ Other studies employing different meth- behaviours were slightly touching the teeth and clenching the
ods without suggesting this possible teeth contact may not stimu- teeth.
17,18
late their attention to this behaviour. However, regardless of the
recording method, it should be noted that the same behaviour has AC K N OW L E D G M E N T S
been reported as more prevalent in individuals with complaints of This study was funded by CAPES
chronic pain related to TMD. 28
It is interesting to note that, although no differences were found C O N FL I C T O F I N T E R E S T
in the inter group analysis for this behaviour, the intra group evalu- All authors declare no conflict of interests.
ation has shown a significant decrease in its frequency right after
appliance placement (T0-T1), from 45.1% to 25.6% in FA group PEER REVIEW
(Table 4). Conversely, the OA group showed a constant habit fre- The peer review history for this article is available at https://publo​
quency during the entire study. ns.com/publo​n/10.1111/joor.13130.
This aspect deserves some comments. The stimulus caused by
FA tends to be more impacting on the system, in general, based on DATA AVA I L A B I L I T Y S TAT E M E N T
the presence of brackets, wires, and all the discomfort caused by The data that support the findings of this study are available from
the apparatus. At first, this sudden intraoral new condition might the corresponding author upon reasonable request.
alter the individuals’ sensory perception, leading to a natural and un-
conscious protection against it, leading to decreasing the behaviour. ORCID
This condition, however, is lost after the patient becomes used to Nayara C. Pereira https://orcid.org/0000-0002-5659-8107
the new intraoral condition, returning to the baseline parameters, Paula V. P. Oltramari https://orcid.org/0000-0002-2285-5179
before the appliance placement. For OA group, this effect does not Paulo C. R. Conti https://orcid.org/0000-0003-0413-4658
seem to exist, that is the interocclusal insertion of a thin plate does Leonardo R. Bonjardim https://orcid.org/0000-0002-0080-7678
CALDAS PEREIRA et al
Renata R. de Almeida-Pedrin https://orcid.
org/0000-0002-4283-1051
Thaís M. F. Fernandes https://orcid.org/0000-0002-4368-8568
Marcio R. de Almeida https://orcid.org/0000-0002-2684-0943
Ana C. C. F. Conti https://orcid.org/0000-0001-9658-1652
REFERENCES
1. Lobbezoo F, Ahlberg J, Raphael KG, et al. International consensus
on the assessment of bruxism: report of a work in progress. J Oral
Rehabil. 2018;45(11):837-844.
2. Endo H, Kenemura K, Tanabe N, Takebe J. Clenching occurring
during the day is influenced by psychological factors. J Prosthodont
Res. 2011;55(3):159-164.
3. Ordonez-Plaza MP, Villavicencio-Caparó E, Alvarado-Jiménez OR,
Vanegas-Alvecillas ME. Prevalencia de bruxismo de vigilia evaluado
por auto-reporte en relación con estrés, ansiedad y depresión. Rev
Estomatol Herediana. 2016;26(3):147-150.
4. Rao SK, Bhat M, David J. Work, stress, and diurnal bruxism: A pilot
study among information technology professionals in bangalore
city, India. Int J Dent. 2011;2011:1–5.
5. Michelotti A, Cioffi I, Landino D, Galeone C, Farella M. Effects
of experimental occlusal interferences in individuals report-
ing different levels of wake-time parafunctions. J Orofac Pain.
2012;26(3):168-175.
6. Colonna A, Lombardo L, Siciliani G, et al. Smartphone-based ap-
plication for EMA assessment of awake bruxism: compliance
evaluation in a sample of healthy young adults. Clin Oral Investig.
2019;24(4):1395–1400.
7. Melo G, Duarte J, Pauletto P, et al. Bruxism: an umbrela review of
systematic reviews. J Oral Rehabil. 2019;46(7):666-690.
8. Manfredini D, Winocur E, Guarda-Nardini L, Paesani D, Lobbezoo
F. Epidemiology of bruxism in adults: a systemic review of the liter-
ature. J Orofac Pain. 2013;27(2):99-110.
9. Bargellini A, Castroflorio T, Casasco F, et al. Short term evaluation
of the effects of orthodontic clear aligners on sleep bruxism activ-
ity. Iran J Ortho. 2017;12(2):7916-7920.
10. Fujiyama K, Honjo T, Suzuki M, Matsuoka S, Deguchi T. Analysis of
pain level in cases treated with Invisalign aligner: comparison with
fixed edgewise appliance therapy. Prog Orthod. 2014;15(1):64-70.
