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Is There an Association Between Bruxism and Intestinal Parasitic

Infestation in Children?

Article  in  Journal of dentistry for children (Chicago, Ill.) · September 2008

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 JDC CLINICAL ARTICLE

Is There an Association Between Bruxism and

Intestinal Parasitic Infestation in Children?
Kranya Victoria Díaz-Serrano, DDS, MSc, PhD
Carolina Brunelli Alvares da Silva, MSc, PhD
Sérgio de Albuquerque, DDS, MSc, PhD
Maria da Conceição Pereira Saraiva, DDS, MSc, PhD
Paulo Nelson-Filho, DDS, MSc, PhD

ABSTRACT
Purpose: Multiple factors have been considered in the etiology of bruxism in pediatric
patients, among which are infestations by intestinal parasites suggested by some authors.
No empirical evidence exists, however, of such association. Therefore, this study’s purpose
was to investigate the existence of an association between bruxism and intestinal parasitic
infestation in children.
Methods: Fifty-seven 6- to 11-year-olds (30 cases and 27 controls) who had not used
anthelminthics 2 months before the baseline examination were enrolled in the study. A
diagnosis of bruxism was based on an intraoral clinical examination performed by a single
trained examiner and on the parent/guardian’s report of any perceived parafunctional habits
(questionnaire-based interview). Bruxism cases were defined as those children with a report
of currently perceived habits of eccentric or centric bruxism (tooth-grinding and tooth-
clenching, respectively) combined with clinical evidence of nonphysiologic wear facets.
The volunteers were required to collect 3 fecal samples (1 every 2 to 3 days). Parasitologic
analysis was performed using the spontaneous sedimentation method. Data gathered from
the intraoral clinical examination, questionnaire, and parasitologic analysis were tabulated
and submitted to statistical analysis using the chi-square test and student’s t test.
Results: Intestinal parasitic infestation was observed in 30% (N=9) of cases and 41% (N=11)
of controls, but no statistically significant association was observed (P=.40).
Conclusion: This study’s findings do not support the existence of an association between
intestinal parasitic infestation and bruxism among the evaluated pediatric population.
(J Dent Child 2008;75:276-9)
Received May 10, 2007; Last Revision December 11, 2007; Revision Accepted December 12, 2007.
KEYWORDS: BRUXISM, CHILDREN, INTESTINAL PARASITES

B
ruxism is a common parafunctional habit character-
ized by involuntary and unconscious movements
Dr. Díaz-Serrano is professor of pediatric dentistry, Dr. Saraiva is resulting in clenching and grinding of the teeth,
professor of epidemiology and biostatistics, and Dr. Nelson-Filho is which affects approximately 30% of children up to 10
professor of pediatric dentistry, all in the Department of Pediatric
Clinics, Preventive and Community Dentistry, School of Dentistry of years old.1,2 Among the consequences of bruxism are tooth
Ribeirão Preto. Dr. da Silva is graduate student in community health, surface wear, tooth fracture, dentin hypersensitivity, mas-
School of Medicine of Ribeirão Preto, and research fellow, Department
of Pediatric Clinics, Preventive and Community Dentistry, School
seter muscle hypertrophy, hypertonicity and sensitivity of
of Dentistry of Ribeirão Preto. Dr. de Albuquerque is professor of masticatory muscles, and limitation of jaw movements.3
parasitology, Department of Clinical, Toxicological and Bromatological Bruxism has also been considered one of the causes of tem-
Analyses, School of Pharmaceutical Sciences of Ribeirão Preto, all at
the University of São Paulo, Ribeirão Preto, São Paulo, Brazil. poromandibular disorders, although a causal relationship
Correspond with Dr. Díaz-Serrano at [email protected] has not yet been clearly demonstrated.4

