Eur Arch Paediatr Dent
DOI 10.1007/s40368-017-0312-x
ORIGINAL SCIENTIFIC ARTICLE
The prevalence of sleep bruxism and associated factors
in children: a report by parents
M. A. Clementino1 • M. B. Siqueira1 • J. M. Serra-Negra2 • S. M. Paiva2
A. F. Granville-Garcia3
Received: 22 February 2017 / Accepted: 22 September 2017
 European Academy of Paediatric Dentistry 2017
Abstract
Aim To evaluate the prevalence of sleep bruxism and
associated factors among children aged 3–12 years as
reported by parents via a questionnaire.
Methods A cross-sectional study was conducted with a
sample of 148 parents/caregivers of children aged
3–12 years treated at paediatric dentistry clinics. Par-
ents/caregivers answered a questionnaire in the waiting
room. Information on the gender and age of the child, age
of parent/caregiver, meaning of bruxism and child’s sleep
(type of sleep, if he/she slept alone, hours of sleep per night
and if nocturnal bruxism could affect his/her health) were
collected. Descriptive statistics were performed and Pois-
son regression with robust variance was employed
(p \ 0.05).
Results The prevalence of sleep bruxism was 32.4%. Most
parents (64.2%) did not know the meaning of bruxism. In
the final Poisson regression model, child’s gender (PR
1.32; 95% CI 1.06–1.66) and restless sleep (PR 1.39; 95%
CI 1.12–1.72) were significantly associated with sleep
bruxism.
Conclusion The prevalence of sleep bruxism was high and
was associated with gender and having restless sleep. Most
parents/guardians did not know the meaning of bruxism.
& A. F. Granville-Garcia
anaflaviagg@hotmail.com
1
Department of Dentistry, State University of Paraı́ba,
Campina Grande, Brazil
2 occurs repeatedly over a prolonged period of time. The
Department of Paediatric Dentistry, University of Minas
Gerais, Belo Horizonte, Brazil
3 headache, jaw muscle pain, discomfort during chewing and
Department of Dentistry, State University of Paraı́ba, Street
Juvêncio Arruda s/n, Bodoncogó, Campina Grande, PB,
Brazil
•
Keywords Bruxism
Sleep bruxism
Children
Restless
sleep
Introduction
Bruxism is a repetitive jaw muscle activity characterised by
clenching or grinding the teeth and/or by bracing or
thrusting the mandible. This parafunctional activity has two
distinct circadian manifestations. It can occur during sleep
(denominated sleep bruxism) or during waking hours
(Lobbezoo et al. 2013; Huynh et al. 2016; Drumond et al.
2017).
The literature reports prevalence rates of bruxism
ranging from 2 to 40%. The prevalence is higher in
childhood and decreases with in age (Manfredini et al.
2013; Serra-Negra et al. 2013; Garde et al. 2014; Saulue
et al. 2015; Soares et al. 2016; Tachibana et al. 2016).
There are also divergences with regard to the data collec-
tion methods used to assess bruxism in children and studies
on this parafunctional habit have been conducted with
different age groups (Lam et al. 2011; Manfredini et al.
2013; Serra-Negra et al. 2013). The divergences in the
results of different studies on bruxism in children under-
score the need for further research on this subject (Serra-
Negra et al. 2010; Vieira-Andrade et al. 2014).
Bruxism has a multifactorial aetiology (Mengatto et al.
2016). Sleep bruxism is a type of sleep disorder (Lam et al.
2011) that is of particular concern to parents, as the noise
produced during tooth grinding is often quite intense and
consequences of this habit are excessive tooth wear,
limited jaw opening (Serra-Negra et al. 2014a, b; Firmani
et al. 2015; Guo et al. 2017).
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A number of theories associate emotional factors with Exclusion criteria

