/jp-journals Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital

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1 JIAOMR /jp-journals Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital RESEARCH ARTICLE Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital and Its Relationship to Age, Gender, Occlusion and Psychological Factors Raheel Ahmed Syed, Arshiya Ara Syeda, Girish Katti, Vini Arora ABSTRACT Background: Temporomandibular disorder (TMD) is a collective term that encompasses many clinical problems involving the masticatory muscles, temporomandibular joints (TMJ) and associated structures and it has high prevalence among populations. Aims and objectives: To determine the prevalence of TMD and its relationship to age, gender, occlusion and psychological factors and to evaluate which age group, gender, malocclusion parameters and psychological factors contribute to the prevalence of TMD. Materials and methods: The study includes a sample of 250 young adults (134 girls and 116 boys) with age ranging from 18 to 25 years, the presence and severity of TMD was determined using a self-administered anamnestic questionnaire composed of 10 questions regarding common TMD symptoms. Morphologic occlusion was evaluated according to Angle s classification (molar classes I, II, III) and to evaluate the psychological factors, The hospital anxiety and depression scale (HADS) developed by Zigmond and Snaith was used. Results: Data were computerized and the SPSS package (version 11.2) was used and nonparametric test of Chi-square for data analysis and unpaired t-test was also used for statistical data analysis. Anamnestic index (AI) showed that the percentage of women (55.22%) had higher degree of TMD symptoms than compared with men (50.86%), comparing the age of men and women free TMD and with TMD, the statistical difference was not significant as (t = 1.35, p > 0.5), distribution of the cases among Angle s class I, II, III occlusion the difference was not statistically significant as (p > 0.5), the degree of anxiety and TMD degree among men and women patients, women had higher anxiety levels as compared to men and no statistical difference was found between the cases of men and women in the depression levels. Conclusion: Prevalence of TMD symptoms in our sample of 250 patients was high for women. Morphologic occlusion was not associated with the presence of TMD symptoms. By considering the psychological factors we found anxiety but not depression associated with TMD symptoms. Keywords: Temporomandibular disorders, The hospital anxiety and depression scale, Anxiety and depression. How to cite this article: Syed RA, Syeda AA, Katti G, Arora V. Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital and Its Relationship to Age, Gender, Occlusion and Psychological Factors. J Indian Aca Oral Med Radiol 2012;24(4): Source of support: Nil Conflict of interest: None declared INTRODUCTION According to the American Academy of Temporomandibular Disorders, temporomandibular disorders or dysfunctions (TMD) is a collective term that encompasses many clinical problems involving the masticatory muscles, the temporomandibular joint (TMJ) and associated structures or both. 1,2 The etiology of TMD remains controversial and is generally viewed as multifactorial. Nevertheless, a number of studies have implicated occlusal inferences and psychological factors as more important than other variables in providing explanation for TMD that are still under discussion. 3,5 Signs and symptoms of TMD were found in all age groups in epidemiological studies that may be as high as 88 and 55% respectively with prevalence being low in small children and increasing with age in adolescence up to young adulthood. 4,5 The role of gender in TMD has also been extensively discussed in the literature. TMD is considered to be 1.5 to 2 times more prevalent in women than in men and 80% of patients treated for the disorder are women. 4,5 Malocclusion has been associated with TMD, when it is believed that the alteration of form might cause alteration in the stomatognathic system function. With the intention of elucidating this relation, several authors have studied class I, II, III malocclusion, posterior crossbite anterior open bite, horizontal overlap and vertical overlap, suggesting that these alterations are responsible for the onset of TMD symptoms. 5,6 Evidence has been accumulating since 1950s that psychological factors are of concern in certain subgroups of patients with TMD. Investigators using various psychological and behavioral assessments have reported depression, anxiety, oral habits, chronic pain and compromised coping skills in a certain percentage of TMD patients. Anxiety has been proposed as an etiological factor through oral habits and increased muscle tension. 5,7,8 AIMS AND OBJECTIVES 1. To determine the prevalence of TMD and its relationship to age, gender, occlusion and psychological factors. 2. To evaluate which age group and gender shows most prevalent TMD. Journal of Indian Academy of Oral Medicine and Radiology, October-December 2012;24(4):

