Anxiety symptoms in clinically diagnosed bruxers
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Journal of Oral Rehabilitation 2005 32; 584–588
Anxiety symptoms in clinically diagnosed bruxers
D . M A N F R E D I N I * , N . L A N D I * , F . F A N T O N I * , M . S E G Ù † & M . B O S C O * *Section of Prosthetic
Dentistry, Department of Neuroscience, University of Pisa and †Section of Prosthetic Dentistry and Temporomandibular Disorders, University of
Pavia, Italy
SUMMARY The present work was an attempt to that subclinical symptoms of the anxiety spectrum
investigate for the existence of an association might differentiate bruxers from controls. In partic-
between anxiety psychopathology and bruxism. ular, significant differences emerged in scores of
The presence of bruxism was investigated according domains evaluating panic (P ¼ 0Æ039), stress sensi-
to validated clinical criteria in 98 subjects, who also tivity (P ¼ 0Æ006) and reassurance sensitivity symp-
filled out a self-report questionnaire (PAS-SR) for toms (P ¼ 0Æ005) of panic-agoraphobic spectrum.
the assessment of panic-agoraphobic spectrum. Support to the existence of an association between
34Æ7% (n ¼ 34) of participants were diagnosed as bruxism and certain psychopathological symptoms
bruxers. The prevalence of anxiety psychopathology has been provided.
was similar between bruxers and non-bruxers, but KEYWORDS: bruxism, psychopathology, anxiety
Mann–Whitney U-test revealed significant differ-
ences in total PAS-SR (P ¼ 0Æ026) score, indicating Accepted for publication 15 September 2004
bruxism easier. A clinical diagnosis of bruxism does not
Introduction
allow to discriminate awake from sleep-related bruxism,
Bruxism is considered the most detrimental among all but has the potential advantage that it may rapidly
the parafunctional activities of the stomatognathic provide preliminary data which can be further investi-
system, being considered a risk factor for temporoman- gated in subsequent polysomnographically-controlled
dibular disorders (1–4), and in particular for myofascial studies. In particular, it could be interesting to conduct
pain (5). Nevertheless, despite the importance of this works on the association between bruxism and some
clinical problem, some recent literature reviews under- temperamental traits, that has been supposed by many
lined the poor knowledge about its aetiology (6–9). For authors for both awake (11–14) and sleep bruxism (15).
example, awake and sleep bruxism, having different Unfortunately, findings from these studies are not
manifestations, with the former characterized by conclusive, also due to the dishomogeneity of criteria
clenching-type activity and the latter by a combination adopted to diagnose bruxism and to the different range
of clenching and grinding-type activity, could have a of psychosocial characteristics which have been inves-
different aetiology and be influenced by different local tigated. Besides, the unspecified use of terms which
and systemic factors (8). Scientific knowledge on brux- could indicate a temporary and non-pathological psy-
ism characteristics and effects is mostly based on chic state or a more complex psychiatric disorder, as in
findings from studies on sleep bruxism, which is more the case of the term anxiety, is often confusing. For
suitable for a reliable diagnosis in a scientific research example, a previous work demonstrated that anamnes-
setting (10). Unfortunately, polysomnographic studies tically diagnosed bruxism is not only associated, as
are expensive and adequately equipped sleep laborat- expected, with a transitory state of anxiety, which is
ories are not numerous. As a consequence, clinical frequent in the modern society, but also with some
diagnostic criteria have been validated (10), to make psychopathologic symptoms, and in particular those of
generalization of results of works on clinically diagnosed the anxiety spectra (16).
ª 2005 Blackwell Publishing Ltd 584ANXIETY SYMPTOMS 585
Given these premises, there is a need for providing The PAS-SR is the self-report version of the Structured
further support and clarity to the supposed bruxism- Clinical Interview for Panic-Agoraphobic Spectrum
anxiety association. To this purpose, the same psycho- (SCI-PAS), that is an assessment instrument based on
metric instrument (PAS-SR) that was used in a previous the recently proposed spectrum model of psychopatho-
study (16) has been adopted in the present investiga- logy (19). Psychometric properties of these instruments
tion to assess the anxiety spectrum of bruxers, as have been already tested and validated. Discriminant
identified by the use of validated clinical diagnostic validity of the SCI-PAS was assessed by comparing
criteria (10). results in patients meeting DSM criteria for panic
disorder and patients with cardiovascular diseases and
university students as control groups (20). Furthermore,
Materials and methods
a good agreement has been shown between interview
Participants were consecutively selected among 20– (SCI-PAS) and self-report (PAS-SR) formats (18).
