Evaluation of biochemical changes and treatment efficacy in patients with bruxism following botox or splint therapy: A Randomized Clinical Trial

doi:10.21203/rs.3.rs-3410100/v1

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Evaluation of biochemical changes and treatment efficacy in patients with bruxism following botox or splint therapy: A Randomized Clinical Trial

https://doi.org/10.21203/rs.3.rs-3410100/v1

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published 28 Dec, 2023

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Objectives: This clinical study aims to analyse the levels of cortisol, dehydroepiandrosterone (DHEA) and tumour necrosis factor alpha (TNF-alpha) in the gingival crevicular fluid (GCF) of persons with bruxism and to compare the efficacy of Botox and occlusal splint treatments through biomarkers.

Materials and methods: A total of 40 patients with bruxism were selected according to the clinical examination and anamnesis of which 20 patients received occlusal splint treatment and 20 botulinum toxin treatment. Gingival crevicular fluid samples were taken from the patients before and after treatment. Cortisol, DHEA and TNF-alpha levels were measured by ELISA test. The change in measurements between time and groups and the time-group interaction were tested by repeated measures ANOVA.

Results: In individuals with bruxism, a statistically significant decrease in cortisol levels was observed after both treatments (p < 0.05), while DHEA levels increased after treatment but were not statistically significant (p > 0.05). There was no statistically significant difference between tnf-alpha intra-group measurements (p > 0.05).

Conclusions: Stress and inflammatory biomarkers were found to be associated with the bruxism. Cortisol levels decreased in people with bruxism after treatment with both occlusal splint and Botox.

Clinical Relevance: It can be suggested that splint and botox treatment are effective for bruxism by reducing the stress levels. Botox treatment is also more effective in reducing stress levels.

Bruxism

biomarkers

cortisol

DHEA

TNF-alpha

occlusal splint

Botox

Bruxism can generally be defined as the clenching and grinding of teeth that occurs when the masticatory muscles are active, either at night or during the day. It is a parafunctional action, which means that the masticatory muscles are still working outside of their normal function. Although the etiology of bruxism is unclear, psychological factors such as stress, trauma, alcohol and smoking addiction, neurotransmitter disorders, neurological diseases and involvement of the dopaminergic system have been implicated [1, 2]. Recent studies show that bruxism has a multifactorial origin that may involve the central nervous system [3]. However, one of the main causes of bruxism is stress. In a significant number of studies on the relationship between stress and bruxism, stress has been shown to be an increase factor in bruxism [4, 5]. Studies on psychological factors in bruxism have shown that electrical activity in masticatory muscles increases when stress is increased [6]. An increase in bruxism has also been observed after stressful and exhausting days [3, 4].

Two basic systems are activated in the body during stress. The responses triggered by stress are transmitted to the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. The HPA axis releases corticotropin-releasing hormone from the hypothalamus, adreno-corticotropic hormone (ACTH) from the pituitary gland and gluco-corticoid hormones (such as cortisol) from the adrenal cortex. This stimulation causes both an increase in muscle tone in the masticatory muscles and may trigger dysfunctional muscle activities such as bruxism and this, in turn, can lead to a general dysregulation of the immune system at both the cellular and humoral levels [7]. Cortisol is secreted by the adrenal cortex due to stimulation of the hypothalamic-pituitary-adrenal axis (HPA axis) and is responsible for activation of anti-stress and anti-inflammatory processes.

Studies describing the role of stress and HPA axis in bruxism have generally focused on cortisol, but psychosocial factors also affect dehydroepiandrosterone (DHEA) levels [8]. DHEA is a neuroactive steroid and is secreted by ACTH in a similar way to cortisol. Both steroid hormones have been reported to be positively correlated with the severity of depression, have been studied in the evaluation of HPA axis dysregulation, and can be detected in blood, saliva and gingival clevicular fluid [9–11]. Although the metabolic functions of cortisol are well known, the role of DHEA in stress-related disorders is unclear. In studies of psychological disorders, there are reports of DHEA levels being higher, lower or unchanged [12–14]. There is also limited information on the relationship between bruxism and DHEA levels. For this reason, both stress hormones were analysed in this study in order to obtain more reliable results.

