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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 102-106

Ecological momentary assessment for awake bruxism diagnosis and treatment

1 Health Sciences Center, Sacred Heart University, Bauru, Brazil
2 Prosthesis and Periodontics, University of São Paulo, Bauru, Brazil
3 Health Sciences Center, Sacred Heart University; Prosthesis and Periodontics, University of São Paulo, Bauru, Brazil

Date of Submission12-Oct-2022
Date of Acceptance16-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Miss. Sarah Barros de Oliveira
R. Irmã Arminda, 10–50 - Jardim Brasil, Bauru - SP, 17011-160, Sacred Heart University Center, Bauru
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_23_22

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Context: Awake bruxism (AB) is a common oral behavior that can cause damage to the stomatognathic system. Ecological momentary assessment (EMA) is a method which collects information about the patient in their natural environment, with several alerts throughout the day. Aims: The aim of the present study was to evaluate the effectiveness of EMA in the diagnosis and treatment of AB, psychosocial aspects in individuals diagnosed with AB and to compare self-report of AB with the diagnosis of AB through the EMA. Subjects and Methods: The research was performed on an online questionnaire in two stages. The initial sample was composed by volunteers from 18 to 50 years-old, randomly recruited through social media, without restriction of sex and occupation. Settings and Design: The first stage involved answering an online questionnaire for the initial diagnosis of AB, and in the second stage, participants underwent EMA for 15 days and answered online questionnaires about perceived stress and anxiety. Statistical Analysis: Statistical analysis consisted of qualitative and quantitative descriptive statistics with parametric and nonparametric tests, with a significance level of 5%. Results: Results showed a significant moderate and positive correlation between the level of AB "tight muscles without teeth contact" and the level of anxiety. Conclusions: As a treatment, EMA can be effective; however, this will depend also on the patient's commitment.

Keywords: Anxiety, bruxism, habits, temporomandibular joint disorders

How to cite this article:
Oliveira SB, da Fonte TP, Berden ME, Conti PC, Cunha CO. Ecological momentary assessment for awake bruxism diagnosis and treatment. J Interdiscip Dentistry 2022;12:102-6

How to cite this URL:
Oliveira SB, da Fonte TP, Berden ME, Conti PC, Cunha CO. Ecological momentary assessment for awake bruxism diagnosis and treatment. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Mar 27];12:102-6. Available from: https://www.jidonline.com/text.asp?2022/12/3/102/365609

   Clinical Relevance to Interdisciplinary Dentistry Top

Regardless of the tool used on the process of Awake Bruxism control, it does not only depends on the professional intervention, but also the commitment of the patient through the process.

   Introduction Top

Bruxism is identified by a repetitive activity of the masticatory muscles. It is characterized by clenching, grinding the teeth and/or holding or pushing the jaw and can occur while awake (awake bruxism [AB]) or during sleep (sleep bruxism [SB]), each one with its own pathophysiology and treatment.[1]

AB can be a result of individual emotional factors that may interfere with emotional well-being.[2],[3] SB is always pointed out as the villain in temporomandibular disorders (TMD), and less relevance is given to AB in TMD patients. It may also be associated with signs and symptoms related to TMJ and masticatory muscles, the TMD, as a predisposing, initiating and/or perpetuating factor along with other factors.[4],[5]

Ecological momentary assessment (EMA) is an evaluation method that emerged for the diagnosis/treatment of AB, collecting behavioral information from repeated momentary alerts in the individual's natural environment,[6] whereas the patient answers his feeling at the time of the alert, many times a day, instead of having to summarize what his perceived all day long, making this tool more effective and accurate.[6],[7],[8] It is necessary to evaluate the effectiveness of EMA, for the diagnosis and treatment of AB. The aim of the present study was to evaluate the effectiveness of EMA in the diagnosis and treatment of AB, the psychosocial aspects in individuals diagnosed with AB and compare self-report of AB with the diagnosis of AB through EMA.

   Subjects and Methods Top

Sample and study design

The research was performed online in two stages. The initial sample was composed of volunteers from 18 to 50 years old, randomly recruited through social media, without the restriction of sex and occupation. An online message or E-mail was sent with a link to access an online "Google Forms" containing the Diagnostic Criteria for TMD (DC-TMD) – oral behavior checklist (OBC) questionnaire and informed consent (access to the questionnaires was permitted only after accepting the informed consent).

