Effects of an occlusal splint compared with cognitive-behavioral treatment on sleep bruxism activity

Effects of an occlusal splint compared with cognitive-behavioral treatment on sleep bruxism activity
Issue online:
13 Feb 2007
Accepted for publication October 2006
To cite this article: Michelle A. Ommerborn, Christine Schneider, Maria Giraki, Ralf Schâfer, Jàrg Handschel, Matthias Franz, Wolfgang H.-M. Raab (2007)
Effects of an occlusal splint compared with cognitive-behavioral treatment on sleep bruxism activity
European Journal of Oral Sciences 115 (1), 7Ò14.
doi:10.1111/j.1600-0722.2007.00417.x
European Journal of Oral Sciences
Blackwell Synergy

Michelle A. Ommerborn11Department of Operative and Preventive Dentistry and Endodontics, Christine Schneider22Institute of Psychosomatic Medicine and Psychotherapy, Maria Giraki11Department of Operative and Preventive Dentistry and Endodontics, Ralf Schâfer22Institute of Psychosomatic Medicine and Psychotherapy, Jàrg Handschel33Department of Cranio- and Maxillofacial Surgery, Faculty of Medicine Heinrich-Heine-University, D?sseldorf, Germany, Matthias Franz22Institute of Psychosomatic Medicine and Psychotherapy, Wolfgang H.-M. Raab11Department of Operative and Preventive Dentistry and Endodontics

Michelle A. Ommerborn, Department of Operative and Preventive Dentistry and Endodontics, Heinrich-Heine-University, Moorenstr. 5, 40225 D?sseldorf, Germany
Telefax: +49Ò211Ò8104021
E-mail: Michelle.Ommerborn@uni-duesseldorf.de
Ommerborn MA, Schneider C, Giraki M, Schâfer R, Handschel J, Franz M, Raab WH-M. Effects of an occlusal splint compared to cognitive-behavioral treatment on sleep bruxism activity. Eur J Oral Sci 2007; 115: 7Ò14. © 2007 The Authors. Journal compilation © 2007 Eur J Oral Sci

Abstract

The impact of an occlusal splint (OS) compared with cognitive-behavioral treatment (CBT) on the management of sleep bruxism (SB) has been poorly investigated. The aim of this study was to evaluate the efficacy of an OS with CBT in SB patients. Following a randomized assignment, the OS group consisted of 29, and the CBT group of 28, SB patients. The CBT comprised problem-solving, progressive muscle relaxation, nocturnal biofeedback, and training of recreation and enjoyment. The treatment took place over a period of 12 wk, and the OS group received an OS over the same time period. Both groups were examined pretreatment, post-treatment, and at 6 months of follow-up for SB activity, self-assessment of SB activity and associated symptoms, psychological impairment, and individual stress-coping strategies. The analyses demonstrated a significant reduction in SB activity, self-assessment of SB activity, and psychological impairment, as well as an increase of positive stress-coping strategies in both groups. However, the effects were small and no group-specific differences were seen in any dependent variable. This is an initial attempt to compare CBT and OS in SB patients, and the data collected substantiate the need for further controlled evaluations, using a three-group randomized design with repeated measures to verify treatment effects.

Sleep bruxism (SB) has been defined by the American Academy of Sleep Medicine (AASM) as a 'stereotyped movement disorder characterized by grinding or clenching of the teeth during sleep' (1). The mechanisms involved in the genesis of SB are not yet clearly understood. Although the etiology of SB is attributed to peripheral factors [e.g. occlusal interferences (2)] and central factors [e.g. neuropathophysiological processes (3), personality traits (4Ò7) and stress (8Ò10)], the assumption of a multifactorial genesis is widely accepted (11, 12). During the past decade, in connection with the methodological improvement of clinical investigations, research has been predominantly focussed on the analysis of central factors (12, 13). A number of studies have proven the major role played by central factors in the development of SB (3, 12, 14Ò17).

