Monitoring of awake bruxism by intelligent app

Background. Bruxism is a topic of much controversy and is continually debated in the field of dentistry due to the multifaceted clinical relationship that results in painful conditions and consequences to patients. The aim of this review was to determine the effectiveness of a smartphones app in monitoring awake bruxism. Methods. PROSPERO (registration number: CRD42021271190). The eligibility criteria were as followed: observational studies, case–control studies, studies that reported odds ratios, and studies on awake bruxism. The following keywords were searched: [smartphones apps] AND [apps] AND [awake bruxism], OR [sleep bruxism], OR [sleep hygiene], OR [parasomnias], AND [habits]. Results. All the included studies found that the use of the smartphone app allows controlled awake bruxism monitoring. The results also show that the slepp bruxism and awake bruxism are interactive, having negative synergism and substantially increasing the risks of temporomandibular joint pain and temporomandibular disorders. Discussion. In the awake bruxims it was possible to identify 70% symptoms through the different frequencies of behavior provided by the App, within the present technological tools have become daily in young and adult population. The app is effective and easy to use by patients, effectively limiting biases the time of evaluation.

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Introduction
The controversy when talking about bruxism will always be latent among the academy, from a concept of parafunction to a concept of phenomena wherein biological, psychological and exogenous factors act in greater or lesser percentages. 1 The independent definitions of day bruxism and night bruxism were pointed out at a meeting of different specialties, with oral rehabilitation experts, maxillofacial surgeons and psychologists, who, in 2020, proposed adequate differentiation between the two. 2 Bruxism is a repetitive jaw muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. 3,4 "Bruxism has two distinct circadian manifestations: it can occur during sleep (indicated as sleep bruxism) or during wakefulness (indicated as awake bruxism)". 5,6 Treatment of bruxism is reduced to several main methods: increasing the vertical dimension of occlusion (VDO) to normal, mesialization of the jaw to influence the position of the articular condyle in the articular fossa and releasing the disc, and positioning the jaw in a balanced stable occlusion. 7 This is achieved by splint therapy for a certain period of adaptation and then the result can be fixed by orthodontic treatment, adhesive restorations or prosthetic construction. The stabilizing (occlusal) splint is indicated for the most common symptoms of TMJ and muscle. 8, 9 Awake bruxism is currently defined as "masticatory muscle activity during wakefulness that is characterized by repetitive or sustained dental contact and/or reinforcements or pushes of the jaw and is not a movement disorder in healthy individuals". 10 Polysomnography (PSG) and electromyography (EMG) have been used for the evaluation of nocturnal bruxism 7 ; however for the evaluation of awake bruxism (AB), there was no specific evaluator, until 2018 when an app (Manfredini, Bracci, 2018) was created to evaluate and monitor it through the use of smart devices (smartphones). 11 Bruxism is not necessarily considered a pathological behavior, but it has clinical consequences, the frequency of AB in the healthy young population allows us to compare with other groups 12 ; in these, psychological factors are determined, including fatigue, muscle pain, tooth wear; having differences between young people and adults differentiating habits and lifestyles that modify the behavior of bruxism. 13 The cognitive relationship in oral health suggests a bidirectional causal relationship, there is limited evidence that inflammatory mechanisms, tooth loss, masticatory dysfunction, temporo mandibular joint dysfunction and para functions (bruxism) have the potential to contribute to cognitive decline. 14 The use of questionnaires (self-reports), such as clinical observation complemented with electromyography (EMG) have helped in the evaluation of awake bruxism; however, the momentary ecological assessment (EMA) combines real-time approaches to the current state of the patient, which facilitates having an objective assessment. 15 The limitations of noninstrumental methods to assess the AB are high and become subjective, the use of EMA allows to collect data in real time for a certain period of time according to the coding of alerts, which are activated according to the daily life of the individual, 16 the usefulness in the research field is highlighted when evaluating the oral activity of the individual, unfortunately the data obtained are partial, with little research. 17 To limit the bias provided by evaluations of the AB, a group of researchers has introduced an app (BruxApp) for smartphones, its foundation of creation is the implementation of EMA, this collects data through alerts (20 daily) with questions of related conditions simple to accept or deny by the individual: teeth in contact, habits, mandibular hypermobility, clenching and grinding of teeth; characteristic signs of AB. 18 It is taken as a starting point young population (young adults) 19 whom the researchers determine as the control group, it is monitored by the app for a week (20 daily alerts), the frequency was 28.3% in young people with AB with a low coefficient of variation in jaw muscle activity. 20 The objective of the present study was to determine the effectiveness of the smartphone app in monitoring awake bruxism. The PICO question was: is the application of smart apps effective in diagnosing daytime bruxism?

