Amendments from Version 1

F1000Research

2046-1402

F1000 Research Limited

London, UK

10.12688/f1000research.133946.2

Research Article

Articles

Evaluation by app in smartphones of awake bruxism at the return of presential classes in two university centers

[version 2; peer review: 1 approved, 1 approved with reservations, 3 not approved]

Velasquez Ron

Byron

Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-5660-3941 a 1 2 Mosquera Cisneros

Veronica

Investigation Methodology Visualization Writing – Original Draft Preparation Writing – Review & Editing 2 Pazmiño Troncoso

Pamela

Investigation Methodology Writing – Original Draft Preparation Writing – Review & Editing 2 Rodriguez Tates

Maria

Investigation Methodology Project Administration Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 2 Alvares Lalvay

Eddy

Conceptualization Investigation Methodology Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-7377-8003 2 Chauca Bajaña

Luis

Investigation Methodology Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-8713-951X 3 Ordoñez Balladares

Andrea

Investigation Methodology Writing – Original Draft Preparation Writing – Review & Editing 3 1State University of New York University Center for Academic and Workforce Development, Manhathan, New York, USA 2UDLA, Universidad de Las Americas, Quito, Via Nayon, 170523, Ecuador 3Universidad de Guayaquil, Guayaquil, Guayas, Ecuador

a byron.velasquez@udla.edu.ec

No competing interests were disclosed.

5 8 2024

2023

766

22 7 2024

2024

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.

Background. The return to normality post-pandemic brought some inconveniences to the population, especially students. To evaluate the frequency of awake bruxism behaviors through the use of an app on smartphones in dental students returning to presential classes. Awake bruxism was evaluated with the creation of an app that according to the authors evaluates: relaxed jaw muscles, dental contact, jaw effort, clenching teeth and teeth grinding, 5 frequent oral conditions in the population. The frequency of awake/daytime bruxism (AB) in healthy individuals when comparing other populations with possible risk factors for additive bruxism (psychological factors, depression, suicide delusions, etc.), evaluating consequent clinical signs (fatigue, muscle pain, attritions and dental openings).

Methods: The sample of three hundred (n=300) young adults legally enrolled in two Ecuadorian universities, the sample was selected among fifth, sixth, seventh, eighth and ninth semester students legally enrolled and who are attending Faculty of Dentistry classes in 2 different cities (Quito and Guayaquil). The app was configured to provide 20 alerts during the day x seven days a week, in real time.

Results. The study obtained 95% reliability and 5% error in research, was used. The relaxation condition was present in all users, but 40% of the alerts were associated with jaw and tooth discomfort, 39% corresponded to the discomfort of mandibular clenching, and 24% corresponded to tooth contact. A direct significant association was found between the state of relaxation and nonrelaxation, with a high probability of reports related to nonrelaxation (p ≤ 0.05).

Conclusions: Awake bruxism with the app was evaluated, identifying 5 behaviors such as: relaxed mandibular muscles, dental contact, mandibular effort, clenching and grinding teeth, frequent conditions in the population; reporting a state of mandibular relaxation, there is a high probability that a condition of nonrelaxation would be reported (p≤0.05).

bruxism ecological momentary assessment smartphone prevalence COVID-19 pandemic.

The author(s) declared that no grants were involved in supporting this work.

Revised Amendments from Version 1

Responding to the reviewers, indicating that the verb evaluation was abstract around the research topic, they recommended using the verb monitor. The objective was corrected by clarifying the goal of the research in a better way, expanding the section of materials and methods with better explanation on the recommendation of the reviewers, the conclusion as it should respond to the objective was also revised. In the introduction, the wording is improved by including references suggested by the reviewers that justify the topic to be investigated. In the materials and methods, contact is made with the creators of the app via email, confirming the authorship of the same, making the application free. Table 1 with the suggested indications is changed. In the discussion it is completely reorganized, the language and references are reviewed, the suggestions to discuss clearly about the use of the app and the follow-up it provides on Awake bruxism are respected, the result of the state of relaxation that the patients had is also discussed, contrasting with other studies that applied EMA fundamental basis of the application. The conclusion is reviewed when the objective is found that the first 4 days of monitoring in the bruxism app showed symptoms such as discomfort in the jaw and teeth, from day 4 the students answered in the record of the alerts in the app that they felt relaxed, according to authors it was due to the brain action that they generate unconsciously to self-control, let's remember that Awake Bruxism is an activity that the patient does not know he has but that is generated in summer hours, for this reason scientists justify that the human brain reconditions its reactions so that it becomes preventive or is on alert of a diagnosed condition.

Background

Bruxism is a debated topic, especially when considering dental clinical manifestations and their relationships with other medical specialties, ¹ causing controversy in confronting effects and consequences. A panel of experts, including dentists, psychologists, and specialists in pain and facial pain, defined bruxism using strategies such as polysomnography (PSG) and electromyography (EMG) ² to determine whether it is triggered by specific clinical signs such as involuntary movements ³ in the chewing muscles. ⁴ There are many studies on this topic; unfortunately, scientific evidence on awake bruxism is limited. The concept of awake bruxism is currently considered muscular activity during wakefulness that is characterized by repetitive or sustained dental contact, accompanied by pushes or mandibular reinforcements (movements) during a person’s conscious activities, which is not necessarily pathological but has clinical consequences. ⁵ ^, ⁶ When comparing populations, awake bruxism has risk factors such as mental disorders, depression, and suicidal delusions, among others, with clinical signs such as fatigue, muscle pain, dental attrition, and temporomandibular joint pain, suggesting the need for the evaluation of intercultural comparisons, social strata and lifestyle habits. ⁷ Evaluation can be performed with noninstrumental approaches such as self-reports (anamnestic questionnaires), clinical observation, instrumental evaluation using electromyography (EMG), and ecological momentary assessment (EMA) strategies. ² ^, ⁸ ^, ⁹

