Estresy Ansiedad ada Con El Bruxismo Nocturno

8/8/2019 Estresy Ansiedad ada Con El Bruxismo Nocturno

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D M D . P h D

Elizabeth Bennett. PhD

stat ist ics Sect ion

to :

This study examined (1) the relationships between electromyo-graphic-measured nocturnal bruxism, self-reported stress, and sev-eral personality variables, and (2) the relationship between belief ina stress-brtixism relationship and self-reported stress. One hundredadult bruxers completed a battery of personality questionnaires,indicated whether tbey believed in a stress-bruxism relationship,presented for a dental exam ination, an d ha d dental impressionstaken. Subsequently, electromyographic measurements of bruxingfrequency and duration were recorded for fifteen consecutivenights. Prior to each night's measurements, subjects indicated theirlevels of stress for the immediately preceding 24 h ours. No overallrelationship was established between electromyographic 7neasuresand the personality variables nor between electromyographic mea-sures and self-reported stress. Correlations between electromyo-graphic mea sures and self-reported stress were statistically signifi-cant for eight individual subjects. Further, subjects with high levelsof stress reported more anxiety, irritability, and depression, andless denial. Subjects who believed in a stress-bruxism relationshipreported greater stress.J OROFACIAL PAIN I995;9;51-5.

S leep bruxism, which is defined as nonfunctional tooth contactduring sleep, continues to have an unknown etiology.' '^Investigators have suggested that local dental, systemic, and/orpsychologic factors may play a role m the expression of the disor-der, but the relative importance of these variables remains unclear.While the importance of occlusai and anatomic factors in explain-ing the etiology and maintenance of the temporomandibular disor-ders, in general, and bruxism, in particular, has been cballenged,^'there is diverse evidence that suggests that bruxing behavior duringsleep IS a centrally mediated problem.''""To what degree psychologic variables impact tbe central expres-sion of sleep bruxing, and just how they may do that, has yet to bedetermined. Some research has provided evidence that psychologicvariables such as anxiety, hostility, and intrapunitive reactions tofrustrating situations are significantly correlated with bruxingbehavior,""" Conversely, other research suggests that bruxers arenormal individuals without higher levels of anxiety, hostility, orfrustration.''"" Emotional stress is one common factor that hasoften been linked to increased bruxing behavior.'*"''Funch and Gale''' studied one patient's self-reported stress levelsover 69 days and found a significant relationship between high antici-patory stress (ie, for the day following sleep bruxing measurement)and tbe subject's bruxing activity measured by electromyograph


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Pierce et albest predictor of bruxing activitj' and that high stresspreceding bruxing measures was not predictive ofEMG-mcasured bruxing activity." Another study of58 .sleep bruxers provided evidence of a negativerelationship between FMG-mcasured sleep brtixingand subjectively perceived same-day stress estimates."^

It remains unclear as to how and to what degreepsychologic variables such as stress impact uponthe central expression of bruxing behavior. At amost basic level, two items are unclear. Is stress afactor perceived by all or only some sieep bruxers?How does perceived stress relate to sleep bruxingbehavior? The aim of this study was to examinethe relationship between sleep bruxism, self-reported stress, and a number of personality vari-ables. A specific goal of the study was to examinethe correlation between perceived daily stress leveland EMG-measured sleep hruxism.

Materials and Methods

SubjectsParticipants were 100 residents of the greaterBuffalo, New York, metropolitan area who weresubjects in a bruxism treatment outcome study.'"Subjects were selected from 350 hruxers who wereeither referred by their dentists or were respon-dents to a newspaper announcement. Selection cri-teria included:1. A self-reported history of bruxism2. Current bruxing activity verified either bysomeone else hearing them brux or by thepresence of wear facets consistent with thebruxism disorder3. Measurable EMG activity indicating bruxismduring sleep

Only one subject was omitted from the studybecause the minimum baseline criterion of 1.0mean bruxing episode per hour was not met.Subjects' ages ranged from 18 to 72 years with amean age of 38. Sixty-five women and 35 mencompleted the study.

