Are lower urinary tract conditions more common in children with sleep bruxism?

Are lower urinary tract conditions more common in children with sleep bruxism?

Erman Ceyhan ^a, Eray Hasirci ^a, Onur Gezgin ^b, Guler Burcu Senirkentli ^b, Yuksel Cem Aygun ^a

Summary

Introduction

Sleep bruxism is a parasomnia caused by rhythmic and non-rhythmic activity of the masticatory muscles during sleep. Prevalence of sleep bruxism is reported up to 40.6% in the literature. Sleep bruxism is a multifactorial issue and associated with multiple dental complications, sleep-related disorders, and psychosocial problems. We aimed to investigate if children with sleep bruxism suffer more from lower urinary tract conditions.

Materials and methods

Prospectively 128 children were included in this study. Sixty-four children constituted in the bruxism group and 64 children constituted in the control group. Children who admitted to the pediatric dentistry clinic with bruxism symptoms were recruited in the bruxism group. Control group constituted of consecutive 64 children who admitted to the pediatric dentistry clinic for routine dental examination. Parents were asked to fill out a questionnaire including Dysfunctional Voiding and Incontinence Scoring System (DVISS) form. Children's demographic data, presence of urinary frequency, presence of urgency, behaviour of voiding postponement, presence of daytime urinary incontinence, presence of enuresis nocturna, presence of fecal incontinence, presence of constipation, status of circumcision, and presence of bruxism related symptoms were recorded. Children with a DVISS score above 8 were considered to have functional voiding disorder. All children underwent a dental examination.

Results

The mean age of children was 73.3 ± 26.9 months. For all children (n = 128), the girl to boy ratio was 40:88. Mean DVISS score was 2.5 ± 3.8 and the mean QOL score was 0.1 ± 0.4 for all children. Eight (6.3%) children were found to have functional voiding disorder based on the DVISS score. There was no statistically significant difference for any lower urinary tract condition between the bruxism group and the control group (Table). Children with bruxism significantly had more tooth wear and masseter muscle hypertrophy (<0.001 and < 0.05).

Discussion

Sleep bruxism has been linked to a number of health issues including dental, systemic and psychosocial problems. Tooth wears, fatigue/pain in chewing muscles, gum recession, facial pain, masseter muscle hypertrophy and temporomandibular joint damage are the main complications of bruxism. Moreover, bruxism has been associated with systemic diseases and sypmtoms like asthma, respiratory illnesses, enuresis nocturna, anxiety, and stress.

Conclusions

Children with sleep bruxism suffer more from tooth wear, masseter muscle hypertrophy, and regional pain over the jaw. Additionally morning fatigue, relationship issues, and respiratory illnesses are more common in bruxist children. Lower urinary tract conditions are not more frequent in children with sleep bruxism.

Keywords

Sleep bruxismChildDiurnal enuresisUrinary tractTooth wear

Abbreviations

DVISSDysfunctional Voiding and Incontinence Scoring SystemQOLQuality of Life

Introduction

Sleep bruxism is a behavior associated disorder with rhythmic and non-rhythmic activity of the masticatory muscles during sleep [1]. Sleep bruxism is more common in children and adolescents and its prevalence decreases with age [[2], [3], [4]]. Various recent studies report bruxism prevalence around 20% for adults and up to 40.6% for children [3,5,6].

Although there are multiple factors causing bruxism, its exact etiology is unknown [[7], [8], [9]]. Apart from various dental problems, sleep bruxism has been associated with many chronic diseases and sleep-related problems [2,4]. Studies have shown that various different factors such as psychosocial problems, socioeconomic factors, passive smoking, stress, personality type, environmental factors, sleep duration, sleep apnea are involved in the etiology of sleep bruxism [10]. While stress has a major role in the development of bruxism in adults, sleep and behavioral issues are more prevalent in children [11].

Stress is an etiological factor found to be associated with both bladder dysfunction and bruxism [12,13]. In animal studies and also in clinical studies, stress exposure is reported to cause changes in voiding dynamics [12,13]. In like manner, stress is reported to be a major risk factor in the development of bruxism [14]. These associations rise the idea that bruxism can also be seen together with lower urinary tract conditions.

Enuresis nocturna is a parasomnia, which is a source of stress by itself. Many studies associated sleep bruxism to enuresis nocturna in children [9,[15], [16], [17], [18], [19]]. However, all the literature data focuses on enuresis nocturna solely. The relation between other lower urinary tract conditions and sleep bruxism has not been studied well. The bruxers suffer general motor restlessness and many daytime symptoms including daytime sleepiness [20]. Thus it can be speculated that daytime lower urinary tract conditions and sleep bruxism may both be present at the same time.

Children with sleep bruxism and enuresis nocturna reported to experience more of sleep disturbances [21,22]. Bruxers found to suffer more from restless sleep, loud snoring, chronic diseases like asthma and upper respiratory tract infections [11,23]. Similarly, prevalence of sleep-disordered breathing, frequent snoring, sleep duration disorder, parasomnias are higher in children with enuresis nocturna [24,25].