30 years old Caucasian patients attending the Section of The reason that self-report version was used in this
Prosthetic Dentistry, Department of Neuroscience, Uni- investigation was essentially practical, since it requires
versity of Pisa, Italy, for conservative care during the only about 15–30 min to be completed and it is more
period from January 2002 to December 2003. Subjects easily accepted by non-psychiatric patients than an
were included on the basis of the presence of all extended psychiatric interview. All patients accepted to
permanent teeth, except third molars. Subjects were fill out the questionnaire after being appropriately
excluded from the study on the basis of the following: informed of the aim of the study.
presence of Research Diagnostic Criteria for Temporo- As regards specific properties of the instruments, the
mandibular Disorders (RDC/TMD) (17) Axis I Group I PAS-SR investigates typical symptomatology of panic
diagnosis of muscle disorders and/or Group III diagnosis disorder, including symptoms composing the DSM
of arthralgia or osteoarthritis; presence of gross maloc- criteria, together with a series of atypical and sub-
clusion; presence of neurological disorders; use of threshold panic and phobic symptoms (19, 21).
medications influencing sleep or motor functions; The 114 items are grouped into the following
presence of chronic pain in other areas of the body; domains:
presence of rheumatic disorders; chronic use of medi- – Separation anxiety: it considers reaction to loss, such
cations for anxiety; history of recreational drug use in as the end or a friendship or partnership, the news of
the 6 months before study. Ninety-eight subjects (53 severe illness, or the sudden death of a loved one or
males, 45 females; mean age 24Æ8) satisfied inclusion/ even a pet.
exclusion criteria. Participants were clinically investi- – Panic symptoms: it explores a number of panic
gated for the presence of bruxism and were assessed for symptoms that may produce imairment similar to that
the presence of anxiety psychopathology by means of a of ful-blown attacks: tiredness, sense of disorientation,
self-report questionnaire. Research was approved by jelly legs, hypersensitivity to noises, light or heat,
the Ethic Committee, and all subjects signed a consen- distress in the presence of an indefinite visual perspec-
sus module prior to the start of the study. tive, such as the open sea.
The presence of bruxism was diagnosed according to – Stress sensitivity: it investigates for the presence of
validated clinical diagnostic criteria (10). Diagnosis of symptoms of abnormal reaction to stressors.
bruxism was made when the patient exhibited, at least – Substance sensitivity: it is devoted to sensitivity to
five nights a week, grinding bruxism sounds during chemicals.
sleep during the last 6 months, as reported by his/her – Anxious expectation: it encompasses two subcatego-
bed partner, and at least one of the following adjunctive ries: anticipatory anxiety focused on the occurrence of
criteria: observation of tooth wear or shiny spots on typical or typical panic symptoms, and a persistent
restorations; report of morning masticatory muscle general state of alertness and insecurity.
fatigue or pain; masseteric hypertrophy upon digital – Agoraphobia: it considers all phobic/avoidant symp-
palpation. All participants were instructed by a trained toms.
psychiatrist to fill out a self-report questionnaire (PAS- – Hypochondria and other phobias: it considers illness
SR) to evaluate the panic-agoraphobic spectrum (18). phobia.
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 584–588586 D . M A N F R E D I N I et al.
– Reassurance sensitivity: it explores symptoms related Table 1. Sex distribution and mean age of bruxers and non-
to the need for relying on reassurance from others as a bruxers
means of coping with an overwhelming senses of
Bruxers (n ¼ 34) Non-bruxers (n ¼ 64)
insecurity and impotence.
