Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2019  |  Volume : 37  |  Issue : 3  |  Page : 245--250

Presence of oral habits and their association with the trait of anxiety in pediatric patients with possible sleep bruxism

Larissa Soares-Silva, ClŠudia Tavares-Silva, Andrea Fonseca-Gonçalves, Lucianne Cople Maia 
 Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

Correspondence Address:
Prof. Lucianne Cople Maia
Rodolpho Paulo Rocco, 325, CEP: 21941-913, Rio de Janeiro


Background: Bruxism is a repetitive masticatory muscle activity with a multifactorial etiology , that can be associated to emotional factors. Aim: The aim of the study is to identify the presence of oral habits (OHs) and their association with the trait of anxiety (State-Trait Anxiety Inventory for Children [STAI-C]) in pediatric patients with possible sleep bruxism (PSB). Methods: Children between 3 and 12 years of age with PSB reported by their parents with complete deciduous or mixed dentition were included in the present study. Sociodemographic data (SD) as well as those on OHs such as only natural (ON), artificial breastfeeding (OA) or both (NA), finger sucking (FS), pacifier use (PC), and biting nails (BN) or objects (OB) were obtained through an interview with the parents/guardians answered the Brazilian version of the STAI-C questionnaire. Statistical Analysis Used: SD and OH as well as STAI-C findings were descriptively evaluated, while the associations between OH and STAI-C with PSB were evaluated using the Chi-square test (P < 0.05). Results: The final sample was 52 children (6.62 ± 1.8 years). Of these, 51.9% were males, 82.7% reported not living in social risk areas, and 21.2% were only children. Considering the OH, patients participated in ON (26.9%), OA (9.6%), and both (63.5%); 13.5% had an FS habit and 46.2% had related PC use; and 80.8% were reported to have OB biting behaviors, while 53.8% participated in BN. The STAI-C was present in 25 (48.1%) patients with PSB and was not associated with the presence of OH. Conclusion: There is no association between STAI-C and OH in pediatric patients with PSB.

How to cite this article:
Soares-Silva L, Tavares-Silva C, Fonseca-Gonçalves A, Maia LC. Presence of oral habits and their association with the trait of anxiety in pediatric patients with possible sleep bruxism.J Indian Soc Pedod Prev Dent 2019;37:245-250

How to cite this URL:
Soares-Silva L, Tavares-Silva C, Fonseca-Gonçalves A, Maia LC. Presence of oral habits and their association with the trait of anxiety in pediatric patients with possible sleep bruxism. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Jun 27 ];37:245-250
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Full Text


Bruxism is a parafunctional, involuntary, rhythmic or nonrhythmic, and spasmodic action of the masticatory system, produced by the masseter, temporal, and mandibular muscles that may lead to tightening or grinding of the teeth.[1],[2],[3],[4] The condition has two distinct circadian manifestations: the first occurs during sleep time (and is known as sleep bruxism), while the second occurs during wakefulness (and is known as awake bruxism).[5]

Bruxism is one of the oral conditions currently most important to researchers, dental clinicians, neurologists, and physicians from sleep medicine domains. Lobbezoo et al. suggested a revision to the classification of bruxism, reorganizing the grinding system into the categories of “possible,” “probable,” and “definitive” sleep and/or awake bruxism, and also made suggestions for clinical and research purposes.[4],[5] According to the authors, a case of possible bruxism is present when parents/guardians report that their child grinds their teeth during sleep time.[4],[5]

Investigators have been working for years to obtain a more profound degree of knowledge on the risks for and associated factors of bruxism. In this regard, evidence is growing in support of a multifactorial etiology, with a genetic influence and potential relevance of emotional factors as well. In general, people have certain personality features as well as a trait of anxiety that lead them to react either as nervous or independent and secure depending on the situation.[6],[7],[8],[9] Furthermore, stress sensitivity has been found to be a key psychological factor associated with bruxism among children, teenagers, and adults.[10],[11],[12]