With respect to the adoption of a stress-related genesis of SB, several studies, using different assessment tools, have verified a correlation between these two factors. To determine the amount of stress, some investigators have measured the urinary catecholamine content in SB patients. As a result, a positive relationship was found between increased epinephrine content and high levels of nocturnal masseter muscle activity (18). A further study showed that epinephrine and dopamine had a significant and strong association with bruxism. The authors concluded from their data that emotional stress is a prominent factor in the development of bruxing behavior (19). In a psychometric investigation of 1784 adults, frequent bruxism was significantly positively associated with severe stress experience (8). Another research group evaluated, in an extensive epidemiological study, where a cross-sectional telephone survey was performed on 13,057 participants, potential risk factors for SB in a general population. The authors deduced from their results that subjects with a highly stressful life, and those with anxiety, were at a higher risk of reporting SB (9). Contrasting results were, however, obtained from two other investigations, which failed to confirm a strong relationship between stress and bruxing activity (20, 21). To summarize the previous investigations, most of the available data suggest a relationship between SB and stress. Hence, for future treatment planning with respect to a causal treatment, the inclusion of stress-oriented management techniques could be beneficial for SB patients.

The management of SB includes pharmacological (22), psychological, and occlusal therapeutic approaches (23). In dentistry, occlusal splints are frequently used in the management of SB (24, 25). However, there are conflicting results regarding the efficacy of an occlusal splint (OS) (14, 26). Some examinations have demonstrated a significant decrease in electromyographic (EMG) activity when wearing a hard maxillary splint compared with a period without an OS (27,28). Interestingly, two recently published studies, which compared the OS with a palatal control device, reported no evidence of an OS-specific effect on SB (13, 29). Owing to the heterogeneous results regarding the efficacy of OS treatment, occlusion is considered to play a minor role in the etiology of SB. Therefore, the OS is currently seen to be a more symptomatic type of treatment. Accordingly, several authors recommend its application predominantly to prevent tooth attrition (13, 14). Nevertheless, the OS is widely used and represents the classical treatment approach in the management of SB.

The psychological approach employs various methods, such as biofeedback, counselling, relaxation techniques, suggestive hypnotherapy, sleep hygiene education, and lifestyle changes (16, 30). Although the results of biofeedback indicated a significant reduction of EMG activity during treatment, EMG activity returned to baseline levels after treatment (31, 32). A recently published study, however, has demonstrated a long-term effect (33). The application of cognitive-behavioral treatment (CBT) for the management of SB has, to date, not been examined in detail. This is surprising as stress is assumed to represent a causal component in the development of SB, as documented in the literature (8Ò10). Hence, a psychological treatment that is focussed on the reduction of perceived stress would act as a primarily causal treatment approach. As derived from the literature, one study applied two psychological techniques Ò directed muscular relaxation and competence reaction Ò to 3Ò6-yr-old children and observed, after termination of the treatment period, a reduction of signs of bruxism in all patients (34). In adult SB patients, only one study has compared stress-reduction behavioral counselling alone, in combination with biofeedback, biofeedback alone, and a waiting list control group pretreatment and 2 months post-treatment. This study found a significant improvement in the behavioral counselling groups compared with the biofeedback group (35). Moreover, the combined treatment was apparently more successful in reducing the subjective symptoms of both diurnal and nocturnal clenching. The authors concluded, from their results, that stress-reduction skills, learned while awake, could have a general effect on stress-induced muscle activity during sleep.

To summarize the currently available data, only a few studies have been reported which applied CBT to a sample of SB patients. Results have given a first hint that CBT could have a positive effect on SB activity. At present, however, there is a lack of published studies which evaluate the effects of CBT in comparison with the standard treatment for SB, viz, the OS. Therefore, the aim of the present study was to compare the efficacy of an OS vs. CBT in SB patients. In particular, SB activity, self-assessment of SB activity and associated symptoms, psychological impairment, and individual stress-coping strategies were recorded and analyzed in a two-group randomized, treatment comparison trial with a pretreatment, post-treatment, and a 6-month follow-up controlled design. The hypothesis used in this investigation was that a reduction in SB activity, self-assessment of SB activity and associated symptoms, and psychological impairment will be observed from pretreatment to post-treatment and from pretreatment to a 6-months follow-up. Furthermore, an improvement of positive stress-coping strategies, predominantly in the CBT group, will be noted.

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