Journal of Dentistry xxx (xxxx) xxx–xxx

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

Personality traits and dental anxiety in self-reported bruxism. A cross-

sectional study
⁎
J. Montero , C. Gómez-Polo
Department of Surgery, University of Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain

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

Keywords: Objectives: The aim of this study was to investigate the association between psychological factors (Personality
Self-reported bruxism and Dental anxiety) with self-reported bruxism-related symptoms.
Personality traits Methods: 526 subjects, over 18 years old and not seeking dental treatment, were recruited from the families and
Dental anxiety acquaintances of dental students from the University of Salamanca. Bruxism activity was estimated by means of
NEO-FFI
a six-item questionnaire aimed at recording common bruxism-related symptoms and clenching/grinding
MDAS
awareness. The Spanish version of the modified dental anxiety scale (MDAS) was used to determine the level of
anxiety perceived in 5 typical scenarios of dental assistance. The NEO-FFI inventory was applied to assess
personality profiles associated with 5 different factors (neuroticism, extroversion, openness, agreeableness, and
conscientiousness). Pearson correlations, Student T-tests, and logistic regression modelling were used for the
statistical analyses.
Results: Thirty-five point nine percent of this adults sample was classified as being bruxers, where sleep bruxers
comprised more than half of the sample at 20.2%. Bruxers tended to perceive more anxiety in all of the situations
included within the MDAS, where they exhibited a higher level of phobia towards the teeth scaling and local
anaesthetic injection. The risk of being considered a bruxer is reduced with age (OR: 0.99), and increases
proportionally for some personality traits, such as neuroticism (OR: 1.06) and extraversion(OR: 1.04), to the
MDAS total score (OR: 1.08) and in smokers (OR: 1.61), after controlling for all potentially confounding factors.
Conclusions: Self-reported bruxism is significantly associated to several personality traits (mainly neuroticism and
extraversion) and to the level of dental anxiety (MDAS score).
Clinical significance: Clinicians should be aware of the typical psychological profiles of patients who ex-
perience bruxism and the relationship with dental phobias.

1. Introduction
Bruxism is an oral condition of great interest to researchers, clin-
icians and patients in the dental, neurological and sleep medicine do-
mains. According to Lobbezzo et al. [1] bruxism is a repetitive jaw-muscle
activity characterized by clenching or grinding of the teeth and/or by bracing
or thrusting of the mandible. Bruxism has two distinct circadian manifes-
tations: it can occur during sleep (indicated as sleep bruxism) or during
wakefulness (indicated as awake bruxism).
To date, the aetiology of bruxism has not been completely de-
termined, but there is consensus about its multifactorial nature. In the
past, peripheral factors like occlusal discrepancies or several morpho-
logical deviations in the orofacial region were considered capable of
initiating and perpetuating non-functional masticatory movements that
try to minimize the impact of such anomalies in the stomatognathic
system [2]. However, such factors are now known to play only a minor
role, if any. Nowadays, the focus is centred on causes related to pa-
thophysiological and psychological factors.
Recent works [2–5] support the idea that some psychological fac-
tors, such as personality and stress, could modulate the occurrence and
severity of such parafunctional behaviour. In the classical study by
Ramfjord published in 1961, [6] the role of “neurotic tensions” in the
aetiology of bruxism was determined. Latter Olkinuora [7] demon-
strated that bruxers were emotionally out of balance and that they
tended to develop more psychosomatic disorders, because their per-
sonality profile was characterized by perfectionism and an increased
tendency towards anger and aggression.
In 1993, Fisher & O'toole reported that [8] the personality of bruxers
differed significantly from non-bruxers. In general, it was observed that
chronic bruxers are shy, stiff, cautious, and aloof, preferring things rather
than people, avoiding compromises, rigid in their ways, affected by feelings
of inferiority, impeded in expressing themselves, apprehensive, and given to

⁎
Corresponding author.
E-mail addresses: javimont@usal.es (J. Montero), crisgodent@hotmail.com (C. Gómez-Polo).

http://dx.doi.org/10.1016/j.jdent.2017.07.002
Received 19 January 2017; Received in revised form 27 June 2017; Accepted 1 July 2017
0300-5712/ © 2017 Elsevier Ltd. All rights reserved.