1. Trait anxiety (Taylor Manifest Anxiety Scand Profile of Mood State'']2. Depression (Pilowsky Depression Scale" Profile of Mood State")3. Denial and irri tabil i ty (Il lness BehaQuestionnaire")4. Health locus of control (MultidimensiHealth Locus of Control Scales")During the initial interview, each subject also cated whether he/she believed bruxing behawas or was not stress related. AI! interviewingcompleted by the same clinician.During the second visit, each sub|ect was train the use of a portable EMC monitor, which msures bruxism-related EMC activity above a 20threshold in the home environment.'' A detadescription of the procedure for these subjEMC recordings is described elsewhere." EMG provided bedside rape recordings of number of bruxing episodes per hour slept quency) and of bruxing activity in terms of onds per hour slept (duration). Subjects winstructed to obtain 15 consecutive nights of Erecordings for basel ine evaluat ion. Regappointments were scheduled to monitor theof the portable EMG. There are a number of isthat are related to the advantages and disadtages of surface EMC that could affect outcoThese issues are addressed by rhe study desbut are not discussed here because they have badequately reviewed previously."" The reliaband validity of the portable EMG used for study has been previously documented.'*"

Immediately before commencing each nigEMC sleep evaluation, the subjects recorded tlevels of stress for the prior 24-hour period. Swas measured on a Likert scale of 1 to 5 accing to the method used by Eunch and Gale,^' 1 indicating no stress present and 5 representhe highest level of stress possihie. Subjreturned their baseline tape recordings and sratings after the 15th night of recording. Twere then randomly assigned to receive vartreatments, the results of which were publispreviously.'"'^-^

ProcedureAt the initial visit, each subject read and signed aninformed consent form, completed a medical historyand psychologic measures, had a dental/head-and-neck examination, and had dental impressions

Data AnalysisPower analyses indicated that with a sample siz100 and a significance level of 0.05, power of or greater is obta ined for correla tion coefficlarger than .25 in absolute value. Correlation


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Pierce et alEta coefficients were calculated for correlation ofnominal variables with continuous variables andPearson's product-moment correlation coefficientswere obtained for correlations between quantitativevariables. Eta correlations weie calculated for theaverage of all subjects' stress ratings (Likert I to 5scale) for each individual night versus (1) prior-night bruxing frequency and duration averages(anticipatory stress variahle), (2) same-night bruxmgfrequency and duration averages, and (3) following-mght hruxing frequency and duration averages.To more closely replicate Funch and Gale's find-ings,-' Pearson's product-moment correlation coef-ficients were calculated for each subject's 24-hourstress ratings (Likert 1 to 5 scale) and that sub-ject's EMG values. The subjects' stress ratingswere correlated with their (1) immediately subse-quent (same nighr) bruxism EMG frequency andduration values, and (2) prior night bruxism EMGfrequency and duration values (anticipatory stressrelationship). Sidak calculations were made to pro-vide a more stringent significance level as a correc-tion for computing multiple correlations.Pearson's correlation coefficients were also cal-culated to compare rhe individual's belief thatbruxing activity is or is not stress related (determi-nation made during initial history) to (1) meanself-reported stress (Likert 1 to 5 scale), (2 ) meanEMG-measured frequency of bruxing activity, and

3 ) mean EMG-measured durat ion of bruxingactivity. In addition, Pearson's correlation coeffi-cients were computed between psychometric scalemeasures (Taylor Manifest Anxiety Scale, Profileof Mood State, Pilowsky Depression Scale, IllnessBehavior Questionnaire, Multidimensional HealthLocus of Gontrol Scales) and overall subject meansof (1) stress ratings, (2 ) frequency of bruxing, and(3) duration of bruxing.

ResultsThe sample mean for the baseline EMG measuresof bruxing episodes per hour was 16.7. The indi-vidual subject means for bruxing episodes per hourranged from 1.4 to 67.6 at baseline.Across the entire subject population, no correla-was found between baseline EMG measuresand personality variables (ie,the five psychometric instru-was no statistically signifi-

self-and EMG measures of bruxing

Table 1 Statistically Significant CorrelationsBetween Self-reported Stress Ratings for 24 HoursImmediately Preceding EMG Measurements ofBruxism (Pearson's r) and Frequency andDuration of BruxingSubjectnumber11416222738396166687639

92* P i .01- P .05tP < 05 after Sidak cornNS = NotstBiisticaiiysig

Frequencyo f b r i ix ing.94*tNS- . 6 4 "- . 8 1 ". 6 5 ", 6 3 "- . 5 4 ".84*t80*t- . 6 3 ", 6 7 ", 6 3 "

NSeclionnificant.

