Muscle Tone Regulation and Bruxism in Chronic Stress: Pathophysiological Links to Tooth Fractures and Dental Hard Tissue Pathology

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a concise and interesting report.  

Author Response

Reviewer #1: - This is a concise and interesting report. 

Authors: The authors express their sincere gratitude to the expert members of the editorial board who participated in the review of the manuscript. In turn, the author team will carefully consider all recommendations and comments provided by the experts, and will take the necessary steps to address any shortcomings and improve the quality of the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

 

Dear Authors,

The manuscript is of significant importance to the field of dentistry.

Comprehensive review articles in dentistry offer in-depth analyses of current research, clinical techniques, and emerging technologies. The suggestions are in accordance with the following:

1. The suggested revision for the title is Muscle Tone Regulation and Bruxism in Chronic Stress: Pathophysiological Links to Tooth Fractures and ”Dental” Hard Tissue Pathology.

2. The manuscript is presented as a review of the literature, but the methodology is unclear. The authors should specify whether the manuscript is a narrative review / scoping review / systematic review. It should describe databases searched, search terms, time range, inclusion/exclusion principles, and article selection approach. Without this information, comprehensiveness cannot be assessed.

3. The investigated databases and the electronic pursuit technique, the used investigation strategy, and the selection of articles and of the acquired data are absent without the procedures and the manner in which the information was utilized for data synthesis. Example for Materials and Methods: The comprehensive review was conducted in MEDLINE, PubMed, Web of Science, and Scopus databases for papers published in the English language in the last 20 years. Results: Out of 3871 eligible papers, 120 were included for final appraisal. Study methodologies included ………………, which were mainly applied to ………………. It is suggested a specialty literature search by using the mentioned keywords in the abstract and a classification of the findings.

4. The PRISMA flow diagram for the identification of studies through the used databases is not presented in text and figure.

5. The studied articles revealed insightful information regarding the studied theme, but the outcomes of this review are not presented in tables.

6. The visuals, including tables or schematics to summarize key comparative data (e.g., comparing methodologies of different studies of search strategy and of the summary of the main findings), are not presented.

7. The preventive section focuses mainly on splints, pharmacology, and botulinum toxin, but because the manuscript emphasizes chronic stress, the authors should also discuss or mention the behavioral interventions, stress management, sleep hygiene, cognitive behavioral approaches, and multidisciplinary management.

8. Future research necessities are not described.

9.      The study's limitations are not presented.

 

It is also necessary to make changes as follows:

- Many sentences are excessively long and should be divided for readability.

- In the introduction section: even if it is a good rationale, it is repetitive (avoid saying “Today” repeatedly).

- The language quality, which requires amendments regarding too-long phrasing of sentences (which reduces the readability).

- The term “Sympathetic Department" (line 150 of manuscript) is not used in scientific medical literature because the sympathetic part of the nervous system is a division or system, not a department! Then, a better choice is represented by “Sympathetic Division” or “Sympathetic Nervous System”, or “Sympathetic autonomic nervous system”. Same in the case of “Parasympathetic Department” (line 203 of manuscript).

- Consistency will enhance the scientific quality and ensure alignment with current consensus terminology. Use one standard term throughout, by replacing, e.g., "chewing muscles" with "masticatory muscles"; "hard tissues of the teeth" with "dental hard tissues"; "nocturnal bruxism" with "sleep bruxism"; and "daytime bruxism" with "awake bruxism," a.s.

- Attention to the scientific accuracy, because some statements need to be softened, e.g. “Bruxism contributes to tooth fractures …” – suggested to be better: “Bruxism may contribute to tooth fractures, particularly when combined with other risk factors such as restoration design, occlusal instability, and compromised tooth structure”; “Stress is the most common factor in the etiopathogenesis of bruxism” – suggested to be better: “Stress is frequently reported as an important contributing factor in the multifactorial etiology of bruxism.”

- The discussion section requires strengthening by transforming the currently descriptive style into stronger synthesis, e.g., the difference between association and causation (why some bruxism patients fracture teeth and others do not); the role of restorations in treated teeth in bruxism and the clinical implications for dentists.

- Since the subject of the manuscript concerns stress-related pathology, in the preventive measures section it should mention the cognitive behavioral therapy, the stress reduction interventions, the sleep hygiene, the biofeedback, and the multidisciplinary management.