the occurrence of sleep bruxism (Restrepo et al. 2008;
Serra-Negra et al. 2012, 2013). Individuals with stress and/ • Illiterate parents/caregivers;
or specific personality traits tend to release the tension • Parents/caregivers with special needs (psychological,
accumulated during the day through sleep bruxism (Serra- psychiatric or neurological disorders) that impeded
Negra et al. 2012, 2013; Firmani et al. 2015; Mengatto providing reliable responses.
et al. 2016). However, none of these theories has been
confirmed.
Pilot study
The diagnosis of bruxism is usually based on an inter-
view, clinical evaluation and objective polysomnography
A pilot study was conducted with 10 parents/caregivers to
(sleep test) (Huynh et al. 2009). The most common method
test the methods. The assessment tool was a questionnaire
for diagnosing bruxism in children is parental reports of
that was validated and employed in a previous study
grinding the teeth (American Association of Sleep Medi-
(Serra-Negra et al. 2013; Tavares-Silva et al. 2016). The
cine 2005; Firmani et al. 2015; Saulue et al. 2015).
participants in the pilot study were not included in the main
Therefore, parents/caregivers play an important role in the
study. The results of the pilot study demonstrated no need
detection of sleep bruxism in children. However, detection
to change the questionnaire or methods.
is often impeded by a lack of prior knowledge regarding
bruxism (Tavares-Silva et al. 2016).
Data collection
The few studies evaluating the prevalence of sleep
bruxism in children have employed different methodolo-
A validated questionnaire (Serra-Negra et al. 2013; Tavares-
gies and only bivariate statistical analyses (Souza et al.
Silva et al. 2016) was created based on the criteria of the
2015; Tavares-Silva et al. 2016). The multivariate statis-
American Association of Sleep Medicine (AASM 2005;
tical analysis used in the present investigation ensures
Serra-Negra et al. 2010). The questionnaire was self-ad-
greater reliability of the results. The purpose of the present
ministered in the waiting room of the paediatric clinic
study was to evaluate the prevalence of sleep bruxism and
without any assistance from the researcher or other family
associated factors among children aged 3–12 years,
member. The diagnosis of sleep bruxism was based on the
reported through parental perception.
reports of parents/caregiver, which is a criterion of the
AASM for children in this age group. Upon completion, the
questionnaire was immediately returned to the researcher.
Materials and methods
The assessment tool contained 17 questions and was
used to collect information on both the children/adoles-
Sample characteristics
cents and the parents/caregivers. The following data on the
children/adolescents were recorded: age, gender, sleep
A cross-sectional study was conducted with 148 par-
characteristics, type of sleep, if they slept alone or other-
ents/guardians of children aged 3–12 years awaiting treat-
wise, hours of sleep per night, and if nocturnal bruxism
ment at the paediatric dentistry clinics of the State University
could affect their health. The following data on the par-
of Paraiba in the city of Campina Grande, Brazil, between
ents/guardians were recorded: relationship to child, whe-
March 2015 and June 2016. The participants constituted a
ther they suffered from nocturnal bruxism and if they had
convenience sample and participation was voluntary.
knowledge of nocturnal bruxism and its causes. Two pre-
Campina Grande (population: 386,000) is an industrialised
viously trained dentists conducted this process. The care-
city in northeast Brazil and is divided into six health districts.
givers answered the questionnaires individually without
The city has a Human Development Index of 0.72 (Brazilian
consultations or discussions with colleagues or family.
Institute of Geography and Statistics 2016).
After completing the questionnaires, the participants
received information on bruxism.
Eligibility criteria
Statistical analysis
Inclusion criteria
Descriptive statistics were performed for age, gender, the
• Parents/caregivers of children aged 3–12 years await-
presence of sleep bruxism and information on the par-
ing treatment at the paediatric dentistry clinics of the
ents/caregivers. Poisson regression with robust variance
State University of Paraı́ba, Brazil.
was used to investigate factors associated with sleep
• Parents/caregivers accompanying the child on the first
bruxism.
visit to the dentist.

