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Year : 2020  |  Volume : 23  |  Issue : 10  |  Page : 1375-1380

Evaluation of sleep bruxism and temporomandibular disorders in patients undergoing hemodialysis

1 Department of Oral Maxillofacial Surgery, Dental Clinic of Baskent University, Dr. Turgut Noyan Research and Practice Hospital, Adana, Turkey
2 Department of Nephrology, Specialist in Nephrology, Baskent University Adana, Dr. Turgut Noyan Research and Practice Hospital, Adana, Turkey

Date of Submission18-Nov-2019
Date of Acceptance17-Apr-2020
Date of Web Publication12-Oct-2020

Correspondence Address:
Dr. E Somay
Department of Oral Maxillofacial Surgery, Dental Clinic of Baskent University, Dr. Turgut Noyan Adana Research and Practice Hospital, Adana - 01120
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_630_19

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Background: Chronic renal failure can cause anxiety, stress, and decrease the life quality. Therefore, this may lead to sleep bruxism, temporomandibular disorders (TMDs), and related health problems. Aim: This study evaluated the incidence of sleep bruxism and TMDs in patients undergoing hemodialysis and compared it with that of healthy individuals. Subjects and Methods: A total of 137 patients (68 hemodialysis patients and 69 healthy individuals) participated in this study. They all filled out a form about age, sex, educational status, marital status, sleep disorders, sleep bruxism, temporomandibular problems, and ice/hard things chewing habits. We performed a muscle examination and used a questionnaire to evaluate the causes of TMD. Parafunctional habits and emotional stress status were examined with these YES/NO question forms. Teeth attritions and six common symptoms (limited mouth opening, deviation/deflexion, clicking, muscle sensitivity, pain, and presence of linea alba) of TMDs and sleep bruxism were evaluated via a clinical examination. The level of significance was determined at P < 0.05. Results: Parafunctional habits such as sleep bruxism (55.1%) (P = 0.010), emotional stress (69.1%) (P = 0.006), sleep disorders (47,1%) (P = 0.000), unilateral chewing (54.4%) (P = 0.040), gum-chewing (45.6%) (P = 0.000), ice chewing (23.5%) (P = 0,000), and hard things biting habits (7.4%) (P = 0.028) were statistically higher in the hemodialysis group than the control group. Deviation/deflexion and presence of linea alba were more frequent in the hemodialysis group than the control group. Conclusions: It can be concluded that hemodialysis patients are more sensitive to TMDs, sleep bruxism and related dental health problems than healthy individuals.

Keywords: Bruxism, hemodialysis, temporomandibular disorders

How to cite this article:
Somay E, Tekkarismaz N. Evaluation of sleep bruxism and temporomandibular disorders in patients undergoing hemodialysis. Niger J Clin Pract 2020;23:1375-80

How to cite this URL:
Somay E, Tekkarismaz N. Evaluation of sleep bruxism and temporomandibular disorders in patients undergoing hemodialysis. Niger J Clin Pract [serial online] 2020 [cited 2022 Dec 10];23:1375-80. Available from:

   Introduction Top

Generally, bruxism is defined as an oral habit characterized by a rhythmic activity of masticatory muscles that causes strong contact between teeth surfaces.[1] Its complex and multifactorial etiology involves systemic, psychological, and/or genetic factors. In 2013 consensus, it was concluded that bruxism is specified as either sleep bruxism (SB) or awake bruxism.[2]

SB is a masticatory muscle activity during sleep and is not a movement disorder or a sleep disorder among healthy individuals.[2] Particularly important factors that influence the occurrence of SB include personality type, genetic predisposition, intake of certain medications, and the presence of stressful situations, intake of caffeine and/or nicotine, especially concerning the influence of these substances on the sleep architecture.[3]

The literature considers bruxism a disorder[4] and states that increased higher levels of masticatory muscle activity enhance the risk of negative oral health consequences (e.g. severe masticatory muscle pain or temporomandibular joint pain, extreme mechanical teeth abrasions, prosthodontic complications).[5],[6] Bruxism and emotional stress may cause temporomandibular disorders (TMDs).[1] It is also suggested that the incidence of bruxism in the people with TMD is between 26% and 66% in people with TMD.[7]

The incidence of SB and TMD is expected to high patients undergoing hemodialysis (HD), given that some chronic diseases such as chronic renal failure often cause an increase in anxiety in patients.[8],[9] However, there is a limited number of studies in the literature on this subject, yet no definite conclusion can be reached.

This study therefore aimed to determine the prevalence of bruxism habits and TMD in patients undergoing HD, to thereby helping improve these individuals'' quality of life of the patients undergoing dialysis, and to determine the additional health problems that may occur due to TMD and bruxism.

