ABSTRACT
Background
Despite various treatment approaches for bruxism, there is limited evidence comparing exercise therapy and occlusal splints, highlighting the importance of this study.
Objectives
To compare the effects of a 6‐week jaw exercise (JE) program with combined jaw and posture exercises (JP) on pain and mandibular motion in patients with probable sleep bruxism. The secondary objectives were to evaluate the effects of the interventions on oral parafunctions, posture, and sleep quality.
Methods
Sixty‐three patients with probable sleep bruxism were randomly assigned to JE, JP, or Occlusal Splints (OS) groups at the University Hospital. Pain levels were assessed using the visual analogue scale (VAS), and the maximum oral opening was measured using a calliper. Secondary outcomes included oral parafunctions, evaluated via the Oral Behaviours Checklist, and posture, assessed using craniovertebral and craniohorizontal angles. Assessments were performed at baseline, post‐treatment (6th week), and 12th week follow‐up. Data were analysed using repeated measures ANOVA (Group × Time).
Results
All groups demonstrated significant pain reductions (p < 0.05), but none of the groups showed superiority (p > 0.05). Mouth opening improved significantly only in the JE group (p < 0.05), with no intergroup differences (p > 0.05). Improvements in oral parafunctions occurred in the JE and JP groups (p < 0.05), but the differences between the groups were not significant (p > 0.05). No significant changes were observed in the craniovertebral or craniohorizontal angles (p > 0.05). No adverse events were observed in any intervention group.
Conclusion
This trial found no substantial superiority between interventions. Exercise‐based therapies (JE and JP) and OS similarly improved pain, mouth opening, and oral parafunctions in bruxism patients, with no postural changes. Further studies should explore long‐term effects in diverse populations.
Trial Registration: ClinicalTrials.gov identifier: NCT05555628
Keywords: bruxism, exercise therapy, mandibular motion, occlusal splint, pain
1. Introduction
Bruxism is defined as masticatory muscle activity that may occur during sleep (i.e., sleep bruxism) or wakefulness (i.e., awake bruxism), and should be regarded as a behaviour rather than a disorder in otherwise healthy individuals. This behaviour should be assessed along a continuum of muscle activity rather than through strict cutoff points [1]. The incidence in adults is 20% for daytime bruxism and 8% for sleep bruxism; however, studies have shown that 85%–90% of the general population experiences bruxism attacks throughout their lives [2]. It is considered to be one of the most harmful activities for the stomatognathic system owing to its clinical results and the associated morphological, pathophysiological, and psychosocial features.
Bruxism affects quality of life by causing pain in the masticatory muscles and neck, tension‐type headaches, decreased pain thresholds in masticatory and cervical muscles, restriction of mandibular range of motion, sleep disorders, stress, anxiety, depression, and deterioration of oral and dental health in general [2, 3]. Bruxism is associated with peripheral, central, and psychological factors; therefore, treatment using multidisciplinary approaches, including physiotherapy, is of great importance [2, 3, 4]. Recent studies have increasingly pointed to the central mechanisms in the pathogenesis of bruxism, highlighting the roles of genetic predispositions and neurochemical imbalances. Genetic polymorphisms in serotonin (HTR2A) and dopamine (DRD1, COMT) receptor genes have been linked to altered neuromodulatory functions, which may predispose individuals to episodes of bruxism [5, 6]. Alterations in serotonergic signalling, in particular, have been associated with changes in emotional regulation and arousal mechanisms, factors known to influence both the onset and intensity of bruxism [5]. A recent study by Zrabkowska et al. identified significant correlations between bruxism severity and elevated inflammatory markers (CRP and fibrinogen), hormonal disturbances, and glucose dysregulation, suggesting that increased sympathetic activity may contribute to bruxism and its cardiovascular comorbidities [7]. Smardz et al. further supported this hypothesis by demonstrating a connection between nocturnal hypoxia, bruxism episodes, and vascular stress markers in OSA patients with obstructive sleep apnea [8]. These findings emphasise the importance of considering bruxism not only as a peripheral muscular disorder, but also as a centrally modulated behavioural manifestation with systemic implications.
A multidimensional approach was used in the conservative treatment of bruxism. Physiotherapy, occlusal splints, medication, and psychological support are among the conservative approaches used [9]. In recent years, the updated literature has emphasised the need for patient‐centred interdisciplinary interventions addressing both the physiological and behavioural components of the disorder. Occlusal splints are commonly recommended for preventing tooth wear and reducing pain intensity, although their effects on electromyographic muscle activity remain under debate [10]. Botulinum toxin type A has shown promising results, particularly in cases where conventional treatments fail, by reducing myofascial pain and jaw‐closing muscle activity [11]. Behavioural interventions, such as biofeedback, especially contingent electrical stimulation, have shown moderate efficacy in reducing sleep bruxism episodes, although long‐term outcomes require further study [12]. In addition, a preliminary study evaluated the use of opipramol in managing severe sleep bruxism, underlining the multifactorial nature of the condition and the importance of exploring novel pharmacological strategies [13].