- The discussion and the conclusion should better distinguish the evidence levels (e.g., association vs. causality).

- Tables should be effectuated for a better visualization of findings.

- Ensure that all references are in conformity to the Medical Sciences Journal style.

 

The manuscript has merit and addresses an important topic, but substantial revisions are necessary before publication.

I recommend major correction, with particular attention to language editing, review methodology, and terminology standardization.

Comments on the Quality of English Language

- Many sentences are excessively long and should be divided for readability.

- In the introduction section: even if it is a good rationale, it is repetitive (avoid saying “Today” repeatedly).

- The language quality, which requires amendments regarding too-long phrasing of sentences (which reduces the readability).

- The term “Sympathetic Department" (line 150 of manuscript) is not used in scientific medical literature because the sympathetic part of the nervous system is a division or system, not a department! Then, a better choice is represented by “Sympathetic Division” or “Sympathetic Nervous System”, or “Sympathetic autonomic nervous system”. Same in the case of “Parasympathetic Department” (line 203 of manuscript).

- Consistency will enhance the scientific quality and ensure alignment with current consensus terminology. Use one standard term throughout, by replacing, e.g., "chewing muscles" with "masticatory muscles"; "hard tissues of the teeth" with "dental hard tissues"; "nocturnal bruxism" with "sleep bruxism"; and "daytime bruxism" with "awake bruxism," a.s.

- Attention to the scientific accuracy, because some statements need to be softened, e.g. “Bruxism contributes to tooth fractures …” – suggested to be better: “Bruxism may contribute to tooth fractures, particularly when combined with other risk factors such as restoration design, occlusal instability, and compromised tooth structure”; “Stress is the most common factor in the etiopathogenesis of bruxism” – suggested to be better: “Stress is frequently reported as an important contributing factor in the multifactorial etiology of bruxism.”

Author Response

Reviewer #2: The suggested revision for the title is Muscle Tone Regulation and Bruxism in Chronic Stress: Pathophysiological Links to Tooth Fractures and” Dental” Hard Tissue Pathology.

Authors: The author team thanks you for your valuable comment and will reconsider the title of the manuscript.

 

- The manuscript is presented as a review of the literature, but the methodology is unclear. The authors should specify whether the manuscript is a narrative review / scoping review / systematic review. It should describe databases searched, search terms, time range, inclusion/exclusion principles, and article selection approach. Without this information, comprehensiveness cannot be assessed.

Authors: The author team thanks you for your valuable comment. This manuscript is a narrative review in which we have attempted to reflect the current state of knowledge regarding the interaction between chronic stress, muscle tone, and pathology of the hard dental tissues. Due to the nature of the chosen narrative style, the initial version of the manuscript did not include data on specific search criteria, databases, or other elements necessary for studies such as systematic reviews. Nevertheless, taking your comment into consideration, we decided to supplement the manuscript with valuable information in the form of a flowchart and a summary table. However, it was decided to generate these elements only for the data related to the impact of abnormalities in muscle tone on hard dental tissues, since compiling such information for the other sections would be extremely challenging due to the diversity and multifaceted nature of the literature search on those topics.

 

- The investigated databases and the electronic pursuit technique, the used investigation strategy, and the selection of articles and of the acquired data are absent without the procedures and the manner in which the information was utilized for data synthesis. Example for Materials and Methods: The comprehensive review was conducted in MEDLINE, PubMed, Web of Science, and Scopus databases for papers published in the English language in the last 20 years. Results: Out of 3871 eligible papers, 120 were included for final appraisal. Study methodologies included ………………, which were mainly applied to ………………. It is suggested a specialty literature search by using the mentioned keywords in the abstract and a classification of the findings.

Authors: The author team thanks you for your valuable comment and will apply this template to describe the research methodology.

 

- The PRISMA flow diagram for the identification of studies through the used databases is not presented in text and figure.

Authors: The author team thanks you for your valuable comment and will add a PRISMA diagram to the text of the manuscript.

 

- The studied articles revealed insightful information regarding the studied theme, but the outcomes of this review are not presented in tables.

Authors: The author team thanks you for your valuable comment and will organize part of the information in the form of a table.

