Received: 23 July 2019

| Revised: 1 October 2019

| Accepted: 15 October 2019

DOI: 10.1111/ipd.12586

REVIEW

Sleep bruxism and oral health‐related quality of life in children:

A systematic review

Jonas Almeida Rodrigues1 | Claudia Britto Azevedo1 | Vitória Oliveira Chami2 |

Marjana Patricia Solano 1
| Tathiane Larissa Lenzi 1

1
Faculty of Dentistry, Post‐Graduate
Program in Pediatric Dentistry, Federal
University of Rio Grande do Sul, Porto
Alegre, Brazil
2
Dental Science Graduate Program, Federal
University of Santa Maria, Santa Maria,
Brazil
Correspondence
Prof. Jonas Almeida Rodrigues, School
of Dentistry, Post‐Graduate Program in
Pediatric Dentistry, Federal University of
Rio Grande do Sul, Ramiro Barcelos 2492,
90035‐003, Porto Alegre, RS, Brazil.
Email: jorodrigues@ufrgs.br
Funding information
Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior—Brasil (CAPES)
Abstract
Sleep bruxism (SB) is a masticatory muscle activity during sleep that can cause sev-
eral consequences to the stomatognathic system. This systematic review investigated
the impact of SB on oral health‐related quality of life (OHRQoL) of 0‐ to 6‐year‐old
children. Literature search was undertaken through PubMed/MEDLINE, LILACS,
Scopus, TRIP, Livivo databases, and grey literature. The search was conducted with
no publication year or language limits. Two reviewers independently selected the
studies, extracted the data and assessed the risk of bias. The quality of evidence was
assessed using GRADE. From 185 potentially eligible studies, three were included
in the review. All studies were conducted in Brazil, published between 2015 and
2017, and used the B‐ECOHIS instrument to evaluate OHRQoL. Two studies found
no association between SB and OHRQoL, whereas one showed a significant nega-
tive impact of SB on the OHRQoL of children. SB was associated with respiratory
problems, presence of tooth wear, dental caries, malocclusion as well as income and
pacifier use. Risk of bias ranged from moderate to high, and the quality of evidence
was judged as very low. The evidence is currently insufficient for definitive conclu-
sions about the impact of SB on OHRQoL of children.

KEYWORDS
Bruxism, Child care, Children, Oral health, Quality of life

1 | IN TRO D U C T ION Nonetheless, when not controlled, SB can cause multiple

Sleep bruxism (SB) is a masticatory muscle activity during
sleep that is characterized as rhythmic (phasic) or non‐rhyth-
mic (tonic), and it is not considered a movement disorder or
a sleep disorder in otherwise healthy individuals,1 but a sign
of a health condition in some (eg, obstructive sleep apnoea,
sleep disorders, gastro‐oesophageal reflux).2-4
Also, it has been suggested that SB may have positive con-
sequences for some bruxers, since it may have a protective
nature, increasing the air patency of the upper respiratory air-
ways5 and stimulating salivation preventing dental erosion.6
Moreover, it is the ending episode of a respiratory arousal.7
consequences on the stomatognathic system. The most recur-
rent signs and symptoms are abnormal tooth wear, tensional
headaches, masticatory muscles pain or fatigue, and temporo-
mandibular disorders.8 In this sense, SB could affect signifi-
cantly the life and well‐being of children and their families.
The prevalence of SB in children is very variable, rang-
ing from 3.5% to 46%.9 This variance may be attributed to
fact that the diagnosis of SB in children is still challenging,
once it is predominantly accessed through parental report.0.10
Other validated methods such as physical examination and/
or questionnaires are often used.11,12 Although polysomnog-
raphy is the current reference standard for diagnosing SB, it