Moreover, physical therapy combined with self‐management education, massage, relaxation, and breathing techniques significantly reduces pain and awake bruxism episodes in patients with chronic temporomandibular disorder myalgia [14]. These findings support a shift toward tailored conservative treatment strategies delivered by multidisciplinary teams [15].
Physiotherapy methods used in the treatment of bruxism can be briefly listed as electrotherapy agents, therapeutic exercises, conservative methods such as relaxation, acupuncture, manual therapy, cognitive behavioural therapy [4] and taping applications [16, 17]. However, systematic reviews have highlighted that although physical therapy shows promising effects on muscle pain, mouth opening, and stress‐related symptoms in patients with bruxism, the methodological quality of the available studies remains low [4].
Therefore, the primary aim of this study was to compare the effects of occlusal splint therapy, jaw exercises, and combined jaw‐posture exercises on pain levels and mandibular motion in patients with probable sleep bruxism. The secondary objectives were to assess the effects of the interventions on oral parafunctional behaviours, postural parameters, and sleep quality.
2. Methods
2.1. Trial Design and Setting
The study was planned as a parallel‐group, randomised controlled trial. This randomised controlled trial was registered at ClinicalTrials.gov (NCT05555628) and was approved by the Adnan Menderes University Faculty of Health Sciences Clinical Research Ethics Committee (03/12/2020‐E.62822). Patients who applied to Aydın Adnan Menderes University Faculty of Dentistry between June 2022 and March 2024 (June 1, 2022, and March 15, 2024).
2.2. Bruxism Diagnosis and Classification
Bruxism was diagnosed based on the criteria of the International Classification of Sleep Disorders—Third Edition (ICSD‐3) by the American Academy of Sleep Medicine (AASM) [18]. In addition, the assessment process was framed in accordance with the international consensus criteria proposed by Lobbezoo et al. (2018), which distinguish between possible, probable, and definite bruxism based on the diagnostic method [1].
In our study, the diagnosis of probable sleep bruxism was established using a combination of self‐reported symptoms and clinical examination findings. Self‐reports were obtained via patient history (anamnesis), inquiring about common behaviours and symptoms (e.g., awareness of teeth grinding, jaw fatigue upon waking, or reports from bed partners). Clinical signs included masseter and temporalis muscle tenderness on palpation, buccal mucosa indentations (linea alba), and tooth wear.
No instrumental assessment (e.g., electromyography or polysomnography) was performed; therefore, patients meeting both criteria were classified as having probable sleep bruxism, according to the 2018 consensus statement.
2.3. Participants
The inclusion and exclusion criteria are shown in Table 1.
TABLE 1.
Inclusion and exclusion criteria.
| İnclusion criteria | Exclusion criteria |
|---|---|
|
|
2.4. Randomization and Allocation Concealment
Patients who were eligible to participate in the study were assessed by an assessor blinded to the group allocation. The assessor met with the patients only during the assessments to maintain blinding for the group allocation. The evaluations were repeated three times: before group assignment (T0), immediately after treatment termination at the 6th week (T1), and at the 12th week follow‐up (T2). To ensure concealed allocation, the randomisation process and patient assignments were conducted independently of the research team.
After the initial assessments, patients were randomly assigned to different groups as follows: Group I, Jaw Exercises Group (JE); Group II, jaw exercises and posture exercises (JP); and Group III, occlusal splint (OS). To provide concealment of the group allocation sequence, someone not involved in the study will make the group assignment and randomisation procedure. Participants were randomly assigned to one of the three treatment groups following simple randomisation procedures (computerised random numbers created using www.randomization.com).
2.5. Intervention
Patients in the JE and JP groups participated in a 6‐week exercise and manual therapy programme, conducted twice a week for 45 min per session. All treatments were administered individually by a physiotherapist with > 10 years of professional experience. Exercise sessions were conducted in an isolated room equipped with the necessary tools. Treatment protocols were reviewed biweekly and adjustments were made by introducing new exercises to monitor progress. The detailed exercise protocols applied to Groups I and II are provided in the File S1.
The interventions in the occlusal splint group were planned as two separate sessions conducted 1 week apart. Patients who underwent occlusal splint fitting measurements were referred for a follow‐up appointment 1 week after receiving the splint to address any potential issues or adjustments. Following 6 weeks of splint use, the patients were referred for a follow‐up evaluation at the 12th week.
The following treatment protocols were applied to the groups.
2.5.1. Jaw Exercise Group (JE)
In the JE group, soft‐tissue techniques were applied to the chin and temporal regions. Then, an exercise protocol for specific muscles (masseter, temporal muscles, SKM, and cervical region muscles) was performed by the patients under the guidance of a therapist. The JE group treatment protocol focused only on the jaw region and not on general issues such as posture. All exercises started with 5 repetitions, and the exercise intensity was increased up to 10 repetitions depending on the patient's tolerance.
2.5.2. Jaw and Posture Exercises Group (JP)
Patients in the JP group underwent diaphragmatic breathing and posture exercises, including upper body and cervical region stabilisation, for 40 min twice a week under the supervision of a physiotherapist. Posture exercises were performed using an elastic exercise band (Theraband; The Hygenic Corporation, Akron, OH, USA) tailored to the patient's muscular strength. Unlike the JE group, this treatment protocol addresses not only the jaw region with a specific exercise programme, but also postural issues.