Dura t iono f b rux ing.95-t, 6 7 "- . 6 3 "- . 8 2 ". 5 9 ", 6 1 "NS.a2*t8 4 ' t- .76*t, 7 0 ", 6 7 ". 5 8 "

anticipatory stress variable. However, when thedata obtained for individual suhjects were exam-ined, there were a number of inreresting results.Seven subjects reported a positive relationship(ranging from r = .63 to r = ,94) between self-reported stress for the 24 hours immediately preced-ing the EMG measurements of bruxism (stress vari-able) and frequency of bruxing (Table 1). Foursubjects, on the other hand, reponed a negative rela-tionship (ranging from r= -,54 to r = -,81) betweenthe same variables. As noted in the table, conserva-tive Sidak corrections indicated that three of theseven positive correlations and none of the four neg-ative correlations were statistically significant.Nine subjects reported a positive relationship(ranging from r = .58 to r = .9,5) between self-reported stress for the 24 hours immediately pre-ceding the EMG measurements of bruxism stressvariable) and duration of bruxing (Table 1), Threesubjects reported a negative relationship (rangingfrom r = -,63 to r = -.82) between the same vari-ables. Conservative Sidak corrections indicatedthat only three of the positive and one of the nega-tive correlations were statistically significant.The relationship between self-reported stress for24 hours following the beginning of nightly EMGmeasurements (anticipatory stress variable) andrhe EMG measurements was also examined. The


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Pierce et alTable 2 Statistical I y Significant CorrelationsBetween Self-reported Stress Ratings for 24 HoursFollowing the Beginning of EMG Measurementsof Bruxism (Pearson's i-) and Frequency andDuration of Bruxingnumber Frequencyof bruxing Durationof hruxing

23440565871768792-Pc.01"Pc 05tP .05 after Sidsk correclionhJS = Not statistically significant.

,90*tNS7 1 "NS6 2 "NSNS6 6 "NS

.90*t.79-t. 63 "- 6 1 "NS

, 6 5 ".74-t

Table 3 Statistically Significant CorrelationsBetween Self-reported Stress Ratings and Measuresof Anxiety, Irritability, D epression, and DenialCharacteristic (instrument] Self-reported stressAnxiety ITaytor Manifest Anxiety Soale) 32*Irritability (lllreis Behavior Questionnaire) 22"Depression IPilowsky Depression Scale) 26-Denial (Illness Behavior Questionnaire) - 28- P i .01P< ,05

between self-reported stress for 24 hours follow-ing the beginning of EMG measurements and fre-quency of bruxing (Table 2). Only one individ-ua l , howe ve r , m a in ta ine d a s t a t i s t i c a l lysignificant relationship between tbese variablesafter tbe Sidak correction (r = ,90). Further anal-yses of the data obtained for individual subjectsrevealed a statistically significant relationsbipbetween self-reported stress for the 24 hours fol-lowing the beginning of EMG measurements andtbe duration of bruxing. Seven subjects reporteda positive relationsbip (ranging from r = .61 to r= ,90); one subject reported a negative relatioti-sbip {r = -.61). Only four of these anticipatorystress/duration correlations proved statisticallysignificant when conservative Sidak calculationswere applied.

Although there was no overall indication of arelationship between sleep bruxism EMC measures

several personality variables and self-repostress (Table 3). Tbat is, subjects witb higher leof self-reported stress were more likely to rehigher levels of anxiety (r = .32), irritability,22), and depression (r = .26); tbose reporting stress were more likely to report bigber levedenial (r = - .28 ) .Finally, the data reveal tbat as tbe subjbelief in a stress-bruxism relationsbip (determduring initial history) increased, tbeir subseqself-reports of stress increased as well {r = .21

DiscussionBruxism bas been described by many tbeoristsresponse to anxiety or stress.'-^''''"' Some exmental evidence, however, suggests that brubehavior may precede anticipated Stressorsleast among some individuals . - ' ' " This s tattempted to more generally evaluate the statissignificance of the relationship between sleep bing behavior and self-perceived stress by subtially increasing the number of subjects beyFuncb and Cale's single subject,'' Althoughsample was 100 times larger tban tbat of Fand Gale, there was no evidence to supporoverall group relationsbip between stressEMC-measured bruxing activity. Tbis held despite tbe temporal relationsbip between sand tbe EMG measures.