EMA allows us to collect data in real time over a given period of time by recording multiple coincident points in the environment. ¹⁰ ^– ¹² This instrumentation goes beyond retrospective questionnaires, making EMA very useful in the evaluation of oral activity. The limitation of EMA is that the data are fragmented, as only specific behaviors are selected. ¹³ ^– ¹⁵ To control this bias, in Italy, the research group under Professor Alessandro Bracci at the University of Pavoda created a smartphone app, which incorporates EMA to collect data on dental contact, jaw clenching, tooth compression and teeth grinding. ¹⁶ ^, ¹⁷

The application provides data on the frequency of awake bruxism behaviors (clinical signs entered into the application) over a period of one week, with evaluation 4 times per day. These data are stored in the memory of the phone. After the evaluation time, we obtained data on the percentage and frequency of clinical signs. ¹⁸

The objective of this study was to monitor the frequency of awake bruxism behaviors in dental students by using a smartphone app.

Materials and Methods

Approval was obtained from the Bioethics Committee of the University of the Americas (CEBE-2022-0601). Three hundred (n = 300) young adults who were legally enrolled in two different Ecuadorian universities (*UDLA/UESG) in Quito and Guayaquil were randomly selected after signing the informed consent form and agreeing to participate in the study. They underwent a one-week registration period with a smartphone app (BruxApp Research ^®, Pontedera, Italy) developed by Dr. Alessandro Bracci et al., with the aim of reporting and monitoring the frequency of AB behaviors in their natural environment; this free application can be accessed via Google Pay and the App store. The students were made aware of the responsibility of participating in the research, making their country and their university known to the world.

The sample included fifth-, sixth-, seventh-, eighth- and ninth-semester students who were legally enrolled and who were attending face-to-face classes conducted by the Faculty of Dentistry at two different Ecuadorian universities (Quito and Guayaquil). The inclusion criteria included having recent generation smartphones, good general health and the absence of temporomandibular joint disorder (TMD)/orofacial pain and/or any documented degenerative, neurological or systemic disease (e.g., rheumatological disease, hormonal disease). An informative meeting was held during which the students maintained contact with the principal investigators (BV, VM, PP, MRT, EAL, LCH, and AO).

During that session, the objective of the study was explained, and training was provided on how to use the app ( Figure 1).

Figure 1. Flow diagram research.

The Bruxism APP collects a person’s data in a self-informed way in their daily life with an EMA approach (ecological approach), sending random messages during the day that alert the person of the conditions of their teeth and jaw muscles; individuals must respond within 5 minutes by touching the cone of the screen of their cell phone and indicating the current condition of their jaw muscles: jaw muscle relaxation, teeth contact, jaw clenching, teeth clenching and teeth grinding.

The objective of the study was explained while providing training for the correct use of the application ( Figure 1).

The students were instructed to download the BruxApp and asked to start their first data collection session the next morning, which included 20 alerts per day at random intervals. The participants were instructed to comply with at least 60% of the requests per day (answering within the first 5 minutes; otherwise, the screen sent an error message) Students who responded to <60% of the alerts were excluded from the study automatically. Data were recorded during a period of 7 days, the records were calibrated from 8.00 to 12.30 and from 14.30 to 22.00, and the participants were instructed to ignore alerts during meals and particular activities (smoking, singing). The application records were recorded all day. After seven valid days of recordings, the software generated an anonymous .csv file, which the students sent to the researchers via prearranged emails. The data were collected by the lead author (B. V.) in collaboration with two resident dentists of the Specialty of Oral Rehabilitation (V. M., P. P., MRT, and EAL) of dentistry and two professors (LCH and A. of the Faculty of Dentistry of the University of Guayaquil).

To maximize the recording window, lunchtime was excluded because the participants were instructed to ignore alerts during meals and activities (smoking, singing). If the minimum number of valid responses per day was not obtained, the software automatically added another recording day to ensure completion of the 7-day protocol.

For the study of awake bruxism, the chi-square test ( Table 1) was used to determine the association between muscle relaxation and nonrelaxation. In the alerts from the app, in the first stage, the muscles were not in occlusal contact (maximum intercuspation); in the second stage, there was occlusal contact (maximum intercuspation) and clenching of the jaw and teeth accompanied by grinding. The existing correlation was direct despite being in different contexts, demonstrating that the conditions were present during the conscious activity of the person (awake). When reporting mandibular relaxation, there was a high probability that muscle relaxation was reported in the application (p≤0.05).

Table 1. Significance test.

Chi-square tests
	Valor	gl	Asymptotic significance (bilateral)
Pearson's Chi-square	1200.000 ^†	16	<.001
Likelihood ratio	902.565	16	<.001
Linear-by-linear association	299.000	1	<.001
N. of valid cases	300

^†

9 boxes (36.0%) had an expected count of less than 5. The minimum expected count was 0.56.

Results

Assuming 95% reliability and 5% error in the research, a sample size of 300 young adults from the two universities involved in the study was included in simple random sampling model. The research was characterized by analyzing variables such as sex and age ( Table 2).

Table 2. Distribution of the sample by sex.

Sex ^†	n	%n
Female	253	84.33
Male	47	15.67
Total ^‡	300	100

^†

Sex.