   Subjects and Methods Top

This study was approved by Baskent University Institutional Review Board (Project no: D-KA 19/08) on 13 March 2019 and was supported by Baskent University Research Fund. Informed consents were obtained from all participants. All procedures that involved human participants were in accordance with the ethical standards of the institutional research committee and with the 2008 Helsinki Declaration and its later amendments or comparable ethical standards.


A total of 137 patients (68 HD patients and 69 healthy volunteers) participated in this study, who admitted to Baskent University Adana Dr Turgut Noyan Research and Teaching Center for dental problems. A survey involving age, sex, educational status, and marital status, sleep disorders, temporomandibular problems, ice/hard things chewing habits and questions that evaluate TMD and SB was completed by each patient [Table 1]. The clinical examination form is shown in [Table 2].
Table 1: Questionnaire form

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Table 2: Clinical examination form

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The inclusion criteria were as follows: male and female volunteer patients who were over the age of 18, had the mental capacity to assess and respond to our questionnaires and had no intellectual disability, and had been on dialysis treatment (HD) for at least three months. All the HD patients were on high-flux HD (blood flow = 350 mL/min, three 4-h sessions per week). Patients who were pregnant, did not freely provide consent, or suffered trauma to the jaw region and were excluded.

Parafunctional habits and emotional stress status were examined with these YES/NO questions. Teeth attritions and six common symptoms of TMD and SB (limited mouth opening, deviation/deflexion, clicking, muscle sensitivity, pain, and presence of linea alba (horizontal linear hyperkeratosis occurring in the occlusion line of the teeth when the mouth is closed, with a negative attraction effect in the inner cheek)[10] were evaluated through a clinical examination by an experienced maxillofacial surgeon. Also, muscle sensitivity examination was performed, and a questionnaire survey was administered to evaluate the causes of TMD and SB.

Maximum mouth opening (MMO) was clinically measured with a ruler. The patients were instructed to open their mouths as much as possible. The patient asked to open as widely as possible and the distance between the incisal edges of upper and lower anterior teeth was measured and considered as the MMO. The lower limit of the normal opening was determined as “more than 35 mm” based on criteria for TMD according to Dworkin et al.[10]

Digital palpation was used for determining muscle sensitivity by an experienced maxillofacial surgeon. Palpation of the masticatory muscles was performed by essentially testing the palmar surface of the middle finger, the index finger and the forefinger testing the adjacent areas. Soft but firm pressure was applied to the muscles, the fingers compressing adjacent tissues with circular movements. During palpation, each patient was asked whether he/she felt pain or not (yes = pain, no = no pain). If there was a pain, that was considered 'muscle sensitivity'

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software program, version 17.0 (SPSS, Chicago, Illinois). If continuous variables were normal, they were described as the mean standard deviation (P > 0.05 in Kolmogorov–Smirnov test), and if the continuous variables were not normal, they were described as the median. Comparisons between groups were applied using the Student's t test for normally distributed data. The categorical variables between the groups were analyzed by using the Chi-square test or Fisher exact test. Values of P < 0.05 were considered statistically.

   Results Top

The patient group consisted of 68 HD patients and the control group consisted of 69 healthy volunteers. Of the dialysis group, 29 (42.6%) were female, and in the control group, 38 (55.1%) were female [Table 3]. The mean age is 51 ± 15 years in HD (patients) group and 47.2 ± 12.9 years in the control group. The mean dialysis duration was 6.9 years (range of 0.2–22 years).
Table 3: Characteristics of participants

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The patient and control groups were similar in terms of age, sex and marital status, and only the level of education was lower in the patient group than in the control group such as researches in the literature [Table 3].[8],[11]

SB (55.1%) (P = 0.010), emotional stress (69.1%) (P = 0.006), unilateral chewing (54.4%) (P = 0.040), gum-chewing habit (45.6%) (P = 0.000), ice-chewing (23.5%) (P = 0,000), hard things biting habits (7.4%) (P = 0.028), and sleep disorders (47,1%) (P = 0.000) were significantly higher in patient group compared to control group [Table 4].
Table 4: Participants' answers to survey questions

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When muscle sensitivity, preauricular pain, limited mouth opening, clicking, teeth attitions, deviation/deflexion in mouth opening and linea alba presence were examined, no significant difference was found between the HD group and the control group except deviation/deflexion and presence of linea alba in the inner cheek [Table 5]. Also, nonsignificant parameters are given in [Table 3], [Table 4], [Table 5].
Table 5: Clinical examination findings

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   Discussion Top

Chronic renal failure and HD treatment can cause anxiety and depression.[7],[8] Emotional factors such as anxiety, fear, dissatisfaction, and stress can cause muscle hyperactivity[12],[13] and bruxism, also parafunctional habits such as bruxism and biting foreign objects frequently constitute the etiology of TMD.[14],[15]

There is the limited number of studies comparing HD patients and healthy individuals in terms of SB in the literature, but Borteletto et al.[16] found a significant relationship between SB and sleep quality in healthy individuals. In this study, only SB was evaluated, and it was found statistically more common in the HD group than in the control group. This result may be due to long dialysis hours, the high emotional stress status of the HD process, and the high prevalence of sleep disorders.