136 | © 2019 BSPD, IAPD and John Wiley & Sons A/S. wileyonlinelibrary.com/journal/ipd Int J Paediatr Dent. 2020;30:136–143.
Published by John Wiley & Sons Ltd
RODRIGUES et al.
has some disadvantages, such as high cost and technical dif-
ficulties when used in children.13
So far, no therapy has been proven to be effective in con-
trolling SB in children, mainly because of the multiplicity of
the phenomena associated with this masticatory muscle activity
during sleep.1,14 Untreated oral and dental changes can cause
disorders in physical, psychological, and social performance,
compromising the simple activities of a child's daily routine.15
Few studies evaluated the impact of SB on oral health‐
related quality of life (OHRQoL) in children.16-20 Although
it has been suggested an influence of SB in OHRQoL when
psychosocial factors and symptomatology are associated with
it,18 there is no agreement on how SB may affect OHRQoL
of children.16-20 Therefore, this systematic review aimed to
assess whether SB is associated with negative impact on
OHRQoL of preschool children.
2 | M ET H OD S
This systematic review was conducted according to the
Preferred Reporting Items for Systematic Reviews and
Meta‐Analyses (PRISMA)21 Statement and recorded in
International Prospective Register of Systematic Review
(CRD42018107062).
2.1 | Focused PICOS question
The research question of this systematic review was: Is SB as-
sociated with a negative impact on OHRQoL of 0‐6 years old
children? Focused PICOS question was defined as follows:
Population: 0‐ to 6‐year‐old children
Intervention: Sleep bruxism
Comparison: Without sleep bruxism
Outcome: OHRQoL
Study design: Observational studies (case‐control, cross‐
sectional, and cohort).
2.2 | Data sources
A comprehensive literature search was undertaken through
PubMed/MEDLINE, Latin American and Caribbean Health
Sciences (LILACS), Scopus, TRIP, and Livivo databases
to identify the literature up to July 2019 related to research
question. The search was conducted with no publication year
or language limits. The subject search used a combination
of controlled vocabulary and text words based on the search
strategy for the PubMed/MEDLINE database as follow:
((((("Sleep bruxism"[MeSH Terms] OR "noc-
turnal teeth grinding disorder" OR "Nocturnal
bruxism" OR "sleep bruxism childhood" OR
"Sleep‐related bruxism")))) AND ((("Quality
  
| 137
Why this paper is important to paediatric dentists
• Sleep bruxism can cause abnormal tooth wear, ten-
sional headaches, masticatory muscles pain or fa-
tigue, and temporomandibular disorders.
• Sleep bruxism is supposed to affect the life and
well‐being of children and their families.
• The evidence on how sleep bruxism may affect
OHRQoL of children based on well‐designed stud-
ies through standardized and validated methods is
insufficient.
of Life" [MeSH Terms] OR "Quality of life"
OR "Life quality" OR "Life qualities" OR "Oral
health‐related quality of life" OR "OHRQoL")))
A sensitive search strategy was adapted for other data-
bases. Grey literature was searched through ProQuest. The
results of searches of various databases were cross‐checked
in order to locate and eliminate duplicates using EndNote X8
(Thompson Reuters, Philadelphia, Pennsylvania).
The inclusion criterion was studies that assessed the im-
pact of the SB on OHRQoL of children. The exclusion crite-
ria were as follows: (a) did not use any validated method for
diagnosing SB; (b) did not assess OHRQoL with validated
instruments; (c) did not compare OHRQoL of children with
and without SB; (d) evaluated the OHRQoL in compromised
subjects (eg, patients with systemic diseases); and (e) did not
include 0‐ to 6‐year‐old children.
2.3 | Search steps: Screening and selection
Step 1: Titles and abstracts were reviewed independently
by two authors (CBA and VOC), using an online software
(Rayyan, Qatar Computing Research Institute), and selected
for further review if they met the inclusion criteria. The inter‐
examiner agreement was calculated (Kappa = 0.88), indicat-
ing good agreement.
Step 2: Full‐text articles of the studies selected in the previous
step were retrieved and reviewed independently by two authors
(CBA and VOC). Those studies that did not show any exclusion
criteria were maintained. The reference lists of selected articles
to this step were evaluated, and the full texts of potentially inter-
esting studies to the research question were evaluated.22
In both steps, any disagreement was firstly solved by dis-
cussion between the reviewers (CBA and VOC). If discrepan-
cies remained, a third author (TLL) was consulted.
2.4 | Data extraction
Both reviewers independently collected the data of the
eligible studies. For each study, the following data were
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|    RODRIGUES et al.