^‡

Total Sex.

The proportion of females among the selected sample was 84.33%, compared with that of 15.67% for males. Thus, the proportion of females in this study was significantly greater than that of males. A total of 79% of the participants were aged 21 to 22 years, which was expected since this sample set consisted of young adults studying at a university ( Table 3).

Table 3. Distribution of the sample by age.

Age (years) ^§	n	%n
19	30	10
21	134	44.7
22	104	34.7
23	10	3.33
24	1	0.33
25	12	4
26	6	2
27	1	0.33
32	2	0.67
Total ^¶	300	100

^§

Age.

^¶

Total Ages.

Relaxation was evident in all users, but 40% of the alerts were associated with jaw and tooth discomfort, 39% corresponded to mandibular clenching, and 24% corresponded to tooth contact ( Table 4).

Table 4. Distribution of alerts according to user conditions.

Conditions	Alerts	%
Relaxed	3652	68.9
Jaw clenching ^§	917	15.28
Tooth contact	573	9.55
Tooth clenching	487	8.12
Pain when opening/closing the mouth	142	2.37
Daytime pressure	142	2.37
Teeth grinding	70	1.17
Difficulty opening the mouth when waking up	10	0.17
Sore teeth	7	0.12
Total	6000	100

^§

Jaw clenching was most relevant

▾ 20 alerts x 300 Participants x 7 days = 42000.

Thus, among the aforementioned symptoms, 63% of the alerts sent by BruxApp were related to specific symptoms. The study was conducted in one week: on the first day, 33% of the participants reported discomfort; on the second day, 61% reported maxillary discomfort; on the third day, 64% reported decreased discomfort; on the fourth day, 21% reported a decrease in discomfort; on the fifth day, the discomfort percentage was maintained; on the sixth day, 41% of the participants reported being relaxed; and on the seventh day, the percentage of participants who reported being relaxed increased by 51% ( Table 5).

Table 5. Distribution of alerts according to condition among sex and age groups.

		Sex/Age (Groups)
		Females years				Males years
Condition		18/21 years	22/25 years	26/32 years	Total	18/21 years	22/25 years	Total	Grand Total
Relaxed	Alerts	1644	1308	115	3067	295	290	585	3652
Relaxed	%Alerts	45.2	35.82	3.19	83.98	8.08	7.94	16.02	100
Tooth clenching	Alerts	242	164	11	417	42	28	70	487
Tooth clenching	%Alerts	49.69	33.48	2.26	85.63	8.62	5.7	14.37	100
Jaw clenching	Alerts	442	307	25	774	83	60	143	917
Jaw clenching	%Alerts	48.20	33.48	2.73	84.41	9.05	6.54	15.59	100
Sore teeth	Alerts	1	1	5	7	0	0	0	7
Sore teeth	%Alerts	14.29	14.29	71.43	100	0	0	0	100
Tooth contact	Alerts	277	194	15	486	50	37	87	73
Tooth contact	%Alerts	48.34	33.86	2.62	84.82	8.73	6.46	15.18	100
Difficulty opening the mouth upon waking	Alerts	5	5	0	10	0	0	0	10
Difficulty opening the mouth upon waking	%Alerts	50	50	0	100	0	0	0	100
Pain when opening/closing the mouth	Alerts	67	48	5	120	12	10	22	142
Pain when opening/closing the mouth	%Alerts	47.18	33.8	3.52	84.51	8.45	7.04	15.5	100
Daytime pressure	Alerts	68	48	4	120	12	10	22	142
Daytime pressure	%Alerts	47.89	33.8	2.82	84.51	8.45	7.04	15.5	100
Teeth grinding	Alerts	34	25	0	59	6	5	11	70
Teeth grinding	%Alerts	48.57	35.71	0	84.29	8.57	7.14	15.71	100
Total	Alerts	2780	2100	180	5060	500	440	940	6000
Total	%Alerts	46.33	35	3	84.33	8.33	7.33	15.7	100

Discussion

The collection of heterogeneous information, the calibration of personal self-reports and group reports on phones, and training in the use of the smartphone app facilitated the data collection. The included population of dental students may have had a positive influence on the results, as having knowledge of what the app is measuring limited the bias in the study.

The app used in the study to monitor the frequency of AB behavior revealed that the symptomatology found was more significant in 84% of women aged 21 to 22 years, and the daily use of technology by young people was helpful in their fulfillment of responses to the alerts of the app. This information coincides with what was proposed by Dias et al. in 2021, which indicates that the use of the EMA approach in smartphone programs for monitoring AB behaviors was useful in the long term, making individuals aware of the recognition of the different pathologies considered by the application. ¹⁹ ^, ²⁰

The BruxApp provides various frequencies and percentages depending on sex and age groups; 32.13% of women and 5.91% of men reported experiencing maxillary discomfort, justifying its diagnostic importance. The report indicated that 68.9% of alerts received responses regarding a state of relaxation (without jaw discomfort). ²¹ ^, ²² When excluding the state of relaxation, mandibular clenching had the greatest significance at 39%. Monitoring the nonrelaxation state with five specific conditions included in the app, such as jaw muscle relaxation, tooth contact, jaw force, teeth clenching, and teeth grinding, resulted in the collection of data for >6000 alerts (20 alerts × 300 participants × 7 days).