As already defined, bruxism can be considered an oral habit (OH) with parafunctional characteristics.[1],[13],[14] OHs include dysfunctions (incorrect physiological functions) such as incorrect swallowing, chewing, habitual mouth breathing, and articulation problems. Relevant parafunctions (stereotypical activities performed unknowingly) include sucking on a pacifier or finger, tongue thrusting, and/or lip biting or sucking. It is important to mention that bruxism can produce destructive effects on normal facial structures. Its duration of habit/day, degree, and intensity are responsible for producing detrimental and long-lasting effects.[15],[16],[17]

The present study aims to identify the presence of OHs and their association with the trait of anxiety in pediatric patients with possible sleep bruxism (PSB).


This research was conducted at the Department of Pediatric Dentistry and Orthodontics of the Dental School at the Federal University of Rio de Janeiro in Rio de Janeiro, Brazil. A convenience sample was adopted, in which all patients diagnosed with PSB that sought for treatment in the period between September 2014 and September 2015 were included. These children were selected after anamnesis, and dental examination was performed by a trained operator to establish legitimacy. To be eligible, children with PSB as reported by their parents were required to be aged between 3 and 12 years and demonstrating complete deciduous or mixed dentition, with no reports of temporomandibular joint disorders. To determine sleep bruxism, the criteria proposed by the assessment, diagnosis, and management of orofacial pain of the American Academy of Orofacial Pain and the 3rd edition of the International Classification of Sleep Disorders were used.[4] Patients with special needs (e.g., neurological, psychological, or any systemic impairment), caries lesions, using orthodontic appliances, and/or having dental anomalies, occlusal disorders, or erosion were excluded.

In the year period before the enrollment of patients, a mean of 20 new patients, between 3 and 12 years of age, weekly sought for treatment in the Department of Pediatric Dentistry of the Dental School, totaling 1020 new patients/year. In this universe, we found that 43 children (4.2%) have presented possible bruxism reported by their parents. Thus, a convenience sample estimated for the period between September 2014 and September 2015 should include at least 43 eligible children.

Data were collected into three phases. First, sociodemographic data of the children (e.g., age, gender, social risk, only child, and parenthood with caregiver) were obtained through an interview with parents/guardians during the first visit. At the same visit, the respondent was asked about the child's OHs, such as natural or artificial breastfeeding, finger sucking and pacifier use, and biting nails and objects. Then, during a second visit, the parent/guardian answered the Brazilian version of the State-Trait Anxiety Inventory for Children (STAI-C) questionnaire.[18],[19] This questionnaire is a parent/guardian-reported scale system for measuring the trait of anxiety already [6],[9],[19],[20],[21] validated for Brazilian population,[9] such as the present study.[22]

Sociodemographic and OH data in pediatric patients with PSB were classified as present or absent and were descriptively analyzed through their absolute and relative frequencies. The scores reported in the STAI-C questionnaire showed a cutoff equal to 41 points. The total score was categorized according to the following ranges: 0–40 points denoted the absence of anxiety and 41–102 points denoted the presence of anxiety.[23]

In addition, the association between the presence of OHs and anxiety level in children with PSB was evaluated using the Chi-square test and Fisher's exact test, with a level of significance of 0.05. Cronbach's alpha (α) values for the internal consistency of the STAI-C questionnaire were also obtained (α = 0.827).

The Research Ethics Committee of the Clementino Fraga Filho Hospital of the Federal University of Rio de Janeiro gave approval for the present study (protocol no. 217-14).


