Development of Questionnaire to Determine the Etiology of Temporomandibular Disorders

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1 Original Article Int J Clin Prev Dent 2014;10(2): ㆍ ISSN (Print) ㆍ ISSN (Online) Development of Questionnaire to Determine the Etiology of Temporomandibular Disorders Ira Tanti, Laura Susanti Himawan, Lindawati Kusdhany Department of Prosthodontics, Faculty of Dentistry University of Indonesia, Jakarta, Indonesia Objective: Several factors could contribute to temporomandibular disorders (TMD), such as the occlusal condition of the teeth, trauma, emotional stress, parafunctions, hormones, and others. To find out the etiology of TMD such as macro trauma, stress, bad habits, and parafunctions are not an easy work. The purpose of this study is to produce a questionnaire to determine the etiology of TMD that is more applicable and appropriate with the characteristics of Indonesian society. Methods: To achieve an adequate and appropriate sampling, a purposive sample was used. The subjects were 23 Indonesian aged over 15 years consisted of 14 women and 9 men, and agree to fill in the informed consent. All participants should have at least one of the five major signs and symptoms of TMD. In order to develop the questionnaire, semi structured interviews with the subjects, observations of the subjects and then discussions with the experts were done. Results: The face and content validity were good, since it brings an agreement between the experts regarding the details of the questions on the questionnaire components i.e. macro-trauma, emotional stress, bad habits and parafunctions. In doing the trial test, subjects could understood and answer the questions of the questionnaire. Conclusion: This questionnaire could be used as a tool to determine the etiology of the TMD, although it requires further study to test the reliability and validity of it. Keywords: temporomandibular joint disorders, etiology, questionnaires Introduction Etiology of temporomandibular disorders (TMD) is complex and multifactorial, due to several factors could contribute to this disorder, such as the occlusal condition of the teeth, trauma, Corresponding author Ira Tanti Department of Prosthodontics, Faculty of Dentistry University of Indonesia, Salemba Raya 4, Jakarta 10430, Indonesia. Tel: , Fax: , iratanti@ymail.com Received May 21, 2014, Revised June 4, 2014, Accepted June 11, 2014 emotional stress, parafunctions, hormones, and others. Because of these, various instruments had been created. The known indices are Helkimo index, Craniomandibular index, The research diagnostic criteria-tmd (RDC-TMD) index (axis I and II), etc. In Indonesia, an index was developed by Himawan et al. [1] called TMD diagnostic index (TMD-DI) [2]. The determination of diagnosis in these instruments were based on clinical signs and symptoms. The only available instrument to diagnose TMD based on etiology is RDC-TMD index axis II, which is a screening instrument dealing with depression, somatization and disability [3]. Although the RDC-TMD has been widely used to diagnose TMD, Indonesia as a developing country still need a simple and reliable tool to determine stress and the other etiology of TMD which could be accepted in culture Copyright c Korean Academy of Preventive Dentistry. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 103

2 International Journal of Clinical Preventive Dentistry of Indonesian society. To find out the etiology of TMD such as macro trauma, stress, bad habits, and parafunctions are not an easy work. The purpose of this study is to produce a tool that is more applicable and appropriate with the characteristics of Indonesian society. Since the prevalence of TMD is high, the result of this study could be used as a reference for TMD prevention. When the etiology known, early intervention could be done, thus the symptoms were not worsen. Besides, quality of life could be improved by limiting the prevalence of TMD. Materials and Methods This qualitative study was conducted at the Faculty of Dentistry, University of Indonesia, Jakarta, and it has been approved by the ethic committee. To achieve an adequate and appropriate sampling, a purposive sample was used. The subjects were 23 Indonesian aged over 15 years consisted of 14 women and 9 men, and agree to fill in the informed consent. Participants must have at least one of the five major signs and symptoms of TMD, e.g. pain in the muscles or temporomandibular joint (TMJ), limited jaw movement, clicking/crepitation/popping in the TMJ, painduring mandibular movement. Screening the psychological factors were based on examination by using RDC-TMD index axis II. In order to develop the questionnaire, semi structured interviews with the subjects, observations of the subjects and then discussions with the experts were done. Interviews with the subjects focused on the etiology of TMD, using a brief semi structured interview guide with a list of topics to be covered. Data were written by interviewer and transcribed on to a Microsoft Word file as soon as possible after the interview had taken place. The qualitative data collection ended when no new data relevant to the etiology of TMD were being expressed. The interviewer also make direct observation of the subject s behavior. Behavior changes could be seen from the expression of the subject. Additionally, physical examinations was done to observed the changes caused by subject s bad habit, parafunction activity, and trauma, e.g. nail changes in nail biting subject, anterior open bite in tongue thrusting subject, calculus in one site arch in unilateral chewing subject, etc. Observation data was written by interviewer when there was a change in behavior or physic on the subject. One single researcher performed all the interviews and observations. Using the data collected from the interview and direct observation/physical examinations, also enriched from the literatures, a list of questions were then created. In order to determine which questions would be included in the questionnaire, experts were consulted individually while blinded to other expert s opinion. Based on those the various etiology of TMD were found. This study involved 3 experts, consisting of 2 prosthodontists and 1 orthodontist to get the face validity. Table 1 showed the questionnaire that was created through the process detailed previously. Afterwards, to test the content validity, the questionnaire were filled by several subjects (5 subjects). Results From 23 subjects, 3 subjects had history of trauma prior developing TMD symptoms, 21 subjects had bad habits, 8 had parafunctions, and 6 subjects were under emotional stress from observation of patient s appearance, and data from RDC-TMD questionnaire axis II. Table 2 showed that some subjects have more than one etiology, and bad habits were the most commonly found as an etiology. The result for the face validity was good, because it brought an agreement between the experts regarding the details of the questions contained on several groups of domains/questionnaire component i.e. macro-trauma, emotional stress, bad habits and parafunctions. Results showed that the content validity were also good, they could answer and understand those questions. From 53 questions, only 3 questions from only 2 subjects need more information i.e,: If ever experienced trauma on facial area, did it mean a trauma on the upper jaw? How could I know that I clench my teeth at night?. How could I know that I grind my teeth at night?. Based on that, it could be inferred that the TMD questionnaire had a good validity. The time needed to fill out the questionnaire was about 12 minutes. Discussion This study showed what were the common risk factors/etiologies for TMD among the subjects in Indonesian people lived in Jakarta. Three subjects had a history of trauma involving the TMJ and the head. This is consisted with the finding of Poveda Roda et al. [4], suggested that patients who were ever exposed to blow around the head and neck showed more severe TMJ symptoms (89%:18%) and also more clinical signs significantly. Bath suggested that the trauma itself in most patients is an initiating etiologic factor. Patients with recent experiences of whiplash injuries have a greater incidence of TMJ pain, limited mouth opening, and masticatory muscle pain on palpation [5]. Each of the 3 subjects had different types of trauma: chin trauma, TMJ trauma caused by a punch, and vehicle accident. On 104 Vol. 10, No. 2, June 2014

