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\begin{document}

\title{Is there a relation between sleeping habits and nocturnal bruxism,
temporomandibular disorders, dental trauma and caries among children?}



\author[1]{Asli Topaloglu Ak}%
\author[2]{Huseyin Kurtulmus}%
\author[2]{sila basa}%
\author[3]{Osman Sabuncuoglu}%
\affil[1]{Istanbul Aydin Universitesi}%
\affil[2]{Affiliation not available}%
\affil[3]{Marmara University School of Medicine}%


\vspace{-1em}



  
  \date{May 08, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: Sleep disorders are common among children and have a negative
impact on growth and development. Recently reports demonstrate a
possible association with oral findings as well. The aim of this study
was to evaluate the possible association between sleeping habits,
bruxism, temporomandibular disorders (TMD), traumatic dental injuries
(TDI) and dental caries in children. Material and Methods: A
cross-sectional study was carried out at IAU Faculty of Dentistry with a
representative sample of a hundred children aged between 6-13.
Children's Sleep Habits Questionnaire (CSHQ) was completed by their
parents. Intra oral examination was carried out in a clinical setting
and presence of nocturnal bruxism, history of TDI were recorded for each
child. Results: Among sleeping habits, bed time resistance was found
significantly related with children who had nocturnal bruxism and
temporomandibular disorders. Untreated dental caries was also found
significantly associated with sleep fragmentation. However, no relation
was found with traumatic dental injuries. Conclusion: Children with
symptoms of bruxism, TMD and untreated dental caries might experience
negative impacts on their sleeping habits and characteristics.
Pediatricians and pedodontists should work in collaboration to identify
causes and clinical features of sleeping habits and disorders in order
to avoid negative effects on stomatognathic system.%
\end{abstract}%



\sloppy


\textbf{Is there a relation between sleeping habits and nocturnal
bruxism, temporomandibular disorders, dental trauma and caries among
children?}

\textbf{ABSTRACT}

\textbf{Aim:} Sleep disorders are common among children and have a
negative impact on growth and development. Recently reports demonstrate
a possible association with oral findings as well. The aim of this study
was to evaluate the possible association between sleeping habits,
bruxism, temporomandibular disorders (TMD), traumatic dental injuries
(TDI) and dental caries in children.

\textbf{Methods:} A cross-sectional study was carried out at IAU Faculty
of Dentistry with a representative sample of a hundred children aged
between 6-13. Children's Sleep Habits Questionnaire (CSHQ) was completed
by their parents. Intra oral examination was carried out in a clinical
setting and presence of nocturnal bruxism, history of TDI were recorded
for each child.

\textbf{Results:} Among sleeping habits, bed time resistance was found
significantly related with children who had nocturnal bruxism and
temporomandibular disorders. Untreated dental caries was also found
significantly associated with sleep fragmentation. However, no relation
was found with traumatic dental injuries.

\textbf{Conclusion:} Children with symptoms of bruxism, TMD and
untreated dental caries might experience negative impacts on their
sleeping habits and characteristics. Pediatricians and pedodontists
should work in collaboration to identify causes and clinical features of
sleeping habits and disorders in order to avoid negative effects on
stomatognathic system.

\textbf{Keywords:} Sleeping habits, Sleep disorders, Children's Sleep
Habits Questionnaire (CSHQ), bruxism, temporomandibular disorders,
malocclusion, traumatic dental injuries, dental caries, children

\textbf{What is already known about this topic?}

Sleeping problems of have been associated with bruxism and
temporomandibular disorders in adult population. Dental caries presence
was found to be related to sleep fragmentation leading to inadequate
sleep in children.

\textbf{What does this article add?}

The present study confirms the sleeping habits are associated with sleep
bruxism and symptoms of temporomandibular disorders in children as well.
Bed time resistance is found to be related to nocturnal bruxism and TMD
symptoms. Furthermore, sleep fragmentation is found to be associated
with untreated dental caries due to severe pain mostly rising from
seconder acute pulpitis cases. Pediatric dentists should be aware of the
fact that oral finding, symptoms can affect the quality of sleep.
Likewise, pediatricians must integrate with pediatric dentists to
diagnose, treat and avoid sleep related oral health problems.