Chronic or recurrent stress is thought to be associated with chronic low-grade inflammation. Sustained high levels of cortisol can also lead to increased inflammation by suppressing the immune system. Therefore, in this study, Tumor Necrosis Factor Alpha (TNF-α), a biomarker of inflammation, was investigated together with stress hormones for a better understanding of causal relationships. Many studies have shown that TNF-α is associated with degeneration of cartilage and bone in the temporomandibular joint, inflammatory pain and inflammation [15]. Understanding the pathogenesis of TNF-α and its therapeutic effect on TMJ, blocking its effects on TMJ may be considered as a new alternative for the treatment of temporomandibular disorders and bruxism.

Early diagnosis of bruxism is of great importance for both treatment and prevention. The constant force on the TMJ caused by bruxism can lead to future TMJ disease, arthritis, joint pain and jaw locking. Differences in the etiology of bruxism require different approaches to its treatment. Today, bruxism treatment approaches can be categorised into personal approaches (cognitive behavioural therapy), pharmacological approaches, dental approaches and other methods [16]. The most common treatment is a combination of various muscle relaxants and occlusal splints, but occlusal splint can be used for a certain period of time. Botulinium toxin A (botox) application, which is a pharmacological treatment option, has also been used frequently in recent years. Recent studies have shown that bruxism has a multifactorial etiology mediated by central nervous and autonomic systems regulating the motor activity of masticatory muscles [17, 18]. BTX-A toxin inhibits neuromuscular transmission and reduces muscle strength, but the muscles return to normal function when the effect of the toxin disappears. Both treatment methods have various advantages and disadvantages. Studies are continuing to determine the most successful treatment method with controlled studies.

In determining the effectiveness of treatment for bruxism, subjective findings can be evaluated as well as the effectiveness of treatment with different methods. Imaging systems, bite force analysis or clinical data have generally been used to determine treatment efficacy. Since the evaluation of the subjective effectiveness of the treatment depends on the patient, it may not be interpreted correctly in some cases. Therefore, a numerical data of the biochemical parameters obtained from the patient can be effective in determining the nature of the bruxism and evaluating the success of the treatment methods applied. Biochemical markers have been frequently used to determine the etiology of bruxism. However, the number of studies using biochemical markers for the evaluation of treatment methods is limited. Therefore, in order to understand the mechanism underlying the pathogenesis of bruxism and to contribute to the development of new treatment methods, this study aimed to compare the changes in stress and inflammatory markers according to the treatment method applied in individuals with bruxism.

Study design

The study was reviewed and approved by the Ethics Committee of Gaziantep University (Decision number: 2022/246). A total of 40 patients with bruxism were selected according to the clinical examination and anamnesis. Firstly, the patients were asked the following questions;

Do you feel pain or tiredness in your jaw when you get up in the morning?
Have you ever noticed that you grind your teeth at night?
Have you ever noticed that you grind your teeth during the day?
During the day have you ever noticed that you clench your teeth?
Do you have a headache in the temporal region when you wake up in the morning?

Then, according to the clinical and anamnesis-based criteria for the diagnosis of bruxism defined by some researchers [19], the patient's expression, abrasion of the teeth, tooth mobility, temporomandibular joint pain, muscle hypertrophy, masticatory muscle fatigue, abrasion of the teeth and tongue were evaluated.

Inclusion and Exclusion Criteria

Individuals with systemic diseases and any pre-existing condition that affects cortisol levels, such as those taking B-blockers, antihistamines, antidepressants or antipsychotics, diuretics and sedatives, were excluded from the study. Those who have had any treatment for TMJ or bruxism in the 6 months before the study, pregnant or breast-feeding women were not included in the study. Clinically examined patients aged 18–40 years were included in the study after signing the informed consent form.