Of the 591 children attending the dental clinic during the period of September 2014 to September 2015, 52 fulfilled the eligibility criteria. The age of the included patients varied from 3 to 12 years (6.62 ± 1.8 years), with 51.9% being males and 48.1% being females. Regarding the factors considered, 82.7% were reported as not living in a social risk area, 21.2% were only children, and the majority have a mother as the primary caregiver (73.1%), as described in [Table 1].{Table 1}

Considering the OHs, 14 patients participated in only natural breastfeeding (26.9%), 5 participated in only artificial (9.6%), and 33 participated in both (63.5%). A total of 7 (13.5%) patients had a finger-sucking habit, 24 (46.2%) reported related pacifier use, and 42 (80.8%) actively bit objects, while 28 (53.8%) bit their nails, as shown in [Table 2].{Table 2}

The mean STAI-C score for the presence and absence of anxiety was 4.29 ± 19.13 points. From the total of 50 patients with PSB, 25 (48.1%) had an anxiety trait and 25 (48.1%) had no anxiety trait, while 2 respondents (3.8%) refused to answer the questionnaire. It was observed in this study that OHs were not associated (P > 0.05) with the presence or absence of an anxiety trait in patients with PSB. Although natural, artificial, and natural and artificial breastfeeding at the same time as well as biting objects and nails were the most frequent OHs seen in patients with PSB, these were not associated with the presence of a trait of anxiety in the same patients, as described in [Table 3].{Table 3}


Bruxism is considered a parafunctional OH [24],[25] and is characterized as a repetitive jaw muscle activity involving a clenching or grinding of the teeth and/or bracing or thrusting of the mandible.[2],[3],[4],[18] It is known at this time that its etiology is not limited to occlusal problems, stress, or medical disorders affecting dopamine;[26] rather, there is a consensus today about the multifactorial nature of bruxism.[19] However, psychological factors seem to play a key role in the development of the condition.[27] In addition, the patient's lifestyle exerts a great influence on the frequency, duration, and severity of bruxism. Some theoreticians of the psychoanalytic tradition suggest that bruxism is a symptom of a serious underlying emotional disease and/or the response to anxiety, frustration, and hostility.[28] In some cases, the trait of anxiety may also be involved with different levels of dental wear,[29],[30] and bruxism can also be triggered by different psychological stimuli, resulting from the distressing behavior in the environment.[31] Lobbezoo et al., in 2006, suggested that individuals who have bruxism also have higher rates of anxiety and depression.[27]

According to the data obtained during the present research, of a total of 52 children (51.9% of males and 48.1% of females), 78.8% were not single children and 73.1% had a mother as the main caregiver. Regarding social risk, 82.7% of the patients do not live in areas of prominent danger. According to Carvalho et al.,[32] the sociodemographic, psychosocial, and lifestyle factors of individuals can influence their health behaviors at any stage of life. However, even if the family environment can influence children's emotional status,[33] in our study, as also seen in the study by Serra-Negra et al.,[34] this situation could not be confirmed, since the majority of patients with PSB did not live in vulnerable areas. Manfredini et al.[35] emphasized that demographic conditions establish a tripod of interacting factors and can influence an individual's emotional state, which can ultimately be related to sleep bruxism and its factors.

The presence of breastfeeding and artificial feeding was the most common OH in our participants with PSB, and although these are not deleterious habits at early ages, when prolonged, these can usually cause oral health problems such as malocclusions.[36] Other deleterious OHs were also seen at a high frequency in the patients of the present study such as biting objects and nails. Some studies have shown a high prevalence of habits associated with bruxism [12],[19],[25],[26] and other parafunctional habits in pediatric patients [18] including nail biting and artificial feeding, among others.[12] The literature suggests that the presence of an OH may influence the acquisition of another,[11],[25] and such could have occurred in the patients of the present study, since bruxism coexists with one or more OHs. However, according to Pereira [37] it was revealed in children aged 3–6 years that the longer the breastfeeding period, the lower the occurrence of habits such as sucking, oral breathing, and bruxism. Another study affirms that exclusive breastfeeding for 6 months satisfies the physiological need for suctioning in a child, decreasing subsequent nonnutritive sucking.[38] Another aspect that could be observed is the possibility of habit replacement, since abandoning a preexisting habit may cause the infant patient to acquire a new one in substitution, in order to relieve their tension and anxiety.[39],[40] In this context, as OHs are transient and could be replaced, new studies are needed to better elucidate this dynamic process.