The final sample consisted of 40 individuals aged from 19 to 46 years (mean age of 32 years old). Participants who received the diagnosis of AB through DC-TMD OBC composed the final sample. Questionnaires answered unsatisfactorily were withdrawn from the study. Therefore, the lack of intellectual and cognitive ability to interpret questions and answers from a self-report questionnaire was the only exclusion criterion used in addition to age.

All the individuals from the final sample went through the second stage. In the second stage, the participants were submitted to EMA for 15 days. In addition, they answered three online "Google Forms" questionnaires related to psychosocial aspects: Perceived Stress Scale (PSS) and Generalized Anxiety Disorder Scale-7 (GAD-7).

Online questionnaires

All individuals accepted a consent form before answering any questions. This consent was shown on the first page of the online questionnaires explaining all research steps and the risks and benefits of participating. Furthermore, all questionnaires were analyzed by the main researcher to guarantee complete answers.

Oral behaviors checklist

The DC-TMD "Oral Behavior Checklist" Questionnaire consists of 21 questions about the frequency of activities (habits and behaviors) during sleep and while awake. For each statement, the individual has the option to mark between five situations related to the frequency of each event. For the present research, only the answers for activities while awake were computed. For awake activities, the affirmative answers range from "never," "a little of the time," "some of the time," "most of the time," and "all the time." Inclusion criteria for AB were to present a positive response ("some of the time," "most of the time," or "all the time") in items three, four, five, and six, of the questionnaire.[9]

Perceived Stress Scale

The PSS was the instrument used to evaluate the level of self-assessed stress, as one of the variables of the psychosocial profile. This scale is a self-administered instrument validated for Brazilian Portuguese, to assess when an individual is in stressful situations and to what extent he perceives himself to be able to deal with the situations. The instrument consists of 10 items, six positive and four negative, answered on a Likert-type frequency scale, ranging from never (0) to always (4).[10] The version used in the present study was translated and adapted to Brazilian Portuguese by Trigo et al. (2010). The PSS generates a single overall perceived stress score by adding the value of items 1, 2, 3, 6, 9, and 10. After the sum of those items, the numerical value of 4, 5, 7, and 8 questions must be inverted and then subtracted from the total sum in the first step.[11]

Generalized Anxiety Disorder Scale

The GAD-7 Scale is a 7-item self-report scale developed by Spitzer et al. as a screening tool and severity indicator for GAD. The GAD-7 addresses scaled responses to situations, the individual has been going through in the past 2 weeks, and how bothered they are by the issues cited in statements. Items with statements are accompanied by a 3-point numerical scale for responses, with "0" representing "never," "1" representing "several days," "2" representing "more than half of the days," and "3" representing "almost every day." The score is obtained with the sum of the answers. Scores of 5–10, 10–15, and 15–21 represent cutoffs for mild, moderate, and severe anxiety, respectively.[12]

Ecological momentary assessment

For AB assessment with EMA, an app called SKEDit (developed by KVENTURES) was used, which communicated automatically through Whatsapp® with the individual's smartphones. A reminder message was sent, at random times during the day, for 15 days, with a link to an online form, and the individuals should answer, in real-time, the following question: "Which of the following options best describes dental contact at this moment?"; with five possible answers: relaxed jaw muscles, tense jaw without teeth contact, teeth with light touch contact, and clenching the teeth and grinding the teeth. The participants received the alert with the form link on Whatsapp®, and all the answers were automatically saved in Microsoft's Excel file.

The alerts started the day after all participants were instructed, through a WhatsApp® message, on how the research would be conducted in the next 15 days, being informed about the exact definition of each AB condition. They were also instructed to respond to each alert in real time. During the research period, the participant could contact the researchers to clarify any doubts. Alerts were sent between 9:00 am to 12:00 pm and from 2:00 pm to 8:00 pm. The platform was programmed to send 10 alerts per day for 2 days, at random times, followed by 2 more days with eight alerts per day, and the following 11 days, with seven alerts per day, all at preset times in the SKEDit App.

