Abstract
Objectives
This study investigated the temporal relationships between apnea–hypopnea (AH) and sleep bruxism (SB) events and correlated SB to various respiratory/sleep indexes in adult patients with concomitant obstructive sleep apnea (OSA) and SB.
Materials and methods
Nocturnal PSG data of 147 consecutive OSA patients were examined for comorbid SB. Among the 49 subjects with coexisting OSA and SB, 26 were randomly selected for in-depth appraisal of temporal patterns which were classified as T1 (unrelated activities), T2 (AH events occur before SB events), T3 (SB events occur before AH events), and T4 (AH and SB events occur simultaneously). Data were analyzed using Mann–Whitney U tests and Spearman’s correlation (α = 0.05).
Results
The majority (84.5%) of AH events were unrelated to SB events. Of the 15.5% of related activities, T2 and T3 patterns occurred in 14.1% and 1.4%, respectively. SB events/index, the percentage of unrelated/related AH-SB events, and T2-T3 episodes were not associated with gender, age, body mass (BMI), and apnea–hypopnea (AHI) index. SB events were related to total sleep time (rs = 0.44), but no significant associations were discerned between SB and AH index.
Conclusions
As most AH events were unrelated to SB events, OSA and SB are probably epiphenomena in adult patients with concomitant conditions. Where AH-SB events were related, the T2 temporal pattern, where SB events were subsequent to AH events, featured predominantly alluding to a specific form of secondary SB triggered by sleep micro-arousals.
Clinical relevance
AH and SB events are probably epiphenomena in adult patients with coexisting OSA and SB. Even so, OSA patients should be routinely screened for SB and vice versa considering their frequent comorbidity.
Similar content being viewed by others
Data availability
The data that support the findings of this study are not openly available and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Ng Teng Fong General Hospital.
References
Melo G, Duarte J, Pauletto P et al (2019) Bruxism: an umbrella review of systematic reviews. J Oral Rehabil 46:666–690
Senaratna CV, Perret JL, Lodge CJ et al (2017) Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev 34:70–81
Lobbezoo F, Ahlberg J, Glaros AG et al (2013) Bruxism defined and graded: an international consensus. J Oral Rehabil 40:2–4
da Costa Lopes AJ, Cunha TCA, Monteiro MCM, Serra-Negra JM, Cabral LC, Júnior PCS (2020) Is there an association between sleep bruxism and obstructive sleep apnea syndrome? A systematic review. Sleep Breath 24:913–921
Pauletto P, Polmann H, Conti Réus J et al (2022) Sleep bruxism and obstructive sleep apnea: association, causality or spurious finding? A scoping review. Sleep 45:073. https://doi.org/10.1093/sleep/zsac073
Manfredini D, Guarda-Nardini L, Marchese-Ragona R, Lobbezoo F (2015) Theories on possible temporal relationships between sleep bruxism and obstructive sleep apnea events An expert opinion. Sleep Breath 19:1459–1465
Lavigne GJ, Rompré PH, Montplaisir JY (1996) Sleep bruxism: validity of clinical research diagnostic criteria in a controlled polysomnographic study. J Dent Res 75:546–552
Malhotra RK, Kirsch DB, Kristo DA et al (2018) American Academy of Sleep Medicine board of directors. Polysomnography for Obstructive Sleep Apnea should include arousal-based scoring: An American Academy of Sleep Medicine Position Statement. J Clin Sleep Med 14:1245–1247
Yap AU, Chua AP (2016) Sleep bruxism: current knowledge and contemporary management. J Conserv Dent 19:383–389
Lobbezoo F, Naeije M (2001) Bruxism is mainly regulated centrally, not peripherally. J Oral Rehabil 28:1085–1091
Lobbezoo F, Visscher CM, Ahlberg J, Manfredini D (2014) Bruxism and genetics: a review of the literature. J Oral Rehabil 41:709–714
Tan MWY, Yap AU, Chua AP, Wong JCM, Parot MVJ, Tan KBC (2019) Prevalence of sleep bruxism and its association with obstructive sleep apnea in adult patients: a retrospective polysomnographic investigation. J Oral Facial Pain Headache 33:269–277
Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191
Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14:540–545
Chou KT, Chang YT, Chen YM, Su KC et al (2011) The minimum period of polysomnography required to confirm a diagnosis of severe obstructive sleep apnoea. Respirology 16:1096–1102
American Academy of Sleep Medicine (2016) Manual for the scoring of sleep and associated events: rules, terminology and technical specifications (Version 2.3). AASM, Illinois
Berry RB, Budhiraja R, Gottlieb DJ et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. Deliberations of the Sleep Apnea definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 8:597–619
Ernst G, Sabán M, Schiavone M, Blanco M, Salvado A, Borsini E (2020) Prevalence and characteristics of obstructive sleep apneas according to severity. Medicina (B Aires) 80:479–486
Raphael KG, Janal MN, Sirois DA et al (2013) Masticatory muscle sleep background electromyographic activity is elevated in myofascial temporomandibular disorder patients. J Oral Rehabil 40:883–891
Saito M, Yamaguchi T, Mikami S et al (2014) Temporal association between sleep apnea-hypopnea and sleep bruxism events. J Sleep Res 23:196–203
Khoury S, Rouleau GA, Rompré PH, Mayer P, Montplaisir JY, Lavigne GJ (2008) A significant increase in breathing amplitude precedes sleep bruxism. Chest 134:332–337
Maluly M, Dal Fabbro C, Andersen ML, Herrero Babiloni A, Lavigne GJ, Tufik S (2020) Sleep bruxism and its associations with insomnia and OSA in the general population of Sao Paulo. Sleep Med 75:141–148
de Holanda TA, Castagno CD, Barbon FJ, Costa YM, Goettems ML, Boscato N (2020) Sleep architecture and factors associated with sleep bruxism diagnosis scored by polysomnography recordings: a case-control study. Arch Oral Biol 112:104685
Martynowicz H, Gac P, Brzecka A et al (2019) The relationship between sleep bruxism and obstructive sleep apnea based on polysomnographic findings. J Clin Med 8:1653
Yap AU, Cao Y, Zhang MJ, Lei J, Fu KY (2021) Age-related differences in diagnostic categories, psychological states and oral health-related quality of life of adult temporomandibular disorder patients. J Oral Rehabil 48:361–368
WHO expert consultation (2004) Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363:157–163
Dancey CP, Reidy J (2017) Statistics without maths for psychology, 7th edn. Pearson, London
Colonna A, Cerritelli L, Lombardo L et al (2022) Temporal relationship between sleep-time masseter muscle activity and apnea-hypopnea events: a pilot study. J Oral Rehabil 49:47–53
Martynowicz H, Wieczorek T, Macek P et al (2022) The effect of continuous positive airway pressure and mandibular advancement device on sleep bruxism intensity in obstructive sleep apnea patients. Chron Respir Dis 19:14799731211052300
Sjöholm TT, Lowe AA, Miyamoto K, Fleetham JA, Ryan CF (2000) Sleep bruxism in patients with sleep-disordered breathing. Arch Oral Biol 45:889–896
Lim LL, Tham KW, Fook-Chong SM (2008) Obstructive sleep apnoea in Singapore: polysomnography data from a tertiary sleep disorders unit. Ann Acad Med Singap 37:629–636
Zein JG, Tawk MM, Dernaika T, Kinasewitz GT, Orr WC (2005) The clinical significance of spontaneous arousals index during polysomnography. Chest 128:380S
Tay DKL, Pang KP (2018) Clinical phenotype of South-East Asian temporomandibular disorder patients with upper airway resistance syndrome. J Oral Rehabil 45:25–33
Smardz J, Wieckiewicz M, Wojakowska A et al (2022) Incidence of sleep bruxism in different phenotypes of obstructive sleep apnea. J Clin Med 11:4091
Schames SE, Schames J, Schames M, Chagall-Gungur SS (2012) Sleep bruxism, an autonomic self-regulating response by triggering the trigeminal cardiac reflex. J Calif Dent Assoc 40:670–676
Oksenberg A, Arons E (2002) Sleep bruxism related to obstructive sleep apnea: the effect of continuous positive airway pressure. Sleep Med 3:513–515
Carra MC, Macaluso GM, Rompré PH et al (2010) Clonidine has a paradoxical effect on cyclic arousal and sleep bruxism during NREM sleep. Sleep 33:1711–1716
Yap AU (1998) Effects of stabilization appliances on nocturnal parafunctional activities in patients with and without signs of temporomandibular disorders. J Oral Rehabil 25:64–68