In Groups I and II, the exercises of the patients under the supervision of a physiotherapist were planned to be performed 2 times a week for six weeks. While the exercise frequency of two times a week showed an effective reduction in pain [19, 20], the same effect was not found in studies in which exercise was performed twice a day [19]. The same exercises were also recommended to the patients as part of a home program. The total time required to complete the exercises was 45 min.
2.5.3. Occlusal Splint Group (OS)
Patients in the OS group received occlusal splint therapy provided by the dentistry department along with guidance on lifestyle modifications to consider in daily activities. After clinical examination by a dentist, an impression of the upper dental arch of each volunteer was taken using an irreversible hydrocolloid to fabricate a maxillary Michigan‐type occlusal splint [10]. The splints were constructed from autopolymerising acrylic resin (Akribel, Belmar, Izmir, Turkey) and designed to fully cover the upper dental arch. Maxillary and mandibular casts were filled with Type III dental stone (Zhermack SpA, Badia Polesine, Italy), and centric relation records were used to mount the casts on a semi‐adjustable articulator. The splints featured a flat occlusal surface with evenly distributed contact with the antagonist teeth and incorporated both canine and protrusion guidance. A uniform acrylic resin thickness of 2 mm was maintained between the maxillary and the mandibular first molars. Final intraoral adjustments were performed to optimise occlusal contact, comfort, and retention (Figure 1).
FIGURE 1.
Maxillary Michigan‐type occlusal splint fabricated with clear PMMA resin.
Volunteers were instructed to wear the splint during sleep, and adjustments were made by the same dentist responsible for the evaluation and fabrication after two weeks. All participants were monitored for adverse events related to splint use or treatment. No complications were reported during the follow‐up. The patients used splints every night for six weeks. At the end of the 6th week, the patients discontinued splint use and were re‐evaluated. Patients discontinued splint use for 6 weeks and were reassessed at week 12th.
The patients used splints every night for a period of six weeks. Any potential side effects or splint‐related discomfort experienced by patients was monitored through biweekly follow‐up phone calls.
2.6. Outcomes
Demographic and anthropometric data were collected during the assessments. The assessments were repeated three times: before treatment (baseline), immediately after the end of treatment (6th week 6), and six weeks after the completion of treatment (12th week). Mandibular range of motion and pain were the primary assessment parameters. The secondary assessments included sleep quality, oral parafunctions, anxiety, and posture.
2.6.1. Primary Outcomes
2.6.1.1. Mandibular Motion
The patients' mandibular range of motion was assessed by measuring active mouth opening, lateral jaw movements, and protrusion in millimetres using a Carbon Fibre Composites Digital Calliper (Resolution: 0.1 mm/0.0″, Accuracy: ±0.2 mm/0.01″).
The distance between the incisal teeth was used for mouth opening and protrusion range of motion measurements. Excursion movements (lateral jaw movements) were measured by placing an erasable mark on the incisal teeth and asking the patient to perform the movement. The distance between the lines on the two teeth was measured and recorded in mm. The patient was taught all desired movements, and the measurement values were then recorded. Within the scope of the study, maximum mouth opening, lateral excursion movements, and protrusion movements of the mandible were used [21].
2.6.1.2. Pain
The pain level of the patients was assessed by evaluating two parameters: pain intensity and pain threshold.
A visual analog scale (VAS) was used to assess pain intensity. On a 10 cm straight line, the patient was asked to mark the intensity of pain felt in the desired areas. A value of 0 indicates the absence of pain, whereas a value of 10 is used to describe unbearable pain. Patients were asked to rate their pain at the time of assessment (not the previous week or month).
The pain threshold was assessed using a pressure algometer (Baseline Dolorimeter, NY, USA). This device, featuring a 1 cm diameter pressure area, objectively measures the applied pressure. A pressure algometer was applied by pressing it at a 90° angle to the target area until the patient reported the first sensation of pain. The pressure value at that time was recorded as the pain threshold. While the patient remained seated, the algometer was appropriately positioned over the measurement area. After the procedure was explained, the results were recorded as the average of three measurements [22].
Pain thresholds of the masseter, anterior temporalis, and upper trapezius muscles were evaluated bilaterally. Lower pain thresholds indicate increased nociceptive activity. Pain thresholds below 2.6 kg/cm2 were considered positive, indicating a decreased pain threshold [23].
2.6.2. Secondary Outcomes
2.6.2.1. Oral Parafuctions
A 21‐item Oral Behaviour Checklist (OBC) questionnaire was used to evaluate the oral habits of the participants. The questionnaire, which questions how often parafunctional habits such as teeth clenching, teeth grinding, nail biting, lip biting, cheek biting, pencil biting, and chewing gum chewing have been performed in the last month, is answered with a 4‐point Likert scale. The total OBC score was used in the analyses. A person's overall score ranged from 0 to 84. The validity and reliability of the questionnaire were demonstrated in the RDC/TMD Validation project [24].