 

- The visuals, including tables or schematics to summarize key comparative data (e.g., comparing methodologies of different studies of search strategy and of the summary of the main findings), are not presented.

Authors: The author team thanks you for your valuable comment and will organize part of the information in the form of a table.

 

- The preventive section focuses mainly on splints, pharmacology, and botulinum toxin, but because the manuscript emphasizes chronic stress, the authors should also discuss or mention the behavioral interventions, stress management, sleep hygiene, cognitive behavioral approaches, and multidisciplinary management.

Authors: The author team thanks you for your valuable comment; the section on preventive measures has been further revised and supplemented with new data in accordance with the recommendations received.

 

- Future research necessities are not described. The study's limitations are not presented.

Authors: The author team thanks you for your valuable comment; the manuscript has been supplemented with a section on future research perspectives. Given the extensive opportunities for development and new discoveries in this field from the standpoint of various scientific disciplines, it is difficult to clearly characterize the existing limitations. Therefore, it has been decided not to include this information in the manuscript.

 

- Many sentences are excessively long and should be divided for readability.

Authors: The author team thanks you for your valuable comment and will break down long sentences into more comprehensible ones.

 

- Future research necessities are not described. The study's limitations are not presented.

Authors: The author team thanks you for your valuable comment; the manuscript has been supplemented with a section on future research perspectives. Given the extensive opportunities for development and new discoveries in this field from the standpoint of various scientific disciplines, it is difficult to clearly characterize the existing limitations. Therefore, it has been decided not to include this information in the manuscript.

 

- In the introduction section: even if it is a good rationale, it is repetitive (avoid saying “Today” repeatedly).

Authors: The author team thanks you for your valuable comment and will revise the text of the introduction in light of the comment.

- The language quality, which requires amendments regarding too-long phrasing of sentences (which reduces the readability).

Authors: The author team thanks you for your valuable comment and will break down long sentences into more comprehensible ones.

 

- The term “Sympathetic Department" (line 150 of manuscript) is not used in scientific medical literature because the sympathetic part of the nervous system is a division or system, not a department! Then, a better choice is represented by “Sympathetic Division” or “Sympathetic Nervous System”, or “Sympathetic autonomic nervous system”. Same in the case of “Parasympathetic Department” (line 203 of manuscript).

Authors: The author team thanks you for your valuable comment and will change the term to the correct one. Unfortunately, translation issues prevented this error from being noticed at an early stage; the text of the manuscript will also be additionally checked for similar incorrect formulations after further translation.

 

- Consistency will enhance the scientific quality and ensure alignment with current consensus terminology. Use one standard term throughout, by replacing, e.g., "chewing muscles" with "masticatory muscles"; "hard tissues of the teeth" with "dental hard tissues"; "nocturnal bruxism" with "sleep bruxism"; and "daytime bruxism" with "awake bruxism," a.s.

Authors: The author team thanks you for your valuable comment and will standardize all terminology to facilitate understanding.

 

- Attention to the scientific accuracy, because some statements need to be softened, e.g. “Bruxism contributes to tooth fractures …” – suggested to be better: “Bruxism may contribute to tooth fractures, particularly when combined with other risk factors such as restoration design, occlusal instability, and compromised tooth structure”; “Stress is the most common factor in the etiopathogenesis of bruxism” – suggested to be better: “Stress is frequently reported as an important contributing factor in the multifactorial etiology of bruxism.”

Authors: The author team thanks you for your valuable comment. Regarding these statements, it should be said that they were derived from the work of other authors, supported by the appropriate references, and have been commented on by our author team. Out of respect for the findings of these researchers, it was decided to integrate their quotations in their original and unaltered form (even though these positions are indeed ambiguous). Taking your comment into consideration, we will attempt to slightly soften these statements while preserving their essential meaning.

 

- Since the subject of the manuscript concerns stress-related pathology, in the preventive measures section it should mention the cognitive behavioral therapy, the stress reduction interventions, the sleep hygiene, the biofeedback, and the multidisciplinary management.

Authors: The author team thanks you for your valuable comment; the section on preventive measures has been further revised and supplemented with new data in accordance with the recommendations received.

 

- The discussion section requires strengthening by transforming the currently descriptive style into stronger synthesis, e.g., the difference between association and causation (why some bruxism patients fracture teeth and others do not); the role of restorations in treated teeth in bruxism and the clinical implications for dentists.