11. Fang X, Qi R, Liu C. Root resorption in orthodontic treatment
with clear aligners: a systematic review and meta-analysis. Orthod
Craniofac Res. 2019;22(4):259-269.
12. Jiang Q, Li J, Mei L, Du J, Levrini L, Abbate GM. Periodontal health
during orthodontic treatment with clear aligners and fixed appli-
ances. J Am Dent Assoc. 2018;149(8):712-720.
13. Schupp W, Haubrich J, Neumann I. Invisalign treatment of patients
with craniomandibular disorders. Int Orthod. 2010;8(3):253-267.
14. Castroflorio T, Bargellini A, Luccchese A, et al. Effects of clear
aligners on sleep bruxism: randomized controlled trial. J Biol Regul
Homeost Agents. 2018;32(2):21-29.
15. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for
Temporomandibular Disorders (DC/TMD) for Clinical and Research
Applications: recommendations of the International RDC/TMD
| 429
Consortium Network and Orofacial Pain Special Interest Group. J
Oral Facial Pain Headache. 2014;28(1):6-27.
16. Manfredini D, Bracci A, Djukic G. BruxApp: the ecological mo-
mentary assessment of awake bruxism. Minerva Stomatol.
2016;65(4):252-255.
17. Bracci A, Djukic G, Favero L, Salmaso L, Guarda-Nardini L,
Manfredini D. Frequency of awake bruxism behaviours in the nat-
ural environment. A 7-day, multiple-point observation of real-time
report in healthy young adults. J Oral Rehabil. 2018;45(6):423-429.
18. Zani A, Lobbezoo F, Bracci A, Ahlberg J, Manfredini D. Ecological
momentary assessment and intervention principles for the study of
awake bruxism behaviors, Part 1: general principles and preliminary
data on healthy young Italian adults. Front Neurol. 2019;10:169-174.
19. Spielberger CD, Gorsuch R, Lushene RE. Manual for the State-Trait
Anxiety Inventory. Palo Alto, CA, USA: Consulting Psychologist
Press; 1970.
20. Cohen S, Karmack T, Mermelsteinm R. A global measure of per-
ceived stress. J Health Soc Behav. 1983;24(4):385-396.
21. Flor H, Behle DJ, Birbaumer N. Assessment of pain-related cogni-
tions in chronic pain patients. Behav Res Ther. 1993;31(1):63-73.
22. Roelofs J, Peters ML, McCracken L, Vlaeyen JW. The pain vigi-
lance and awareness questionnaire (PVAQ): further psychometric
evaluation in fibromyalgia and other chronic pain syndromes. Pain.
2003;101(3):299-306.
23. Manfredini D, Ahlberg J, Winocur E, Lobbezoo F. Management of
sleep bruxism in adults: a qualitative systematic literature review. J
Oral Rehabil. 2015;42(11):862-874.
24. Manfredini D, Lombardo L, Vigiani L, Arreghini A, Siciliani G. Effects
of invisible orthodontic retainers on masticatory muscles activity
during sleep: a controlled trial. Prog Orthod. 2018;19(1):24-28.
25. Ohrbach R, Michelotti A. The Role of Stress in the etiology of oral
parafunction and myofascial pain. Oral Maxillofac Surg Clin North
Am. 2018;30(3):369-379.
26. Bracci A, Lange M, Djukic G, Guarda-Nardini L, Manfredini D.
Ecological momentary assessment of awake bruxism behaviors. J
Craniomandibular Function. 2018;10(3):217-228.
27. Machado NAG, Costa YM, Quevedo HM, et al. The association of
self-reported awake bruxism with anxiety, depression, pain thresh-
old at pressure, pain vigilance, and quality of life in patients under-
going orthodontic treatment. J Appl Oral Sci. 2020;28:e2019040.
28. Sato F, Kino K, Sugisaki M, et al. Teeth contacting habit as a con-
tributing factor to chronic pain in patients with temporomandibular
disorders. J Med Dent Sci. 2006;53(2):103-109.
How to cite this article: Pereira NC, Oltramari PVP, Conti
PCR, et al. Frequency of awake bruxism behaviour in
orthodontic patients: Randomised clinical trial: Awake
bruxism behaviour in orthodontic patients. J Oral Rehabil.
2021;48:422–429. https://doi.org/10.1111/joor.13130
This document is a scanned copy of a printed document. No warranty is given about the
accuracy of the copy. Users should refer to the original published version of the material.