Randomization method

Once eligible volunteers were enrolled in the study, they were randomly assigned to the groups with equal probability and independently of their previous assignment. A colour was determined for each treatment group and the patient was asked to choose one of the two colours for the treatment method to be applied to the patient after diagnosis, and the treatment was planned according to the chosen colour. Patients with yellow staining are treated with occlusal splints. Patients with red staining are treated with Botox.

GCF samples collection

The paper strip method, which studies have shown to be the most effective method of GCF collection, was used [20, 21]. All patients were sampled at the same time (09:00 a.m.- 11:00 a.m.) as circadian rhythms can affect hormone levels in GCF. In addition, all participants were instructed not to eat or drink anything on the sampling day. Prior to treatment, two samples were collected from each participant. Samples were taken from the same teeth in all patients (teeth 15–16). Filter paper strips (PerioPaper, Oroflow, Amityville, NY) were carefully inserted into the gingival sulcus for 30 seconds to avoid mechanical trauma. Strips contaminated with blood or saliva were removed and fresh samples were taken from sites that met the sampling criteria. Samples were collected in sterile Eppendorf tubes (Eppendorf tubes, Interlab, Istanbul, Turkey) and stored at -80°C until analysis. In botox treatment group, since the effect of the injected substance lasts for up to 6 months, the sample was taken again 6 months after treatment. In occlusal splint treatment group, after the normal period of use of the occlusal splint, which is 8–12 weeks, sample collection was repeated.

Treatment protocols

Botulinum toxin injection was performed in 3 points at a distance of 1.5 cm or more from the lower border of the mandible [22]. BTX-A (Allergan, Irvine, CA, USA) dose was 30 U in each masseter muscle. In total, 60 U injections were given to each patient. No injection was performed into the temporal muscle

For occlusal splint therapy, after taking the upper jaw measurements of the patients, a hard cast model was obtained. A splint was fabricated on the cast using a 1.5 mm hard plate (Dentsply, USA). A 4–6 mm wide acrylic block was made in the anterior region of the splint using autopolymerising acrylic to determine the centric relation position. The lower jaw was placed in the centric relationship position and this contact point was marked on the anterior block. After the centric relationship position was determined, the splint was removed from the mouth and cold acrylic was added to all occlusal surfaces except the anterior stop. In the canine region, extra acrylic was added to form the canine ramp and the splint was placed in the patient's mouth [23]. In order to obtain occlusal closure in the predetermined centric relationship position, the patient was instructed to close the mouth by biting the notch in the anterior acrylic block. To check the conformity of the canine ramps, articulation paper was used during protrusion and laterotrusion movements to ensure that only the canine ramps were in contact during these movements and that disocclusion occurred in the posterior region. Since an occlusal splint was used, which has a ramp with canine protector and raises the occlusal vertical dimension by an average of 2–3 mm, the splint was used for a maximum of 3 months. Patients were asked to use the splints for at least 8 hours a day for 3 months.

Biochemical procedures

For the study, 500 µL of sterile PBS (Hyclone, USA) was added to the DOS papers, vortexed vigorously and kept at + 4o C overnight. After incubation, the strips were removed and the levels of TNF-a (FineTest, Cat. No: EH0302, China), DHEA (FineTest, Cat. No: EU2945, China) and cortisol (FineTest, Cat. No: EH0461, China) were measured using the enzyme-linked immunosorbent assay (ELISA) method using a commercially available kit. TNF-a was measured by sandwich ELISA, and DHEA and cortisol were measured by competitive sandwich ELISA. The microplates were washed using an ELISA washing device (Biotek ELx50, USA). The colour intensity of the microplates was measured at 450 nm using an ELISA reader (Biotek ELx800, USA).