All these associations lead to the thought that bruxism may be associated with lower urinary system conditions as well. We hypothesized that children with sleep bruxism will suffer more from functional voiding disorders such as urinary incontinence, frequency, enuresis nocturna etc. In the present study, we investigated whether lower urinary tract conditions are more common in children with sleep bruxism.

Materials and Methods

A total of 128 children were included in this prospective study. The number of patients to be included in the study was determined by power analysis prior to children recruitment. Sixty-four of these children constituted in the bruxism group and 64 children constituted in the control group. Children who admitted to the Pediatric Dentistry Clinic with bruxism symptoms were recruited in the study group. Control group constituted of consecutive 64 children who admitted to the pediatric dentistry clinic for routine dental examination. Children who have bruxism signs and symptoms were excluded from the control group. Children who are under follow-up for lower urinary tract symptoms, children with known neurogenic, orthopedic, and urological diseases or syndromes were excluded from the study. This prospective study was approved by Baskent University Institutional Review Board and Ethics Committee (Project no: KA21/06).

Lower urinary tract symptom assessment

For all children, parents were asked to fill out a questionnaire after the dental examination in order to evaluate children's lower urinary tract conditions and bruxism related symptoms. With this questionnaire; children's demographic data, presence of urinary frequency, presence of urgency, behaviour of voiding postponement, presence of daytime urinary incontinence, presence of enuresis nocturna, presence of fecal incontinence, presence of constipation, and status of circumcision were recorded. Additionally, the validated Dysfunctional Voiding and Incontinence Scoring System (DVISS) was filled for all children (Supplementary File) [26]. With the final question of the DVISS questionnaire, patients' Quality of Life (QOL) scores were assessed on a scale of 0–3 (Supplementary File) [26].

Children with a DVISS score above 8 were considered to have functional voiding disorder. A technician was in charge of gathering the questionnaires, that the pediatric dentist who examined children was blind to the questionnaire results.

Dental examination

Dental examinations of children were carried out by pediatric dentists (OG and GBS) conforming to a predetermined template. A comprehensive questionnaire for bruxism related symptoms were filled for all children (Table 1). Children who grind and/or clench their teeth while sleeping were diagnosed with bruxism as recommended in the literature [4]. During the dental examination, the presence of increased tooth wear in the occlusal or incisal areas and the presence of masseter muscle hypertrophy were recorded.

Table 1 – Bruxism Questionnaire

Statistical analysis

The sample size was calculated with Cohen's d formula by using G∗Power v3.1.9.7 for Windows. The total number of children required for this study is calculated as 128 (64 bruxism group and 64 control group) with 80% power and 95% confidence level (d = 0.50). Statistical analyses were performed using IBM SPSS Statistics for Windows v.23® (IBM Corp., Armonk, N.Y., USA). Continuous variables are shown as mean ± SD and median (min–max). The Mann–Whitney U test was used to analyze non-parametric continuous variables. Comparison of categorical variables was performed using the Chi-square test. Correlation between normally distributed data was analyzed by Pearson's correlation. The level of statistical significance was set at p < 0.05.

Results

The mean age of children was 73.3 ± 26.9 months. For all children (n = 128), the girl to boy ratio was 40:88. Seventy-four (84.5%) boys were circumcised. Six boys (6.8%) and two (5%) girls had constipation (p = 0.694).

Mean DVISS score was 2.5 ± 3.8 (median: 1, range 0–25) and the mean QOL score was 0.1 ± 0.4 (median: 0, range 0–3) for all children. Eight (6.3%) children were found to have functional voiding disorder based on the DVISS score. The correlation between children's ages and DVISS scores were not significantly different (p = 0.302, r = −0.092). Similarly, there was no statistically significant correlation between children's ages and QOL scores (p = 0.910, r = 0.010). There was no statistically significant difference between boys and girls regarding total DVISS scores (p = 0.649, median 1 vs 2 respectively) and QOL scores (p = 0.476, median 0 vs 0 respectively).

Demographics and lower urinary tract characteristics of children in the bruxism group and the control group were shown in Table 2. In terms of lower urinary tract conditions, there was no statistically significant difference between the two groups. Dental findings of children were listed in Table 3.

Table 2. Demographics and lower urinary tract characteristics of children in the bruxism group and the control group

Table 3. Dental findings in the bruxism group and the control group

Discussion

Sleep bruxism is a prevalent phenomenon in childhood [3]. It causes numerous morbidities and it impairs one's life quality. Apart from regional symptoms like facial pain, jaw and dental problems, sleep bruxism has been associated with many systemic conditions including sleeping disorders, neurobehavioral problems, stress and emotional disturbances [4,10,11,18]. In like manner, most of the lower urinary tract conditions bare behavioral component in childhood [17]. Considering all these perpectives, we contempleted whether bruxism pertains to lower urinary tract conditions.