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Bivariate Poisson regression analysis was used to Table 1 Demographic characteristics of the sample
determine the associations between the independent vari- Variables Frequency (n) %
ables and the occurrence of bruxism. The frequency dis-
tribution of the data was determined considering the effect Child’s gender
size correction (Pearson 1905). Bivariate Poisson regres- Male 76 48.6
sion analysis also considered the effect size. Female 72 51.4
In the multivariate model, the backward stepwise pro- Child’s age
cedure was used to incorporate variables with a p value \ 7 years 77 52.0
\ 0.20 in the bivariate analysis. The multivariate analysis C 7 years 71 48.0
began with two variables and the remaining variables were Bruxism
incorporated one by one. Variables with a p value [ 0.05 Present 48 32.4
were removed from the final model. This procedure was Absent 100 67.6
performed until all variables were analysed and only those Parent/caregiver
with a p value \ 0.05 in the adjusted analysis were main- Mother 114 77.0
tained in the final regression model. The Statistical Pack- Father 13 8.8
age for Social Sciences (SPSS for Windows, version 20.0, Grandfather/grandmother 14 9.5
SPSS Inc, Chicago, IL, USA) was used to enter the data Other 7 4.7
and conduct the analyses. Knowledge of meaning of bruxism
Age categorisation considered the WHO classification Yes 53 35.8
for the primary dentition (children under 7 years) and No 95 64.2
mixed dentition (children 7–12 years) in bivariate and
multivariate analyses (WHO 1997).
sleep bruxism was associated with a child’s gender, par-
Ethical aspects ent’s/caregiver’s age, knowledge on part of parent/care-
giver regarding bruxism, occurrence or history of bruxism
The procedures were conducted in accordance with the in parent/guardian, type of sleep (child sleeps well/has
standards for experiments involving human subjects and difficulty sleeping). Bivariate Poisson regression analysis
the 1975 Declaration of Helsinki (revised in World Medi- considered the effect size to confirm the clinical signifi-
cal Association 2013). This study was submitted for cance of the associations. In the final Poisson model,
approval by the ethics committee of the State University of however, only child’s gender (PR 1.32; 95% CI 1.06–1.66)
Paraiba in compliance with Resolution No. 466/2012 of the and difficulty sleeping (PR 1.39; 95% CI 1.12–1.72) were
Brazilian National Board of Health. After receiving clari- significantly associated with sleep bruxism (p \ 0.05).
fications regarding the procedures and being assured of the
absence of risks, parents/caregivers who agreed to partic-
ipate signed a statement of informed consent. Discussion

The prevalence of sleep bruxism reported by parents/care-

Results
A total of 148 children participated in the study. The girls
accounted for 51.4% of the sample. The prevalence of
sleep bruxism reported by parents/guardians was 32.4%.
Among the parents/caregivers, 64.2% reported not having
knowledge of sleep bruxism (Table 1).
Table 2 shows the frequency of children who had sleep
bruxism related to gender and age. Sleep bruxism was more
frequent among female children (64.5%). The prevalence
of bruxism was higher in children aged 4 and 9 years.
Table 3 displays the associations between the indepen-
dent variables (child’s gender and age, parent’s/caregiver’s
age, knowledge on part of parent/caregiver regarding
bruxism and information on the child’s sleep) and the
dependent variable (bruxism). In the bivariate analysis,
givers was high, and similar to rates reported in the literature
(Serra-Negra et al. 2013; Soares et al. 2016). Other studies
have shown a lower prevalence than the present study
(Tachibana et al. 2016; Tavares-Silva et al. 2016). The
prevalence of sleep bruxism in early childhood varies across
studies mainly due to differences in the age groups evaluated
and the methods employed (Manfredini et al. 2013; Serra-
Negra et al. 2013; Garde et al. 2014; Soares et al. 2016).
In the present study, most parents/caregivers were una-
ware of the meaning of bruxism, which may have led to an
underestimation of the prevalence of this parafunctional
habit. In a previous investigation, 61.9% of parents/care-
givers lacked knowledge of sleep bruxism and did not
know what caused the condition (Tavares-Silva et al.
2016). There therefore appears to be large gaps in knowl-
edge about bruxism that need to be clarified by healthcare