2.6.2.2. Anxiety
The State Trait Anxiety Scale is a Likert‐type scale developed by Spielberger et al. and adapted to the Turkish population. It measures state and trait anxiety levels separately with 20 questions [23]. The Trait Anxiety Scale measures the continuity of anxiety that a person tends to experience. High scores indicate high anxiety levels, low scores indicate low anxiety levels, and the total score value varies between 20 and 80. A high score indicates a high level of anxiety, and a low score indicates a low level of anxiety [25].
2.6.2.3. Sleep Quality
The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality. The PSQI items were structured based on clinical observations of patients with sleep disorders, existing sleep quality scales referenced in the literature, and findings from an 18‐month clinical follow‐up focused on the PSQI. The validity and reliability of the Turkish version of the scale were established by Ağargün in 1996 [25]. The PSQI comprises 19 self‐rated questions grouped into seven subcomponents. The total PSQI score was calculated as the sum of these seven components, ranging from 0 to 21, with scores above 5 indicating poor sleep quality. This approach has been widely utilised for the evaluation of sleep disorders, including cancer [26].
2.6.2.4. Postural Assessement
Posture was assessed using a photographic method, focusing on the craniovertebral and craniocervical angles. Photographs were obtained from the right lateral view using a camera mounted on a tripod fixed at a height of 115 cm and positioned 1.5 m away. The assessments were conducted in a quiet independent room [27]. This method allows objective numerical data to be obtained for the cervical posture evaluation.
The assessments were repeated in a quiet room at the same time of day. Patients were asked to sit with their feet in contact with the ground and look straight ahead, without being instructed to sit upright. They were directed to keep both feet touching the floor and to rest their hands comfortably on their knees, while maintaining a natural forward gaze.
2.7. Statistical Analysis
All statistical analyses were conducted using SPSS version 21.0. Data normality was assessed using visual and analytical methods, which confirmed normal distribution. A 3 (group) × 3 (time) repeated‐measures analysis of variance was used to compare techniques. When significant p‐values were observed, post hoc analyses were performed with Bonferroni correction. Effect sizes were calculated using partial eta squared (η 2), with values interpreted as 0.01 = small, 0.06 = medium, and 0.14 = large [28]. Statistical significance was set at p < 0.05 for all measurements. The data were reported using an intention‐to‐treat approach.
3. Results
A total of 63 patients diagnosed with probable sleep bruxism were included in this study. The population was divided into three groups: jaw exercise (n = 20), jaw and posture (n = 22), and splint (n = 21) (Figure 2).
FIGURE 2.
Flowchart Showing Patient All.
Throughout the study, no adverse effects related to occlusal splint impression or use, jaw and posture exercises, or manual therapy interventions were observed.
According to the G‐Power Post hoc analyses performed in this study [pain data (η 2 = 0.037, effect size = 0.196)], a power above 90% was obtained. The analyses obtained from the demographic data (Table 2) and disease‐specific parameters indicated that the study groups were homogeneous (p > 0.05) in all numerical and categorical baseline data, with the exception of the education and occupation parameters.
TABLE 2.
Baseline demographics.
| JE (n = 20) | JP (n = 22) | OS (n = 21) | p | |
|---|---|---|---|---|
| Gender (F/M) | 14/6 | 18/4 | 18/3 | 0.434 |
| Age (years) (M ± SD) | 33.45 ± 10.20 | 31.73 ± 10.19 | 35.00 ± 14.71 | 0.667 |
| Height (cm) (M ± SD) | 166.40 ± 10.56 | 164.82 ± 8.06 | 165.14 ± 7.33 | 0.828 |
| Weight (kg) (M ± SD) | 65.60 ± 15.77 | 62.95 ± 13.19 | 66.90 ± 15.15 | 0.669 |
| Duration of pain (months) (M ± SD) | 43.6 ± 37.1 | 51.3 ± 34.0 | 51.8 ± 35.9 | 0.265 |
| Have you received treatment before? (Y/N) | 13/7 | 17/5 | 2/19 | 0.146 |
Abbreviations: F/M, female/male; JE, jaw exercise; JP, jaw and posture exercises; M ± SD, mean ± standard deviation; OS, occlusal splint.
3.1. Primary Outcomes
3.1.1. Mandibular Motion
In the analyses performed to determine the changes in maximal mouth opening, a time interaction was observed [F(2,72) = 6.592, p = 0.002, η 2 = 0.155], while a time‐group interaction [F(4,72) = 1.911, p = 0.118, η 2 = 0.096] was not recorded. Post hoc analysis showed that progress was observed only in the jaw group (p < 0.05), while no change was recorded in the jaw‐posture and splint groups (p > 0.05). However, this change in the jaw group was not significantly different between the groups (p > 0.05).
In the right lateral deviation analysis, there was a time interaction [F(2,72) = 43.653, p < 0.001, η 2 = 0.548] but no time‐group interaction [F(4,72) = 1.247, p = 0.299, η 2 = 0.065]. The post hoc analyses revealed that while all three groups demonstrated progress (p < 0.05), there was no significant difference between the groups (p > 0.05).
