INTRODUCTION

Bruxism is a jaw muscle activity disorder characterised by clenching or grinding of the teeth and can be seen in both children and adults (1,2). Unintentional teeth grinding and clenching during daytime is called “diurnal bruxism” or “daytime bruxism”, while its night time version is called “nocturnal bruxism” or “sleep bruxism” (3). Teeth grinding is usually observed during sleep, while clenching occurs when the person is awake and especially at tense, anxious, excited, or stressful times (2,4).

Contrary to functional behaviors such as chewing, swallowing, or speaking, jaw and tooth movements in bruxism are defined as parafunctional habits due to the absence of any functional purpose (5). Although bruxism is common in the community, the majority of individuals with this habit are generally unaware of their parafunction (6).

Generally, dentists worry about the harmful effects of bruxism on oral/perioral structures and the temporomandibular joint. For the diagnosis of this parafunction, detailed anamnesis and intra/ extraoral examination are essential (7,8). In the past, bruxism was considered as a habit only seen in adults and consequently, almost all of the bruxism studies were done in these groups. However, it was later shown to be also common in children, even during the early childhood (9). Studies showed that the prevalence of nocturnal bruxism decreases with age (10,11).

The bruxism is more common among children than adults, and the prevalence of bruxism in children ranges from 3.5% to 40.6% and it has no gender preference (12). Childhood bruxism may persist in adulthood (13). Early detection prevents the chewing system components from being damaged and promotes well-being and comfort (14). Therefore, it is very important for parents to seek help when they suspect their children to exhibit tooth grinding and clenching (15).

It is challenging to assess and diagnose bruxism. Clinical signs and symptoms including pain, masticatory muscular hypertrophy, pain, temporomandibular joint disorders and headache can confirm bruxism diagnosis in adults. However, these signs and symptoms have not been established in pediatric populations (16). Therefore, parental reports is one of the most important parameters in the diagnosis of bruxism in the absence of quantitative data (eg, sleep recordings) (15,16), because teeth grinding results in characteristic sounds that are easily recognized by the family members (17). In studies conducted in USA and Brazil, the prevalence of sleep bruxism in children based on parental reports was reported to be 38% and 35.3%, respectively (18,19). In addition, some researchers have reported that keeping the room doors open increased the parents’ reports of bruxism (18). Moreover, it is important for the parents to have the knowledge and to be aware of these parafunctional habit symptoms and to seek appropriate treatment in such cases. However, the number of studies evaluating family knowledge about bruxism of their children is quite small (17,20,21). To the best of the authors’ knowledge, there is no study reporting data of parents knowledge about bruxism in their children in Turkey. Therefore, the purpose of this study was to evaluate the knowledge of parents about bruxism in their children at the pediatric dentistry and oral surgery clinics in the Faculty of Dentistry of the Mersin University, Mersin, Turkey.

MATERIALS AND METHODS

The study protocol was approved by the Clinical Research Ethics Committee of Mersin University (2018/90) and was performed in accordance with the Declaration of Helsinki. Parents who agreed to participate in the study answered the questionnaire individually after they were informed about its contents. Informed consent was obtained from all individual participants included in the study. This cross-sectional study was conducted on parents in the waiting room during their children’s appointments recruited at both the pediatric dentistry and oral surgery clinics in the Faculty of Dentistry of the Mersin University, Mersin, Turkey, in the period of March to November 2018.

According to the power analysis, a total of 172 participants were found to be sufficient (power: 0.95, effect size: 0.3 and 5% standard error). Finally, 300 participants were included to the study to compensate possible dropouts. A flow diagram to describe the study process is presented in Figure 1. We conducted a pilot study with 20 parents to test the questionnaire which was modified from a questionnaire that was validated by Serra-Negra et al (13). The results of the pilot study demonstrated that there is no need to change the questionnaire and the participants of the pilot study were not included in the present study.

Only the parent/caregiver who accompanied the child filled out the questionnaire. The questionnaire was given to the parents and they were asked to read and fill it. The inclusion criteria for parents were as follows: parents with children aged 6 months - 16 years, parents accompanying their children in the dental visit, parents with a child, parents agreed to participate in the survey. The exclusion criteria for patients were as follows: non-literate parents, parents who refused to take the survey, guardians other than the parents.

In the 20-question questionnaire, 18 questions were closed-ended and 2 of them were open-ended. The first six questions were about the demographic data of parents and their children, while the questions 7-16 were related to awareness and attitude of parents about bruxism in their children, and the questions 17-20 were aimed to determine the bruxism knowledge of parents.

IBM SPSS Statistics 22 for statistical analysis (SPSS IBM, Turkey) program was used for the analysis. Chi-Square and Spearman correlation tests were used to compare the qualitative data as well as descriptive statistical methods (frequency). Statistical significance was p<0.05.

RESULTS

The questionnaire was distributed to 300 individuals who met the inclusion criteria and a total of 265 parents (159 were female and 106 were male) participated in the study and answered the questionnaire (88.33% participation rate). Most of those parents (60.8%) were between the ages of 31-40 and only 2.6% were over 51 years old. Information on educational backgrounds of the participants is shown in Table 1.

The age of the children ranged from 6 months to 16 years with a mean age of 8.15±2.71 years and the majority of the children were male (%54.7) (Table 1). Most of them were sleeping alone (66.4%) and for more than 8 hours a night (79.2%). Sleep patterns of only 6% of the children were defined as restless by their parents. The rates of children who were easily distressed or stressed/ anxious were 40.8% and 35.8, respectively (Table 2).