F I G U R E 1 Flow diagram of literature

Records identified through database searching search and selection criteria
Identification

(PubMed/MEDLINE = 34, Scopus = 25, TRIP =

28, LILACS = 5, Livivo = 25, ProQuest = 93

Records after duplicates removed

(n = 185)
Screening

Records screened Records excluded

(n = 185) (n = 180)*

Full-text articles
Eligibility

assessed for eligibility Full-text articles excluded

(n = 5) (n = 2)**

Studies included in
qualitative and
Included

quantitative syntheses
(n = 3)

*Exclusions: Did not associate sleep bruxism and oral health-related quality of life (n = 163);
Participants were not children (n = 17)

**Exclusions: Participants were older than 6 y old (n = 2)

systematically extracted: author, year of publication, study 3 | RESULTS

design, country, sample size, age of participants, criteria for
diagnosing SB, OHRQoL questionnaire, and outcome. If the
required data were not complete, the authors would be con-
tacted by e‐mail.
2.5 | Risk of bias and quality of
evidence of the included studies
The methodological quality of the included studies was as-
sessed by the same reviewers, who appraised each study
independently, using standardized Joanna Briggs Institute
(JBI) critical appraisal tools for observational studies. The
risk of bias was categorized as ‘high’ when the study reaches
up to 50% score ‘yes’; ‘moderate’ when the study reached
51%‐70% score ‘yes’; and ‘low’ when the study reached
more than 71% score ‘yes’.23
The quality of evidence was graded according to the
Grading of Recommendation, Assessment, Development,
and Evaluation (GRADE) working group of evidence.24
3.1 | Study selection
The search strategy identified 185 potentially relevant re-
cords, excluding duplicates. The first screening resulted in
five studies remained for full‐text reading. Finally, three
papers were included in the systematic review. Figure 1
shows the flow chart summarizing the selection process for
studies.
3.2 | Descriptive analysis
One included paper19 was classified as case‐control studies
and two17,20 as cross‐sectional, with the participation of 83
children with SB and 141 without. Moreover, studies were
conducted in Brazil and published between 2015 and 2017.
Parental report and questionnaire application were the
main methods used for diagnosing SB. Only one study per-
formed clinical evaluation in association with parents’ re-
port.19 To evaluate the association of SB and OHRQoL,
 RODRIGUES et al.

TABLE 1 Summary of descriptive characteristics of the included studies

Exposition
Study characteristics Population characteristics Other measures Main findings

Sample Sleep
Author, size and bruxism
Year Study mean age Sample diagnosis OHRQoL
(Country) design (y ± SD) Age group setting methods instrument Findingsa Main conclusions
Antunes et Case‐con- 61 (37 3‐6 y old With SB: 21 Self‐re- B‐ECOHIS Age, gender, behaviour, B‐ECOHIS total scores: SB SB did not signifi-
al (2015)19 trol girls) Without ported respiratory problems, group: 4.52 (±5.02) Control cantly impact on
Brazil 3.95 ± 0.99 SB: 40 question- parafunctional hab- group: 4.70 (±6.09) P = .91 OHRQoL
naire to its, presence of wear, Associations between SB and res-
the parents malocclusion, dental piratory problems (P = .04, OR:
and caries, relation degree of 0.33, CI: 0.09 to 1.14), dental
clinical caretaker, caretaker edu- wear (P < .01, OR: 0.01), maloc-
evaluation cational level, economic clusion (P < .01, OR: 0.06), and
classification dental caries (P = .02, OR: 0.22)
were observed
Almeida et Cross‐ 75 (33 3‐5 y old With SB: 33 Parental B‐ECOHIS Pacifier users have 2.3 times SB did not signifi-
al (2016)20 Sectional girls) Without report more chance of developing SB cantly impact on
Brazil NR SB: 42 (P = .001) OHRQoL
B‐ECOHIS total scores were not
affected by the presence of SB
Silva et al Cross‐ 88 (39 2‐5 y old With SB: 29 Parental B‐ECOHIS The presence of SB was sig- SB had a nega-
(2017)16 Sectional girls) Without report nificantly associated with total tive impact on
Brazil NR SB: 59 B‐ECOHIS score (P = .031). OHRQoL
Significant associations were
found between the function do-
mains (P = .001) and self/image/
social interaction (P = .009)
Abbreviations: NR, not related by the authors; SB, sleep bruxism.
a
Data calculated by the authors.
  