Please cite this article as: J, M., Journal of Dentistry (2017), http://dx.doi.org/10.1016/j.jdent.2017.07.002
J. Montero, C. Gómez-Polo
worrying. A few years later Kampe et al. observed that bruxers, in terms
of personality, tended to score higher in somatic anxiety and muscular
tension and lower in socialization [9].
A recent systematic review focussing on the role of psychological
factors in the aetiology of bruxism in adults reported the major per-
sonality traits that characterize bruxers (eg, aggressiveness, neuroticism,
perfectionism, and stress sensitivity), occurring mainly during wakeful-
ness [10]. Thus, the idea than not all types of personalities are equally
susceptible to the bruxism disorder seems to be supported by the lit-
erature.
Personality can be defined as the dynamic organization of the psy-
chobiological systems that modulate adaptation to changing environ-
ments through several personality traits, which are long-lasting patterns
of how we perceive, relate to, and think about oneself, other people and
the world as a whole [11]. Since bruxism is likely to be a result of
emotional tension and psychosocial disorders that force the subject to
respond with a prolonged contraction of his/her masticatory muscles
[10], it could be argued that some personality traits, such as neuroti-
cism, extraversion, and conscientiousness may underlie the behaviour
related to bruxism. In addition, more anxiety and phobias have been
reported in association with bruxism [12].
Nowadays, there is a lack of research that focuses on evaluating the
global personality profile and the level of dental anxiety among
bruxers. The present study aims to assess the association between
psychological factors (Personality and Dental anxiety) with self-re-
ported bruxism-related symptoms.
2. Methods
A cross-sectional study was carried out on five hundred and twenty-
six subjects, over 18 years old and not seeking dental treatment, which
were recruited using a snowball technique from the families and ac-
quaintances of dental students from the University of Salamanca during
the Christmas holidays in 2015. Students were instructed to collect data
from both gender and from distinct age intervals in order to have a
broad spectrum of age with balanced gender. A written informed con-
sent was obtained from all individual included within the study, in
accordance with the Bioethics Committee of the University of
Salamanca. The sample size was estimated for detecting significant
differences in personality scores using the t-test for independent groups,
with a power of 95% and a significance level of two-side alpha = 0.05,
using the data dispersion values from the first 100 subjects of the pilot
study (2 units of mean differences and 7 units of common standard
deviation), resulting in a minimum of 320 subjects for such bivariate
analysis. But in order to maintain enough effective sample size with
which to explore the multi-factorial nature of the personality among
self-reported bruxers and also for compensating missing data we
decided to over recruit the initial sample. In the 526 subjects that
comprised the main study, were already included the initial 100 sub-
jects of the pilot study. The final response rate of this survey was 92%.
For all participants, sociodemographic (age, gender, education, and
etc.) and behavioural data (brushing habits, smoking and dental at-
tendance patterns) were collected in a face-to-face interview performed
by the dental students. Moreover, the prosthodontics status, the number
of standing teeth and occlusal units were registered by inspection, for
capturing clinical variables that could be potentially related with the
psychological background or with the awareness of bruxism or acting as
confounding factors for the logistic regression analyses. Given the
simplicity of such exploration and that all the students were trained
with this methodology from the clinical practices, no calibration was
made. Additionally, a self-completed questionnaire, consisting of sev-
eral items regarding bruxism-related symptoms, dental anxiety and
personality traits, was also obtained from all participants. The various
sections within this questionnaire are described in the following para-
graphs.