During the 7-day observation period, data on 42000 alerts were collected. Zani et al. (2021) used the BruxApp in 2 Italian universities for monitoring AB behaviors by assessing the state of relaxation and nonrelaxation, coinciding with 5 conditions: relaxation of the mandibular musculature, 76.4%; contact with teeth, 13.6%; mandibular bracing, 7.0%; teeth clenching, 2.5%; and teeth grinding, 0.5%.21,22 Data collected using the EMA approach in observational studies indicate a reference in the frequency of AB behaviors, indicating that predisposing factors may vary in women under normal conditions, stress factors, and hormonal factors. ²³ ^, ²⁴

Jaw clenching was the most frequently reported, at 15.28%, and dental pain was the least frequently reported, at 0.17%, and the combined frequency of AB in a state of nonrelaxation was 23.6% ²⁵; the consideration of psychological factors within the etiology of AB, which relates to sex, provides a statistical variable indicating that men control their emotions better ²⁶ than women do. Studies conducted by Bracci et al. (2018) showed similarities with our study, revealing a slight difference in sex when monitoring AB behaviors with EMAs, which was not a determinant of the outcome. ¹⁰ ^, ²⁷

No statistically significant differences were found between the population participating in the research (UDLA; USG), the self-reported strategies for AB, which helped in the data collection, and the alerts generated by the app during the 7-day monitoring period, which controlled the bias of the study due to the alarm that was activated according to the program. ²⁸ ^, ²⁹

The alerts generated in the evaluation by using the application provided diverse results: 33% of participants reported experiencing jaw discomfort the first day, 61% reported it on the second day, 64% reported it on the third day, 21% reported it on the fourth day, the result did not change on the fifth day, 41% reported experiencing relaxation on the sixth day, and 51% reported experiencing relaxation on the seventh day.

The natural fluctuation in the recognition consisting of the symptomatology reported regarding the specific AB behaviors recorded in the app demonstrates considerable variability. ³⁰ ^, ³¹ These findings indicate that relaxed muscles are recognized in a high percentage of the investigated population, taking the baseline results as a starting point when evaluating the combined frequencies of all the symptoms of AB indicated in the app. ³² ^, ³³

The EMA strategy used in the smartphone application indicated a medium frequency value that provided reliability in monitoring AB behaviors, reducing the influence of natural fluctuations directly related to the specific symptomatology. ³⁴ ^, ³⁵ Unfortunately, e-mail registration limited daytime contact with the patients with TMD, ³⁶ ^, ³⁷ and it is recommended that future research evaluate the increase or decrease in the frequency of AB symptoms, relating them to eating habits, smoking habits, medication use, and psychological problems. ³⁸ ^, ³⁹

Compared with the findings of other similar studies that have contributed to updating the concept of bruxism by providing strategic evaluation options, ⁴⁰ ^, ⁴¹ population comparisons will be made better by translating the BruxApp ⁴² ^, ⁴³ into several languages, which opens the possibility of conducting multicenter epidemiological research on bruxism.

Conclusion

During 7 days of monitoring the frequency of AB behaviors through a smartphone app, the student population experienced discomfort in the jaw and teeth in the first 4 days, reaching a state of relaxation on the seventh day.

Data availability

Zenodo. Evaluation by app in smartphones of awake bruxism at the return of presential classes in two university centers, https://doi.org/10.5281/zenodo.7979723. ⁴³

This project contains the following underlying data:

•

Table 1: Significance test

•

Table 2.docx (Data of distribution of the sample by gender)

•

Table 3.docx (Data of distributions of sample by age)

•

Table 4.docx (Data of distribution of alerts according to user conditions)

•

Table 5.docx (Data of distribution of alerts according to condition among sex and age groups)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

The authors would like to express their special thanks to Universidad de Las Américas.

References 1

Emodi

Manfredini

Shalev

: Awake Bruxism-Single-Point Self-Report versus Ecological Momentary Assessment. J. Clin. Med. 2021 Apr 15;10(8):1699. 33920877

10.3390/jcm10081699

PMC8071231

Lobbezoo

Ahlberg

Raphael

: International consensus on the assessment of bruxism: Report of a work in progress. J. Oral Rehabil. 2018 Nov;45(11):837–844. 29926505

10.1111/joor.12663

PMC6287494

De Baat

Verhoeff

Ahlberg

: Medications and addictive substances potentially inducing or attenuating sleep bruxism and/or awake bruxism. J. Oral Rehabil. 2021 Mar;48(3):343–354. 32716523

10.1111/joor.13061

PMC7984358

Lobbezoo

Ahlberg

Glaros

: Bruxism defined and graded: An international consensus. J. Oral Rehabil. 2013 Jan;40(1):2–4. 23121262

10.1111/joor.12011

Matthew

Manchery

: Can chronic oral inflammation and masticatory dysfunction contribute to cognitive impairment? Curr. Opin. Psychiatry. 2020 Mar;33(2):156–162. 10.1097/YCO.0000000000000581

Emodi

Manfredini

Shalev

: Psychosocial and Behavioral Factors in Awake Bruxism-Self-Report versus Ecological Momentary Assessment. J. Clin. Med. 2021 Sep 27;10(19):4447. 34640465

10.3390/jcm10194447

PMC8509197

Souza

Carvalho

Fugueredo

: Awake bruxism frequency and psychosocial factors in college preparatory students. Cranio. 2020 Oct 14;1–7.

Bracci

Lange

Djukic

: Ecological momentary assessment of awake bruxism behaviors: Possible developments and clinical usefulness of a smartphone application. Front. Neurol. 2019 Mar 5;10:170.