|
139
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|
  

TABLE 2 Ascertainment of bias risk in analytical cross‐sectional and case‐control studies included in systematic review

Were the Were Were the

Were the study Was the strategies outcomes Was ap-
criteria for in- subjects and exposure Were objective, stand- to deal with measured propriate
Cross‐ clusion in the the setting measured in a ard criteria used for Were con- confound- in a valid statistical
sectional sample clearly described in valid and reli- measurement of the founding fac- ing factors and reliable analysis
Study defined? detail? able way? condition? tors identified? stated? way? used?
Almeida − − − − ? ? − +
et al,
(2016)20
Silva et al, + + − − − − − +
(2017)16
Case‐ Were the Were cases Were the same Was exposure measured Was exposure Were Were strate- Were Was the Was appropri-
control groups and controls criteria used in a standard, valid and measured in confound- gies to outcomes exposure ate statistical
Study comparable matched ap- for identifica- reliable way? the same way ing factors deal with assessed in period of analysis used?
other than propriately? tion of cases for cases and identified? confound- a standard, interest long
the presence and controls? controls? ing factors valid and enough
of disease stated? reliable to be
in cases or way for meaningful?
the absence cases and
of disease in controls?
controls?
Antunes + + + ‐ + + ? − ? +
et al,
(2015)19
Note: −: No (high risk of bias).
+: Yes (low risk of bias).
?: Unclear (no information or uncertainty over the potential for bias).
RODRIGUES et al.
RODRIGUES et al.
TABLE 3 Grading of recommendations assessment, development, and evaluation (GRADE) summary
Question: Is sleep bruxism associated with a negative impact on OHRQoL of children aged 0‐6 years old?
Certainty assessment
No of participants
(studies)
Follow‐up Risk of bias Inconsistency
B‐ECOHIS Scores (assessed with: B‐ECOHIS)
83 cases Seriousa Seriousb
141 controls (3 observa-
tional studies)
a
The risk of bias across studies the studies was considered borderline moderate. Only two studies used questionnaires to evaluate the presence of SB.
b
The studies were considered heterogeneous, especially regarding methods for diagnosing SB.
c
Inconsistency among the studies was considered serious, once the results of one study contrasted from the others. In addition, one study did not present B‐ECOHIS
total score for both control and SB groups.
all three papers17,19,20 used the validated Brazilian version
of Early Childhood Oral Health Impact Scale (B‐ECOHIS)
questionnaire.
SB was associated with respiratory problems, presence
of tooth wear, dental caries, malocclusion as well as family
income and pacifier use. In two studies,19,20 SB did not sig-
nificantly affect the OHRQoL. Conversely, in other paper,17
the presence of SB was significantly associated with the total
B‐ECOHIS score as well as with function domain and self‐
image/social interaction, showing a negative impact on the
OHRQoL of children. A summary of descriptive characteris-
tics of the included studies is available in Table 1.
3.3 | Risk of bias and quality of
evidence of the included studies
Risk of bias of the selected studies ranged from moderate
to high. Limitations related to method used for diagnosing
SB and lack of management of the confounding factors were
the major problems identified. The overview of the quality
analysis for included studies is shown in Table 2. A very low
quality of evidence was judged according to the GRADE
(Table 3).
4 | D IS C U SS ION
This is the first systematic review that investigated if SB is
associated with a negative impact on OHRQoL of 0‐ to 6‐
year‐old children. Due to limited number of included studies
(I2 = 74%), the quantitative evaluation was not explored.
All three studies used the Brazilian version of Early
Childhood Oral Health Impact Scale (B‐ECOHIS), which
is a validated questionnaire that measures the perception
of parents/guardians about the impact of oral conditions
on the quality of life of young children and their families.
It is divided into two sections (Impact on the child—CIS/
  