Authors: The author team thanks you for your valuable comment; the relevant section will be supplemented with the necessary data.

 

- The discussion and the conclusion should better distinguish the evidence levels (e.g., association vs. causality).

Authors: The author team thanks you for your valuable comment; the relevant section will be supplemented taking this comment into account.

 

- Tables should be effectuated for a better visualization of findings.

Authors: The author team thanks you for your valuable comment and will organize part of the information in the form of a table.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

The article is a review of how chronic stress affects masticatory muscle tone and bruxism, and how that can contribute to tooth wear and fractures. However there are several aspects that could be enhanced to improve the quality and impact of the work:

 

Line 1: The title is long and slightly overloaded; the title should be more concise and clearly reflect the main outcome or mechanism discussed.

Lines 20–33: The abstract should state the review question, approach, and main conclusions more clearly, with less general background.

Lines 35–52: The introduction needs a clearer knowledge gap and a sharper statement of novelty and aim.

Lines 53–116: This section is informative, but it would improve with tighter organization and a clearer link between anatomy and clinical relevance.

Lines 117–149: The autonomic nervous system section should better separate established evidence from speculative interpretation.

Lines 150–201: The sympathetic section is strong, but it needs more critical discussion of study limitations and causality.

Lines 203–222: The parasympathetic section is too brief and should be expanded or integrated more effectively.

Lines 223–230: Figure 1 is useful, but the caption and labels should be simplified for readability.

Lines 231–275: This section would benefit from synthesis instead of listing study findings one by one.

Lines 276–287: The stress–bruxism relationship should be presented more cautiously because the evidence is still limited.

Lines 288–306: The tooth-fracture section is relevant, but the language should avoid implying bruxism is the sole cause.

Lines 307–347: The clinical manifestations section should better address confounding factors such as age, occlusion, and erosion.

Lines 348–364: The preventive measures section needs a more balanced comparison of treatment options and their limitations.

Lines 365–384: The conclusion repeats earlier points and should be replaced with a stronger, more focused synthesis.

Lines 396–622: The references contain formatting inconsistencies and should be carefully standardized. ​​

I believe the following papers add value to the current research:

Vaida, L.; Dima, R.; Cuc, E.; Negrutiu, B.; Moca, A.; Lile, I.E.; Daragiu, D.; Alexandru, Z.; Albert, E.; Todor, B. Comparative Study on the Efficiency of Intermaxillary Elastic Polymers Used in the Treatment of Skeletal Class II Malocclusions in Growing Patients. Mater. Plast. 2019, 56, 341–345. https://doi.org/10.37358/MP.19.2.5183

Negrutiu, B.M.; Vaida, L.L.; Todor, B.I.; Judea, A.S.; Lile, I.E.; Moca, A.E.; Judea-Pusta, C.T. An important morphological feature of the face: upper lip length. Rom. J. Morphol. Embryol. 2019, 60, 537–541. PMID: 31658327.

Comments on the Quality of English Language

The English could be improved to more clearly express the research.

Author Response

Reviewer #3: The article is a review of how chronic stress affects masticatory muscle tone and bruxism, and how that can contribute to tooth wear and fractures. However there are several aspects that could be enhanced to improve the quality and impact of the work.

Authors: The authors express their sincere gratitude to the expert members of the editorial board who participated in the review of the manuscript. In turn, the author team will carefully consider all recommendations and comments provided by the experts, and will take the necessary steps to address any shortcomings and improve the quality of the manuscript.

 

Line 1: The title is long and slightly overloaded; the title should be more concise and clearly reflect the main outcome or mechanism discussed.

Authors: The author team thanks you for your valuable comment. The title is indeed quite extensive, but in our opinion, this particular format for the manuscript title is able to fully reflect its content and present to the reader information about the issues addressed within our work.

 

Lines 20–33: The abstract should state the review question, approach, and main conclusions more clearly, with less general background.

Authors: The author team thanks you for your valuable comment and will revise the introduction in accordance with the recommendations.

 

Lines 35–52: The introduction needs a clearer knowledge gap and a sharper statement of novelty and aim.

Authors: The author team thanks you for your valuable comment and will revise the introduction in accordance with the recommendations.