Every item is scored 1 (positive response) or 0 Females 18 (40%) 27 (60%)
(negative response), so that total score ranges from Males 16 (30Æ2%) 37 (69Æ7%)
Mean age 24Æ2 25Æ5
0 to 114. Patients scoring 35 or more are considered to
have clinically meaningful panic-agoraphobic spectrum
symptoms (18). Table 2. Prevalence of anxiety psychopathology (PAS-SR
score ¼ 35)
Statistical analysis
Bruxers (n ¼ 34) Non-bruxers (n ¼ 64)
Participants were divided into two groups (bruxers and PAS-SR < 35 30 (88Æ3%) 57 (89Æ1%)
non-bruxers). Chi-square test was performed to compare PAS-SR ¼ 35 4 (11Æ7%) 7 (10Æ9%)
prevalence of anxiety psychopathology between the two
groups, while mean scores in PAS-SR were compared by
means of Mann–Whitney test. Based on data existing in sensitivity, anxious expectation, agoraphobic, and
the literature on PAS-SR psychometric properties and hypocohondria symptoms (Table 3).
estimated variance in scores (18, 22), power analysis
revealed that sample size was sufficient to detect a
Discussion and conclusions
clinically significant difference between groups in
PAS-SR score with an alpha level of 0Æ05 and a power Recent investigations sponsored the role of psychic
of 0Æ90. All statistical procedures were performed with factors in the aetiopathogenesis of parafunctional
the Statistical Package for the Social Sciences (SPSS 9Æ0)*. activities. A relationship between stress and emotional
tension and bruxism, especially during awake, surely
exists, but no works in the literature investigated the
Results possible presence of psychopathological symptoms in
According to the above-mentioned parameters, brux- bruxers. When approaching to the study of such a
ism was diagnosed in 34 of 98 (34Æ7%) subjects, while complex issue, some methodological problems occur.
the remaining 64 of 98 (65Æ3%) participants did not The first problem is represented by the assessment and
meet criteria for bruxism. No significant differences diagnosis of bruxism itself. Polysomnography represents
between groups emerged as regards age (T ¼ 1Æ698; the standard of reference for the diagnosis of sleep
P ¼ 0Æ093) and gender (Chi-Square ¼ 1Æ034; bruxism but, unfortunately, the possibility of employing
P ¼ 0Æ309) (Table 1), although prevalence of bruxism sleep laboratory for large-sample, cross-sectional,
was slightly higher in females (18 of 45 – 40%) than in screening oriented works is limited by the high costs
males (16 of 53 – 30Æ2%). Anxiety psychopathology, as and the paucity of equipped sleep laboratories, the
identified by PAS-SR score ‡35, was diagnosed in four necessity of many recordings in consecutive nights, the
of 34 (11Æ7%) bruxers and in seven of 64 (10Æ9%) non- complexity of study designs. For these reasons, many
bruxers (Table 2); therefore, prevalence of anxiety clinical methods, such as interviews, questionnaires,
psychopathology was not significantly different tooth wear evaluation, electromyographic recordings,
between bruxers and non-bruxers. muscle palpation, were proposed to assess bruxism (3, 4).