\textbf{Is there a relation between sleeping habits and nocturnal
bruxism, temporomandibular disorders, dental trauma and caries among
children?}

\textbf{INTRODUCTION}

It is well noted that sleep has an important effect on the growth and
development of a child. Yet, sleep disorders are common in children from
infancy through adolescence.\textsuperscript{(1-3)} Sleeping habits and
patterns should be detected by parents, and pediatricians prudently to
avoid possible adverse effects on general
health.\textsuperscript{(4)}Sleeping habits may vary from resistance to
bedtime, delayed and fragmented sleep to inability to sleep alone. These
are all associated with the socio-cultural, physical, emotional and
neurological development.\textsuperscript{(5,6)}

In order to identify sleeping habits of a child many techniques and
instruments and questionnaires are available. The Children's Sleep
Habits Questionnaire (CSHQ) is a parent-proxy valid and reliable
instrument that investigates children's sleep habits and sleep-related
difficulties.\textsuperscript{(7)}

Sleeping disorders are defined mainly as the dyssomnia and parasomnia
according to the International Classification of Sleep Disorders
(ICSD).\textsuperscript{(8)} Dyssomnia defines inadequate, excessive or
poor quality of sleep whereas parasomnia indicates behavioral problems
that occur in sleep such as sleep apnea, sleep terror, sleepwalking,
enuresis and bruxism. \textsuperscript{(3)}

Exacerbated nocturnal bruxism may lead to an imbalance in the
stomatognathic system. This may cause heterogeneous musculoskeletal
disorders, including temporomandibular joint and/or related structures
in the long term. The perception of discomfort leads to the prevention
of stability in the stomatognathic system with the presence of
dysfunction. \textsuperscript{(9-11)} This chronic disorder and fatigue
is a condition that affects quality of life and sleep negatively. Hence
early diagnosis and follow ups are crucial. Notably, child bruxers are
reported to have fragmented sleep which affects the sleep quality
adversely.\textsuperscript{(12-14)} One other factor that can affect
sleeping pattern is dental caries which can also lead to awakening from
sleep at nights. A cohort study revealed that late bed time was
associated with dental caries incidence as
well.\textsuperscript{(15)}Like chain reaction, poor sleep quality
impacts the attention level and motor skills. This might increase the
frequency of dental trauma incidence.\textsuperscript{(16,17)}
Considering sleep problems are common in the pediatric population, its
potential relation with bruxism, tmd, tdi and dental caries are in scope
of researchers' interest. Therefore, the aim of this study was evaluate
the possible association between sleeping habits, bruxism,
temporomandibular disorders (TMD), traumatic dental injuries (TDI) and
dental caries through CSHQ in children aged between 6-13 years.

\textbf{METHODS}

The study protocol was approved by the Human Research Ethics Committee
of the Istanbul Ayd\selectlanguage{polish}ı\selectlanguage{english}n University (2020/169). The study was carried out
in full compliance with the World Medical Association Declaration of
Helsinki.

This cross-sectional study involved 100 children aged between 6-13 years
old who referred to Istanbul Ayd\selectlanguage{polish}ı\selectlanguage{english}n University Faculty of Dentistry
Department of Pediatric Dentistry with their parents for their routine
controls or dental treatment. The exclusion criteria included systemic
diseases, fixed/removable intra/extra oral appliance and lack of
cooperation. Written consent was obtained.

The data on sleeping habits were collected through parent proxy report
through Children's Sleep Habit Questionnaire (CSHQ) that has 33
questions. It is segmented in four main subjects: bedtime resistance,
sleep behavior problems, sleep fragmentation and daytime sleepiness.
Each item has three response options regarding how often the
investigated conditions occurred the previous week. Frequencies were
coded as `usually' if the specified behavior occured more than four
times a week, `sometimes' for 2-4 times a week and `rarely' for 0-1 time
a week. Presence of bruxism and history of traumatic dental injury was
recorded as well.