The diagnosis of sleep bruxism generally based on medical history in daily clinical practice [4,9]. Parents usually get anxious by the sound and seek for solution at dentistry units. Performing a polysomnography for the diagnosis of sleep bruxism may be the most objective method but it is not feasible in most of the cases [4]. The agreement between parent reported diagnosis and the diagnosis made by polysomnography was reported to be poor for sleep bruxism [27]. Since most of the studies in the literature based the bruxism diagnosis on parent reports, we used parent reports for the diagnosis [8,10].

The psychosocial and behavioral aspects of bruxism have been investigated broadly by many studies and systematic reviews [8,23,28]. Sleep bruxism has been associated with emotional stress, anxiety, antisocial disorders, thought disorders, bad temper, depression, hyperactivity [8,23,28,29]. Withal, studies emphasize that psychosocial involvement of bruxism is more prominent over the age of five [28]. Bruxism is reported to be highly prevalent in children with mental health problems and children with peer problems [29]. Likewise, we observed that a statistically significant presence in familial and social relationship issues among children with bruxism in this study. In the study of Lam et al., authors had demonstrated higher rates of poor temper, poor academic results, and chronic diseases (asthma, upper respiratory tract infections, and allergic rhinitis) [11]. Correspondingly, in our series there were more children with respiratory illnesses in the bruxism group.

It has been reported that children suffering from sleep bruxism experience difficulty getting up and wake up tired in the morning due to the frequent awakings and nightmares [9,11,30]. This disrupted sleep pattern is the main cause of the daytime symptoms related to sleep bruxism and leads to major morbidities [30]. In this study, children with bruxism found to be more complaining from waking up tired in the morning.

It is speculated that enuresis nocturna and sleep bruxism are linked to each other [17]. Patients with sleep bruxism typically experience sleep disruption and arousal from sleep [10,27,31]. We believe this coexistence may cause an unintentional precaution against enuresis nocturna, as we found no significant difference regarding proportion of enuretic children in the two group. However, some authors reported higher rates of enuresis nocturna in children with bruxism [9,18,19]. In the study of Neveus et al., authors surveyed 1390 children from elementary schools [19]. Among children with nocturnal enuresis and daytime incontinence, authors reported significant association between bruxism and enuresis nocturna history (n = 58) when compared to dry children (OR: 1.9, 95% CI 1.0–3.4). Even though the number of children who currently suffer from enuresis (n = 114) were higher than children with current enuresis, authors have failed to present a robust association for children with current enuresis or daytime incontinence. Bacci et al. compared the findings of their series (n = 29) with a previous large numbered study (Rutter's A2 Child's behavior scale: adaptation and reliability studies, n = 16,614) and reported higher rates of enuresis and encompresis in the bruxism sample [18]. In a study on large community sample, authors reported adjusted odds ratio of nocturnal enuresis as 2.20 (%95 CI, 1.10–4.43) in children with sleep bruxism [11]. A study from Turkey reported higher proportion of bedwetting in children who have bruxism [9]. We found no significant difference for enuresis nocturna, urinary incontinence, fecal incontinence or any other lower urinary tract conditions in this prospective study.

Sleep bruxism is considered as a sleep related movement disorder with day-time symptoms where repetitive masticatory muscle contractions are present [30]. Serra-Negra et al. reported higher incidence of muscle pain in the mouth region in children who have sleep bruxism [30]. In this study, children with bruxism have reported to have more pain in the jaw/head region in the morning. Lam et al. demonstrated a male predominance for sleep bruxism in their series [11]. However, we found no significant dominance regarding gender in any group in this study.

Similarly, some other high volume series reported no difference regarding gender in their series for bruxist children [30,32,33].

As a result of repetitive sleep bruxism, many dental and temporamandibular joint disorders may develop including erosion of dental tissues, pathological tooth destruction, gum recession, fatigue and pain in chewing muscles, open deviation, facial pain, headaches and masseter muscle hypertrophy [4,10,11,18,30]. Tooth wear is the most reported complication related to sleep bruxism. In this study, we found marked difference for increased tooth wear and masseter muscle hypertrophy in the bruxism group correspondingly.

This study has few limitations, albeit its prospective design. Since we desired to focus on lower urinary tract conditions, we did not use a detailed questionnaire for psychosocial and sleep related manifestations of sleep bruxism. The use of polysomnography would have endorsed the bruxism diagnosis and also it would have helped the documentation of enuresis nocturna. Considering its impracticality, we did not use polysomnography in this study.

Conclusions

Sleep bruxism is a morbid disorder that it causes various dental problems and daytime symptoms. Tooth wear, masseter muscle hypertrophy, and regional pain over the jaw are common dental problems seen in children with sleep bruxism. Sleep bruxism leads to morning fatigue and associated with familial and social relationship disorders as well as respiratory ilnesses. Nevertheless, there is no concurrence of sleep bruxism and any lower urinary tract conditions.

Declarations of interest

None.

Acknowledgments

This study did not received any funding. We thank Biostatistics Spc. Dr. Eylem Gul and Dr. Yunus Akdogan for their expertise and assistance in statistical analyses.

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