2 Raheel Ahmed Syed et al 3. To evaluate which malocclusion parameters contributes to the prevalence of TMD. 4. To evaluate the association of psychological factors to the prevalence of TMD. MATERIALS AND METHODS The study includes a sample of 250 young adults as inclusion criteria (134 girls and 116 boys) with age ranging from 18 to 25 years, randomly selected from the outpatients attending the Department of Oral Medicine and Radiology at Al-Badar Rural Dental College and Hospital, Gulbarga, Karnataka. The ethical committee of Al-Badar Rural Dental College and Hospital had approved the conduct for this research. Exclusion criteria for our study include: 1. Patients with trauma to the TMJ. 2. Patients with congenital abnormalities related to TMJ. 3. Patients following odontogenic infections like abscess, cyst or any other periapical pathological swellings in relation to TMJ. 4. Any pre- or postsurgical complications in relation to the TMJ. 5. Any metastatic tumors, cysts or carcinomas of the oral cavity in relation to the TMJ. Anamnestic Questionnaire For data capture regarding to our study we used a selfapplicable history questionnaire, without the interference of the researcher, aiming at detecting TMD. The presence and severity of TMD was determined using a selfadministered anamnestic questionnaire composed of 10 questions regarding common TMD symptoms. This questionnaire is a modified version of Helkimo s anamnestic index (AI) and has been previously used by Fonseca et al and Conti et al. It has demonstrated a high efficiency in obtaining a diagnosis and was easy to apply. 5,9 Ten questions of AI proposed by Da Fonseca et al used in our study: 1,5,9 Do you have difficulty in opening your mouth? Yes/no Do you have difficulty in moving or using your jaw? Yes/no Do you have tenderness or muscular pain when chewing? Yes/no Do you have frequent headaches? Yes/no Do you have neck aches or shoulder pain? Yes/no Do you have pain in or about the ears? Yes/no Are you aware of noises in the jaw joints? Yes/no Do you consider your bite normal? Yes/no Do you use only one side of your mouth when chewing? Yes/no Do you have morning facial pain? Yes/no 262 After the patient has answered the following 10 questions the questionnaire was interpreted for TMD presence and the scores were given as: 1 For each yes answer, a score of 2 was assigned, sometimes had a score of 1 ; and no, a score of 0. For questions 6 and 7, if the symptoms were bilateral, 1 more point was added to the total value. Also for question 4, 1 more point was added when pain, besides frequent, was also intense. 2 The scores were calculated and were distributed for the presence or absence of the symptoms: A score of 0 indicates the absence of symptoms. A score of 1 indicates the occasional occurrence. A score of 2 indicates the presence of dysfunction. A score of 3 indicates severe pain or bilateral symptoms. After summing up the scores we grouped the patients of our study into four categories: 2,5,10 Score 0-3: TMD free. Score 4-8: Mild TMD. Score 9-14: Moderate TMD. Score 15-23: Severe TMD. OCCLUSION EXAMINATION Morphologic occlusion was evaluated according to Angle s classification (molar classes I, II, III). 5 Hospital Anxiety and Depression Scale The level of anxiety and depression was self-rated using The hospital anxiety and depression scale (HADS) developed by Zigmond and Snaith in 1983, as this scale provides an acceptable, reliable, valid and easy to use practical tool for identifying and quantifying depression and anxiety. 5,10 The HADS used in our study contained 14 questions with equally distributed questions for anxiety and depression. 10 Seven questions for anxiety I feel tense or wound up I get a sort of frightened feeling Worrying thoughts go through my mind I can sit at ease and feel relaxed I get a sort of frightened feeling like butterflies in the stomach I feel restless as if I have to be on the move I get sudden feeling Seven questions for depression I still enjoy the things I used to enjoy I can laugh and see the funny side of things I feel cheerful I feel as if I am slowed down I have lost interest in my appearance I look forward with enjoyment to things I can enjoy a good book or of panic radio or TV program