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Table 2 Frequency of bruxism

Age of the children (years) Presence of bruxism
in children related to gender and
age in a Brazilian population Gender of the children
Female n (%) Male n (%) Total n (%)

2 2 (4.1) 1 (2.0) 3 (6.1)

3 1 (2.0) – 1 (2.0)
4 7 (15.1) – 7 (15.1)
5 1 (2.0) – 1 (2.0)
6 3 (6.2) 3 (6.2) 6 (12.4)
7 4 (8.3) 1 (2.0) 5 (10.3)
8 2 (4.1) 1 (2.0) 3 (6.1)
9 4 (8.3) 3 (6.2) 7 (14.5)
10 4 (8.3) 1 (2.0) 5 (10.3)
11 2 (4.1) 2 (4.1) 4 (8.2)
12 1 (2.0) 5 (11.0) 6 (13.0)
Total 31 (64.5) 17 (35.5) 48 (100)

professionals. As childhood bruxism can persist into
adulthood (Serra-Negra et al. 2009), early diagnosis can
help control the habit and prevent harm to components of
the masticatory system (Serra-Negra et al. 2013). Thus,
knowledge of sleep bruxism is essential and allows par-
ents/caregivers to report the medical history and current
medical status of their children with greater accuracy.
Some researchers report that bruxism is more prevalent
in boys (Liu et al. 2005; Nahás-Scocate et al. 2014). In the
present investigation, however, girls were statistically
associated with this parafunctional habit, whereas other
studies have found no significant association between sleep
bruxism and gender in a paediatric population (Bharti et al.
2006; Manfredini et al. 2013). A number of studies report
that girls in the menarche phase may have sensory disor-
ders in trigeminal muscles caused by sex hormones, which
may be directly related to bruxism and temporomandibular
disorder (Pereira et al. 2010; Fernandes et al. 2016).
The present study showed that sleep bruxism was more
prevalent among older children (7–12 years). Some studies
have shown a greater prevalence of sleep bruxism in the
mixed dentition (Restrepo et al. 2006; Kobayashi et al.
2012; Restrepo et al. 2016). The premature appearance of
some teeth, occlusal imbalances, and the possible effects of
occlusal and periodontal forces may explain these associ-
ations (Restrepo et al. 2016).
Restless sleep was statistically associated with the
occurrence of sleep bruxism. Previous studies report that
children with bruxism may exhibit other sleep disorders,
which are clinically known as parasomnias and include
talking during sleep, sleepwalking, bed-wetting, snoring
and the occurrence of nightmares (Khatwa et al. 2013;
Tavares-Silva et al. 2016). The authors of one study found
that episodes of bruxism coincided with changes in the
stages of sleep as well as interrupted, fragmented sleep,
suggesting an association (Bader et al. 1997). It is possible
that adversities during the day can cause difficulty sleeping,
leading to functional changes in average levels of para-
functional muscle contractions. However, children with
normal slumber may also have a history of bruxism
(Khatwa et al. 2013; Nahás-Scocate et al. 2014) and further
studies on these aspects should be conducted.
The number of hours of sleep per night was not signifi-
cantly associated with bruxism. This may be due to the lack
of knowledge on the part of parents/caregivers regarding the
meaning of bruxism. In contrast, previous studies have
reported an association between sleep bruxism and the
number of hours of sleep. It is believed that less than 8 h of
sleep per night diminishes sleep quality and is therefore a
risk factor for the development of bruxism (Lavigne et al.
2008; Serra-Negra et al. 2012). The influence of bruxism on
quality of sleep can affect the mood, concentration, rea-
soning and other cognitive aspects of individuals. Sleep
deprivation can have a negative effect on the learning pro-
cess, resulting in poor academic performance, and can exert
an impact on health (Serra-Negra et al. 2013, 2014a, b).
The present study has the limitations inherent to a cross-
sectional design and the answers to the questionnaire may
have been subject to information bias. The under-notification
of bruxism can occur when parents/caregivers are unaware
of this habit in their children. Thus, longitudinal studies
should be conducted to gain a better understanding of the
causality of factors in the occurrence of this parafunctional
habit. However, the high prevalence of sleep bruxism and
general lack of knowledge on the part of parents/caregivers
underscore the need for public health policies that involve a
multidisciplinary approach to this problem.
According to the perceptions of parents/caregivers, the
prevalence of sleep bruxism was high in the present sample
of children. This parafunctional habit was associated with

