Bruxism – Assessment

Introduction

Over the years, the diagnosis of bruxism has been based on purely visual examination, observing elements such as dental wear, cheek and tongue indentations, as well as the possible appearance of torus (exostosis on the inner side of the gums). However, as explained in previous posts, it is now known that bruxism does not necessarily involve dental contact. This means that bruxism patients without dental wear can be found, implying that through simple visual examination, there is a percentage of the bruxist population, with symptoms, that remains undiagnosed. It is also important to consider comorbidities, meaning that bruxism could be a protective response to a sleep disorder such as obstructive sleep apnea syndrome (OSAS) or gastroesophageal reflux disease (GERD). Along these lines, with the aim of performing an exploration as accurate as possible according to current evidence and providing greater coverage to the undiagnosed population group, a group of experts including Daniele Manfredini and Frank Lobbezoo developed the STAB method for evaluating bruxism.

The STAB Method

The STAB (Sleep-Time Assessment of Bruxism) method, developed and refined by experts in dentistry and sleep medicine over recent years, is an advanced methodology for evaluating and diagnosing bruxism, primarily during sleep. The scientific validity of the STAB method is supported by research and clinical studies that have demonstrated its efficacy in providing a more accurate and detailed diagnosis of bruxism, overcoming the limitations of conventional methods based on self-reports or subjective clinical evaluations.
The STAB method’s exploration components are divided into two main categories: non- instrumental and instrumental. non-instrumental and instrumental.

1. Non-Instrumental Exploration Components

• Clinical evaluation:This includes a physical examination of the patient, focusing on mandibular musculature and dental condition. It looks for evidence of tooth wear, muscle sensitivity, and other physical signs of bruxism.
• Patient history:Detailed information is collected about sleep habits, stress levels, and the presence of symptoms related to bruxism, such as headaches or jaw pain.
• Specific tests::
  • The Self-Reported Bruxism Questionnaire (CBA) provides an overview of the patient’s bruxism-related symptoms at functional, musculoskeletal, and dental levels.
  • The Pittsburgh Sleep Quality Index helps assess sleep quality and detect potential OSAS.
  • Other valuable tools include the Perceived Stress Scale and the Nijmegen Questionnaire,specifically designed to detect hyperventilation symptoms.
• Functional Tests:Due to the strong relationship between bruxism and sympathetic autonomic activity, it can be useful to assess aspects such as the patient’s breaths per minute to identify hyperventilation patterns (more than 13 breaths per minute) and the body’s O2 level test, which can provide an approximation of CO2 deficiencies characteristic of hyperventilation patterns and excessive sympathetic activity.

(This section is added by me and is not part of the STAB method as it was originally designed, but rather reflects my clinical perspective.)

2. Instrumental Exploration Components

• Polysomnography (PSG): This sleep monitoring technique records various physiological functions during sleep, such as brain electrical activity, eye movements, muscle activity, and respiration. It is conducted during an overnight hospital stay.
• Polygraphy:This is a simplified version of polysomnography performed at the patient’s home. This type of study is designed to be less intrusive than hospital-based polysomnography. During home polygraphy, portable equipment is used to record essential bodily functions while the patient sleeps in their usual environment. Typically, these devices monitor aspects such as breathing, obstructive or central apneas, heart rate, blood oxygen levels, body movements, and sleep position. However, unlike hospital-based polysomnography, home polygraphy usually does not record brain activity or eye movements. This method is commonly used to diagnose sleep disorders, especially obstructive sleep apnea. Although less comprehensive, it can suffice for certain diagnoses and is more accessible for many patients.
• Specific portable devices:These devices, designed to be used during sleep, monitor mandibular muscle activity, allowing for the detection and quantification of bruxism episodes. They may include mandibular movement sensors and electromyography to record muscle activity. One of the most well-known systems is the BiteStrip.

Conclusions about the STAB Method

The STAB method stands out for its comprehensive and evidence-based approach, combining clinical evaluations with cutting-edge technologies for more effective bruxism diagnosis and treatment. However, it is not without its challenges. As with many aspects of scientific evidence, the STAB method faces significant difficulties when being implemented clinically, whether by a physiotherapist or a dentist.
It requires considerable time dedication during consultations and, most importantly for the patient, involves high financial costs.
In this regard, from a physiotherapy perspective, it is particularly relevant to develop a thorough non-instrumental evaluation. In cases of suspected other sleep disorders, such as OSAS, complementary tests such as polygraphy or PSG should be considered. As mentioned in the previous article, SB may act as a protective response to sleep apnea or gastroesophageal reflux disease (GERD).

Physiotherapist ColFiCat: 4545 / Osteopath DO MROE: 544
Miembro de la Sociedad Española del Sueño (SES)
Miembro de la Sociedad Española del Sueño (SES)

Bibliography

• Lobbezoo F, Ahlberg J, Verhoeff MC, Bracci A, Nykänen L, Manfredini D. Translation and cultural adaptation of the Standardized Tool for the Assessment of Bruxism (STAB) and the Bruxism Screener (BruxScreen): A 12-step guideline. J Oral Rehabil. 2024 Jan;51(1):67-73. doi: 10.1111/joor.13602. Epub 2023 Sep 25. PMID: 37749858.
• Manfredini D, Ahlberg J, Aarab G, Bender S, Bracci A, Cistulli PA, Conti PC, De Leeuw R, Durham J, Emodi-Perlman A, Ettlin D, Gallo LM, Häggman-Henrikson B, Hublin C, Kato T, Klasser G, Koutris M, Lavigne GJ, Paesani D, Peroz I, Svensson P, Wetselaar P, Lobbezoo F. Standardised Tool for the Assessment of Bruxism. J Oral Rehabil. 2024 Jan;51(1):29-58. doi: 10.1111/joor.13411. Epub 2023 Feb 10. PMID: 36597658.
• Manfredini D, Ahlberg J, Aarab G, Bracci A, Durham J, Ettlin D, Gallo LM, Koutris M, Wetselaar P, Svensson P, Lobbezoo F. 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. doi: 10.1111/joor.12938. Epub 2020 Feb 17. PMID: 31999846.
• Manfredini D, Ahlberg J, Aarab G, Bracci A, Durham J, Emodi-Perlman A, Ettlin D, Gallo LM, Häggman- Henrikson B, Koutris M, Peroz I, Svensson P, Wetselaar P, Lobbezoo F. The development of the Standardised Tool for the Assessment of Bruxism (STAB): An international road map. J Oral Rehabil. 2024 Jan;51(1):15-28. doi: 10.1111/joor.13380. Epub 2022 Nov 7. PMID: 36261916.