 

Lines 53–116: This section is informative, but it would improve with tighter organization and a clearer link between anatomy and clinical relevance.

Authors: The author team thanks you for your valuable comment and will revise this section in accordance with the recommendations.

 

Lines 117–149: The autonomic nervous system section should better separate established evidence from speculative interpretation.

Authors: The author team thanks you for your valuable comment and will adjust this section in accordance with the recommendations.

 

Lines 150–201: The sympathetic section is strong, but it needs more critical discussion of study limitations and causality.

Authors: The author team thanks you for your valuable comment. In this section, we have attempted to present the main data known regarding the influence of the sympathetic nervous system on masticatory muscle tone. The discussion of limitations and the section discussion will be provided below, in the conclusion and discussion section.

 

Lines 203–222: The parasympathetic section is too brief and should be expanded or integrated more effectively.

Authors: The author team thanks you for your valuable comment. Unfortunately, to date there is very little information regarding the interactions between the parasympathetic division and masticatory muscle tone. We will expand this section in accordance with the recommendations, delving deeper into the available data, but will additionally highlight the need for further investigation of this topic.

 

Lines 223–230: Figure 1 is useful, but the caption and labels should be simplified for readability.

Authors: The author team thanks you for your valuable comment; we will endeavor to improve the clarity of the illustration.

 

Lines 231–275: This section would benefit from synthesis instead of listing study findings one by one.

Authors: The author team thanks you for your valuable comment. This section contains introductory information regarding the nature of the interaction between the psycho-emotional state and muscle activity. In this section, we have attempted to focus on known facts, bringing them together in one place. The summary of the findings from this section will be combined with the discussion of other sections and presented below.

 

Lines 276–287: The stress–bruxism relationship should be presented more cautiously because the evidence is still limited.

Authors: The author team thanks you for your valuable comment and will provide a more accurate wording of the statement.

 

Lines 288–306: The tooth-fracture section is relevant, but the language should avoid implying bruxism is the sole cause.

Authors: The author team thanks you for your valuable comment and will provide a more precise formulation of the idea.

 

Lines 307–347: The clinical manifestations section should better address confounding factors such as age, occlusion, and erosion.

Authors: The author team thanks you for your valuable comment and will expand this section with additional data.

 

Lines 348–364: The preventive measures section needs a more balanced comparison of treatment options and their limitations.

Authors: The author team thanks you for your valuable comment; the relevant section will be supplemented in accordance with the recommendations.

 

Lines 365–384: The conclusion repeats earlier points and should be replaced with a stronger, more focused synthesis.

Authors: The author team thanks you for your valuable comment and will expand this section with additional data.

 

Lines 396–622: The references contain formatting inconsistencies and should be carefully standardized. ​​

Authors: The author team thanks you for your valuable comment; the references will be revised and corrected accordingly.

 

I believe the following papers add value to the current research:

Vaida, L.; Dima, R.; Cuc, E.; Negrutiu, B.; Moca, A.; Lile, I.E.; Daragiu, D.; Alexandru, Z.; Albert, E.; Todor, B. Comparative Study on the Efficiency of Intermaxillary Elastic Polymers Used in the Treatment of Skeletal Class II Malocclusions in Growing Patients. Mater. Plast. 2019, 56, 341–345. https://doi.org/10.37358/MP.19.2.5183

Negrutiu, B.M.; Vaida, L.L.; Todor, B.I.; Judea, A.S.; Lile, I.E.; Moca, A.E.; Judea-Pusta, C.T. An important morphological feature of the face: upper lip length. Rom. J. Morphol. Embryol. 2019, 60, 537–541. PMID: 31658327.

Authors: The author team thanks you for the information provided. These works are indeed a very valuable addition to the manuscript and will certainly be discussed in the text and added to the reference list.

Comments on the Quality of English Language. The English could be improved to more clearly express the research.

Authors: The author team thanks you for your valuable comment; the relevant parameter of our manuscript will be corrected in accordance with the recommendations.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

This review highlights the significant merits of addressing the important topic of the multidisciplinary nature of research concerning the connections between neuroscience, dentistry, stress physiology, and pathology.

I recommend publication of the manuscript in its current revised form.

Reviewer 3 Report

Comments and Suggestions for Authors

-