In the left lateral deviation analysis, a time interaction [F(2,72) = 24.191, p < 0.001, η 2 = 0.402] was calculated, while a time‐group interaction [F(4,72) = 2.106, p = 0.089, η 2 = 0.105] was not found. Post hoc analysis showed that there was an improvement in JP and OS (p < 0.05), whereas no change was observed in JE (p > 0.05). However, these changes were not significant between the groups (p > 0.05).
As a result of the analyses performed for protrusion, time interaction [F(2,72) = 15.918, p < 0.001, η 2 = 0.307] and time‐group interaction [F(4,72) = 0.609, p = 0.658, η 2 = 0.033] were not found. The post hoc results showed that the JE and JP groups improved (p < 0.05), while the OS showed no change (p > 0.05). However, these changes in the jaw and jaw posture groups did not show superiority between the groups (p > 0.05).
3.1.2. Pain
Pain assessment according to the VAS showed a time interaction [F(2,76) = 47.107, p < 0.001, η 2 = 0.554], but no time‐group interaction [F(4,76) = 0.740, p = 0.568, η 2 = 0.037]. The post hoc results demonstrated that despite progress being recorded in all groups (p < 0.05), no superiority was identified between groups (p > 0.05).
3.1.3. Pain Threshold
In the analyses for right and left masseter pain threshold changes, both right [F(2,66) = 1.942, p = 0.160, η 2 = 0.056] and left masseter time interaction [F(2,66) = 1.771, p = 0.178, η 2 = 0.051] and right [F(4,66) = 2.668, p = 0.052, η 2 = 0.139] and left masseter time‐group interaction [F(4,66) = 0.976, p = 0.427, η 2 = 0.056] were not recorded.
In the analyses of temporal pain threshold, neither right [F(2,66) = 1.569, p = 0.216, η 2 = 0.045] nor left temporal time interaction [F(2,66) = 1.371, p = 0.261, η 2 = 0.040], right [F(4,66) = 1.341, p = 0.264, η 2 = 0.075], and left temporal time‐group interaction [F(4,66) = 2.315, p = 0.066, η 2 = 0.123] were found.
Similarly, in the analyses of trapezius pain threshold, neither right [F(2,64) = 0.600, p = 0.552, η 2 = 0.018] nor left trapezius time interaction [F(2,64) = 0.017, p = 0.983, η 2 = 0.001], and right [F(4,64) = 1.001, p = 0.414, η 2 = 0.059] nor left trapezius time‐group interaction [F(4,66) = 1.326, p = 0.270, η 2 = 0.077] were recorded.
3.2. Secondary Outcomes
3.2.1. Oral Parafunctions
As a result of the analyses performed for OBC, a time interaction [F(2,78) = 5.609, p = 0.005, η 2 = 0.126] was observed, while a time‐group interaction [F(4,78) = 1.205, p = 0.315, η 2 = 0.058] was not recorded. Post hoc analyses revealed an improvement in the JE and JP groups (p < 0.05), while no change was found in the OS group (p > 0.05). However, these changes were not significant between the groups (p > 0.05).
3.2.2. Anxiety
As a result of the analyses performed for the State Trait Anxiety Scale, time interaction was calculated [F(2,78) = 8.775, p < 0.001, η 2 = 0.184], while time‐group interaction [F(4,78) = 0.237, p = 0.917, η 2 = 0.012] was not observed. The post hoc results showed an improvement only in the OS group (p < 0.05), while there was no change in the JE and JP groups (p > 0.05). However, this change in the splint group did not demonstrate superiority between the groups (p > 0.05).
3.2.3. Posture Assessment
In the analysis of the change in cranio‐vertebral and cranio‐horizontal angles, neither craniovertebral [F(1,41) = 0.009, p = 0.923, η 2 < 0.001] nor cranio‐horizontal time interaction [F(1,42) = 2.275, p = 0.139, η 2 = 0.051], cranio‐vertebral [F(2,41) = 0.567, p = 0.571, η 2 = 0.027], nor cranio‐horizontal time‐group interaction [F(2,42) = 0.354, p = 0.704, η 2 = 0.017] were observed.
3.2.4. Sleep Quality
In the analysis of sleep quality, neither time interaction [F(2,44) = 2.084, p = 0.137, η 2 = 0.087] nor time group interaction [F(4,44) = 1.884, p = 0.130, η 2 = 0.146] was observed. Detailed data and post hoc analyses are summarised in Table 3.
TABLE 3.