Subsequently, the relationship between individual subject's stress and EMG-meassleep bruxing activity was evaluated. Only asubjects had an mcreased bruxism response reto high same-day stress. Also, only four of 97jects exhibited a discernible relationsbip betwEM C - m e a su r e d b r ux ing and next-day s(anticipatory stress variable). Thus, tbese dataport only a very weak link between percestress and bruxing activity.This outcome appears to be consistent withfinding of Clark et al' that high bruxing activlikely to be related to a lack of awareness reing stressful life events. In tbis context, it isesting that tbose bruxers who reported less swere also somewhat more likely to report blevels of denial. Independent data on bruxerssupport tbe view tbat bruxers deny symptomssignificantly higher rate than the general potion.'" In tbe current study, bowever, thedenial/low stress relationship was rather wonly 5% of tbe variance was accounted for b


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Pierce et al

related to subseqtjent self-report of daily stress andbecause only a few individuals had a demonstrablestress-bruxism relationship, it appears unlikelythat self-perceived daily stress is a major factor insleep-bruxing behavior. This is not to say thatbruxing activity is not related to stress, but itmight indicate that (1 ) bruxets are not very awareof the stressful nature of daily events, and/or(2 ) they minimize tbe personal impact of lifeevents.Although the present sttidy did not demonstratea statistically significant group correlation betweenEMG-measured bruxing activity and psychologicvariables, our data suggest that some individualsver idical ly associated increasing stress withincreasing bruxing behavior. It is also apparentthat there wete far more individual bruxers whodid not reliably make that stress-bruxing associa-tion. This failure to make a reliable stress-bruxingassociation occurred despite the fact that there wasa measurable positive relationship between higherself-reported stress and bruxer anxiety, irritability,and depression levels. These individual differencesmay be related to differences in coping styles.The purpose of exploring coping mechanisms isto provide a useful taxonomy of coping styles tohelp explain the relationship between adaptive andmaladaptive outcomes. For instance, several stud-ies have provided evidence that a Type A behaviorpattern is correlated with bruxing behavior.-"""Type A behavior is, in a general sense, a copingsryle that can be characterized as an extreme desireto control life events,''- Since life events do notalways yield to such control, the Type A individualis likely to encounter periods of extreme stress.Given the right combination of predispositionalvariables (social, psychologic, biologic, and situa-tional), this stress could be expressed, at leasthypothetically, as sleep bruxism. In their constantquest for control. Type A individuals are evidentlyunaware of, ignoring, or denying the internallyand externally induced stresses that result fromtheir coping style. The existence of a low level ofstress awareness for Type A bruxers may be sup-ported by our finding that higher denial scoreswere related, albeit weakly, to lower perceivedstress levels.While it is generally accepted that sleep bruxismis mediated via the central nervous system,' therole played in the mediation process by psycho-logic variables such as experienced life stressremains unclear based on the present study andthat of others.''""-" If knowledge related to person-

the understanding, diagnosis, and treatment ofpsychophysiologic disorders such as bruxism,more research addressing the relative importanceof psychologic variables in the expression of thesedisorders is needed. To date, the data suggest thatthe relationship between psychologic variables andthe expression of bruxism is more complex than asimple cattse-and-effect relationship motivated byperceived life stress-

Ackn owl edg mentThis rcscarirh was supported in part hy USPHS research grantsDF.-05344 and DE-04358 from the National institute cf DentalResearch, National Institute of Health, Berhesda, Maryland,

References1, Glaro,i AG, Rao SM, Briixism: A critical review, PsycholBull 1977;g4;767-781,2 , Rugh JD, Harlan H. Nocturnal bruxism and remporc-mandibular disordets, lni Jankovic J, Tolosa E (eds). Ad-vances in Neurulugy, vol 49, New York: Raven Press.1988:329-341,3, Bailey JO Jr, Rugh JD, Effect of occlusal ad)u,itment onbtuxi sm as moni tored by noc turna l EMG recordings[abstract 199], J Dent Res 1980;59:317,4, Egermark-Eriksson 1, Carlsson GE, Ingervall B, Prevalenceof mandibular dysfunction and orofacial parafunction in