3 JIAOMR Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital The patients were asked to mark the options which were rated as 0 to 3 below the questions and were calculated to get the possible scores ranging from 0 to 21 for anxiety and 0 to 21 for depression. 5,10 The scoring system for HADS is as follows: Score 0 to 7 normal. Score 8 to 10 mild. Score 11 to 14 moderate. Score 15 to 21 severe disorders. STATISTICAL ANALYSIS Data were computerized and the SPSS package (version 11.2) was used for the analysis. The percentages of the subjects with TMD (of different grades of severity), malocclusion, anxiety and depression in both genders were calculated. The association between TMD degree and occlusion, HADSa and HADSd was done using nonparametric test of Chi-square for data analysis and unpaired t-test was also used for statistical data analysis. RESULTS The results obtained in our study from the anamnestic index showed that the percentage of women (55.22%) with TMD symptoms were higher as compared to men (50.86%) (Table 1 and Graph 1). The percentage of men (35.34%) associated with mild TMD degree were equivalent as compared with women (35.07%). The percentage of women (16.42%) associated with moderate TMD degree were higher as compared to men (10.34%). The percentage of men (5.19%) associated with severe TMD degree were higher as compared to women (3.73%). The overall TMD percentage was 53.20% but this difference was not statistically significant (Chi-square: χ 2 = 1.32, p > 0.05) (Table 2 and Graph 2). The patients with TMD cases among men and women, women had higher TMD symptoms (55.22%) as compared to men (50.86%) and when the comparison was done for free TMD cases, men (49.14%) had higher free of TMD symptoms than women (44.78%) but this difference was not statistically significant (Chi-square: χ 2 = 1.32, p > 0.05). The mean age of women free of TMD was and with TMD was (t = 0.45, p > 0.05) and the mean age of men free of TMD was and with TMD was (t = 1.27, p > 0.50). The mean age of men with TMD was greater as compared to women but overall comparing the age of men and women free TMD and with TMD, the statistical difference was not significant as (t = 1.34, p > 0.5) (Table 3 and Graph 3). The majority of the patients irrespective of men and women associated with TMD levels exhibited class I occlusion. No significant association between morphologic occlusion and TMD levels was found (Chi-square: χ 2 = 0.27, p > 0.5) (Table 4, Graphs 4A and B). The percentage of the degree of anxiety with TMD degree among men and women, women (66%) had high anxiety levels with TMD degree as compared to men (34%) and when we compared men and women free anxiety levels with TMD degree, men were high (54.60%) followed by women (45.30%). The percentage of women (67.20%) with mild anxiety associated with TMD degree was high as compared to men (32.80%). In moderate level of anxiety associated with TMD degree the percentage of women (61.80%) was high followed by men (38%). In severe level of anxiety associated with TMD degree women showed 100% anxiety levels (Table 5 and Graph 5). This shows that the difference was highly statistically significant among men and women for the degree of anxiety associated with TMD degree (Chi-square: χ 2 = 10.39, p < 0.01). The percentage of the degree of depression with TMD degree among men and women, women (53.24%) had high depression levels with TMD degree as compared to men Graph 1: Men and women with TMD degree and free TMD Graph 2: Severity of patients with TMD degree Journal of Indian Academy of Oral Medicine and Radiology, October-December 2012;24(4):

4 Raheel Ahmed Syed et al (46.75%) and when we compared men and women free depression levels with TMD degree, women were high (53.75%) followed by men (46.20%). The percentage of women (56.90%) with mild depression associated with TMD degree was high as compared to men (43.10%). In moderate level of depression associated with TMD degree the percentage of men (61.11%) were high followed by women (38.99%). In severe levels depression associated with TMD degree women showed 100% depression levels (Table 6 and Graph 6). A B Graph 3: Age among men and women with free TMD and with TMD Graphs 4A and B: Association of malocclusion with TMD degree (A) Angle s class I malocclusion with TMD degree, (B) Angle s class II malocclusion with TMD degree DISCUSSION Our research was focused to find the prevalence of signs and symptoms of TMD on a sample of outpatients attending Al-Badar Rural Dental College and Hospital, Gulbarga, and its association to age, gender, morphologic occlusion and psychological factors. Data collection was carried out by means of a self-applied questionnaire. The anamnestic index used to measure TMD degree provided a substantial amount of information in a short period of time and was sensitive and useful for identifying the TMD degree in the studied population. 