The rate of clenching and grinding of teeth during sleep (21.5%) was higher than the rate when they were awake (7.2%). Interestingly, the ratio of the parents seekied treatment for their children because of this harmful habit was very low (3.8%). It was observed that in case of bruxism, 37.7% of the parents would seek help from the dentist, 18.5% from a medical doctor and 11.3% from a psychologist. However, 32.1% of the parents stated that there was no need for treatment for teeth clenching and grinding (Table 2).

Most of the parents stated that bruxism was caused by dental problems and emotional factors (33.6% and 32.8%), and that tooth clenching and grinding would negatively impact the health of children (%77.4). On the other hand, only 8.3% of the parents were able to correctly define bruxism (Table 3).

There was a statistically significant difference between the educational background of the parents and the ability to define bruxism (p<0.001). The paired comparisons showed that the ratio of parents who defined bruxism correctly was significantly lower among primary school graduates (1%) compared to high school (15.7%) and university (13.8%) graduates (Table 4).

DISCUSSION

Bruxism is a parafunctional habit that has increased in children in recent years and can also be transferred from childhood to adulthood (13). If diagnosed and treated early, the damage of teeth, temporomandibular joint, and chewing muscles can be prevented (14). Children with bruxism, especially children with nocturnal bruxism, are not aware of these habits (6, 22). Therefore, getting information from family members is an effective way for early diagnosis of this habit (15). In this study, we aimed to evaluate the parents' knowledge and awareness of bruxism in their children.

The rate of prevalence of nocturnal bruxism in children (21.5%), which was calculated based on the information obtained from parents participating in the present study, was consistent with the previous findings (17,23). However, in some studies, the prevalence of nocturnal bruxism was found to be higher (19,20,24,25). The difference between these studies may be explained by the application of different methodologies and/or the differences between the age groups of the patients.

The data obtained from the parents through the questionnaire are subjective and may be affected by memory biases (6). The audio and video recordings performed through the night, measurement of chewing muscle activity by electromyography (EMG) and polysomnographic (PSG) recordings provide more definitive results in the evaluation of bruxism (26). But these are expensive and time-consuming techniques for children. For this reason, in epidemiological studies, the option is to use information obtained from parents according to World Helath organizaiton (WHO) guidelines (27).

In the study by Serra Negra et al. (20), 95% of the parents defined bruxism correctly, while in the study by Tavares Silva et al. (17), only 38.1% of the parents provided a correct definition for bruxism. In contrast to the previous studies, the rate of correct definition of bruxism was found to be 8.3% in the present study. Authors believed that the reason for the low rate of identification of bruxism in this study was due to the difference in educational background of the parents. In this study, majority of the parents were primary school graduates and the rate of the parents with primary school graduates that were able to correctly define bruxism were significantly lower than those of high school and university graduates. This is the first study to compare the relationship between parents' education levels and the correct definition of bruxism.

Being informed about bruxism and early recognition of the symptoms may help parents to seek treatment which can enable prevention of the development of more important problems in children. In the current study, the rate of the parents who seek treatment for bruxism in children was very low (3.8%). However, in such condition, it was determined that they would mostly consult dentists. In a previous study, it was reported that 10.4% of the parents whose children exhibited teeth clenching and grinding would seek treatment from a dentist, 0.7% from a medical doctor and 0.7% from a psychologist (17). Another study suggested that parents seek help for bruxism more from medical doctors (54.1%) and religious/mystical authorities (26.8%), and less from dentists (19.1%) (20). Authors think that the reason for the high rate of parents seeking treatment from a dentist in this study is due to the fact that the study was conducted in the faculty of dentistry.

Bruxism, which has multifactorial etiology, has been found to be associated with metabolic causes, psychosocial effects or environmental factors (6). In a study in which parents' knowledge about bruxism in children was investigated, parents believed bruxism to be caused by emotional factors (63.8%), religious/mystical influences (20.4%), and dental problems (10.4%) (20). In the study by Tavares Silva et al. (17), the most common cause of bruxism in children according to the parents was the emotional factors, and to a lesser extent religious/mystical effects. In the present study, the most common causes of bruxism according to the parents were dental problems (33.6%) and emotional factors (32.8%). Differences among the parents' cultural backgrounds, education and beliefs may affect the results of different studies. In addition, the fact of the study being conducted in the dental school may lead to the high rate of selection of dental problems as the etiological factor in this study.

There were several limitations in this study. First, this survey-based study results were subjective and might be affected by memory biases. Second, questionnaire did not include questions about whether parents sleep in the same room with their children, if they were staying in separate bedrooms whether the rooms were close to each other, whether the children’s room door was open or how often parents checked their sleeping children. Another potential limitation of this study was that children were not clinically examined for symptoms of bruxism such as attrition, temporomandibular joint problems and tenderness in the chewing muscles. Therefore, further studies involving multiple observers and EMG or PSG records are needed to overcome these limitations.

CONCLUSION

Parents play an important role in the diagnosis of bruxism in their children by recognizing the sounds that occur during grinding of teeth. More parental knowledge and awareness about these symptoms would enable seeking appropriate treatment. In this study, it was observed that some parents had inadequate knowledge about bruxism in children and this was mostly related to the educational background of the parents.

REFERENCES

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