Marpaung

Selms

MKA

van Lobbezoo

: Prevalence and risk indicators of pain-related temporomandibular disorders among Indonesian children and adolescents. Community Dent. Oral Epidemiol. 2018 Aug;46(4):400–406. 29781511

10.1111/cdoe.12382

Bastani

Manchery

Samadbeik

: Digital Health in Children’s Oral and Dental Health: An Overview and a Bibliometric Analysis. Children. 2022;9:1039. 10.3390/children9071039

Shopova

Bozhkova

Yordanova

: Case Report: Digital analysis of occlusion with T-Scan Novus in occlusal splint treatment for a patient with bruxism. F1000Res. 2022;10:10. 10.12688/f1000research.72951.2

Kaplan

Ohrbach

: Self-Report of Waking-State Oral Parafunctional Behaviors in the Natural Environment. J. Oral Facial Pain Headache. Spring 2016;30(2):107–119. 27128474

10.11607/ofph.1592

Dias

Rodrigues

Serra

: Utility of Smartphone-based real-time report (Ecological Momentary Assessment) in the assessment and monitoring of awake bruxism: A multiple-week interval study in a Portuguese population of university students. J. Oral Rehabil. 2021 Dec;48(12):1307–1313. 34536309

10.1111/joor.13259

Bracci

Djukic

Favero

: 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 Jun;45(6):423–429. 10.1111/joor.12627

Lavigne

Rompré

Montplaisir

: Sleep bruxism: Validity of clinical research diagnostic criteria in a controlled polysomnographic study. J. Dent Res. 1996;75(1):546–552. 8655758

10.1177/00220345960750010601

Funato

Ono

Baba

: Evaluation of the non-functional tooth contact in patients with temporomandibular disorders by using newly developed electronic system. J. Oral Rehabil. 2014;41(3):170–176. 24447128

10.1111/joor.12129

PMC4263305

Heboyan

Karobai

Hamed

: Bruxism as a Consequence of Stress and Movement Disorders: Brief Review. Eur. J. Gen. Dent. 2022;11:081–083. 10.1055/s-0042-1754374

Manfredini

Bracci

Djukic

: BruxApp: the ecological momentary assessment of awake bruxism. Minerva Stomatol. 2016 Aug;10(4):252–255. 30881335

10.3389/fneur.2019.00169

PMC6405426

Zani

Lobbezoo

Bracci

: Smartphone based evaluation of awake bruxism behaviors in a sample of healthy young adults findings from two University centers. J. Oral Rehabil. 2021 Sep;48(9):989–995. 34041773

10.1111/joor.13212

PMC8453860

Colonna

Lobardo

Siciliani

: Smartphone-based application for EMA assessment of awake bruxism: compliance evaluation in a sample of healthy young adults. Clin. Oral Investig. 2020 Apr;24(4):1395–1400. 10.1007/s00784-019-03098-2

Goldstein

Auclair

: The clinical management of awake bruxism. J. Am. Dent. Assoc. 2017 Jun;148(6):387–391. 10.1016/j.adaj.2017.03.005

Bulanda

Ilczuk

Nitecka

: Sleep Bruxism in Children: Etiology, Diagnosis, and Treatment-A Literature Review. Int. J. Environ. Res. Public Health. 2021 Sep 10;18(18):9544. 34574467

10.3390/ijerph18189544

PMC8471284

Cavallo

Carpinelli

Savarese

: Perceived stress and bruxism in university students. BMC. Res. Notes. 2016 Dec 21;9(1):514. 28003024

10.1186/s13104-016-2311-0

PMC5178076

Manfredini

Serra

Carboncini

: Current Concepts of Bruxism. Int. J. Prosthodont. September/October 2017;30(5):437–438. 28806429

10.11607/ijp.5210

Bracci

Djukic

Salmaso

10.1111/joor.12627

Shopova

Mladenov

: Case Report: A digital workflow in the treatment of bruxism in a young patient. F1000Res. 2022;10:10. 10.12688/f1000research.72961.2

Thymi

Rollman

Visscher

: Experience with bruxism in the everyday oral implantology practice in the Netherlands: a qualitative study. BDJ Open. 2018 Nov 9;4:17040. 30425840

10.1038/s41405-018-0006-4

PMC6226535

Manfredini

Ahlberg

Bracci

: Towards a Standardized Tool for the Assessment of Bruxism (STAB)-Overview and general remarks of a multidimensional bruxism evaluation system. J. Oral Rehabil. 2020 May;47(5):549–556. 31999846

10.1111/joor.12938

Shopova

Yordanova

: Software Details in Occlusal Splint Creation through 3Shape Design Studio. Open Access Maced. J. Med. Sci. 2021;9(D):330–335. 10.3889/oamjms.2021.7870

Mark

: What is bruxism? J. Am. Dent. Assoc. 2021 Sep;152(9):788. 10.1016/j.adaj.2021.06.012

Nagappan

Madhanmohan

Manchery

: Oral Health-Related Quality of Life and Dental Caries Status in Children With Orofacial Cleft: An Indian Outlook. J. Pharm. Bioallied Sci. 2019 May;11(Suppl 2):S169–S174. 10.4103/JPBS.JPBS_285_18

Hardy

Bonsor

: The efficacy of occlusal splints in the treatment of bruxism: A systematic review. J. Dent. 2021 May;108:103621. 33652054

10.1016/j.jdent.2021.103621

Dadnam

Al-Saffar

: Pandemic bruxism. Br. Dent. J. 2021 Mar;230(5):271. 33712754

10.1038/s41415-021-2788-3

PMC7953193

Sabbagh

Heppner

: Patients’ perceptions on temporomandibular disorder treatment with hydrostatic oral splints - a pilot study. BDJ Open. 2022 Feb 5;8(1):4. 35124698