7-, 11 - atid 15-year-old Swedish children, Eur J Ort ho d198I ;3 :163-172,5, Ingervall B. Mohlin B. Thilander B. Prevalence of symp-toms of functional disturbances of the masticatory systemin Swedish men. J Oral Rehabii 1 9gO ;7:l8S -l97 .6, Kardachi BJR, Bailey JO Jr, Ash MM Jr . A comparison ofbiofeedback and occ lusa l ad jus tment on bruxi sm, JPenodontol 197S;49;367-372,7, Rngh J, Barghi N, Drago C, Experimental occlusal dis-c repanc ies and noc turna l hruxi sm, J P ros the t Dent1984;51;549-553,8, Ashcroft GW, Ecdes ton D, Waddell JL, Recogn ition ofamphetamine addicts, Br Mod J 195;l:i7,9, Lindq vist B, Heijbel J, Bruxism in children w ith b raindamage. Acta Odontol Scaud 1974;32:313-319,10 , Satoh T. Harada . Depression of tbe H-reflex duringtooth gtinding in sleep, Physiol Behav 1972;9;893-894,11 , Satoh T, Harada Y, Electtophysiological study on tooth-grinding during s leep. Electroercephalogr Ci in Neuro-physiol 1973;35;267-275,12, Molin C, Levi L, A psycho-odontologic investigation ofpat ients with bruxism. Acta Odontol Scand 196;24:373-391,13 , Vemallis F, Teeth grinding: Some relationships to anxiety,hostility and hypetactivity,J Clin Psychol 195S;n:389-391,14 Thaller JL. Rosen G, Saltzman S, Study of the relationshipof frustration and anxiety to bruxism, J Periodontol 1967;38:15-19,15 , Heller RF, Forgione AG, An evaluation of bruxism con-


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Pierce et al16 . Pierce C, Gale E. Pychometric evaluation of bruxerslabstract 752|. J Dent Res 1984;63:25'1.17 . Reding C, Zepelin H, Monroe L. Personality study of noc-turnal teeth grinders. Percept Mot Skills \96S;26:523-S.18 . Dordick B, Gallon R. Developtnent of a model to studybruxistn in the kborntory, J Dent Res I 97S;.S7(spe[:ialissue A):366.19. Glares AG. Incidence of diurnal and nocturnal bruxistn. J

PresthetDent l981;45;545-549.2 0 . Hicks RA, Conti PA, Bragg HR. Increases in nocturnalbruKism among college students implicate stress. Mi;dHypotheses 1930; 3 3:23 9-240.2 1 . Lindqvist B, Bruxism and emotional distnrbantt. OdontolRev 1972;23:231-242.2 2 . Pingitore MA, Chrobak V, Ptrie J. Tbe social and psy.choiogic factors iif bruxism. J Prosthet Dent 199\;65:443^46.2 3 . Rugb JD, Soiberg WK. ElectromyograpKic studies of briix-st behavior before and during treattnent. Calif Dent AssocJ 1975;3:56-59.2 4 . Funch DP, Gale EN. Factors associated with nocturnal

bruxistn and it.s treatment. J Behav Med 1 5 8 0 3 : 3 8 5 - 3 9 7 ,2 5 . Clark GT, Rugh JD, Handleman SL, Beemsterboer PL.Stress perception and nocturnal masseter muscle activity. JDent Res 1977;5(special issue E)d61.2 6 . Pierce CJ, Gale EN. A comparison of different treatmentsfor nocturnal bruxisra, J Dent Res 1988;67:597-601.2 7 . Taylor J. A personality scale of manifest anxiety. JAbnorm Soc Psychol 1953;48:28S-290.2 8 . McNair DM, Lorr M, Droppleman LF. Edits Manual fottbe Profile of Mood States. San Diego: Educational andIndustrial Testing Service, 1981.2 9 . Pilowsky !. Further validation of a questiomiaire tnetbodfor classifying depressive il lness. ,) Affective Disord1979;1:179-1)5.3 0 . Pilovtsky I, Spence N. Manual for rhe Illtiess BehaviourQuestionnaire (IBQl. Adelaide, South Australia: LIniv ofAdelaide, 1981.