5,11,12 In our study, we observed that (55.22%) women had a higher degree of TMD signs and symptoms than that of men (50.87%). These values are in agreement with the studies done by Bonjardim et al in a sample of 196 patients, women (57.43%) had a higher prevalence of TMD signs and symptoms when compared to men (42.11%). Garcia et al (1997) in a sample of 122 students (61%) had some degree of TMD signs and symptoms out of which 84 (68.85%) of them were women. Similar results were found with Conti et al (68%) as both the authors used the same questionnaire to evaluate the TMD. This was also in agreement with other studies done by Widmalm et al, Sonmez and Yap et al. 5,8,12-16 Our study revealed that out of 116 men, 49.13% were free of TMD, 35.34% were mild, 10.34% were moderate Graph 5: Anxiety associated with TMD degree Graph 6: Depression associated with TMD degree 264

5 JIAOMR Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital and 5.19% showed severe signs and symptoms and out of 134 women, 44.78% were free of TMD, 35.07% were mild, 16.42% were moderate and 3.73% showed severe signs and symptoms of TMD. The overall TMD percentage was 53.20% but this difference was not statistically significant (Chi-square: χ 2 = 1.32, p > 0.05). Our results were in agreement with the study done by Bonjardim et al in a sample of 196 patients, when compared TMD degree among men and women, 42.57% of women were free of TMD signs and symptoms, 46.53% had mild TMD, 7.92% had moderate and 2.98% had severe TMD signs and symptoms. Among men 57.89% were free of TMD signs and symptoms, 34.74% had mild TMD, 6.32% had moderate TMD and 1.05% had severe TMD signs and symptoms. Table 1: Men and women with TMD and free of TMD Gender Patients with Patients free Total (n) TMD (n) of TMD (n) Men 59 (50.86%) 57 (49.14%) 116 (100%) Women 74 (55.22%) 60 (44.78%) 134 (100%) Total 133 (53.20%) 117 (46.80%) 250 (100%) Our results were in a close match with the studies done by Conti et al which comprised 310 students (51.61% females and 48.39% males) with a mean age of years. The anamnestic questionnaire in the study done by Conti et al revealed that 58.71% of subjects were asymptomatic, 34.84% had mild TMD signs and symptoms, 5.81% had moderate and only 0.65% had severe TMD signs and symptoms. 12 Our results were in agreement with the study done by Pedroni et al (2003) who evaluated 50 Brazilian college students. The anamnestic questionnaire in the study done by Pedroni et al revealed that 68% of the volunteers had some degree of TMD. Among them 15.62% females were TMD free, 46.87% had mild TMD signs and symptoms, 20% had moderate and 9.37% had severe signs and symptoms of TMD. Among men, 61.11% were TMD free, 33.33% had mild TMD signs and symptoms and 5.55% had moderate signs and symptoms of TMD. 17 In our study, mild TMD degree was the most prevalent category for female and male patients, this was also in agreement with the studies done by Dekon et al (2002), Pedroni et al (2003), Oliveira AS (2006) and Bonjardim et al (2007) who also found similar results using the Fonseca Table 2: Severity of patients with TMD degree TMD degree Men (n) Women (n) Total Free of TMD 57 (49.13%) 60 (44.78%) 117 (46.80%) Mild 41 (35.34%) 47 (35.07%) 88 (35.20%) Moderate 12 (10.34%) 22 (16.42%) 34 (13.60%) Severe 6 (5.19%) 5 (03.73%) 11 (04.40%) Total 116 (100%) 134 (100%) 250 (100%) Chi-square: χ 2 = 1.32, p > 0.05, not significant Table 4: Association of malocclusion with TMD degree Molar Free TMD Mild TMD Moderate Severe class TMD TMD I II III Chi-square: χ 2 = 0.27, p > 0.05 Table 3: Age among men and women with free TMD and with TMD Sex Age free of TMD Age with TMD t-value Significant p-value Female Mean ± SD (59) Mean ± SD (75) 0.45 > ± ± 2.14 Male Mean ± SD (57) Mean ± SD (59) 1.27 > ± ± 2.03 Total ± ± >0.05 Table 5: Anxiety associated with TMD degree TMD degree Free of Mild Moderate Severe Total Grand anxiety (M/F) anxiety (M/F) anxiety (M/F) anxiety (M/F) (M/F) total Free TMD 45/43 11/14 02/02 58/ Mild TMD 28/19 06/19 06/10 40/48 88 Moderate TMD 08/05 03/09 02/06 00/01 13/21 34 Severe TMD 01/01 01/01 03/03 00/01 05/06 11 Total 82 (54.60%)/ 21 (32.80%)/ 13 (38.20%)/ 00/02 (100%) 116 (34%)/ (45.33%) 43 (67.20%) 21 (61.80%) 134 (66%) Grand total Chi-square: χ 2 = 10.39, p < 0.01 Journal of Indian Academy of Oral Medicine and Radiology, October-December 2012;24(4):