Widmalm et al.[41] separately reported an association between bruxism and other parafunctional habits in young children. OHs and sucking habits are the most frequent examples of driving dental needs.[11] According to Gonçalves et al.,[36] 53% of the children had at least one habit and that the habit of nail biting was the most prevalent at 35%. Zapata et al.[42] concluded in their study that 23.13% of participants had used just a baby bottle and had bruxism, while 12.6% had used a baby bottle and pacifier and had bruxism. In their studies, it was found clearly that the presence of certain habits increased the chance of the occurrence of bruxism.[33],[43] Simões-Zenari and Bitar [40] observed the existence of an association between bruxism and the use of pacifiers, biting of the lips, and biting of the nails. Children who used pacifiers had a sevenfold increased risk of developing bruxism and a fivefold increased risk of chewing on their lips. Serra-Negra et al.[43] concluded that there is an association between bruxism and other parafunctions in children. These children tend to bite objects and are more susceptible to the development of bruxism. Therefore, the existence of bruxism and other parafunctions in children suggests that these parafunctions are not “necessary,” but rather are “sufficient,” as previously reported by Vanderas.[44] Some limitations of the present study include its convenience sample and the absence of a control group composed of pediatric patients without PSB. Regardless this last limitation, the high frequencies of OHs in patients with PSB in the present study largely corroborate the existing literature and suggest that there is a need for further investigations of the relationship of these OHs and in patients with and without sleep bruxism, mainly based in probabilistic samples.

The evaluation of the trait of anxiety in children is performed, in general, through questionnaires, typically via self-reporting.[22],[45] Here, we observed in a balanced way the presence or absence of the trait of anxiety in our patients. According to Donnarumma et al.,[19],[27] the trait of anxiety plays a role in influencing the intensity and frequency of clenching episodes. Calderan,[33] in their study, described the trait of anxiety in pediatric patients with bruxism but did not confirm a relationship between bruxism and anxiety, similarly to in the present study. de Alencar et al.[22] found that emotional factors such as stress, anxiety, or other personality traits influence some habits in sleep bruxism patients, while Canto et al.[46] found an association between sleep bruxism and psychosocial factors in children, especially between bruxism and the personality traits of stress, anxiety, and tension. In clinical practice, once a psychological origin of the condition has been diagnosed, the patient must be referred to a skilled professional in order to ensure the implementation of an effective and long-lasting treatment.[47]


It can be concluded that there is no association between the existence of a trait of anxiety and OHs in patients with PSB. Controlled studies with larger sample size are warranted, however, to better explore this important issue in dental literature.

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Conflicts of interest

There are no conflicts of interest.