Statistical analyses

The Shaphiro-Wilk test was used to test the normality of numerical variables. The change in measurements between time and groups and the time-group interaction were tested by Repeated measures ANOVA. The programme SPSS 22.0 version package was used in the analyses. P < 0.05 was considered significant.

Cortisol values

A statistically significant difference was found in cortisol values both between groups and within groups (p = 0.002, p = 0.001). There was a statistically significant difference between the cortisol levels before and after treatment in both groups (p = 0.001) (Table 1). Cortisol levels decreased more in the Botox group and less in the occlusal splint group (Fig. 1).

Table 1

Subject scores for cortisol levels intra and inter groups
	DHEA / B.T.	DHEA / A.T.	P¹
Occlual splint	0,2 ± 0,13	0,43 ± 0,41	0,572
Botox	0,22 ± 0,12	0,35 ± 0,15
P²	0,002*		0,315³
*Significant at p < 0.05 level,
¹Inter-Group, ²Intra-Group, ³GroupTime Interaction*

DHEA values

In DHEA values, no significant difference was found between the groups (p = 0.572). A significant difference was found in intra-group measurements (p = 0.002) (Table 2). An increase occurred in both groups before and after treatment, but this difference was not statistically significant (p = 0.315) (Fig. 2).

Table 2

Subject scores for DHEA levels intra and inter groups
	Tnf-alpha / B.T.	Tnf-alpha / A.T.	P¹
Occlual splint	42,68 ± 11,04	52,78 ± 14,31	0,001*
Botox	77,77 ± 33,63	55,01 ± 17,42
P²	0,223		0,003*³
*Significant at p < 0.05 level,
¹Inter-Group, ²Intra-Group, ³GroupTime Interaction*

TNF-alpha values

There was a statistically significant difference between the groups in Tnf-alpha measurements (p = 0.001). There was no statistically significant difference between intra-group measurements (p = 0.223). There was a statistically significant difference between Tnf-alpha levels before and after treatment in both groups (p = 0.003) (Table 3). An increase was observed in the occlusal splint group after treatment, while a decrease occurred in the botox group after treatment (Fig. 3).

Table 3: Subject scores for Tnf-alpha levels intra and inter groups

	Tnf-alpha / B.T.	Tnf-alpha / A.T.	P¹
Occlual splint	42,68 ± 11,04	52,78 ± 14,31	0,001*
Botox	77,77 ± 33,63	55,01 ± 17,42
P²	0,223		0,003*³

*Significant at p<0.05 level,

¹Inter-Group, ²Intra-Group, ³Group*Time Interaction

There is still a lack of definitive information on the etiology and treatment of bruxism. There are many studies that report that bruxism is stress-related [1–6]. Stress exists in our daily lives. The presence of stress alone does not automatically cause a disorder or disease. However, prolonged exposure to stressors can cause the organism to go through a period of exhaustion with negative effects. Studies have reported that people under stress are more likely to have bruxism [24, 25]. However, there are studies that do not support this association [26, 27]. A recent systematic review and meta-analysis showed a positive association between bruxism and stress symptoms [6]. Therefore, in this study, it was accepted that stress affects bruxism and it was evaluated whether stress symptoms decreased when bruxism was treated.