6 Raheel Ahmed Syed et al Table 6: Depression associated with TMD degree TMD degree Free of Mild Moderate Severe Total Grand depression (M/F) depression (M/F) depression (M/F) depression (M/F) (M/F) total Free TMD 39/47 12/14 03/02 54/ Mild TMD 31/32 08/11 03/03 42/46 88 Moderate TMD 09/13 04/07 00/01 13/21 34 Severe TMD 01/01 01/01 05/01 00/01 01/07 11 Total 80 (46.20%)/ 25 (43.10%)/ 11 (61.11%)/ 116 (46.75%)/ 93 (53.75%) 33 (56.90%) 07 (38.99%) 00/01 (100%) 134 (53.24%) 250 Grand total Chi-square: χ 2 = 0.94, p > 0.05 questionnaire to evaluate the prevalence of TMD signs and symptoms. 12,17,18 Although the difference in TMD prevalence between males and females are not yet confirmed, but some theories have been proposed for female predominance. According to the theory, Smith et al suggested female seek treatment more frequently than men because they maintain a healthier relationship and close contact with the health professional. Weinberg and Sandstron et al believed that males can easily handle stress factors than females. More recently Lewitt and Mikinney et al found females with TMD compared to males with TMD and reported a higher level of severity of all physical and psychological symptoms. Also the presence of estrogen receptors in the TMJ and the possible role of exogenous hormones have been suggested to be important for gender difference. Despite these theories, the true reason for why females present with higher signs and symptoms of TMD and present frequently for treatment remains unknown and warrant additional studies In our study, we found that the mean age of women free of TMD and with TMD was (20.47) and (20.29) respectively and the mean age of men free of TMD and with TMD was (20.72) and (21.18) respectively but there was no statistical correlation found between the age group of men and women (t = 1.34, p > 0.05). This was in agreement with the several studies which showed that the severity of TMD symptoms varies with age. The increase of signs and symptoms during childhood and adolescence has been taken by some that TMD is progressive, at any rate in women, while the large fluctuation of signs and symptoms, where spontaneous remission is very common, has been interpreted by others that TMD is a self-limiting disorder. In women the symptoms generally increase after puberty, to peak at the reproductive age group (between years). 5 The increase in TMD symptoms between age 15 and age 25 observed at the 10-year follow-up in a study done by Magnusson et al (1999) seemed to have leveled out, and in general no significant increase was found up to the age of 35 years. On the other hand, fluctuation in TMD symptoms was evident also during the last 10-year period. 266 Continuing development into more serious conditions was rare, e.g. clicking did not develop into locking in any subject, and the prevalence of frequent TMD symptoms was about the same (10-12%) at both 25 and 35 years of age. 22 The role of occlusion in TMD has been extensively studied for a long time. Although occlusal factors have been considered as an important predisposing and initiating factor in the past, recent publications suggest no scientific evidence for positive relationship between occlusion factor and TMD. This was in agreement with our findings in which the majority of the patients (94.2%) irrespective of men and women associated with TMD levels exhibited class I occlusion with (5.2%) exhibited class II occlusion. No significant association between morphologic occlusion and TMD levels was found (Chi-square: χ 2 = 0.27, p > 0.05). Our findings were in agreement with Mohlin et al who found no association between any single malocclusion and the severity of clinical signs. Jenni et al did not find any significant connection between occlusal interferences and the degree of clinical dysfunction. Gesch et al, reported a weak association between malocclusion and the functional and clinical parameters of occlusion as well as subjective TMD Henrikson, Ekberg and Nilner (1997) concluded that normal occlusions has a lower chance of presenting signs and symptoms of TMD, while some occlusal characteristics, such as posterior condylar displacement with consequent typical changes in the condylar form and more frequently found in the individuals with class II malocclusion, increase the chances of signs and symptoms of TMD. These characteristics influence the muscular activity and consequently the mandibular movement with predisposition to TMD. 17 The relationship between TMD and psychological disturbances has been extensively studied. The percentage of sample in our study, irrespective of the gender with mild anxiety associated with TMD degree was 25.60%. In moderate level of anxiety associated with TMD degree the percentage was 13.60% and in severe level of anxiety associated with TMD degree the percentage was 0.80%.