Bruxism activity was estimated by means of a six-item questionnaire
2
Journal of Dentistry xxx (xxxx) xxx–xxx
with good face and content validity [13], which was previously used by
Pintado et al. for similar studies [14]. The items were answered di-
chotomically with either a ‘yes’ or a ‘no’. The patients were instructed to
answer ‘yes’ only if they considered that their habit was frequent en-
ough to be clinically relevant (i.e. more frequent than 3×/week and/or
several hours per day).
Subjects classified as bruxers gave a positive response to at least two
of the following six items:
1 Has anyone heard you grinding your teeth at night?
2 Is your jaw ever fatigued or sore on awakening in the morning?
3 Are your teeth or gums ever sore on awakening in the morning?
4 Do you ever experience temporal headaches on awakening in the
morning?
5 Are you ever aware of grinding your teeth during the day?
6 Are you ever aware of clenching your teeth during the day?
Among bruxers we distinguished between diurnal and nocturnal
activities based on the bruxism-related symptoms. Hence we considered
awake bruxers if at least one of the affirmative responses to the ques-
tionnaire was in the items 5 or 6; whereas the sleep bruxers were those
subjects whose all the affirmative responses were in the items 1–4.
The Spanish version of the Modified Dental Anxiety Scale (MDAS)
was used to determine, on a 5-point Likert scale format (not an-
xious = 1 to extremely anxious = 5), the level of anxiety acknowl-
edged by subjects in the 5 common situations during dental office as-
sistance. [15]. To do this, two scoring strategies were used. The total
score was obtained by adding up all of the item responses, as re-
commended by the developers of the MDAS_TS. In addition, we also
counted the number of items recorded as very anxious or extremely
anxious (coded as 4 and 5, respectively) in order to obtain a useful
quantitative variable proportional to the level of dental anxiety
(MDAS_SC).
For the global personality assessment, the Spanish Version of the
NEO-FFI inventory (60-items) was applied to identify the participants’
personality profiles [16]. It was derived from a factor analysis on the
scores of the original extended inventory (240 items) developed by
Costa & McCrae [17]. The 60 items were divided conceptually into 5
factors (neuroticism, extroversion, openness, agreeableness and con-
scientiousness), which are widely accepted as the five basic domains of
the human personality.
These five relatively independent personality dimensions are
Neuroticism (i.e. a predisposition towards negative affect expressed
through anxiety, depression and hostility), Extroversion (i.e. a desire for
both a greater quantity and intensity of interpersonal interaction),
Openness (i.e. a tendency to seek new experiences and perspectives),
Agreeableness (i.e. a perspective that emphasizes positive qualities in
others and offers an accommodating social presence), and
Conscientiousness (i.e. a quality associated with persistence and at-
tention-to-detail in goal-directed behaviors).
The responses were coded on a 5-point Likert scale (from strongly
disagree = 1 to strongly agree = 5). For each factor, the additive score
was calculated by adding up the response codes coherently oriented
towards the trait being assessed (because some items were inversely
set). The potential range of scores of each domain was 0 to 48 points
and the average of scores was calculated within subgroups. The higher
the scores on a give domain the stronger the personality trait.
The inter-group comparisons for qualitative (nominal and ordinal)
and quantitative variables were done using the Chi-squared test and
ANOVA test with Post Hoc Bonferroni correction, respectively. Using
Pearson coefficients, we studied the linear relationship between the
scores obtained for bruxism symptoms, anxiety and personality. Finally,
we calculated a forward stepwise logistic regression model as a function
of all of the sociodemographic, behavioural and clinical and person-
ality-related variables for predicting the risk of being a self-reported
bruxer. The predictive capacity of the model was calculated with the R2
J. Montero, C. Gómez-Polo Journal of Dentistry xxx (xxxx) xxx–xxx