10.1038/s41405-022-00096-7

PMC8818047

Duanmu

Liu

Ren

: Development of a biomechanical model for dynamic occlusal stress analysis. Int. J. Oral Sci. 2021;13:29. 34493701

10.1038/s41368-021-00133-5

PMC8423745

Goldstein

DeSantis

Goodcacre

: Bruxism: Best Evidence Consensus Statement. J. Prosthodont. 2021 Apr;30(S1):91–101. 10.1111/jopr.13308

Manfredini

Colonna

Bracci

: Bruxism: a summary of current knowledge on aetiology, assessment and management. Oral Surg. 2020;13(4):358–370. 10.1111/ors.12454

Youny

Salinas

Wiens

: The effect of patient specific factors on oclussal forces generated: best evidence consensus statement. J. Prosthodont. 2021;30(S1):52–60. 10.1111/jopr.13334

Malvin

Lobbezzo

Karen

: Stress-evoked muscle activity in women with and without chronic myofascial face pain. J. Oral Rehabil. 2021;48:1089–1098.

Pereira

Oltramari

PVP

Conti

PCR

: Frequency of awake bruxism behaviour in orthodontic patients: Randomised clinical trial: Awake bruxism behaviour in orthodontic patients. J. Oral Rehabil. 2021 Apr;48(4):422–429. 33278836

10.1111/joor.13130

Silva

Ortiz

Maracci

: Association among headache, temporomandibular disorder, and awake bruxism: A cross-sectional study. Headache. 2022 Jun;62(6):748–754. 10.1111/head.14322

Velásquez Ron

Mosquera Cisneros

Pazmiño Troncoso

: Monitoring of awake bruxism by intelligent app. F1000Res. 2022;11:479. 36606116

10.12688/f1000research.110673.2

PMC9768384

Velasquez Ron

Rodriguez Tates

: Evaluation by app in smartphones of awake bruxism at the return of presential classes in two university centers. Zenodo. F1000Res. 2023;1(23): 215. 10.5281/zenodo.7979723

10.5256/f1000research.168484.r328134

Reviewer response for version 2

de Araujo

Gabriela

1 Referee https://orcid.org/0000-0002-2812-3542 1Universidade Federal de Santa Maria, Santa Maria, Brazil

Competing interests: No competing interests were disclosed.

16 10 2024

2024

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

reject

Dear authors, investigating the frequency of behaviors related to awake bruxism, especially in a sample of university students, is important given the increased incidence of this outcome. The topic and idea of the study is relevant, since the use of apps can help change behavior and help identify important signs. However, the study has significant errors in the writing, limiting readers' comprehension on several points. In addition, the shows insufficiency of important information, especially in the study's methodology, could lead to future studies being reproduced. After reading, some aspects could be clarified to improve the article, so please leave your comments below.

#Abstract: -The methodology section shows insufficient important information for an initial understanding of the study. How does the app assess the frequency of bruxism? It's not clear how the app identifies the behaviors of tooth contact, muscle relaxation, teeth grinding and the apartment.

-Describe the statistical analysis used.

#Introduction: - Bruxism has different types of classification depending on how the diagnosis is made. In this case, as the bruxism was self-reported by the student through the app, the most correct term to describe it is “possible bruxism”. Please take care to use the correct term throughout the study.

- Please reference the following sentence: “When comparing populations, awake bruxism has risk factors such as mental disorders, depression, and suicidal delusions, among others”

- Please describe in the introduction a study from the last five years that has assessed possible awake bruxism in students, and what the associated factors are. The introduction also shows insufficiency data on the prevalence of this condition, especially in relation to the study sample (young students).

- Are there any studies that have evaluated bruxism-related apps? If so, please describe.

#Methods: - Please include that “possible awake bruxism” was assessed through the participants' self-report;

-Important information on data collection is missing. How were participants contacted to take part in the study and download the app? When was the study carried out? Was it after the COVID-19 pandemic?

- Why were only university students from recent semesters included? Were only dental students considered? It is not clear here.

- Why was there no sample calculation? Especially in descriptive studies, this is unpredictable. I suggest calculating the power of the study.

- The statistical analysis part is not very clear. Be careful when relating the chi-square test to the expression “association”. The statistical analysis was carried out to check the distribution of the sample (frequencies) and not associations.

#Results: - There are many tables that don't need to exist. I suggest adding the distribution tables for the sex and age variables. I also suggest classifying the age variable categorically (adolescents, young adults and adults) according to the World Health Organization classification.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

dentistry; pediatric dentistry; social and preventive dentistry; epidemiology.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

10.5256/f1000research.168484.r328132

Reviewer response for version 2

Medina

Dyanne

1 Referee https://orcid.org/0000-0002-5291-4264 1University of São Paulo, São Paulo, Brazil

Competing interests: No competing interests were disclosed.

11 10 2024

2024

recommendation

reject

In the abstract, I can identify some deficiencies in the study. The second sentence begins with "To" but is incomplete and shows insufficient clarity. Additionally, the description of awake bruxism behaviors is confusing. In the background section, these behaviors are defined in one way, but in the results, they are labeled differently, and in the conclusion, yet another set of names is used. This inconsistency makes it unclear which behavior is being discussed.