REVISED Amendments from Version 1
The review carried out in the first version of the manuscript, recommends elaborating specific changes in text rather than in form, including references that further clarify the issue is the central point of its recommendations. In the abstract section, writing is improved in results and the abbreviations in the discussion are clarified. In the introduction it is recommended to expand it using more references on the subject, also incorporate literature that justifies the relationship of bruxism with the loss of vertical dimension and temporomandibular disorders, it was also incorporated that bruxism can be considered as a trigger of inflammatory processes in loss of teeth, masticatory pathologies and temporomandibular disorders In Table 1 the author Ibriglio is changed by Shopoba, D. et al. 2022 the relevance of the paper is much more attached to the issue of the proposed systematic review, In Table two the titles of the papers are removed, allowing to visualize only the authors with the year of publication, making a better summary in all the sections that does not disperse the interest of the reader as recommended by the reviewers. When correcting the references, all the numbering is relocated, the incorporated works mention bruxism a lot as a public health problem. The corrections made according to the recommendations, improved the initial paper, substantially clarifying the topic, preparing the way for observational research, cross sectional or case control in the short or long term on Awake bruxism.  The following complete articles published between January 2014 and June 2021 were included: a total of 857 records were obtained; 27 other records were obtained from other sources; 427 duplicate records were deleted; 200 studies were screened; and 102 records were excluded. In total, 98 studies were included in the qualitative analysis, and 16 studies were includedin the quantitative analysis ( Figure 1).
The authors (BVVR, VMC, PP, LCHB, EDL) independently reviewed the titles and summaries, excluded duplicates and irrelevant articles, and considered only full-text articles. The dates and names of all authors in the final review article were included. Any conflict with respect to the inclusion and exclusion criteria was resolved by the third and fourth authors (MRT, AOB). To control for bias, the Scala JADAD (Table 1) was used. The data extraction procedure was evaluated according to the criteria of all authors. Articles were classified by the author/year, study objective, study type, methodology, results (standard mean and deviation) and conclusions.

Results
SB is related to nonfunctional occlusion, while AB is related to occlusal interactions, suggesting the need for a different therapeutic approach (Table 2).