Table 1 Table 2
Sociodemographic, behavioral and clinical description of the study sample (n = 526). Description of the bruxing activity and the symptoms management in the study sample
(n = 526).
SOCIODEMOGRAPHICS Mean SD
Anamnestic Questionnaire Regarding Bruxing Prevalence of affirmative
Age(years) 43.7 19.0 Activity respondents
Age groups N %
Self-report Bruxism according to Pintado et al. N %
< =34 years 210 39.9
[14]
35–64 years 236 44.9
> =65 years 80 15.2
1. Has anyone heard you grinding your teeth at 110 20.9
Gender night?
Women 262 49.8 2. Is your jaw ever fatigued or sore on awakening 127 24.1
Men 264 50.2 in the morning?
3. Are your teeth or gums ever sore on awakening 123 23.4
Educational level
in the morning?
Secondary School 130 24.7
4. Do you ever experience temporal headaches on 145 27.6
High School 127 24.1
awakening in the morning?
University 269 51.1
5. Are you ever aware of grinding your teeth 58 11.0
Residence during the day?
Urban 344 65.4 6. Are you ever aware of clenching your teeth 159 30.2
Rural 182 34.6 during the day?

Behaviour N % Prevalence of Self-reported Bruxim N %

Non Bruxers (less than two affirmative items) 337 64.1
Brushing
Mild Bruxers (two or three affirmative items) 113 21.5
once/day 152 28.9
Hard Bruxers (4–6 affirmative items) 76 14.4
twice or more/day 374 71.1
Type of Self-reported bruxism N %
Smoking habit
Non bruxers 337 64.1
yes 121 23.0
Awake bruxers (affirmative responses including 83 15.8
no 405 77.0
items n° 5 or n° 6)
Visits to dentist Sleep bruxers (only affirmative responses to items 106 20.2
Regular 223 42.4 n°1–4)
Problem-based 303 57.6
Symptoms management strategies in bruxers (n = 189)
Clinical Variables N % Do you know the occlusal splint for reducing such 111 58.7
symptoms?
Prosthodontic Status
Drugs intake for reducing such symptoms 22 11.6
Complete Denture 37 7.0
Perceived Treatment needs 43 22.8
Removable Partial Dentures 48 9.1
Do you believe your symptoms are Stress-related 133 70.4
Tooth-supported fixed partial dentures 98 18.6
Which tissues are being damaged because of the bruxism activity
Natural dentition 343 65.2
Teeth 129 68.3
Occlusal status Mean SD Joint 114 60.3
Number of Standing teeth in maxilla 12.1 3.9 Gums 77 40.7
Number of Standing teeth in mandible 12.2 3.7 Have you ever wear an occlusal splint 41 21.7
Number of Occlusal Units 11.5 4.1 If Yes, Was it effective in reducing your 32 78.0
symptoms?

of Nagelkerke.
The Statistical Package for the Social Sciences v.20. (SPSS Inc.,
Chicago, IL) was used for the statistical analyses. The cut‐off level for
statistical significance was 0.05. We used the STROBE guidelines for
reporting this study.
3. Results
As depicted in Table 1, the sample was comprised of adults aging
between 18 and 94 years old (mean age = 43.7 ± 19.0 years), equally
distributed by gender, with a high educational level (51.1% university
degrees), and living in urban areas (65.4%). In terms of behavioural
traits, 77% of the sample was non-smokers, generally showed good oral
health habits (71.1% brushed their teeth at least twice a day), and
42.4% regularly visited the dentist (Table 1). Regarding the prostho-
dontics status, the majority of the sample did not wear any type of
dental prosthesis (65.2%) and on average had 11.5 ± 4.1 occlusal
units (antagonistic fixed teeth in contact during the maximal inter-
cuspal position).
In Table 2, the responses regarding the self-reported bruxism ac-
tivities and strategies are depicted. The most prevalent activities iden-
tified from the 6-item questionnaire for assessing bruxism were: item
n°6: clenching the teeth during the day (30.2%) and item n°4: experiencing
temporal headaches on awakening in the morning (27.6%). According to
these responses, 35.9% of the sample was classified as being bruxers,
and in particular sleep bruxers (20.2% of the sample). Among the
bruxers, 70% believed that their symptoms were stress-related and
21.7% had worn occlusal splints, which are mostly effective at reducing
related symptoms (78%). More than 60% of the bruxers acknowledged
that they had teeth and joint damage due to bruxism activity, but only
22.8% of them recognised the need for treatment.
Regarding the psychological factors behind bruxism, Table 3 shows
that the bruxers’ personality scores were significantly higher in neuro-
ticism, extraversion and openness and lower in conscientiousness. Except
for conscientiousness no significant differences were found in the
average scores of the personality traits between awake and sleep
bruxers. Moreover, the number of items recorded as very or extremely
anxious was higher among sleep bruxers for the MDAS (1.1 ± 1.5) than
non bruxers (0.7 ± 1.3). In addition the sleep bruxers tended to per-
ceive more anxiety in all the MDAS situations, with a phobia towards
the teeth scaling and local anaesthetic injection being significantly
more prevalent. Furthermore, smoking was significantly more common
in bruxers (29.6%) than in non-bruxers (19.6%).
By means of Pearson’s coefficients it was observed that the number
of self-reported symptoms (depicted in Table 2) was significantly cor-
related with neuroticism (r = 0.25;p < 0.001), openness (0.11;
p < 0.01), agreeableness (r = −0.10; p < 0.05), conscientiousness
(r = −0.11; p < 0.05), the MDAS-TS(r = 0.09; p < 0.05) and the
MDAS-SC (r = 0.12; p < 0.01).
The logistic regression model highlighted that the risk of being
classified as a bruxer was reduced with age, and increased pro-
portionally with some personality traits, such as neuroticism and

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J. Montero, C. Gómez-Polo Journal of Dentistry xxx (xxxx) xxx–xxx

Table 3 been previously reported elsewhere [18].