3 1 . Wallston K, Wallston B, DeVcllis R. Development ofMultidimensional Health Locus of Coiitrol (MHScales. Hcaltb Educ Monograpbs 1978:6:160-170-32 . Lund JP, Widmcr CG. An evaluation of rbe use of surelectromyograph y in rbe diagnosis, documentation, treatment of dental patients. J Graniomandib DisorFacial Oral Pain I989;3:125-137.3 3 . Mohl ND, Lund JP. Widmer CG, McCall WD Jr. Devfor the diagnosis and treatment of temporomandibdisorders. Part II: Eiectromyograpby and sonographProsthet Dent 1990;63;332-335.3 4 . Bowley JE, Stockstill JW, Pierce CJ. Reliability and vity of instrumentation used to record nocturnal clencand/or grinding. J Orofacial Pain 1993;7:378-385.3 5 . Pierce CJ, Gale EN, Methodological considerations cerning the use of bruxcore plates to evaluate noctubruxism. J Dent Res 1989;68:1110-1114,

3 6 . Cohen J. Statistical Power Analysis for the BehaviSciences, ed 2. Hillsdale, NJ: Lawrence Eribaum, 19883 7 . Moulron RE. Emotional factors in non-organic tempmandibular joint pain. In: Scbwartz L, Ghayes CM (Facial Pain and Mandibular Dysfunction. PbiladelpWB Saunders, 1368:318-334.

38 . Rugii JD, Robbins JW. Oral babit disorders. In: lngeBD , (ed). Behavioral Aspects in Dentistry. New YAppletor-Century-Crofts 1982:179-202.39 . Birnbaum R. Autonomie Reaction to Threat Confrontarioii Conditions of Psychological Stress (unlished doctoral dissertation], Berkeley, CA: UnivCalifornia, Berkeley, 1964.4 0 . Pierce C. Evaluation of the psychological profile of bers [abstract 305|. J Dent Re.s 1994;73(special issue):14 1 . Hicks RA, Chancellor C. Nournal bruxism and Typebehavior in college students. Psychol Rep 19871211-1214.42 . Lazarus RS, Folkman S. Stress, Appraisal, and GopNew York: Springer, 1984:120-128.

ResumenEstrs, estrs anticipsdor, y medidas psicolgicas rela-cionadas al bruxismo durante el sueoEste estudi examin: (V las relaciones entre el bruxismo noc-turno medido por medio de electromiografia, el estrs auto-reportado, y diversas variables de la personalidad, y (2) larelacin enlre la creencia de una relacin bruxismo-est res y elestrs auto-reportado Cien adultos que bru>;aban, completaronuna serie cuestionarios de personalidad, e indicaron si elloscreian en la relacin entre ei bruKismo y el estrs. Estas per-sonas tambin recibieron un examen dentai y se es tomimpresiones dentales. Subsecuentemente, se registraron rnedi-das e iectromo grficas de la frecuencia y duracin del bruxismo,por quince noches consecutivas. Cada noche antes de realizarlas medidaselectrorniogrficas, las personas indicaron los nive-les de estrs correspondientes a las 24 horas anteriores. No seestableci una relacin general entre las medidas eieotro-miogrficas y las variables de personalidad, ni tampoco entrelas medidas electromiogrficas y el estres auto-reporlado

ZusammenfassungSt ress , Stressbereitschaft , und psychologisMessungen verbunden mit nchtlichem Bruxismus,Diese Studie prfte (!) die Be7iehungen zwischen elektrographisch gemessenem nacbtlichem Bruxismus und einPersnlich keitsvariabien und f2.f die Beziebung zwisciienGlauben an einen Zusammenbang zwischen Stress Bruxismus und dem subjektiven Stress. 100 erwachsene Bfllten eine Reibe von Persniichkeitsfragebogen aus, gabeob sie an einen Zusammenbang zwischen Stress und Bruxiglaubten und wurden iahnr tlicb untersucht. In der Folge den elektromyographische Messungen der Brjxismusfrequund -dauer wbrend 15 aufeinanderfolgenden Nacbvorgenommen. Vor jeder Nacbt gaben die Personen den Gihres Stresses in den vorangebenden 24 Stunden an. Es wkein gesamthafter Zusammenhang zwischen den eiektromgraphischen Werten und den persniicben Vanabien und nicht zwischen den olektromyographischen Werten und subjektiven Stress gefunden. Eine Korreiation zwisciien


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Estresy Ansiedad ada Con El Bruxismo Nocturno