There are studies that evaluate the relationship between bruxism and stress through questionnaires [28, 29]. The survey method has a number of advantages, but it may produce different results because it provides quantitative patient-related data. Therefore, in our study, the change of stress biomarkers, which quantitative data can be obtained, was measured. In studies on bruxism, biomarkers such as catecholamines, cortisol and alpha-amylase have generally been evaluated [30–32]. Studies in which catecholamines were evaluated, higher levels were found in patients with bruxism compared to those without [30, 31]. Similarly, studies in which cortisol levels were measured, higher cortisol levels were found in individuals with bruxism [33, 34]. The literature describing the role of stress and the HPA axis in bruxism has focused on cortisol, but psychosocial factors may also affect DHEA levels [8]. There is no prospective study investigating changes in cortisol and DHEA levels after bruxism treatment. Therefore, two different stress hormone changes were analysed in our study. The results of our study showed that two different bruxism treatments had an effect on local stress hormone levels. While a significant decrease in cortisol levels occurred after both treatments, a different change in DHEA levels has occurred. While DHEA levels were expected to decrease after treatment, they increased in both treatment groups, but this increase was not statistically significant. In the study by Cakmak et al. [35], cortisol and DHEA levels were analysed in gingival crevicular fluid using a method similar to our study, and no change in DHEA levels was observed after periodontal treatment. At the same time, it has been reported that DHEA levels vary in stress-related diseases, with increases observed in some and decreases in others [12, 13]. This difference in our study may be due to the lack of sufficient data on DHEA as a stress biomarker.

There are studies showing that chronic or recurrent stress causes low-grade inflammation in the body [15]. However, the relationship between bruxism and inflammation remains unclear. In a study, it was reported that there was a positive correlation between inflammatory markers and bruxism [36]. It has been reported that proinflammatory cytokines such as tumour necrosis factor-α (TNF-α) are related to TMD disorders, and TNF-α production and concentration play a high role in the pathogenesis of TMD [15]. When bruxism is not treated, it can cause TMJ problems in the future. Therefore, the relationship between TNF-α biomarker and bruxism was evaluated in this study. According to our results, there was a significant decrease in TNF-alpha after treatment of bruxism with Botox, whereas there was an increase after treatment in the occlusal splint group. The reason for this difference cannot be explained. Further studies investigating the relationship between inflammatory markers and bruxism are needed.

One of the aims of this study was a quantitative comparison of the effectiveness of two different bruxism treatment methods by means of biomarkers. Studies evaluating the efficacy of Botox treatment have reported that BTX-A infiltrations can reduce the frequency of bruxism attacks, the force of chewing, and the pain it causes [37]. These studies generally examined changes in the masseter muscle and performed occlusal force analysis and reported a 30% decrease in masseter muscle volume [38, 39]. Other studies evaluating the efficacy of Botox treatment have also reported a decrease in myofascial pain symptoms [40, 41]. In studies evaluating the effectiveness of occlusal splints, it was reported that the splint changed the force distribution by reducing parafunctional activity and decreased muscle sensitivity [42]. Sener and Oral [43] emphasised that occlusal splint and Botulinum toxin therapy significantly reduced pain compared to the pretreatment period. Both treatments were found to be equally effective for bruxism in their study. There are few studies evaluating the efficacy of treatment for bruxism using biomarkers. Sriharsha et al. [44] reported that cortisol levels decreased in 70% of subjects after the use of soft occlusal splint. In our study, cortisol levels decreased after treatment in both Botox and occlusal splint groups. In the Botox group, a greater decrease occurred compared to the pre-treatment period. Further methodological and prospective studies are needed to confirm the relationship between biomarkers and bruxism and to help clarify the direction of the relationship between these variables.

According to the results of the study, cortisol levels decreased in people with bruxism after treatment with either occlusal splint or Botox. These data show that bruxism, which increases under stress, significantly reduces stress when treated. There is not a relationship between chronic stress and inflammation in the GCF samples.

The authors have no conflicts of interest to declare.

Ethics committee approval was obtained for the study from the clinical research ethics committee of Gaziantep University. (Decision number: 2022/246)

This study was performed in line with the principles of the Declaration of Helsinki.

Written informed consent was obtained from all patients who participated in the study.

Funding:

The authors did not receive support from any organization for the submitted work.

Author Contributions: IK formed the hypothesis and idea of the research. IK and MO provided the organization for the design, execution of the study. IK and HU prepared the experimental environment and made the measurements. All of the authors participated in preparation of the manuscript and that they have approved the final version.

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Evaluation of biochemical changes and treatment efficacy in patients with bruxism following botox or splint therapy: A Randomized Clinical Trial

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