I have never encountered the term "jaw effort" in the context of awake bruxism. In physiology, "jaw effort" is distinctly defined as "jaw bracing" or "jaw clenching." Jaw effort refers to the amount of force or muscular activity required to perform a specific task, such as chewing, which involves dynamic jaw movements during repetitive actions. In contrast, jaw bracing refers to the often subconscious contraction of the jaw muscles, typically involving sustained tension. The way this was described raises concerns that participants may have been given instructions that led them to misreport their behaviors.

In the introduction, the study by Souza does not specifically state that individuals with awake bruxism are at risk for suicidal delusions. In fact, Souza's study is unique in the field and lacks further evidence to support such claims, so this cannot be presented as a fact, nor can the other risk factors. Additionally, the phrase "when comparing populations" is vague—what populations are being compared?

Furthermore, in the introduction, the authors mention instrumental approaches such as PDG and EMG, but these concepts are discussed separately. They should be consolidated since they pertain to the same topic. I also noticed that there is no mention in the introduction of the significance of returning to classes or why this is an important moment to assess students’ frequency of awake bruxism.

The rationale for assessing relaxation versus non-relaxation is not well explained. I strongly recommend reviewing other articles on EMA and awake bruxism, where the behaviors are more clearly described, as the explanation in the methods section is quite confusing.

The methods section needs to be better detailed to align with the results being presented. In the results section, a condition called "daytime pressure" is suddenly introduced, though it was not mentioned previously in the methods, along with other new conditions.

The manuscript requires substantial revision, particularly regarding its design, objectives, results, and interpretation. Additionally, the discussion and conclusion need to be more clearly articulated, they are many inconsistencies to allow publishing this article. That said, the authors have done commendable work with a substantial and representative sample.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

My research area are: Temporomandibular disorders, bruxism, ecological momentary assessment, fatigue, chewing performance and quantitative sensory testing.

10.5256/f1000research.168484.r310982

Reviewer response for version 2

B V

Swapna

1 Referee https://orcid.org/0000-0002-4991-7157 Sulaya

kavishma

1 2 Co-referee 1Manipal Academy of Higher Education (Ringgold ID: 76793), Manipal, India 2Department of Prosthodontics and Crown& Bridge, Manipal Academy of Higher Education, Manipal, Karnataka, India

Competing interests: No competing interests were disclosed.

7 10 2024

2024

recommendation

approve-with-reservations

I would like to appreciate the efforts made by the authors in considering all the suggestions from the reviewers for improving the manuscript.

I have few suggestions

1. Abstract – background of the study still remains unclear, could be re written in better way to improve the readership.

2. Introduction - terminologies like pushes or mandibular reinforcement, additive bruxism, jaw effort is still mentioned, are these terminologies appropriate.

3. Recheck reference number 16, it is not by Dr Alessandro Bracci.

4. The conclusion needs to be elaborated as it is too short.

Is the work clearly and accurately presented and does it cite the current literature?

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Prosthodontics

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

10.5256/f1000research.146965.r274092

Reviewer response for version 1

B V

Swapna

1 Referee https://orcid.org/0000-0002-4991-7157 Sulaya

kavishma

Competing interests: No competing interests were disclosed.

22 5 2024

2024

recommendation

reject

This manuscript aims to evaluate the use of smartphone applications in university students with awake bruxism.

Abstract- The background is not clear and needs to be rewritten more meaningfully. Please re-write the aim of the study and the conclusion.

The methodology of this study is interesting as the tool used for evaluation is gaining popularity, however the manuscript needs to be improvised and more comprehending to improve the readership. The English language requires lot of corrections and improvement as most of the sentences do not convey the intended meaning to the reader.

The reference number 16 cited is not by Dr Alessandro Bracci, about development of the app, It is wrongly cited. Is the app available as free version for download? How did the researcher persuade the respondents to download it?

What is the full form of BA, mentioned in discussion? The reference number 24, 25 does not match with information about gender differences.

The conclusion should be rewritten as this sentence “Bruxism awake with the app was evaluated, identifying 5 behaviors such as’’ makes no sense.

Is the work clearly and accurately presented and does it cite the current literature?

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Prosthodontics

We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Velasquez Ron

Byron

Prosthesis, Universidad de Las Américas, Quito, Quito, Ecuador

Competing interests: We have no conflicts of interest to disclose.

25 6 2024

Dear Mr. Editor, after the corrections recommended by the reviewers and yours, we present an Original Research article entitle Monitoring the frequency of awake bruxism behaviors in dental students from two university centers by using a smartphone app, for consideration by F1000reserach . We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere. In this paper was to monitor the frequency of awake bruxism behaviors in dental students by using a smartphone app. We attach the comments of the reviewers and the new manuscript with all the changes made. We believe that this manuscript is appropriate for publication by F1000reserach.

Reviewed 1 : Maria Beatriz Duarte Gaviao

Please, revised the English language in the Introduction, as commented above. Almost paragraphs need to be rewritten, specially the last one, in which the first sentence does not make sense considering the study design, since the AB was not evaluated before or during the pandemic. Moreover, the aim needs to be better described and conclusion must be in agreement.

Please, check if the BruxApp was developed by Dr Alessandro Bracci et al. The reference 16 does not match with this information, as well as the authors of reference 16 did not developed the app, I think.

Statistical analysis must be inserted in the end of Methods. Please, explain why the condition of relaxation and non relaxation was associated. Why is this association important?

Many paragraphs of the Discussion are results, not characterizing discussion.

The Conclusion is not reliable, since stress with parafunctions were not evaluated.