276 Díaz-Serrano et al Bruxism and parasitic infestation Journal of Dentistry for Children-75:3, 2008
 Bruxism has a multifactorial etiology that includes mal- or controls (without bruxism). Children with a history of
occlusions, occlusal interferences, psychogenic factors, and bruxism, but no current manifestation of this parafunctional
some systemic conditions such as allergies, endocrinological habit was excluded from the study and only individuals with
disturbances, malnutrition, and gastrointestinal disorders.5 active bruxism at the time of evaluation was enrolled.
Among these gastrointestinal disorders, intestinal parasit-
ism has been reported as a possible risk factor for bruxism.
CASE DEFINITION
Popular beliefs and some literature reports6,8,9 have suggested
Cases of bruxism (N=30) were defined as those children whose
the existence of a possible association between bruxism
parents/guardians had reported currently perceived habits
and infestation by intestinal parasites. Marks5 stated that
of eccentric or centric bruxism (tooth-grinding and tooth-
eradication of intestinal parasitic infestations might reduce
clenching, respectively), combined with clinical evidence
or even eliminate bruxism. Ahmad6 suggested that intestinal
of nonphysiologic wear facets. Perceived habits of bruxism
infestation with Enterobius, for example, would play a role
included a parental report of having heard “rasping” or
in the etiology of bruxism. Van Wyk et al9 speculated that
“scratching” sounds produced by tooth-grinding while the
tooth-grinding could be a component of the clinical syn-
children were asleep or having noticed the presence of this
drome observed in Schistosoma matthei infection in cattle.
parafunctional habit by observing suggestive muscular and
The biological feasibility of such a correlation, however,
mandibular movements during grinding and/or clenching
has not yet been established. Some authors have attempted
of the teeth.
to explain this association based on similarities between
Controls (N=30) were those children whose parents/
parasitism and allergies, which are a known risk factor for
guardians reported no lifetime tooth-grinding/clenching
bruxism. Sleeping disorders are a common consequence of
or presence of nonphysiologic wear facets.
both allergies and parasitic infestation due to digestive pain.10
In spite of the biological plausibility, there is a lack of
empirical evidence demonstrating that parasitic infestation CLINICAL EXAMINATION
is actually associated with bruxism. In fact, the reports of Intraoral clinical examination was performed by a single
such an association are from studies based only on com- trained examiner. Wear facets were evaluated by direct ob-
mon characteristics among children infected with parasites servation and graded 1, 2, and 3, according to the severity of
without comparison groups.6,8,9 the dental wear, as described by Nilner and Lassing.13 When
Intestinal parasites are still a very common health more than 1 grade was given to the same patient, the highest
problem in underdeveloped and developing countries.11 grade prevailed.
In Brazil, it has been estimated that approximately 11% to
20% of children have some type of parasites, mostly Giar-
PARASITOLOGIC ANALYSIS
dia lamblia and Ascaris lumbricoides.11,12 Given the public
All children underwent parasitologic analysis for detection of
health importance of both intestinal parasitic infestation
intestinal parasites. The children and their parents/guardians
and bruxism, this study’s purpose was to investigate the
were instructed to collect 3 stool samples at 2- to 3-day inter-
existence of an association between bruxism and intestinal
vals. The 3 samples were required to increase the likelihood
parasitic infestation in children.
of detecting an intestinal parasitic infestation.
For collection of the stool samples, the participants were
METHODS given 3 Coprotest kits (NL Comércio Exterior Ltda, São
This clinical study was conducted with children admitted to Paulo, Brazil), which are commercially available devices for
the Pediatric Dentistry Clinic of the School of Dentistry of stool analysis, containing 10% formalin as a preservative.
Ribeirão Preto, University of São Paulo, Ribeirão Preto, São The latter allows for conservation of the fecal material for
Paulo, Brazil) for regular dental treatment (mostly dental car- over 30 days until the parasitologic analysis is completed.
ies treatment and prevention). All parents/guardians signed an Analyses were performed according to the spontaneous
informed consent authorizing the enrolment of their children sedimentation method, proposed by Hoffman et al.14 The
in the study after approval by the Ethics in Research Com- parasitologic analyses were performed at the Department
mittee (process no. 2002.1.1104.58.0), in compliance with of Clinical, Toxicological, and Bromatological Analysis of
the Brazilian National Health Council Resolution 196/96. the School of Pharmaceutical Sciences of Ribeirão Preto,
All 6- to 11-year-olds referred for dental treatment during the University of São Paulo, Brazil.
first semester of 2006, and who had not taken anthelminthics
in the previous 2 months before examination,8 were screened
STATISTICAL ANALYSIS
for the study. Information on perception of children’s brux-
Association between bruxism and presence of intestinal
ism characteristics was obtained by a questionnaire-based
parasites was tested by chi-square, and the student’s t test
interview with the parents/guardians.
was used for comparison of the means. The significance level
Clinical evidence was gathered by means of detailed
was set at P<0.5. All analyses were performed using SAS
intraoral clinical examination. A total of 80 children were
statistical software 8.0 (SAS Institute, Inc, Cary, NC).
screened for the study and classified as cases (with bruxism)