Six common clinical symptoms of TMD and bruxism were evaluated and no statistically significant correlation was found in terms of clicking, preauricular pain, limited mouth opening in the control group and the HD group in this study. But there was a significant difference between the control group and the HD group in terms of deviation/deflexion and the presence of linea alba in the inner cheek. In the literature deviation and deflexion are also found to be the symptoms of TMD and bruxism.[2] Excess bruxism and anxiety in the HD group may indicate a higher likelihood of TMD, and therefore deviation/deflexion may be more common in the HD group in this study. Also, unilateral chewing is often observed in the HD group compared to the control group, and this may be the cause of deviation. As SB is more common in the HD group, linea alba is more likely to be seen in this context.

In this study, sleep disorder was more common in the HD group than in the control group. Although Inonu et al.[17] reported that sleep disorders are common in patients with end-stage renal disease, Gencdal et al.[18] found that sleep quality is quite common among dialysis patients in their studies; it was not possible to compare our research with other studies because there are limited number of studies comparing healthy individuals with HD patients in terms of sleep disorder.

Stress was significantly higher in the HD group compared to the control group. This result can be explained by the study of Bujang et al.[19] in dialysis patients. Like their study, this study revealed that the prevalence of psychological symptoms among patients with dialysis was significantly high, especially for depression and anxiety. Also, due to the control group is selected from systemically healthy individuals, stress, and anxiety status was expected to be less in this group.

Several studies in the literature[20],[21] reported that xerostomia is common in HD patients because of the limitation of liquid intake and gum chewing increases saliva flow, alleviating the symptoms of xerostomia and reducing thirst.[22],[23] In this study, in the HD group, gum-chewing habit was seen more than in the control group. The reason for this result may be increased dryness of the mouth due to the limitation of fluid intake in dialysis patients and attempting to dampen the mouth environment by chewing ice or chewing gum and attempting to relieve xerostomia complaints.

In this study, when parafunctional habits were evaluated, a statistically significant difference was observed in the HD group compared to the control group. As stated in the literature, the emotional distress of dialysis patients causes psychological disorders and therefore affects the overall quality of life, the authors state that psychological symptoms occur in patients initiating dialysis treatment[24],[25] or that quality of life decreases[26],[27] parafunctional habits such as biting nails and biting hard objects are associated with reduced quality of life and increased anxiety and this situation may increase the risk of TMD.[28],[29] Parallel to literature, this result may be explained by the fact that dialysis treatment may affect patients both physically and mentally; the emotional stress of dialysis patients may cause psychological disorders and all of these causes increase in parafunctional habits. However, this habit was seen in a small number of people in this study; it was not appropriate to generalize, but it can be associated with a high level of anxiety in the HD group.

As teeth attrition is a symptom of SB,[30] in our study, the examination of teeth attrition was also evaluated to determine the habit of bruxism, and no statistically significant difference was found between two groups in terms of teeth attritions. Because no similar study was found in the literature, we suggest that this may be due to the similar incidence of bruxism in both groups and the higher prevalence of parafunctional habits in the HD group.

Symptoms such as muscle sensitivity, limited mouth opening, joint noise, and preauricular pain were frequently seen in patients with bruxism habits; there was no statistically significant difference between two groups in terms of these subjective symptoms. As there was no such study in the literature before, it was not possible to compare this result, but the fact that the findings were subjective and that there was a difference in educational level between the two groups suggested that the reliability of the answers might have been affected.

In this context, stress, sleep disturbances, unilateral chewing, deviation/deflexion, and parafunctional habits such as gum-chewing and biting hard things, SB, and presence of linea alba in the inner cheek are more common in dialysis patients.

The limitations of this study were the subjectivity according to the responses of the patients to the questionnaire and there was no additional assessment by a mental health professional. As the first diagnosis of bruxism in this study was determined by the YES/NO questionnaire, individuals with this habit and not aware of it affect the prevalence of bruxism.

   Conclusion Top

As a result, it can be concluded that dialysis patients are more sensitive to TMD, SB, and related dental health problems than healthy people. As there are not enough studies on this subject in the literature, further studies are needed on large patient groups in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of Interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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