Intra oral examinations were done by one operator in order to avoid
inter-operator bias in a clinical setting. Carious lesions were recorded
using WHO criteria. The clinical examination included TMJ examination,
Angle Classification and malocclusion. Canines and incisor teeth and
adjacent soft tissues were examined for clinical findings of traumatic
dental injuries.

TMJ examination was rated according to Helkimo anamnestic and clinical
pain-dysfunction index. Lack of symptoms were encoded as `Grade 0', mild
symptoms (feeling of fatigue in the muscles, muscle stiffness and / or
pain, masticating muscular disorders) were encoded as `Grade 1'and
serious symptoms (not being able to open the mouth too much, jaw locking
or dislocation, pain and limitation in mandibular movements, pain in the
area of the tmj and / or masticatory muscles, condyle-disc
irregularities in tmj) were encoded as `Grade 2'.

Occlusion was recorded according to Angle Classification and presence of
overjet, anterior open bite, overbite, crowding, spacing, crossbite was
also noted as malocclusion.

\textbf{Statistical Analysis}

The statistical analysis was conducted using SPSS 25 (IBM Corp. Released
2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM
Corp.) Data were analyzed by Fisher's Exact Test and Chi Square test. In
cases where the expected frequencies are less than 20\%, evaluation was
made with the ``Monte Carlo Simulation Method'' to include these
frequencies in the analysis. For the significance level of the tests, p
\textless{}0.05 and p \textless{}0.01 value were accepted.

\textbf{RESULTS}

A total of 100 patients (55 female and 45 male) who met the inclusion
criteria and their parents were included in this study. Most of these
parents were represented by mothers (76\%), followed by fathers (21\%)
and other relatives (3\%).

40\% of parents reported that their children had nocturnal bruxism.
Gender was found insignificant with the presence of bruxism. The
prevalence of TMJ disorder symptoms was 9\%. A significant relation was
found among children with nocturnal bruxism and TMD symptoms. The
presence of bruxism was significantly higher in individuals who had TMJ
disorder symptoms (p\textless{}0,05). (Table-1)

There was a statistically significant relation between bruxism and
bedtime resistance. The presence of bruxism was significantly higher in
child who had bedtime difficulties (p=0.02) (Table-2)

A statistically significant relation between children with TMJ disorder
symptoms and bed time resistance (p=0.02) and sleep behavior disorder
was noted. (p=0.04) (Table-3)

The prevalance of untreated dental caries was 98\%. The presence of
caries was also found significantly associated with awakening from sleep
at nights and sleep fragmentation. (p=0.001) (Table-4)

The permanent molar relationship was \%79 Class I, \%11 Class II and
\%10 Class III according to Angle Classification. There was no
significant relation found between the sleeping characteristics.

The prevalence of traumatic dental injury was 22\%. However, no
significant relation was found between sleeping habits. (p
\textgreater{}0.05)

\textbf{DISCUSSION}

Today, sleeping habits of children are in the focus of not only
pediatricians but dentists as well. The relationships between sleeping
habits and possible TMJ problems, malocclusion, TDI, bruxism and dental
caries have been investigated recently and still holds a major area of
research interest.\textsuperscript{(15-17)}

In this study, Turkish Version of CSHQ was used for data colletion. This
questionnaire was translated to Turkish and validated and reported to be
a reliable instrument for assessing sleep habits and screening possible
sleep problems of Turkish children.\textsuperscript{(18)}Although there
are various concerns that parent's notifications may differ from the
child's self-report, scales based on parents' reports are frequently
used in both psychiatry and pediatric practices.\textsuperscript{(19)}It
is noteworthy that, American Academy of Sleep Medicine considers the
reports of parents to be reliable and sufficiently objective for use in
epidemiological studies.\textsuperscript{(8)}

In the present study, prevalence of sleep bruxism was found 40\%.
However bruxism prevalance among children displays a fluctuating
pattern.\textsuperscript{(4,9,11,20)} In a systematic review by Machado
et al., the prevalence rates of sleep bruxism vary from 5.9\% to 49.6\%,
and these variations show can be attributed to different diagnostic
criteria used for bruxism.\textsuperscript{(9)} Therefore,
evidence-based studies with standardized and validated diagnostic
criteria are required for accurate assessments.
\textsuperscript{(9)}Insana et al. reported that sleep bruxism affected
more boys than girls.\textsuperscript{(20)} In the study by Cheifetz et
al., there was also a trend for males to be more likely to brux than
females.\textsuperscript{(11)} However, in the present study no
significant relation was found between presence of sleep bruxism and
gender.