Within and between group comparisons among groups.
| Outcomes | Jaw exercise group (JG) | Jaw and posture exercise group (JP) | Occlusal splint group (CG) | p* | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre | Post (6 week) | Post (12 week) | p + | Pre | Post (6 week) | Post (12 week) | p + | Pre | Post (6 week) | Post (12 week) | p + | |||
| Range of motion | Maximal oral opening | 37.63 ± 5.37 | 40.09 ± 4.08 | 40.82 ± 3.07 |
0.013 a 0.011 b 1.000 c |
38.00 ± 3.50 | 39.60 ± 3.91 | 37.58 ± 5.33 |
0.299 a 1.000 b 0.436 c |
36.62 ± 5.75 | 39.05 ± 5.78 | 40.33 ± 4.15 |
0.285 a 0.338 b 1.000 c |
0.118 |
|
Excursion right |
3.91 ± 2.08 | 5.70 ± 1.53 | 5.83 ± 1.67 |
0.006 a 0.018 b 1.000 c |
3.92 ± 1.58 | 6.09 ± 1.67 | 6.15 ± 1.50 |
< 0.001 a < 0.001 b 1.000 c |
4.59 ± 1.78 | 6.52 ± 0.71 | 6.48 ± 1.56 |
< 0.001 a 0.001 b 1.000 c |
0.299 | |
|
Excursion left |
4.15 ± 2.08 | 5.60 ± 1.65 | 5.36 ± 1.79 |
0.069 a 0.271 b 1.000 c |
3.93 ± 1.60 | 6.01 ± 1.65 | 6.56 ± 2.08 |
< 0.001 a < 0.001 b 0.229 c |
4.48 ± 1.51 | 6.28 ± 1.39 | 6.41 ± 1.62 |
0.019 a 0.025 b 1.000 c |
0.089 | |
| Protruction | 3.53 ± 1.75 | 4.71 ± 1.45 | 4.80 ± 1.31 |
0.092 a 0.019 b 1.000 c |
3.51 ± 1.20 | 4.78 ± 1.76 | 5.01 ± 1.40 |
0.043 a 0.003 b 0.352 c |
4.27 ± 1.49 | 5.65 ± 1.51 | 5.48 ± 1.58 |
0.090 a 0.440 b 0.257 c |
0.658 | |
| Pain and pain threshold values | Pain VAS | 6.00 ± 2.29 | 2.07 ± 1.90 | 2.33 ± 2.02 |
< 0.001 a < 0.001 b 1.000 c |
6.14 ± 1.55 | 2.17 ± 1.50 | 3.72 ± 1.67 |
< 0.001 a 0.003 b 0.009 c |
6.57 ± 1.50 | 3.12 ± 2.06 | 3.55 ± 2.42 |
0.001 a 0.001 b 1.000 c |
0.568 |
| Massater right | 1.18 ± 0.30 | 1.54 ± 0.54 | 1.52 ± 0.66 |
0.071 a 0.077 b 1.000 c |
1.18 ± 0.44 | 1.34 ± 0.29 | 1.30 ± 0.28 |
0.190 a 0.530 b 1.000 c |
1.29 ± 0.50 | 1.07 ± 0.38 | 1.22 ± 0.50 |
0.575 a 1.000 b 1.000 c |
0.052 | |
| Massater left | 1.18 ± 0.37 | 1.42 ± 0.44 | 1.34 ± 0.41 |
0.079 a 1.000 b 1.000 c |
1.22 ± 0.57 | 1.29 ± 0.26 | 1.28 ± 0.37 |
0.914 a 1.000 b 1.000 c |
1.14 ± 0.36 | 1.01 ± 0.51 | 1.70 ± 1.94 |
1.000 a 0.437 b 0.221 c |
0.427 | |
| Temporal right | 1.80 ± 0.52 | 2.46 ± 0.98 | 2.26 ± 0.81 |
0.301 a 0.980 b 1.000 c |
1.93 ± 0.62 | 2.26 ± 0.60 | 2.19 ± 0.61 |
0.400 a 0.930 b 1.000 c |
1.99 ± 0.48 | 1.57 ± 0.50 | 2.36 ± 2.02 |
0.300 a 1.000 b 0.165 c |
0.264 | |
| Temporal left | 1.88 ± 0.83 | 2.31 ± 1.05 | 1.82 ± 0.35 |
0.290 a 1.000 b 0.272 c |
1.83 ± 0.56 | 2.39 ± 0.72 | 2.16 ± 0.65 |
0.073 a 0.228 b 1.000 c |
1.91 ± 0.70 | 1.56 ± 0.57 | 1.61 ± 0.82 |
0.301 a 0.257 b 0.280 c |
0.066 | |
| Trapezius right | 2.88 ± 1.37 | 3.26 ± 1.65 | 3.00 ± 1.41 |
0.383 a 0.374 b 1.000 c |
2.24 ± 0.99 | 2.58 ± 0.84 | 2.58 ± 1.00 |
1.000 a 1.000 b 1.000 c |
2.11 ± 0.70 | 2.27 ± 1.12 | 2.45 ± 1.60 |
1.000 a 1.000 b 1.000 c |
0.414 | |
| Trapezius left | 2.87 ± 1.44 | 3.27 ± 2.15 | 2.78 ± 0.97 |
1.000 a 1.000 b 1.000 c |
2.41 ± 0.95 | 2.58 ± 1.05 | 2.59 ± 1.01 |
0.955 a 0.954 b 1.000 c |
2.53 ± 1.18 | 1.97 ± 0.90 | 2.50 ± 1.53 |
0.382 a 1.000 b 0.694 c |
0.270 | |
| Secondary outcome measures | Oral parafuction | 34.25 ± 8.80 | 32.44 ± 7.43 | 29.33 ± 8.57 |
0.098 a 0.035 b 1.000 c |
35.41 ± 8.93 | 28.61 ± 10.24 | 31.53 ± 12.18 |
0.024 a 0.176 b 1.000 c |
34.86 ± 9.40 | 29.75 ± 6.62 | 33.18 ± 12.53 |
1.000 a 1.000 b 0.934 c |
0.315 |
| Anxiety | 48.70 ± 4.51 | 47.25 ± 3.94 | 47.53 ± 4.85 |
0.154 a 0.393 b 1.000 c |
49.09 ± 5.15 | 47.33 ± 5.05 | 45.88 ± 6.31 |
0.159 a 0.072 b 1.000 c |
49.05 ± 6.56 | 49.56 ± 10.84 | 46.73 ± 7.48 |
0.046 a 0.173 b 1.000 c |
0.917 | |
| Sleep quality | 8.08 ± 1.88 | 8.53 ± 1.85 | 9.67 ± 3.37 |
1.000 a 0.136 b 0.465 c |
8.18 ± 2.07 | 6.53 ± 2.20 | 7.27 ± 2.40 |
0.325 a 0.960 b 1.000 c |
7.73 ± 2.61 | 8.20 ± 2.04 | 8.55 ± 2.21 |
1.000 a 0.319 b 1.000 c |
0.130 | |
| Craniovertebral angle | 57.35 ± 5.611 | 56.47 ± 8.61 | 0.871 b | 58.13 ± 5.48 | 59.17 ± 6.02 | 0.328 b | 56.80 ± 5.17 | 55.76 ± 5.37 | 0.637 b | 0.571 | ||||