As regards psychiatric ratings, significant differences In the present work, clinical criteria which were origin-
between bruxers and non-bruxers emerged in total ally proposed to screen patients for research sleep
PAS-SR scores and in scores of domains evaluating laboratory studies have been adopted (10). Despite the
panic, stress sensitivity and reassurance sensitivity use of such standardized criteria, a clinical approach to
symptoms. No significant differences have been shown the diagnosis of bruxism still presents some shortcom-
for the presence of separation anxiety, substances ings, not allowing a distinction between sleep and awake
bruxism, a gradation of bruxism severity, so limiting
*SPSS Inc., Chicago, IL, USA. generalizibility of results. Nevertheless, it is probably the
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 584–588ANXIETY SYMPTOMS 587
Table 3. Mean ratings of bruxers
PAS-SR Bruxers (n ¼ 34) Non-bruxers (n ¼ 64) U-value P-value
and non-bruxers in PAS-SR
Total score 21Æ44 13Æ09 15Æ80 11Æ56 790Æ5 Æ026
Separation anxiety 3Æ32 2Æ03 2Æ98 2Æ20 946Æ5 Æ284
Panic symptoms 6Æ76 5Æ58 4Æ58 4Æ52 813Æ0 Æ039
Stress sensitivity 0Æ76 0Æ74 0Æ38 0Æ60 768Æ0 Æ006
Substances sensitivity 0Æ76 0Æ89 0Æ75 0Æ98 1062Æ0 Æ833
Anxious expectation 1Æ38 1Æ44 0Æ89 0Æ99 895Æ5 Æ129
Agoraphobia 2Æ82 3Æ21 2Æ12 2Æ68 937Æ5 Æ251
Hypochondria 0Æ94 1Æ20 1Æ03 1Æ23 1038Æ5 Æ692
Reassurance sensitivity 4Æ59 3Æ36 2Æ80 2Æ91 712Æ5 Æ005
simplest approach to a complex disorder in phase of The existence of a stress–bruxism relationship has
preliminary data gathering. been proposed by many (13–15). For example, high
Another problem in the study of the relation between levels of daily stress have been suggested to be a risk
bruxism and psychopathology is represented by the factor for bruxism (14), although the mechanisms
possible presence of temporomandibular disorders in relating bruxism and stress are unclear. Recent works
bruxers. TMD are a number of conditions for which an suggested that stressful events may have an influence
association with psychopathological symptoms has been on sleep quality, potentially disrupting sleep and caus-
described (23–25). Also, bruxism is considered a major ing sleep disorders (15). By contrast, an interesting work
risk factor for temporomandibular disorders (1, 2). In investigating the amount of self-reported stress in
particular, both bruxism and some forms of psychopa- relation to electromyographically recorded bruxism
thology appear to be somehow related to painful TMD during the night before the stress report (anticipatory
(26), and in particular to muscular forms (5, 22). stress) and the night following the report (current stress)
For these reasons, patients with painful temporo- found no association between stress and bruxism (28).
mandibular disorders were excluded from the study. Similarly, another study found only a weak correlation
Within the limitations of this paper, results from the between self-reported stress and bruxism (29).
present investigation do not support the existence of an However, on the basis of results from the present
association between bruxism and anxiety psychopa- investigation, according to which bruxers appear to be
thology, whose prevalence was not different between more sensitive to stress than non-bruxers, a need for
subjects with or without bruxing behaviour, but they studies taking into account subjective susceptibility to
suggest that certain subthreshold manifestations could emotional factors has to be pointed out.
characterize bruxers, as some symptoms of panic- In conclusion, the cross-sectional nature of the
agoraphobic spectrum have an higher prevalence in present investigation does not allow to draw conclu-
bruxers than in non-bruxers. sions about the causal relationship between anxiety
In particular, symptoms that most differentiated and bruxism, but it may add some information to the
bruxers from non-bruxers are manifestations related existing neurological and psychiatric literature which
to typical and atypical panic, stress sensitivity, and showed an association between anxiety symptoms and
reassurance sensitivity. other sleep disorders and suggested the existence of
Such findings confirmed those from a work which some shared pathogenetic pathways and a partial
demonstrated more anxiety in a group of bruxers (12) therapeutic overlap (30–32).
and those from a controlled polysomnographical study Therefore, well-designed multidisciplinary trials are
which found an increased level of anxiety in sleep strongly needed to establish if the detected differences
bruxers to vigilance and reaction time as well (27). between bruxers and non-bruxers for the presence of
More interestingly, the use of the spectrum model of subthreshold manifestations of the anxiety spectrum
psychopathology consents to show that bruxers also are actually an important factor in the pathogenesis of
have an increased stress sensitivity, lending support to bruxism or represent the manifestation of a comorbid
the theory that bruxism is somehow related to a poor subclinical entity.
skill to cope with stress, perhaps representing an All these observations must be interpreted according
abnormal reaction to stress itself. to current theories about bruxism as a centrally
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 584–588588 D . M A N F R E D I N I et al.
mediated multifactorial disorder which could share and specifications, critique. J Craniomandib Disord Fac Oral
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18. Shear MK, Frank E, Rucci P et al. Panic-agoraphobic
ated disturbances.
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J Psychiatr Res. 2001;35:59–66.
19. Cassano GB, Michelini S, Shear K, Coli E, Maser JD, Frank E.
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