Potential sleep bruxism is hereditary. Muscle pains, snoring and mouth
breathing are important signals for detecting sleep bruxism in children.
Sleep fragmentation was also found associated with sleep
bruxism.\textsuperscript{(29)} Nocturnal agitation and nightmares were
found to be associated with possible nocturnal bruxism. Moreover, young
children with evening chronotype were reported to have an tendency
toward possible sleep bruxism.\textsuperscript{(30)}

In the present study, nocturnal bruxism was found to be associated with
sleeping habits. The presence of bruxism was significantly higher in
child who had bedtime difficulties. In parallel to this finding, Oner et
al. reported that sleep quality was associated with nocturnal bruxism in
children.\textsuperscript{(21)}

9\% of the children showed TMJ disorder symptoms in the present study.
TMD prevalence in children and adolescents vary from 16 to
68\%.\textsuperscript{(22)} Mostly, study populations' subjective TMD
symptoms were jaw clicking , muscle tenderness, pain on opening and
limited opening.\textsuperscript{(11)}

In the present study, there was a statistically significant relationship
between TMJ disorders symptoms with sleeping characteristics and and
bruxism. Children with bed time resistance were more likely to have TMD
disorder symptoms. In contrast to our findings, Cheifetz et al.,
reported that TMD symptoms were not associated with
bruxism.\textsuperscript{(11)} However, our findings were in line with
Lei et al. that reported TMD symptoms were significantly associated with
psychological distress and disturbed sleep.\textsuperscript{(23)}

When functional changes that occur with factors such as occlusal
conflicts reach a certain level, they begin to produce textural changes.
In the present study, the prevalence of malocclusion was found 62\%
among children, and Class I was the most frequent molar relationship
(79\%). Numerous studies have been published on the prevalence of
malocclusion with reported prevalence ranging from 39\% to
98\%.\textsuperscript{(24,25)} Our result is in line with Sayin et al.,
reporting that Class I was the most frequently seen malocclusion in
Turkish orthodontic population.\textsuperscript{(26)} However, no
significant relation was found between malocclusion and sleeping habits
which may be attributed to limited sample size.

Factors such as traumas and parafunctional habits can change the
existing structural tolerance of TMJ. In this study, the prevalence of
traumatic dental injury was 22\%. In a study by Carvalho et al., the
overall prevalence of dental trauma was found \%37.1 in
school-children.\textsuperscript{(27)} No significant correlation was
found between sleep disorders and traumatic dental injuries in our
study. Based on previous literature, traumatic dental injuries tended to
be associated with sleep disorders. Sleep disorders in children can
affect motor skills, cognition and concentration. A bad night sleep can
affect a person's mood and concentration the next
day.\textsuperscript{(17)} It was stated that sleep deprivation was
associated with accidental injuries; 86\% increase in trauma incidences
when children slept less than 10 hours the night before the
accident.\textsuperscript{(28)} In addition, waking up three to four
times at night, which is an indication of agitated sleep, was associated
with a higher traumatic dental injury prevalence.