Finally, the manuscript needs intense reformulation regarding the design, aim, results and their interpretation, and a more precise discussion and conclusion. Despite this, the authors have performed a good job using an expressive sample.

Response to comments from reviewers:

English language reviewed

Cites references reviewed

Introduction totally changed

Aim changed

The Bracci Team created the app (Siena University)

References 16 corrected.

Statistical analysis changed the order

Relaxation and non-relaxation were associated, the app allows in its monitoring to decipher if the patient is relaxed, in some cases the patient does not accept that he is not relaxed, the monitoring clarifies that on some occasions he may be asymptomatic and therefore does not know the condition.

Discussion totally changed

Conclusion totally changed

Reviewer 2 : Swapna B V

This manuscript aims to evaluate the use of smartphone applications in university students with awake bruxism.

Abstract- The background is not clear and needs to be rewritten more meaningfully. Please re-write the aim of the study and the conclusion.

In introduction, the abbreviation SB is for sleep bruxism, but it is wrongly mentioned. There are other abbreviations that have not been expanded, eg. EMA, GA. Please check whether the use of terminologies like pushes or mandibular reinforcement, additive bruxism is appropriate. The methodology of this study is interesting as the tool used for evaluation is gaining popularity, however the manuscript needs to be improvised and more comprehending to improve the readership. The English language requires lot of corrections and improvement as most of the sentences do not convey the intended meaning to the reader.

What is the full form of BA, mentioned in discussion? The reference number 24, 25 does not match with information about gender differences.

The conclusion should be rewritten as this sentence “Bruxism awake with the app was evaluated, identifying 5 behaviors such as’’ makes no sense.

Response to comments from reviewers:

Abstract totally changed

Aim changed

Conclusion totally changed

SB corrected

Abbreviation reviewed

The manuscript is corrected

English language reviewed

References 16 corrected.

For academic purposes the app is free, a letter from the institution must be sent that proves the study to be carried out.

The participants were socialized about their ailments, as they did not know the subject and explained to them, the study aroused a lot of interest.

BA changed for AB (awake bruxism)

References 24,25 reviewed

Conclusion totally changed

Velasquez Ron

Byron

Prosthesis, Universidad de Las Américas, Quito, Quito, Ecuador

Competing interests: We have no conflicts of interest to disclose.

25 6 2024

Response to comments from reviewers:

Reviewer 2 .

This manuscript aims to evaluate the use of smartphone applications in university students with awake bruxism.

Abstract- The background is not clear and needs to be rewritten more meaningfully. Please re-write the aim of the study and the conclusion.

What is the full form of BA, mentioned in discussion? The reference number 24, 25 does not match with information about gender differences.

The conclusion should be rewritten as this sentence “Bruxism awake with the app was evaluated, identifying 5 behaviors such as’’ makes no sense.

Response to comments from reviewers:

Abstract totally changed

Aim changed

Conclusion totally changed

SB corrected

Abbreviation reviewed

The manuscript is corrected

English language reviewed

References 16 corrected.

For academic purposes the app is free, a letter from the institution must be sent that proves the study to be carried out.

The participants were socialized about their ailments, as they did not know the subject and explained to them, the study aroused a lot of interest.

BA changed for AB (awake bruxism)

References 24,25 reviewed

Conclusion totally changed

10.5256/f1000research.146965.r224191

Reviewer response for version 1

Shopova

Dobromira Antonova

1 Referee https://orcid.org/0000-0003-1287-930X 1Department of Prosthetic Dentistry, Faculty of Dental Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria

Competing interests: No competing interests were disclosed.

14 5 2024

2024

recommendation

approve

The work is clearly and accurately presented and it cites the current literature properly.

The study design is appropriate and the work is with technically and scientifically sound.

The sufficient details of methods and analysis provide to allow replication by other researchers.

The statistical analysis and its interpretation are appropriate.

All the source data underlying the results are available to ensure full reproducibility.

The conclusions are adequately drawn and supported by the results.

1. 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. Authors can add and more similar articles to enrich their article. 50 cited articles are too small number.

2. Long tables make the results quite difficult. Try to systematize the cited authors more tightly.

3. The discussion is voluminous enough and a sufficient number of authors are compared.

4. The conclusion consists of one short sentence. Authors can submit their opinion on the most suitable app according to them.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

I am a prosthodontics.I am interested in digital technologies in dentistry - additive manufacturing and milling CAD/CAM. I also started working in the field of implantology.

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.

10.5256/f1000research.146965.r224184

Reviewer response for version 1

Gaviao

Maria Beatriz Duarte

1 Referee 1University of Campinas (UNICAMP), Piracicaba, Brazil

Competing interests: No competing interests were disclosed.

14 5 2024

2024

recommendation

reject

This manuscript aimed to evaluate the awake bruxism in university students using a smartphone application.

This is an important and interesting issue, the sample is adequate and the authors have looked for a good methodology. Nevertheless, the manuscript needs reworking to be more comprehensible.

In general, the English language needs to be revised. Furthermore, cited references must be checked for the names of the authors and their respective numbers throughout the text, synchronized with the list of references.

Abstract: The “Background” does not make sense. Please, rewrite and defined the aim precisely. Also define the app used, BruxApp app, so as not to confuse the reader. The phrase “Awake bruxism was evaluated with the creation of an app that according to the authors evaluates…” it seems that the authors of this manuscript created the app. It is not possible to understand what additive bruxism is.

The conclusion repeats the results and is vague.

Text

Statistical analysis must be inserted in the end of Methods. Please, explain why the condition of relaxation and nonrelaxation was associated. Why is this association important?