| CranioHorizontal angle | 25.49 ± 5.18 | 25.99 ± 6.74 | 0.439 b | 22.64 ± 5.96 | 24.30 ± 5.73 | 0.097 b | 23.55 ± 6.41 | 23.14 ± 5.35 | 0.761 b | 0.704 | ||||
Note: Significance of Bold values indicate statistically significant differences (p < 0.05).Excursion Right: displacement of the jaw in the right direction. Excursion Left: displacement of the jaw in the left direction. Pain VAS: pain assessed via Visual Analog Scale, Massater Right: massater muscle pain threshold from right side, Massater Left: massater muscle pain threshold from left side, Temporal Right: Temporal muscle pain threshold from right side, Temporal Left: Temporal muscle pain threshold from left side, Trapezius Right: Sağ trapez ağrı eşiği. Trapezius Left: Trapezius muscle pain threshold from left side. Oral Parafunction: Oral Behaviour Checklist, Anxiety: Stait‐Trait Anxiety Inventory Sleep Quality: Pitssburg Sleep Qualit Index Result. Craniovertevbra Angle: Postural Assessment Result. Cranio horizontal Angle: Postural Assessment Result. p +: within‐group comparisons. p*: between groups comparisons.
Pre‐post (baseline‐6th week).
Pre‐post (baseline‐12th week).
Post (6th week)‐post(12th week).
4. Discussion
Our study was designed to compare the effects of jaw exercises, with and without the addition of posture exercise training, to occlusal splint use on mouth opening and pain in probable sleep bruxism treatment. The study evaluated changes after a 6‐week treatment period and the sustainability of these effects at the 12‐week follow‐up. Adequate sample size and homogeneity of the groups' demographic and baseline data ensured the validity of the results and minimised external influence.
Maximal mouth opening, defined as the primary variable, showed statistical improvement only in the jaw‐exercise group. However, this did not result in significant differences between groups. Lateral excursion movements improved significantly across all groups, but none of the groups demonstrated superiority. Similarly, protrusion values improved in both the jaw and jaw posture exercise groups, but these improvements were not statistically different between the groups.
Pain levels, assessed using the VAS, showed significant improvement in all treatment groups, particularly in the first six weeks. However, the intergroup differences were not significant. The results for pain threshold, sleep quality, and postural analysis revealed that treatment techniques did not significantly affect these variables.
Oral parafunctional habits improved significantly in the jaw and jaw posture groups, yet no intergroup differences were observed. Anxiety levels showed improvement only in the occlusal splint group, but this was not statistically significant compared with the other groups.
Restriction of mandibular movement can increase muscle tension and pain [29]. Improvements in mandibular range of motion observed in the JE group align with previous studies [4], which highlighted the benefits of exercise programmes and manual therapy on muscle flexibility. Calisgan et al. reported similar outcomes when combining jaw‐specific exercises with manual therapy and home programmes [30]. These results are consistent with a recent systematic review by Müggenborg et al., which supports the use of manual trigger point therapy as a potentially effective and safe strategy for orofacial myofascial pain management in clinical practice [31].
Bruxism, characterised by tooth clenching and grinding, significantly affects mouth opening and is closely linked to temporomandibular joint (TMJ) disorders. Bruxism involves rhythmic masticatory muscle activity (RMMA), which leads to muscle fatigue and stiffness that restrict mouth opening. Significant pain reductions observed across all groups suggest similar effects on pain management; however, differences in more specific parameters, such as pain threshold, were not apparent [32].