Daytime sleepiness is the main aspect of sleep behavior associated with
the prevalence of traumatic dental injuries and dental
caries.\textsuperscript{(17,31)} The prevalance of dental caries is very
high in the present study which unfortunately reflects the unmet oral
health care in Turkey\textsuperscript{(32)} Subsequently, retardation in
growth, missing of school and fragmentation of sleep is
inevitable.\textsuperscript{(33)} Dental caries was found associated
with sleep fragmentation in the present study which is also in line with
previous reports.\textsuperscript{(31,33)}

It should be noted that various limitations should be considered when
interpreting the data in this study. Sleep disorders and bruxism was
evaluated based on the subjective judgment of parents. The role of the
family is very important in the diagnosis of pediatric nocturnal bruxism
cause it occurs by recognizing the characteristic sounds produced by the
grinding of teeth at night.\textsuperscript{(4)} Therefore, although
parents' answers are subjective in this study, it is the most
appropriate method to collect data for reliable and large sample
studies.

The relationship between sleep problems and higher bruxism and
temporomandibular disorders prevalence suggests that sleep samples
should be investigated in scientific research using other methodological
diagnostic methods to confirm these findings. In this manner, data on
sleep behaviors obtained when collecting the patient's history before a
dental appointment can be useful for a better orientation to parents in
preventing bruxism and temporomandibular disorders. Consequently,
integration with paediatricians, pedodontists and psychiatrics is the
key factor to diagnose, treat and avoid sleep related oral health
problems.

\textbf{CONCLUSION}

In this study, sleeping habits were significantly associated with
bruxism, temporomandibular disorders and dental caries in children aged
between 6-13. No significant correlation was found, however, between
sleep characteristics and malocclusion and traumatic dental injuries.
Pediatricians and pediatric dentists should work in partnership to
identify causes and clinical features of sleeping disorders in order to
prevent possible oral and dental damages in children.

\textbf{ACKNOWLEGMENTS}

Authors would like to thank Istanbul Aydin University Dental Faculty
staff for their support and special thanks to Assoc. Prof Mustafa Agah
Tekindal for his assistance in statistical analysis.

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\begin{longtable}[]{@{}llllllll@{}}
\toprule
& & & Nocturnal Bruxism & Nocturnal Bruxism & Total & \(\chi^{2}\)
& p\tabularnewline
\midrule
\endhead
& & & No & Yes & & &\tabularnewline
TMD & No & n & 58 & 33 & 91 & ~5,881 & 0,015*\tabularnewline
& & \% & 63,70\% & 36,30\% & 100,00\% & &\tabularnewline
& Yes & n & 2 & 7 & 9 & &\tabularnewline
& & \% & 22,20\% & 77,80\% & 100,00\% & &\tabularnewline
Angle & Class I & n & 47 & 32 & 79 & ~2,645 & 0,289\tabularnewline
& & \% & 59,50\% & 40,50\% & 100,00\% & &\tabularnewline
& Class II & n & 5 & 6 & 11 & &\tabularnewline
& & \% & 45,50\% & 54,50\% & 100,00\% & &\tabularnewline
& Class III & n & 8 & 2 & 10 & &\tabularnewline
& & \% & 80,00\% & 20,00\% & 100,00\% & &\tabularnewline
Malocclusion & No & n & 26 & 12 & 38 & ~1,811 & 0,178\tabularnewline
& & \% & 68,40\% & 31,60\% & 100,00\% & &\tabularnewline
& Yes & n & 34 & 28 & 62 & &\tabularnewline
& & \% & 54,80\% & 45,20\% & 100,00\% & &\tabularnewline
Dental Trauma & No & n & 49 & 29 & 78 & 1,175 & 0,278\tabularnewline
& & \% & 62,80\% & 37,20\% & 100,00\% & &\tabularnewline
& Yes & n & 11 & 11 & 22 & &\tabularnewline
& & \% & 50,00\% & 50,00\% & 100,00\% & &\tabularnewline
Dental caries & No & n & 2 & 0 & 2 & 1,361 & 0,243\tabularnewline
& & \% & 100,00\% & 0,00\% & 100,00\% & &\tabularnewline
& Yes & n & 58 & 40 & 98 & &\tabularnewline
& & \% & 59,20\% & 40,80\% & 100,00\% & &\tabularnewline
Total & Total & n & 60 & 40 & 100 & &\tabularnewline
& & \% & 60,00\% & 40,00\% & 100,00\% & &\tabularnewline
\bottomrule
\end{longtable}