Description of the personality traits and the dental anxiety status in bruxers and non- We decided to over recruit the sample, because since this is an ex-
bruxers.
ploratory study then the bigger the sample the clearer the picture of the
Non-Bruxers Awake Sleep Bruxers potential predictors or confounders of the multifactorial construct as-
(n = 337; Bruxers (n = 106; sociated with the self-reported bruxism. With the snowball technique
64.1%) (n = 83; 20.2%) the oversampling is a common event that increases the analytic power.
15.8%) We think that the snowballing recruitment technique is a cost-effective
PERSONALITY TRAITS Mean sd Mean sd Mean sd
method for cross-sectional studies with exploratory purposes.
To our knowledge this is one of the first studies assessing the per-
NEUROTICISM†† (a,b/a,c) 18.7 7.4 22.0 7.9 21.2 7.0 sonality of self-reported bruxers by using a widely accepted ques-
EXTROVERSION† 29.9 7.2 31.6 8.0 31.0 7.1 tionnaire based on the five-factor domains universally accepted in dif-
OPENNESS†(a,c) 24.5 7.7 26.2 8.2 26.4 7.9
ferential psychology [19]. The NEO-FFI has been translated into several
AGREEABLENESS 31.0 6.6 30.4 7.0 30.2 6.8
CONSCIENTIOUSNESS††(a,c/ 32.2 6.8 32.3 6.8 29.3 6.4 different languages and is known to be valid and applicable to a number
b,c) of different contexts, according to McCrae & Costa [20], being currently
DENTAL ANXIETY Mean sd Mean sd Mean sd considered the gold standard for assessing the personality of the human
MDAS-TS (Total score by 10.8 4.7 11.1 5.0 11.8 5.1 being. This self-completed inventory of 60 items provides a quick, re-
summing items codes) liable, and accurate assessment of the five personality domains and is
MDAS-SC: (number of items 0.7 1.3 0.8 1.5 1.1 1.5 particularly useful when global information on personality is needed.
reported as very or extreme
anxious) †(a,c)
The data obtained from our study are in agreement with data reported
for the distinct personality domains in the Spanish validation study
Prevalence of extreme anxiety N % N % N %
[19], in which neuroticism had an average score of 20.5 ± 7.5, agree-
within the following
situations of the MDAS ableness: 30.0 ± 5.9, conscientiousness: 30.5 ± 6.6 and extraversion:
Going for dental treatment 25 7.4 8 9.6 14 13.2 31.7 ± 6.7. However, in the reference study [19] reported a higher
Sitting in the Waiting Room 32 9.5 9 10.8 16 15.1 level for openness with an average score of 28.3 ± 6.7, among the
Drilling a Tooth 80 23.7 25 30.1 33 31.1
Spanish general population [19]. This difference in openness could be
Scaling and polishing teeth* 30 8.9 8 9.6 19 17.9
Injecting local anaesthesia* 65 19.3 18 21.7 33 31.1
due to the socio-educational profile of the sample. In the reference
population study the sample was younger and belonged to a higher
*Statistically significant comparisons after Chi Square tests (p < 0.05) educational level, where 65% of the sample was university students,
**Statistically significant comparisons after Chi Square tests (p < 0.01) and 27% were health education professionals (i.e. working face-to-face
†Statistically significant inter-group comparisons according to ANOVA test (p < 0.05) with customers/users).
††Statistically significant inter-group comparisons according to ANOVA test (p < 0.01)
Here, we have observed, after applying logistic regression, that the
(a,b,c) These letters besides the symbol † indicate the subgroups (a = Non-bruxers;
b = Awake-bruxers; c = Sleep-bruxers) that are statistically different after Post Hoc
level of neuroticism and extraversion is proportional to the risk of be-
Bonferroni correction. coming a bruxer (Table 4). The neurotic profile of bruxers has already