Schellenberg JB, Maislin G, Schwab RJ (2000) Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal structures. Am J Respir Crit Care Med 162:740–748
Hang LW, Huang CS, Cheng WJ (2021) Clinical characteristics of Asian patients with sleep apnea with low arousal threshold and sleep structure change with continuous positive airway pressure. Sleep Breath 25:1309–1317
Wieckiewicz M, Bogunia-Kubik K, Mazur G et al (2020) Genetic basis of sleep bruxism and sleep apnea-response to a medical puzzle. Sci Rep 10:7497
Castroflorio T, Bargellini A, Rossini G, Cugliari G, Deregibus A (2017) Sleep bruxism and related risk factors in adults: a systematic literature review. Arch Oral Biol 83:25–32
Guo H, Wang T, Niu X et al (2018) The risk factors related to bruxism in children: a systematic review and meta-analysis. Arch Oral Biol 86:18–34
Woo HJ, Lim JH, Ahn JC et al (2020) Characteristics of obstructive sleep apnea patients with a low body mass index: emphasis on the obstruction site determined by drug-induced sleep endoscopy. Clin Exp Otorhinolaryngol 13:415–421
Kim SJ, Ahn HW, Hwang KJ, Kim SW (2020) Respiratory and sleep characteristics based on frequency distribution of craniofacial skeletal patterns in Korean adult patients with obstructive sleep apnea. PLoS ONE 15:e0236284
Kim DH, Lee SH, Lee SH (2020) Sleep bruxism episodes in patients with obstructive sleep apnea syndrome determined by in-laboratory polysomnography. Appl Sci 10:8587
Yo SW, Joosten SA, Wimaleswaran H et al (2022) Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med 18(9):2103–2111. https://doi.org/10.5664/jcsm.9990
Winck M, Drummond M, Viana P, Pinho JC, Winck JC (2017) Sleep bruxism associated with obstructive sleep apnoea syndrome - a pilot study using a new portable device. Rev Port Pneumol 23:22–26
Zhang XB, Zen HQ, Lin QC, Chen GP, Chen LD, Chen H (2014) TST, as a polysomnographic variable, is superior to the apnea hypopnea index for evaluating intermittent hypoxia in severe obstructive sleep apnea. Eur Arch Otorhinolaryngol 271:2745–2750
Dumais IE, Lavigne GJ, Carra MC, Rompré PH, Huynh NT (2015) Could transient hypoxia be associated with rhythmic masticatory muscle activity in sleep bruxism in the absence of sleep-disordered breathing? A preliminary report. J Oral Rehabil 42:810–818
Tauman R, O’Brien LM, Barbé F, Iyer VG, Gozal D (2006) Reciprocal interactions between spontaneous and respiratory arousals in adults with suspected sleep-disordered breathing. Sleep Med 7:229–234
Ohlmann B, Bömicke W, Behnisch R, Rammelsberg P, Schmitter M (2022) Variability of sleep bruxism-findings from consecutive nights of monitoring. Clin Oral Investig 26:3459–3466
Smardz J, Martynowicz H, Wojakowska A et al (2020) The meaning of the masticatory muscle tonic-type electromyographic pathway correlated with sleep bruxism and sleep-related breathing disorders - a polysomnographic study. Sleep Med 68:131–137
Acknowledgements
The authors would like to thank Shaffinaz Abdullah Rahman for her assistance with the research.
Author information
Authors and Affiliations
Contributions
Yap AU: Conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, visualization, supervision, project administration, writing—original draft.
Tan MWY: Conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, project administration, writing—review and editing.
Tan SHX: Methodology, software, validation, formal analysis, resources, data curation, visualization, writing—review and editing.
Chua AP: Conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, supervision, project administration, writing—review and editing.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate
This study was approved by the National Healthcare Group Domain Specific Review Board (reference number: 201600223) with the waiver of consent.
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Yap, A.U., Tan, M.W.Y., Tan, S.H.X. et al. Sleep bruxism events: an epiphenomenon of severe obstructive sleep apnea?. Clin Oral Invest 27, 4633–4642 (2023). https://doi.org/10.1007/s00784-023-05089-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00784-023-05089-w