The jaw exercise protocol, including manual therapy (JE) and the protocol with postural exercises (JP), aimed to relax painful and stiff muscular structures. Despite these improvements, the lack of intergroup differences suggests that these protocols may require greater long‐term continuity. Uçar et al. observed similar muscle flexibility outcomes using a single exercise protocol. Unlike Robacado exercises, our protocol focused on achieving maximal range of motion to enhance mouth opening [20].
Pain associated with temporomandibular dysfunction often results from prolonged mandibular clenching, leading to muscle fatigue and altered joint loading [33]. Exercises performed at the pain threshold may reduce the clenching behaviour. Improvements in mouth opening observed in the JE group suggest the effectiveness of the targeted exercises. However, the combined jaw and posture exercises did not yield the same clear benefits. These findings are consistent with recent evidence by von Piekartz et al. (2024), who demonstrated that tailored manual therapy and bruxism neuroscience education effectively improved pain and mandibular function in awake bruxism patients while stressing the importance of individualised treatment approaches [34]. The omission of manual therapy in future studies may help clarify the effects of exercise protocols.
Romeo et al. demonstrated reductions in pain and improved range of motion using manual therapy alone for myogenic TMJ dysfunction [35]. Unlike their study, our protocol included exercises targeting active stretching, particularly for the masseter and pterygoid muscles. The high proportion of Type I fibres in the masseter muscle may explain its prolonged activation without fatigue in bruxism. Our exercises aimed to improve muscle flexibility, viscoelastic properties, and range of motion. Future protocols tailored to the characteristics of Type II muscle fibres may yield further insights.
In the occlusal splint group, pain reduction and improved range of motion likely resulted from passive joint space protection during sleep. These findings are consistent with previous systematic reviews that reported that occlusal splints may contribute to pain reduction and improved function in patients with bruxism and temporomandibular disorders [10]. Moreover, the integration of physical therapy techniques with occlusal splint therapy has been proposed as a potentially effective approach to enhance treatment outcomes, as highlighted in a systematic review by Amorim et al. [4]. Our study separated these treatments to evaluate their individual effects, precluding direct comparisons with the combined approaches.
This randomised, evaluator‐blinded clinical trial found no significant differences in posture among the three treatment methods. Miçooğulları et al. reported craniovertebral angle improvements with a more comprehensive exercise protocol including the scapulothoracic region, whereas our protocol focused on the jaw and cervical regions [36]. Posture, influenced by numerous factors, may require long‐term evaluation to detect significant changes.
Few studies have investigated the posture of patients with bruxism. Some studies suggest an association between TMD and postural deviations, while others do not [37, 38]. These contradictory findings likely stem from methodological inconsistencies. Future studies should use more sensitive and functional assessment methods.
Daytime tooth clenching in bruxism often correlates with difficulties in stress management. Awareness training can help patients recognise and mitigate clenching behaviours, potentially preventing long‐term recurrences. None of the three treatment protocols significantly improved sleep quality, in contrast to the results of other studies. The absence of assessments of bruxism severity in our study may explain this discrepancy. Longer follow‐up periods might clarify the relationship between sleep and bruxism [39, 40, 41, 42].
4.1. Limitations
Different assessment methods could enhance the findings on exercise protocols for myofascial pain and mandibular range of motion. Practitioner blinding was not feasible owing to methodological constraints. High dropout rates resulted from patient dissatisfaction or extended treatment intervals, which affected follow‐up. Nevertheless, manual therapy was provided at least twice a week, and all exercises were supervised by physiotherapists. Analysing the data using the intention‐to‐treat principle strengthened the conclusions of the study. Although the diagnostic classification was based solely on sleep‐related features, a small number of participants (fewer than 10) reported occasional daytime clenching behaviours during the clinical interviews. These instances were not considered in the diagnostic process and no distinct clinical impact was observed on the study outcomes.
4.2. Conclusion
This controlled study indicates that jaw exercise, jaw and posture exercise, and occlusal splint therapy can be considered viable options for managing pain and improving mandibular range of motion in patients with probable sleep bruxism. These noninvasive treatment approaches may offer clinicians and patients alternatives to more complex interventions, allowing for personalised treatment plans tailored to the individual's needs and preferences. Clinicians should decide the best treatment option for patients by considering the balance of costs and benefits. Given the comparable efficacy of these non‐invasive treatments, clinicians should tailor interventions based on patient‐specific factors, such as cost, patient preference, and potential side effects.
Ethics Statement
Adnan Menderes University Faculty of Health Sciences Non‐Interventional Clinical Research Ethics Committee Date/No: 25.11.2020 date, 92 340 882–050.04.04 number, 2020/054 protocol no.
Conflicts of Interest
The authors declare no conflicts of interest.
Peer Review
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/joor.14027.
Supporting information
Data S1.
Data S2.
Acknowledgements
This study was funded by the Scientific Research Projects Unit of Adnan Menderes University (Project no: SBF‐21002).
Funding: This work was supported by the Scientific Research Projects Unit of Aydın Adnan Menderes University (Project no: SBF‐21002).
This study is conducted in Aydın Adnan Menderes University Physiotherapy and Rehabilitation Unit and Dentistry Faculty in 2022–2024.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1.
Data S2.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.