been described by classical studies decades ago, [6,7] where the term
Table 4 “neurotic tensions” was associated with the etiopathology of bruxism.
Logistic regression model (forward stepwise) for predicting the risk of being classified as However, in contrast to what has been proclaimed by authors such as
bruxer after including all the potential predictors (sociodemographic, behavioural, clin- Fisher & O'toole, [8] who reported that chronic bruxers achieved lower
ical and personality-related).
scores in interpersonal warmth and boldness, and higher scores for in-
Parameters β p-value OR CI-95% OR security and tension, we have observed that self-reported bruxers are
significantly more extroverted. Specifically, we have observed that in
Lower Upper general bruxers tend to experience a higher level of joy and excitement
when chatting in social relationships. Conversely, Fisher & O'toole [8]
Age −0.01 0.036 0.99 0.98 0.99
Neuroticism Score 0.06 0.0001 1.06 1.03 1.09 found that bruxers tended to worry with feelings of anxiousness, guilt,
Extraversion Score 0.03 0.016 1.04 1.01 1.06 and tension. Furthermore, according to our linear correlation analysis,
MDAS Total Score 0.08 0.035 1.08 1.01 1.16 it was detected that the number of bruxism-related items and the level
Smoker 0.48 0.029 1.61 1.05 2.48 of openness are significant and directly correlated, which implies that
bruxers are more open-minded, have greater intellectual or artistic in-
Chi: 42.75, df:5; p-value < 0.001. R2 de Nagelkerke = 0.11
terests and are less bored. Future studies are needed to address these
contradicting results, although, several hypotheses could be raised to
extraversion, in relation to the MDAS total score, and in smokers, after
explain this discrepancy. Probably, the most plausible explanation for
controlling for all potentially confounding factors (Table 4).
this finding could rely on the fact that Fisher & O’toole clinically as-
sessed bruxism primarily on chronic periodontal patients [8]. They
4. Discussion determined the bruxism based on the specific history of pain and dys-
function, awareness of the bruxism and the objective abrasion of tooth
This study assesses the psychological background (Personality/ surfaces [8]. Hence, it might be argued that patients classified in their
Anxiety) of self-reported bruxism, which is an emerging line of research study as chronic bruxers, had suffered from higher levels of chronic
that focuses on the central causes of bruxism, as has been recently pain/dysfunction and presented more evidently worn teeth. It has been
highlighted [2,10]. However, to date, there is still a need for re- clearly determined that patients of chronic pain have higher anxiety,
searchers to identify the personality traits associated with individuals depression, and as a consequence developed less facets of extraversion
who perceive they suffer from bruxism-related symptoms. and openness [21]. It seems plausible to presume that there exists a
Although, the cross-sectional design of this study did not allow higher social impact on chronic patients with evidently worn teeth than
conclusions to be drawn regarding the causal relationship between those without this condition. Therefore, bruxing should be conceived as
psychological factors and self-reported bruxism, this work carried out an expressive neurotic behaviour that reveals conflicting feelings of
on a large convenience sample might contribute to the understanding of those who manifest it, and ultimately, as a peculiar type of coping with
the association between personality, anxiety and self-reported bruxism. stressful events.
In addition, the existence of some shared pathogenetic pathways has Regarding the bruxism diagnosis methodology, it should be