| 141
Overall certainty
Indirectness Imprecision Publication bias of evidence
Not serious Seriousc None ☒☐☐☐
Very low
Family—FIS) with a total of 13 domains.20 The total score of
the questionnaire ranges from 0 to 52 points and is obtained
by a simple sum of the answers. Higher scores have a nega-
tive impact on OHRQoL.25
Antunes et al19 and Almeida et al20 showed that total B‐
ECOHIS scores were not significantly associated with SB.
On the other hand, Silva et al17 found a significant association
of SB with function domains and self‐image/social interac-
tion. Moreover, the presence of SB was significantly associ-
ated with the total B‐ECOHIS score.
The diagnosis methods of SB in children are considered
as a limitation of included studies. A questionnaire applied
to parents was used to identify the presence of possible SB.
Only one study23 associated the parent's perceptions with
clinical examination (probable SB). The diagnosis of SB is
challenging in Dentistry. Firstly, it should be evaluated by
patient's history (eg, report of patients or parents/guardians
of nocturnal tooth grinding; orofacial discomfort or pain—
possible SB) and clinical examination (eg, presence of tooth
wear, fractured restorations, masticatory muscle hypertro-
phy—probable SB), being these findings confirmed by poly-
somnography (definite SB).1
The cost of polysomnography, however, limits its use,
mainly in epidemiological studies.2 Besides, the results may
be not representative because the examination is not per-
formed in the family environment and, mainly in children,
the cooperation for evaluation can be compromised.19 Thus,
the parents'/guardian's report of nocturnal tooth gridding is a
well‐accepted criterion for identifying the presence of possi-
ble sleep bruxism in children by the American Association of
Sleep Medicine.12 This diagnosis criterion, however, is sub-
jective, and underreporting of sleep bruxism can occur when
parents are not aware of this habit in their child.
Multiple risk factors have been associated with SB. It
has been evidenced that second‐hand smoke and sleep dis-
turbances present stronger association with SB in children
with 7‐11 years old.4 This systematic review has pointed
142
|    RODRIGUES et al.
out that SB in children is associated with respiratory prob-
lems, malocclusion, as well as pacifier use and household
income.
A variety of conditions may interact with sleep bruxism
(and with each other) in the clinical setting, thus influencing
the particular degree of sleep bruxism that leads to a nega-
tive health outcome. Nevertheless, there are still many un-
solved issues concerning the aetiology of sleep bruxism that
have consequences on the clinical management strategies.
It is important to highlight that the measuring tools for
quality of life are used for oral health and not specific to SB.
Therefore, being SB highly influenced by multifactorial and
emotional aspects, it could be hypothesized that the negative
impact of OHRQoL could also trigger SB.
Included studies scored moderate and high bias risk and
were rated as very low quality of evidence. Limitations of the
method for diagnosing SB and the lack of management of
the confounding factors may have compromised the validity
of some studies. Furthermore, all studies were performed in
Brazil. Since results must be analysed considering environ-
mental, social, economic, and cultural factors, which influ-
ence people's behaviour and health perceptions, the external
validity of findings is limited. The type of epidemiological
observational study is also a limitation of this review. One
included paper19 was classified as case‐control design and
other17 as cross‐sectional. The study design was not clear in
another study20 and the examiners classified as cross‐sec-
tional. The case‐control study design is often used in the
study of rare diseases or as a preliminary study where little
is known about the association between the risk factor and
disease of interest.26
Further evidence‐based studies evaluating this associa-
tion through standardized and validated diagnostic methods
are necessary to construct a more reliable evidence. In con-
clusion, there is insufficient evidence to state whether the
presence of SB has a negative impact on OHRQoL of 0‐ to
6‐year‐old children.
ACKNOWLEDGMENTS
This study was financed in part by the Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior—Brasil
(CAPES)—Finance Code 001.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
AUTHOR CONTRIBUTIONS
JAR and CBA conceived the ideas; CBA and VOC collected
the data; JAR and TLL analysed the data; and JAR, CBA,
MPS, and TLL led the writing.
ORCID
Jonas Almeida Rodrigues https://orcid.
org/0000-0001-8887-2329
Tathiane Larissa Lenzi https://orcid.
org/0000-0003-3568-5217
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How to cite this article: Rodrigues JA, Azevedo CB,
Chami VO, Solano MP, Lenzi TL. Sleep bruxism and
oral health‐related quality of life in children: A
systematic review. Int J Paediatr Dent. 2020;30:136–
143. https​://doi.org/10.1111/ipd.12586​