   Results Top

The final sample consisted of 40 individuals aged from 19 to 46 years (mean age of 32 years old). Among these, only 18 (13 females and five males) had sufficient EMA adherence during the 15 days of AB assessment. Therefore, only data from these 18 individuals were used for statistical analysis. The alerts started on September 4, 2021, and ended September 18, 2021. There were a total of 113 alerts during the 15 EMA assessment days. The average number of alerts responded during this period was 65, which corresponds to 57.5% of the total alerts sent, varying from a minimum of 25 alert responses (22%) and maximum of 95 (84%) of the total alerts answered.

All individuals presented a diagnosis of some AB level through EMA, which is in accordance with the OBC result since the final sample individuals should have an AB diagnosis through the OBC questionnaire. Only four individuals, from a total of 18, responded positively with some level of AB to all alerts, therefore, they were not, at any time during the alerts, with relaxed muscles and no touching teeth. The total number of responses received from the 18 individuals was 1163 [Table 1], 73.2% referred to some level of AB. Of the total of 18 individuals, only five obtained a negative correlation between the alert days and the type of AB, that is, only in five individuals, and the EMA was effective in reducing the AB (P < 0.05 and R ranging from −0.754 to −0.257). In the 1st week, 609 alerts were answered, with 76.5% (n = 466) of the alerts being positive for AB. In the 2nd week, 554 alerts were answered, with 69.5% (n = 385) of the alerts being positive for AB [Table 2]. Overall, Student's t-test showed that week 1 data were statistically different from week 2 data for AB levels (P = 0.006).
Table 1: Total of alert responses according to the level of AB

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Table 2: Total of responses weekly and its variation according to the level of AB and its variation through the 15 days of evaluation

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It was found that when comparing the responses of individuals to the AB questionnaire and EMA, there was no significant correlation between AB levels, expected to clenching (rs = 0.525 and P = 0.025), and there was a significant moderate positive correlation, revealing that those who most responded "clenching" was those who reported clenching in the initial questionnaire.

The data obtained from the PSS and GAD-7 questionnaires showed an average PSS score of 21 and an average score of 10 equivalents to "mild anxiety" in the GAD-7 questionnaire. The Spearman's correlation test showed a significant moderate positive correlation (rs = 0.558 and P = 0.016) of AB level and anxiety only with the AB level "tight muscles without teeth contact." Pearson's correlation test showed that the higher the level of stress, the higher the level of anxiety (r = 0.697 and P < 0.001).

   Discussion Top

The present study aimed to evaluate the effectiveness of EMA for AB diagnosis and a possible treatment tool. According to the results, it was possible to verify that EMA is a valid instrument for AB diagnosis, but it requires a great commitment from the patient to be used for this purpose. During the research, there were some difficulties in getting the collaboration of all participants. As mentioned before, according to the OBC results, 40 individuals were selected to participate in the second stage of the research but only data from 18 individuals (45%) were possible to use for statistical analysis, as they were the only ones who completed the 15 EMA's days.

The 18 selected candidates answered an average of 57.5% of alerts, representing only half of the alerts sent during the day, with less commitment on weekends. This shows the great difficulty faced with the use of EMA, despite being a great tool for accessing real-time habits.[13],[14] According to Colonna et al.'s study,[15] the minimum threshold defined for AB diagnosis using EMA is 60% of alerts answered per day. In the present study, 57, 5% was considered to have reached the minimum threshold, since it is in proximity to 60%. Colonna et al. also emphasized the fact that, as it is a momentary assessment, the individual needs to be willing to stop his activities to respond to the alert or focus on himself and his behavior at the moment, which most of the time, decreases the frequency of responses to the alerts.[15]

In the present study, the EMA method was effective, individually, in decreasing AB levels from 1 week to another in only five of the 18 individuals evaluated; however, in general, there was a tendency to decrease the AB levels over 1 week when compared the results from 1st and 2nd weeks. Similar results were shown by Zani et al. whereas it was used EMA not only for diagnostic purposes but also as a tool for AB treatment (ecological momentary intervention [EMI]) suggesting an increase in the frequency of relaxed jaw muscles' condition and a decrease in teeth contact, thus indicating a certain degree of AB behaviors variability over time and also a potentially supporting an EMI effectiveness.[16]

Another finding revealed by the current study is a significant positive correlation between the AB level "tense muscles without tooth contact" and anxiety level. In addition, Pearson's correlation test showed that the higher the level of stress, the higher the level of anxiety of the individuals. These results allow us to reinforce, first of all, the fact that AB is not characterized only by teeth contact as many general clinicians continue to believe but also by the presence of a constant muscle contraction without tooth contact, a statement already well established in the International Consensus on the Assessment of Bruxism in 2017.[3] In regard to the correlation between anxiety, stress levels, and AB, they seemed to be related; however, according to Carvalho[17] is not easy to determine the direct relationship between these three variables, because there is not enough scientific evidence, which means that for an effective treatment, other etiological aspects must be considered, rendering a multi-professional approach and addressing the psychological treatment when necessary.