Discussion
All the authors agree that the use of the smartphone app allows controlled AB monitoring by the patient. The current study also showed that the two bruxism are interactive, with negative synergism substantially increasing the risks of TMJ pain and TMD. Signs such as contact between the teeth, clenching of teeth, teeth grinding, and jaw clenching are well defined    The intensity of episodes of awake bruxism increases in individuals with a high trait of anxiety. in the application in AB, it was possible to identify 70% symptoms through the different frequencies of behavior provided by the app, within the present technological tools have become daily in young and adult population. 21 In the studies reviewed, the EMA was clear for the entire assigned sample. 22,23 In the studies that entered the analysis, the six conditions indicated by the application menu were investigated, relaxed jaw muscles (non-contact teeth), teeth in contact (sander in fixed position), mandibular clenching (without contact between the teeth), dental clenching (strong contact in fixed position), dental grinding and area of pain (temporary, interciliary, temple, preauricular, auricular, mandibular angle, mentonian, neck, frontal, infra and supraorbital), 24,25 the data that were obtained were handled by the application menu that allowed to precisely extract a Microsoft Excel file (20 alerts Â 7 days) in real time. 26 The limitation that was found in the present systematic review is the difficulty of comparing with other studies by the different experimental designs (retrospective), while to apply self-reports are unique times. 27 By assessing population behavior frequency is the baseline for observational EMA studies that aids massive data collection, 28 it also helps to compare findings related to dietary habits, smoking, medications, psychological pathologies, and comorbid conditions. 29 Some studies take as a control group young population Kardeş and Kardeş 2019 analyzed healthy young population finding dental contact (13.6%), teeth grinding (0.5%) and relaxed jaw muscles (76.4%), with a combined frequency of AB of (23.6%). 30 Some studies take as a control group young population Bracci et al. 2018 analyzed healthy young population finding dental contact (13.6%), teeth grinding (0.5%) and relaxed jaw muscles (76.4%), with a combined frequency of AB of 23.6%. 31 These results could be considered a reference point for future research on the epidemiological characteristics of AB in healthy young adults, young people with pathologies, adults and geriatric patients. 32,33 The importance of psychological factors was determined, well-defined changes after the COVID-19 pandemic, having been analyzed in AB, the findings were that females are more likely to experience stress, compared with males, the explanation women report better about their emotions 34 but the depressive state leads to generate AB crisis with BS in the two genders due to the socio-economic conditions generated by the pandemic, it should be clarified that previous systematic reviews found no gender differences in the frequency of AB 35 which contrasts with current information. 36 No significant differences were found in the university population, young adults, some authors point out that the monitoring could have been carried out in transition for the student population so that high stress was not indicated, it would be important to develop future research in times such as semester evaluations to determine significant differences. 37 It should be considered that the elaboration of the self-report must be controlled, so that unnecessary biases are avoided, for this reason the calibration of the instrument is essential whether individual or group, avoiding or reducing homogeneity to a minimum, 38,39 through training and socialization that allows the population to understand the reliable use of self-report based on EMA. 40 The characteristics of the populations studied directly influence the results, the age factor, educational level, work activity, socioeconomic status are aspects that influence in substance. 41,42 Camara M, et al. 2020 found that in one week the relaxation of the mandibular muscles was very low, they conclude that not only in healthy young population the symptoms change from one day to the next, 43 the population comportment must be specific, this makes variable the behavior of the AB monitored with the app, recognizing natural fluctuation and difficulty in recognizing the symptoms. 44 Muscle relaxation can be recognized by the individual, also clenching of teeth, 45 can be a good reference to evaluate the behavior of AB to be a conscious and controlled activity, 46 other authors indicate that the use of SMEs provides reliability in the monitoring of AB, the reason lowers the influence of natural fluctuation that the population presents regardless of age or gender. It is recommended to conduct future research that considers long-term monitoring of AB, the hypothesis should be tested that the manifestations of AB: relaxed jaw muscles (non-contact teeth), teeth in contact (sander in fixed position), mandibular clenching (no contact between teeth), dental clenching (strong contact in fixed position), dental grinding and area of pain (temporary, interciliary, temple, preauricular, auricular, mandibular angle, mentonian, neck, frontal, infra and supraorbital, clinical consequences such as temporo mandibular joint dysfunction, regional myalgias 47 are determined. Continuing with the technological line, the effectiveness of an email-based registration and recovery system should be studied if the individual detects non-functional diurnal contact or muscle contracture, an effective strategy for the treatment of temporo mandibular disorders. 48 An assessment of the associated factors and conditions can, in theory, increase or decrease the frequencies of AB behaviors in the app monitored population based on the EMA selfreport (e.g., dietary, or smoking habits, medication use, psychological problems, and comorbid conditions). 50,51 Data can be added to ongoing studies that consider the 2018 definition of bruxism 52 and the refinement of assessment strategies. Comparisons between populations are necessary and can be used in the context of an ongoing multicenter project on the epidemiology of bruxism. 53

Conclusions
The app used to monitor awake bruxism is effective, and its ease of use allows a fundamental approach to diagnosis. It should be noted that the use of the App allows us to monitor the variable behavior of awake bruxism.

Discussion
The authors constantly compare findings between the 2 types of bruxisms. I suppose this deviates from the main aim -which is only focussed on AB.
○ Are all the limitations addressed? Bias, strength of evidence.

Conclusion
Please add the key findings from the SR and significance of the findings.

Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes
Are sufficient details of the methods and analysis provided to allow replication by others? Yes

Is the statistical analysis and its interpretation appropriate? Yes
Are the conclusions drawn adequately supported by the results presented in the review? Partly © 2022 Shopova D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Dobromira Shopova
Medical University of Plovdiv, Plovdiv, Bulgaria The introduction is short, with only 17 cited authors. In general, the number of references is not large -50, which tends to the minimum for a review article. I ask the authors to add more articles, especially those published in the last 5 years. If desired, they can use some of those that I consider appropriate: Shopova D, Bozhkova T, Yordanova S and Yordanova M. Case Report: Digital analysis of occlusion with T-Scan Novus in occlusal splint treatment for a patient with bruxism [version 2; peer review: 2 approved]. F1000Research 2022, 10:915 1 -It presents a digital device of measurement of occlusal forces, which is very useful in nowadays practice.
management. Problems of Dental Medicine, 46, 18-27. -It presents modern method of bruxism treatment, very similar with the purpose of the reviewed article. All of these articles presented the modern methods of diagnosis and treatment in bruxism cases. They can be find in Google scholar or linked to this report, some of them are uploaded in Scopus or Web of Science. Authors can add and more similar articles to enrich their article. 50 cited articles are too small number.
Long tables make the results quite difficult. Try to systematize the cited authors more tightly.
The discussion is voluminous enough and a sufficient number of authors are compared.
The conclusion consists of one short sentence. Authors can submit their opinion on the most suitable app according to them.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.