*p\textless{}0,05

Table-1 Association between nocturnal bruxism and TMD, Angle
Classification, malocclusion, dental trauma and dental caries

*A significant relation was found among children with nocturnal bruxism
and TMD symptoms p\textless{}0,05).\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
& & & Nocturnal Bruxism & Nocturnal Bruxism & Total & p\tabularnewline
\midrule
\endhead
& & & Presence & Absence & &\tabularnewline
Bed Time Resistance & No & n & 45 & 21 & 66 & ~0,020*\tabularnewline
& & \% & 68,20\% & 31,80\% & 100,00\% &\tabularnewline
& Yes & n & 15 & 19 & 34 &\tabularnewline
& & \% & 44,10\% & 55,90\% & 100,00\% &\tabularnewline
Sleep Behavior Problem & No & n & 60 & 38 & 98 & ~0,080\tabularnewline
& & \% & 61,20\% & 38,80\% & 100,00\% &\tabularnewline
& Yes & n & 0 & 2 & 2 &\tabularnewline
& & \% & 0,00\% & 100,00\% & 100,00\% &\tabularnewline
Waking up at night-Sleep fragmentation & No & n & 58 & 39 & 97 &
~0,811\tabularnewline
& & \% & 59,80\% & 40,20\% & 100,00\% &\tabularnewline
& Yes & n & 2 & 1 & 3 &\tabularnewline
& & \% & 66,70\% & 33,30\% & 100,00\% &\tabularnewline
Unable to wake up/Daytime Sleepiness & No & n & 54 & 31 & 85 &
0,086\tabularnewline
& & \% & 63,50\% & 36,50\% & 100,00\% &\tabularnewline
& Yes & n & 6 & 9 & 15 &\tabularnewline
& & \% & 40,00\% & 60,00\% & 100,00\% &\tabularnewline
Total & Total & n & 60 & 40 & 100 &\tabularnewline
& & \% & 60,00\% & 40,00\% & 100,00\% &\tabularnewline
\bottomrule
\end{longtable}

Table-2 Association between sleeping habits and nocturnal bruxism

* A significant relation was found among children with nocturnal bruxism
and bed time resistance p\textless{}0,05\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
& & & TMD symptoms & TMD symptoms & Total &\tabularnewline
\midrule
\endhead
& & & No & Yes & &\tabularnewline
Bed Time Resistance & No & n & 57 & 9 & 66 & 0,024~*\tabularnewline
& & \% & 86,40\% & 13,60\% & 100,00\% &\tabularnewline
& Yes & n & 34 & 0 & 34 &\tabularnewline
& & \% & 100,00\% & 0,00\% & 100,00\% &\tabularnewline
Sleep Behavior Problem & No & n & 90 & 8 & 98 & ~0,041*\tabularnewline
& & \% & 91,80\% & 8,20\% & 100,00\% &\tabularnewline
& Yes & n & 1 & 1 & 2 &\tabularnewline
& & \% & 50,00\% & 50,00\% & 100,00\% &\tabularnewline
Waking up at night-Sleep fragmentation & No & n & 88 & 9 & 97 &
~0,580\tabularnewline
& & \% & 90,70\% & 9,30\% & 100,00\% &\tabularnewline
& Yes & n & 3 & 0 & 3 &\tabularnewline
& & \% & 100,00\% & 0,00\% & 100,00\% &\tabularnewline
Unable to wake up/Daytime Sleepiness & No & n & 77 & 8 & 85 &
0,732\tabularnewline
& & \% & 90,60\% & 9,40\% & 100,00\% &\tabularnewline
& Yes & n & 14 & 1 & 15 &\tabularnewline
& & \% & 93,30\% & 6,70\% & 100,00\% &\tabularnewline
Total & Total & n & 91 & 9 & 100 &\tabularnewline
& & \% & 91,00\% & 9,00\% & 100,00\% &\tabularnewline
\bottomrule
\end{longtable}



tal caries

* A significant relation was found among children with dental caries and
bed time resistance p\textless{}0,05

\selectlanguage{english}
\FloatBarrier
\end{document}