7 JIAOMR Prevalence of Temporomandibular Joint Disorders in Outpatients at Al-Badar Dental College and Hospital In our study, it was found that comparing the percentage of the degree of anxiety with TMD degree among men and women, women (66%) had high anxiety levels with TMD degree as compared to men (34%) and when we compared men and women free anxiety levels with TMD degree, men were high (54.60%) followed by women (45.30%). The percentage of women (67.20%) with mild anxiety associated with TMD degree was high as compared to men (32.80%). In moderate level of anxiety associated with TMD degree the percentage of women (61.80%) was high followed by men (38%). In severe level of anxiety associated with TMD degree women showed 100% anxiety levels. This shows that the difference was highly statistically significant among men and women for the degree of anxiety associated with TMD degree (Chi-square: χ 2 = 10.39, p < 0.01). The percentage of sample irrespective of gender with mild depression associated with TMD degree was 23.20%. In moderate level of depression associated with TMD degree the percentage was 7.20% and in severe levels depression associated with TMD degree was 0.40%. The percentage of the degree of depression with TMD degree among men and women, women (53.24%) had high depression levels with TMD degree as compared to men (46.75%) and when we compared men and women free depression levels with TMD degree, women were high (53.75%) followed by men (46.20%). The percentage of women (56.90%) with mild depression associated with TMD degree was high as compared to men (43.10%). In moderate level of depression associated with TMD degree the percentage of men (61.11%) were high followed by women (38.99%). In severe levels depression associated with TMD degree women showed 100% depression levels. Out of 250 patients, depression cases associated with TMD degree were only 45.70%, hence there was no statistical difference found among men and women for the degree of depression associated with TMD degree (Chisquare: χ 2 = 0.94, p > 0.01). Our results for anxiety and depression were high as we compared with the study done by Bonjardim et al 5 in a sample of 101 girls and 95 boys with age ranging from 18 to 25 years, the majority of the participants irrespective of gender were free from anxiety (65.81%) and depression (95.39%) symptoms according to HADS. With mild (23.98%), moderate (4.61%) and severe (0.52%) anxiety levels and (4.61%) mild depression respectively. Our study was in agreement with Bonjardim et al 8 as he found a statistically significant association between TMD degree and HADSa (15.20%) and 1.38% of subjects presented with mild and moderate/severe anxiety symptoms but not between TMD degree and HADSd (9.67%) moderate/severe depression symptoms. Subjects free of anxiety and depression comprised the majority of the sample. Mazzetto et al asserted that anxiety plays an important role in TMD, acting as a predisposing or aggravating factor. Furthermore, anxiety may be an important factor in the perception of pain, with anxious subjects paying more attention to pain. This possibility has been confirmed by other studies, which indicate that anxiety is related to increased pain reports in clinical settings. 25 Beaton et al and Niemi et al found higher level of stress symptoms among the TMD patients when compared to healthy subjects. Thus, considering that stress is associated with psychological disturbances, such as anxiety and depression. Thus, we can say that there appears to be a relationship between stress and degree of TMD in our study as well. 26,27 CONCLUSION The exact role of occlusion and psychological factors in contributing to TMD and the reason why females constitute the majority of patients are still unknown. 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