Journal of Dentistry for Children-75:3, 2008 Bruxism and parasitic infestation Díaz-Serrano et al 277
 dental wear was 2 (N=17), followed by grade 1 (N=8) and
Table 1. Bruxism Characteristics (Group 1; n=30) grade 3 (N=5).
Intestinal parasitic infestation was observed in 30%
Bruxism characteristics n (%) (N=9) of cases and 41% of controls (N=11; Figure 1). Re-
sults from the parasitologic analyses among cases revealed
Noticeable grinding sounds during sleep 25 (83) that: 7 children tested positively for Giardia lamblia; 1
child tested positively for Enterobius vermicularis; 1 child
Bruxism type tested positively for Giardia lamblia and Enterobius vermicu-
Centric 2 (7) laris; and the remaining 21 children tested negatively for
Eccentric 22 (73)
enteric parasites (Table 2). Results from the parasitologic
analysis among controls revealed that: 9 children had tested
Centric and eccentric 6 (20) positively for Giardia lamblia; 1 tested positively for Ascaris
lumbricoides; 1 tested positively for Hymenolepys nana; and
Occasion of occurrence the remaining 16 children tested negatively for enteric
Sleep bruxism 19 (63) parasites (Table 2).
Wakeful bruxism 3 (10)
No statistically significant difference (P =.40) was found
between cases and controls regarding the presence of an
Sleep and wakeful bruxism 8 (27) intestinal parasitic infestation.

Wear facets - degree 1 8 (27)

DISCUSSION
Wear facets - degree 2 17 (57) This study’s findings did not show a statistically significant
Wear facets - degree 3 5 (17) association (P=.40) between bruxism and infestation by in-
testinal parasites. These results, however, should be addressed
with caution. A possible explanation for the lack of statistical
RESULTS significance could be the type 2 error, as the study popula-
A total of 30 cases and 30 controls were included in this tion was relatively small considering the high prevalence of
study. Three children from the control group were excluded, exposure. The present study had the capacity of identifying an
however, because they failed to collect the fecal samples for odds ratio of 2.5 with a power of 80%, with the expected 20%
the parasitologic analysis. of exposure. For the actual findings, however, the power was
Case and control groups were statistically similar to each reduced to 50%. In addition to the lack of power, it should
other regarding gender (p=.70) and age (p=.62) distribu- be considered that controls were identified in the pediatric
tion. Among the cases, there were 54% of males compared dental clinic and that it is possible they were not from the
to 48% of males in the control group. The mean age for same population from which cases emerged, resulting in a
cases and controls was 8.1 (Standard Deviation, SD=1.5) selection bias. Still, confounder factors were not measured
and 7.9 (SD =1.6), respectively. and the possibility of interaction of parasites with other fac-
Among the children with bruxism, 22 presented eccen- tors cannot be disregarded.
tric bruxism, 2 presented centric bruxism, and the remain- This study’s outcomes, however, are consistent with those
ing 6 children presented both types of bruxism. Data on of Gilman et al,15 who reported that symptoms frequently
Table 1 show that the most commonly attributed grade of attributed to Enterobius vermicularis infections, such as
perianal itching, enuresis, and tooth-grinding, occurred in a
similar proportion of infected children
(15%, 17% and 13%, respectively) and
p noninfected individuals (11%, 13%,
p
and 11%, respectively). Likewise, our
findings agree with those of Castro et
al,8 who studied 120 1- to 14-year-old
children and observed that, although
bruxism was a symptom predomi-
nantly observed in children suffering
from ascariasis (63% of the cases), the
proportion of this parafunction in chil-
dren with enterobiasis, giardiasis, and
without parasitosis (27%, 20%, and
27%, respectively) was very similar.

Figure 1. Distribution of intestinal parasites in children with and without bruxism.