1Diniz MB, Silva RC, Zuanon AC. Childhood bruxism: A warning sign to pediatric dentists and pediatricians.. Rev Paulista Pediatria 2009;27:329-34.
2Bader G, Lavigne G. Sleep bruxism; an overview of an oromandibular sleep movement disorder. REVIEW ARTICLE. Sleep Med Rev 2000;4:27-43.
3Shinkai R. Prevalence of nocturnal bruxism 2-11-year-old children. Rev Odontol Univ São Paulo 1998;12:29-37.
4Lobbezoo F, Ahlberg J, Raphael KG, Wetselaar P, Glaros AG, Kato T, et al. International consensus on the assessment of bruxism: Report of a work in progress. J Oral Rehabil 2018;45:837-44.
5Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: An international consensus. J Oral Rehabil 2013;40:2-4.
6Karibe H, Shimazu K, Okamoto A, Kawakami T, Kato Y, Warita-Naoi S. Prevalence and association of self-reported anxiety, pain, and oral parafunctional habits with temporomandibular disorders in Japanese children and adolescents: A cross-sectional survey. BMC Oral Health 2015;15:8.
7Coelho AT, Lorenzini LM, Suda EY, Rossini S, Reimão R. Sleep quality, depression and anxiety in college students of last semesters in health area's courses. Neurobiologia 2010;73:35-9.
8Esenyel S, Unal F, Vural P. Depression and anxiety in child and adolescents with follow-up celiac disease and in their families. Turk J Gastroenterol 2014;25:381-5.
9Biaggio AM, Natalício L, Spielberger CD. Child form development in Portuguese from Spielberger's State-Trait Anxiety Inventory for Children (STAI-C). Arq Bras Psicol Apl 1977;29:31-44.
10Serra-Negra JM, Lobbezoo F, Martins CC, Stellini E, Manfredini D. Prevalence of sleep bruxism and awake bruxism in different chronotype profiles: Hypothesis of an association. Med Hypotheses 2017;101:55-8.
11Manfredini D, Lobbezoo F. Role of psychosocial factors in the etiology of bruxism. J Orofac Pain 2009;23:153-66.
12Manfredini D, Arreghini A, Lombardo L, Visentin A, Cerea S, Castroflorio T, et al. Assessment of anxiety and coping features in bruxers: A portable electromyographic and electrocardiographic study. J Oral Facial Pain Headache Summ; 30:249-54.
13Bisinélli FG. Occurrence of bruxism in children with deleterious oral habits. Florialópolis, SC; 2015. p. 13-59.
14Emodi-Perlman A, Eli I, Friedman-Rubin P, Goldsmith C, Reiter S, Winocur E. Bruxism, oral parafunctions, anamnestic and clinical findings of temporomandibular disorders in children. J Oral Rehabil 2012;39:126-35.
15Sikorska A, Cudziło D, Matthews-Kozanecka M, Turska-Malińska R. Impact of incorrect oral habits on mastication anomalies in children and adolescents – Literature review and own observations. Dev Period Med 2016;20:325-7.
16Kamdar RJ, Al-Shahrani I. Damaging oral habits. J Int Oral Health 2015;7:85-7.
17Vasconcelos FM, Massoni AC, Ferreira AM, Katz CR, Rosenblat A. Occurrence of Deleterious Oral Habits in Children from Recife, Pernambuco, Brazil. Pesqui Bras Odontoped Clín Integrada 2009;9:327-32.
18Cao Y, Liu ZK. Use of the state-trait anxiety inventory with children and adolescents in China: Issues with reaction times. Soc Behav Personal Int J 2015;43:397-410.
19Oliveira MT, Bittencourt ST, Marcon K, Destro S, Pereira JR. Sleep bruxism and anxiety level in children. Braz Oral Res 2015;29. pii: S1806-83242015000100221.
20Fourchard F, Courtinat-Camps A. Neuropsychiatry of Childhood and Adolescence. Press, Corrected Proof; May, 2013. [doi: 10.1016/j.neurenf. 04.005,2013].
21de Alencar NA, Leão CS, Leão AT, Luiz RR, Fonseca-Gonçalves A, Maia LC. Sleep bruxism and anxiety impacts in quality of life related to oral health of Brazilian children and their families. J Clin Pediatr Dent 2017;41:179-85.
22Cheifetz AT, Osganian SK, Allred EN, Needleman HL. Prevalence of bruxism and associated correlates in children as reported by parents. J Dent Child (Chic) 2005;72:67-73.
23Machado E, Dal-Fabbro C, Cunali PA, Kaizer OB. Prevalence of sleep bruxism in children: A systematic review. Dental Press J Orthod 2014;19:54-61.