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Table 3 Bivariate and multivariate Poisson regression models for independent variables associated with bruxism
Variables Bruxism Bivariate Size effect Multivariate
Absent Present Unadjusted PR * Adjusted PR  
n (%) n (%) p value (95% CI) p value (95% CI)

Child’s gender
Male 55 (76.4) 17 (23.6) 1.00 1.00
Female 45 (59.2.) 31 (40.8) 0.020 2.229 (1.095–4.536.) 0.18 0.014 1.328 (1.060–1.664)
Child’s age
\ 7 years 54 (70.1) 23 (29.9) 0.488 1.00 0.05
C 7 years 46 (64.8) 25 (35.2) 1.276 (0.640–2.543)
Parent’s/caregiver’s age
B 34 years 54 (73.0) 20 (27.0) 0.143 1.00 0.12
[ 34 years 45 (61.6) 28 (38.4) 1.680 (0.837–3.373)
Hours of sleep per night
B8h 31 (62.0) 19 (38.0) 0.366 1.395 (0.680–2.862) 0.07
[8 h 66 (69.5) 29 (30.5) 1.00
Parent/caregiver thinks bruxism affects health
No 25 (61.0) 16 (39.0) 1.480 (0.698–3.373)
Yes 74 (69.8) 32 (30.2) 0.306 1.00 0.08
Parent/caregiver has/had bruxism
No 38 (29.9) 81 (70.1) 1.00
Yes 11 (52.4)) 10 (47.6) 0.109 2.129 (0.834–5.433) 0.13
Child sleeps well
No 9 (50.0) 9 (50.0) 0.094 2.308 (0.160–1.175) 0.13
Yes 90 (69.8) 39 (30.2) 1.00
Restless sleep
No 47 (81.0) 11 (19.0) 0.050 1.00 0.23 0.002 1.00
Yes 53 (58.9) 37 (41.1) 2.983 (1.368–6.502) 1.394 (1.126–1.725)
Child sleeps alone
No 64 (68.8) 29 (31.1) 0.673 1.165 (0.574–2.365) 0.03
Yes 36 (65.5) 19 (34.5) 1.00
CI confidence interval, PR prevalence ratio
* Poisson regression not adjusted for independent variables and bruxism
  Variables incorporated in multivariate model (p \ 0.20): child’s gender, child’s age, knowledge of bruxism, parent/caregiver has/had bruxism,
child sleeps well, child has difficulty sleeping, child sleeps alone

the female gender and the occurrence of restless sleep.
Moreover, the majority of parents/caregivers did not know
the meaning of bruxism.
Compliance with ethical standards
Conflict of interest Marayza Alves Clementino, Maria Betânia
Siqueira, Júnia Maria Serra-Negra, Saul Martins Paiva, Ana Flávia
Granville-Garcia declare that they have no conflict of interest.

Conclusions Ethical approval All procedures were conducted in accordance with

The prevalence of sleep bruxism in a Brazilian child pop-
ulation was high and was associated with gender and
having restless sleep. Most parents/guardians did not know
the meaning of bruxism.
the ethical standards of the institutional and/or national research
committee as well as the 1964 Declaration of Helsinki and its sub-
sequent amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all partici-
pants in the study.

123

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