278 Díaz-Serrano et al Bruxism and parasitic infestation Journal of Dentistry for Children-75:3, 2008
 3. Attanasio, R. Nocturnal bruxism
Table 2. Presence of Intestinal Parasites in Groups 1 and 2
and its clinical management. Dent
Clin North Am 1991;35:245-52.
Intestinal parasites Group 1 (with bruxism) Group 2 (without bruxism) 4. Lobbezoo F, Lavigne GJ. Do
n=30 n=27
bruxism and temporomandibular
n (%) n (%) disorders have a cause-and-effect rela-
tionship? J Orofac Pain 1997;11:15-23.
Giárdia lamblia 7 (23) 9 (33) 5. Marks MB. Bruxism in allergic
Enterobius vermicularis 1 (3) 0 (0)
children. Am J Orthod 1980;77:48-59.
6. Ahmad R. Bruxism in children.
Giardia lamblia and Enterobius
vermicularis
1 (3) 0 (0) J Pedod 1986;10:105-26.
7. Ish-Horowicz M, Korman SH,
Hymenolepys nana 0 (0) 1 (4)
Shapiro M, Har-Even U, Tamir I,
Ascaris lumbricoides 0 (0) 1 (4)
Strauss N, Deckelbaum RJ. Asymptom-
atic giardiasis in children. Pediatr
Infect Dis J 1989;8:773-9.
These outcomes are consistent with our assumption that 8. Castro VM. Prurito abnal, nasal,
an association between bruxism and intestinal parasitic bruxismo y sialorrea en niños con enterobiasis o asca-
infestation does not seem to exist. riasis. Acta Pediatr Esp 1985;6:122-4.
Giardia lamblia was the intestinal parasite most fre- 9. Van Wyk JA, Van Rensburg LJ, Heitmann LP. Schis-
quently detected in the parasitologic analysis of both cases tosoma matthei infection in cattle. The course of the
(27%) and controls (33%). According to Ish-Horowicz intestinal syndrome, and estimate of lethal dose of
et al,7 parasitic infestation with Giardia lamblia is usually carcariae. Onderstepoort J Vet Res 1997;64:65-5.
asymptomatic, which would possibly explain the absence 10. Galdon-Castillo A, Galera-Mendoza L, Egea-Gonzalez
of bruxism, even in infected children. A, Gonzalez-Olsen A, Sanchez-Gonzalez Y, Paniagua-
Moreover, individuals suffering from Ascaris lumbricoides Soto J. Disorders affecting the digestive system during
intestinal infestation are usually asymptomatic.16 It may sleep. Rev Neurol 2004;38:757-65.
be speculated that bruxism did not manifest in control 11. Rocha RS, Silva JG, Peixoto SV, Caldeira RL, Frimo
group patients infected with Ascaris lumbricoides because JO, Carvalho OS, Katz N. Assessment of schitosomiais
of this. The parasitologic analysis also detected Enterobius and other intestinal parasites in schoolchildren of the
vermicularis in fecal samples of 2 patients (7%) with bruxism Bambui municipality, Minas Gerais, Brazil. Rev Soc
and Hymenolepys nana in fecal samples of 1 patient (4%) Bras Med Trop 2000;33:431-6.
without bruxism. 12. Costa-Macedo L, Rey L. Frequency and precocity of
human intestinal parasitism in a group of infants from
Rio de Janeiro, Brazil. Rev Inst Med Trop S Paulo
CONCLUSIONS 1997;39:305-6.
This study’s findings did not show evidence of a positive 13. Nilner M, Lassing SA. Prevalence of functional dis-
association between bruxism and intestinal parasitic infesta- turbances and diseases of the stomatognathic system
tion in the surveyed pediatric population. Further research, in 7- to 14-year-olds. Swed Dent J 1981;5:173-87.
perhaps with a larger population and addressing other issues, 14. Hoffman WA, Pons JA, Janer JL. The sedimentation-
should be conducted to investigate whether the association concentration method in Schistosomiasis mansoni. PR
of these conditions is consistent. J Public Health Trop Med 1934;9:281-98.
15. Gilman RH, Marquis GS, Miranda E. Prevalence and
ACKNOWLEDGMENTS symptoms of Enterobius vermicularis infections in a
This study was supported by a grant-in-aid from The São Peruvian shanty town. Trans R Soc Trop Med Hyg
Paulo State Foundation (FAPESP; process no. 02/09836-0). 1991;85:761-4.
16. Koumanidou C, Manoli E, Anagnostara A, Palyviou P,
Vakaki M. Sonographic features of intestinal and bili-
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Journal of Dentistry for Children-75:3, 2008 Bruxism and parasitic infestation Díaz-Serrano et al 279

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