24Cortese SG, Fridman DE, Farah CL, Bielsa F, Grinberg J, Biondi AM. Frequency of oral habits, dysfunctions, and personality traits in bruxing and nonbruxing children: A comparative study. Cranio 2013;31:283-90.
25Biaggio ÂM. Child form development in portuguese from spielberger's state-trait anxiety inventory for children. Arquivos Bras Psicol 1980;32:106-18.
26Donnarumma V, Cioffi I, Michelotti A, Cimino R, Vollaro S, Amato M. Analysis of the reliability of the Italian version of the oral behaviours checklist and the relationship between oral behaviours and trait anxiety in healthy individuals. J Oral Rehabil 2018;45:317-22.
27Lobbezoo F, Van Der Zaag J, Naeije M. Bruxism: Its multiple causes and its effects on dental implants – An updated review. J Oral Rehabil 2006;33:293-300.
28Funch DP, Gale EN. Factors associated with nocturnal bruxism and its treatment. J Behav Med 1980;3:385-97.
29Heller RF, Forgione AG. An evaluation of bruxism control: Massed negative practice and automated relaxation training. J Dent Res 1975;54:1120-3.
30Meklos JF. Bruxism diagnosis and treatment. J Periodontol 1956;27:277-83.
31Antonio AG, Pierro VS, Maia LC. Bruxism in children: A warning sign for psychological problems. J Can Dent Assoc 2006;72:155-60.
32Carvalho AD, Lima MD, Silva JM, Neta NB, Moura LD. Bruxism and quality of life in schoolchildren aged 11 to 14. Ciência Saúde Coletiva 2015;20:3385-93.
33Calderan MF. Sleeping habits, stress and anxiety in children with bruxism; 2015.p. 80.
34Serra-Negra JM, Paiva SM, Abreu MH, Flores-Mendoza CE, Pordeus IA. Relationship between tasks performed, personality traits, and sleep bruxism in Brazilian school children – A population-based cross-sectional study. PLoS One 2013;8:e80075.
35Manfredini D, Lobbezoo F, Giancristofaro RA, Restrepo C. Association between proxy-reported sleep bruxism and quality of life aspects in Colombian children of different social layers. Clin Oral Investig 2017;21:1351-8.
36Gonçalves LP, Toledo OA, Otero SA. The relationship between bruxism, occlusal factors and oral habits. Dent Press J Orthod 2010;15:97-104.
37Pereira Cruvinel AD, Fernandes Calderan M, Cusicanqui Mendez DA, Aguirre A, Estefania P, Moreira Machado MA, et al. The relationship between breastfeeding duration, deleterious oral habits, and dental caries in babies. Odontolo Clín Cien 2016;15:1-6.
38Trawitzki LV, Anselmo-Lima WT, Melchior MO, Grechi TH, Valera FC. Breast-feeding and deleterious oral habits in mouth and nose breathers. Rev Bras Otorrinolaringol 2005;71:747-51.
39Laberge L, Tremblay RE, Vitaro F, Montplaisir J. Development of parasomnias from childhood to early adolescence. Pediatrics 2000;106:67-74.
40Simões-Zenari M, Bitar ML. Factors associated to bruxism in children from 4-6 years. Pro Fono 2010;22:465-72.
41Widmalm SE, Christiansen RL, Gunn SM. Oral parafunctions as temporomandibular disorder risk factors in children. Cranio 1995;13:242-6.
42Zapata M, Bachiega JC, Marangoni AF, Jeremias JE, Ferrari RA, Bussadori SK, et al. Occurrence of anterior open bite and harmful oral habits in children from 4 to 6-year old. Revista CEFAC 2010;12:267-71.
43Serra-Negra JM, Paiva SM, Auad SM, Ramos-Jorge ML, Pordeus IA. Signs, symptoms, parafunctions and associated factors of parent-reported sleep bruxism in children: A case-control study. Braz Dent J 2012;23:746-52.
44Vanderas AP. Relationship between oral parafunctions and craniomandibular dysfunction in children and adolescents: A review. ASDC J Dent Child 1994;61:378-81.
45da Silva WV, de Figueiredo VL. Childhood anxiety and assessment instruments: A systematic review. Braz J Psychiatry 2005;27:329-35.
46De Luca Canto G, Singh V, Conti P, Dick BD, Gozal D, Major PW, et al. Association between sleep bruxism and psychosocial factors in children and adolescents: A systematic review. Clin Pediatr (Phila) 2015;54:469-78.
47Oliveira AL, Fragelli C, Andrade MF. Multidisciplinary approach in the treatment of childhood bruxism. Rev Uningá 2017;25:2318-579. Available from: [Last accessed on 2019 Mar 26].