4
J. Montero, C. Gómez-Polo
mentioned that there are various ways to assess bruxism activity; while
questionnaires are the most commonly used method and are mainly
carried out within large sample populations. Although there is a lack of
universally accepted criteria for the diagnosis of bruxism, [22] a simple
questionnaire based on yes or no answers about the participants’
awareness of bruxism has been frequently used in epidemiological
studies [23]. In this study we used the typical set of six items with the
same dichotomous response that was initially used by Pintado et al.,
[14] and later by other authors [24] for detecting bruxers.
However, one must bear in mind that in this study we only detected
possible bruxers according to a recent international consensus, which
suggests that a diagnostic grading system of “possible”, “probable”, and
“definite” sleep or awake bruxism should be adopted for clinical and
research purposes, depending on the methodology applied [1]. Self-
reported bruxism by means of a questionnaire and/or the anamnestic
part of a clinical examination would only detect “possible” sleep or
awake bruxism, while “probable” sleep or awake bruxism should be
based on both self-reported bruxism and the specific clinical examina-
tion [1]. The “definite” sleep or awake bruxism would also require a
polysomnographic or electromyograhic assessment, respectively [1].
The accuracy of these diagnostic methods is unclear, (sensitivity and
specificity) but we believe that for the investigative purposes of this
study, the questionnaire-based assessment would present greater sen-
sitivity and lower specificity than exhaustive clinical assessments, be-
cause anamnesis is the first step in diagnosing possible bruxism (high
sensitivity tool) that should be latter confirmed by more specific as-
sessments (oral examination, electromyography, polysomnography…)
[1]. However, the awareness of the bruxism needs to be explored in
future studies, where self-reported bruxism is complemented with other
specific clinical assessments in order to confirm the possible cases and
types of bruxism.
In this study we have found that both awake and sleep bruxers share
a comparable personality profile, despite they are currently considered
distinct entities (i.e. awake bruxism being an oral habit; and sleep
bruxism being a sleep disorder). Our findings support the current theory
that characterises bruxism as a multifactorial disorder, which may share
some neurological deficits with other centrally mediated conditions.
Our results are in agreement with those obtained in a recent study
performed on Turkish adults, which found that bruxers differed sig-
nificantly in terms of depression, anxiety, hostility, phobic anxiety,
paranoid ideation, and other psychological-related attributes [25].
Other authors have revealed that mood disorders are more prevalent
among bruxers [26], suggesting that bruxers are probably chronic
worriers.
Additionally, there is evidence regarding the effect of gender on
dental attrition, where males have a higher risk than females of tooth
wear [27]; however, a recent systematic review stated that bruxism
activities are unrelated to sex, but are related to a decrease associated
with age [28]. We agree with the abovementioned statement, since we
found, within a logistic regression model, that the prevalence of
bruxism activity decreased with age, but was unrelated to gender
(Table 4).
Regarding the association of bruxism and dental fear, we found that
bruxers reported significantly higher anxiety according to the MDAS
[15]. Recently Winocur et al. demonstrated a significant association
between bruxers and dental fear among 480 Israeli adults, using the
same methodology (i.e. questionnaire-based determination of bruxim
and dental anxiety) [29].
The rationale of this association may rely upon the fact that per-
sonality modulates all human behaviour and that specifically, the level
of neuroticism increases emotional stress (susceptibility to negative
emotions). Neuroticism is quite likely to disturb the quality of sleep
during the night among sleep bruxers [18] and could therefore increase
the parafunctional activities during the day for awake bruxers [4].
An important fact, which should be taken into account before the
interpretation of our findings, is that the level of neuroticism-related
5
Journal of Dentistry xxx (xxxx) xxx–xxx
traits may bias the self-reported health or symptoms assessment, since it
is proportional to the susceptibility to experiencing negative emotions
[30]. Therefore, since we estimated bruxism based on a self-completed
questionnaire, it may be plausible that the strong association found
between several personality traits and bruxism would be reduced if a
confirmatory assessment of bruxism had been implemented.
All the psychological factors analysed in this study came directly
from the subjects, whose perceptions regarding personality traits and
bruxism-related symptoms have demonstrated a significant and strong
association. We are well aware that the information gathered by some
personality profiles might be altered (overscored or underscored), but
in this study we wanted to capture the subjects’ own perception of
themselves, rather than a clinical-based rating, in order to visualize and
quantify this association. A major limitation might come from the fact
that bruxism could be a considered a subconscious disorder that may
not be accurately reflected using self-assessment. It should also be ac-
knowledged that the convenience sample used for this study may be
adequate for exploring the potential associations and to create hy-
pothesis on which future works might be based, but it is not re-
presentative of the general population, and thus all the associations and
scores reported here should be taken with caution.
5. Conclusions
Self-reported bruxism is significantly associated to several person-
ality traits (mainly neuroticism and extraversion) and to the level of
dental anxiety (assessed by the MDAS score).
Conflict of interest
Montero J declares that he has no conflict of interest. Gómez-Polo C
declares that she has no conflict of interest.
Ethical approval
All procedures performed in this study were in accordance with the
ethical standards of the institutional and/or national research com-
mittee and with the 1964 Helsinki declaration and its later amendments
or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants in-
cluded in the study.
Funding
The work was supported by Advances in Oral Health Group of the
University of Salamanca (Spain).
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