Despite being a more realistic method for AB diagnosis nowadays, EMA highly depends on the collaboration and commitment of the patient; therefore, it is interesting to add another diagnostic method along with EMA, such as self-report questionnaires. As an intervention, EMA can be effective, as long as the patient is willing to collaborate. Finally, there seems to exist a positive correlation between psychological aspects, such as stress, anxiety, and AB events. Future studies with more representative samples are required to confirm these findings including some other aspects associated with AB behaviors.

   Conclusions Top

The EMA is a valuable tool for the control of AB, but it depends on the patient's cooperation. Other methods can be used to complement AB control, but the first rule is that the patient needs to recognize himself as a modifier of the condition.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Lobbezoo 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.  Back to cited text no. 1
Lavigne GJ, Khoury S, Abe S, Yamaguchi T, Raphael K. Bruxism physiology and pathology: An overview for clinicians. J Oral Rehabil 2008;35:476-94.  Back to cited text no. 2
Lobbezoo 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.  Back to cited text no. 3
Donnarumma MD, Muzilli CA, Ferreira C, Nemr K. Temporomandibular disorders: signs, symptoms and multidisciplinary approach. Rev Cefac 2010;12:788-94.  Back to cited text no. 4
Murali RV, Rangarajan P, Mounissamy A. Bruxism: Conceptual discussion and review. J Pharm Bioallied Sci 2015;7:S265-70.  Back to cited text no. 5
Stone AA, Shiffman S. Ecological momentary assessment (EMA) in behavioral medicine. Ann Behav Med 1994;16:199-202.  Back to cited text no. 6
Stone AA, Schwartz JE, Neale JM, Shiffman S, Marco CA, Hickcox M, et al. A comparison of coping assessed by ecological momentary assessment and retrospective recall. J Pers Soc Psychol 1998;74:1670-80.  Back to cited text no. 7
Stone AA, Shiffman S. Capturing momentary, self-report data: A proposal for reporting guidelines. Ann Behav Med 2002;24:236-43.  Back to cited text no. 8
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications: Recommendations of the international RDC/TMD consortium network* and orofacial pain special interest group. J Oral Facial Pain Headache 2014;28:6-27.  Back to cited text no. 9
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.  Back to cited text no. 10
Trigo M, Canudo N, Branco F, Silva D. Estudo das propriedades psicométricas da Perceived Stress Scale (PSS) na população portuguesa. Psychologica 2010;53:353-78.  Back to cited text no. 11
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.  Back to cited text no. 12
Kaplan SE, Ohrbach R. Self-report of waking-state oral parafunctional behaviors in the natural environment. J Oral Facial Pain Headache 2016;30:107-19.  Back to cited text no. 13
Bracci A, Djukic G, Favero L, Salmaso L, Guarda-Nardini L, Manfredini D. Frequency of awake bruxism behaviours in the natural environment. A 7-day, multiple-point observation of real-time report in healthy young adults. J Oral Rehabil 2018;45:423-9.  Back to cited text no. 14
Colonna A, Lombardo L, Siciliani G, Bracci A, Guarda-Nardini L, Djukic G, et al. Smartphone-based application for EMA assessment of awake bruxism: Compliance evaluation in a sample of healthy young adults. Clin Oral Investig 2020;24:1395-400.  Back to cited text no. 15
Zani A, Lobbezoo F, Bracci A, Ahlberg J, Manfredini D. Ecological momentary assessment and intervention principles for the study of awake bruxism behaviors, Part 1: General principles and preliminary data on healthy young Italian adults. Front Neurol 2019;10:169.  Back to cited text no. 16
Carvalho GA, Sousa GP, Pierote JJ, Lima DE, Costa IV, Silva FA, et al. Anxiety as an ethological factor of bruxism-literature. Res Soc Dev 2020;9:e95973925.  Back to cited text no. 17


  [Table 1], [Table 2]


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