3 Ira Tanti, et al:questionnaire to Determine the Etiology of TMD Table 1. Temporomandibular disorders questionnaire based on etiology Domain Butir-Items Score Macro trauma Bad habits Parafunctions Stress 1. Have you ever experienced trauma on the facial area? 2. Have you ever experienced trauma on the chin area? 3. Have you ever experienced trauma on theright lower jaw area? 4. Have you ever experienced trauma on the left lower jaw area? 5. Have you ever experienced trauma on the upper jaw area? 6. Have you ever had trauma on the neck? 1. Do you chew on one side of the jaw? 2. Do you have the habit of nail biting? 3. Do you have thehabit of biting the hard objects e.g. sewing needles, pencil, etc.? 4. Do you like to chew gum? 5. Do you like to lean the chin? 6. Do you like sucking the cheeks? 7. Do you have a habit of sleeping on one side? 8. Do you have the habit of thumb sucking? 9. Do you like to play the jaw? 10. Do you like to bite theupper lip? 11. Do you like to bite the lower lip? 12. Do you like to suck the tongue? 13. Do you like to suck your tongue and cheeks at the same time? 14. Do you have a habit of playing the appliance (dental appliance) or prosthesis in your mouth? 15. Do you breathe through your mouth? 16. When you say copet, cepat, dapat rapidly and repeatedly, whether the tip of your tongue is on the lower edges of the front teeth (tongue thrust)? 17. Do you snore while sleeping? 18. Do you have daytime sleepiness? 1. Do you clench your teeth during the day? 2. Do you clench your teeth at night? 3. Do you grind your teeth during the day? 4. Do you grind your teeth at night? 5. Has any one heard you grinding your teeth frequently during sleep? 1. Do you feel sad because of something not expected to happen? 2. Do you feel pain in your head? 3. Do you feel weak or missing balance? 4. Do you feel pain in the heart or chest? 5. Do you feel excessive worry? 6. Do you feel less energy? 7. Do you blame yourself? 8. Do you feel easy to cry? 9. Do you feel lonely? 10. Don t you interested in any? 11. Do you have problems with sleep? 12. Do you feel hopeless for the future? 13. Do you feel life has ended? 14. Are you overeating? 15. Do you feel unable to control something important in your life? 16. Do you feel nervous, confused and depressed? 17. Do you feel there is something missing from you? 18. Do you find that you can t cope with anything to be done? 19. Do you angry because something happen outside of your control? 20. Do you find it very difficult toface of something that you can t fix it? 21. Did you wake up while sleeping? 22. Do you feel everything is difficult? 23. Do you feel worthless? 24. Do you feel guilty? 105

4 International Journal of Clinical Preventive Dentistry Table 2. The proportion of TMD etiology Characteristic Trauma Bad habits Parafunctions Stress TMD (n=23) a Proportion (%) TMD: temporomandibular disorders. a There are some subjects have more than one etiology of TMD. subjects that received trauma to the chin and TMJ, TMD signs and symptoms appeared immediately after the trauma event; however the subject that experienced vehicle accident, TMD symptoms appeared 5 months later. Some literature suggests that bad habits such as chewing on one side, gum chewing, sucking finger, leaning on chin and others are often associated with the occurrence of TMD. Winocur et al. [6] suggested that gum chewing, nail biting, biting on hard objects and jaw playing were associated with the occurrence of TMD. In this study it was found that 21 subjects had at least one of those bad habits. Many of these subjects had also other bad habits that have not been previously described such as lip biting, cheek biting, tongue sucking, tongue thrusting and others. Unilateral chewing is a known risk factor of TMD. In this study, subjects with higher rates of this variable have higher rates of TMD than those who chewed bilaterally. Tay et al. [7] suggested that subjects with severe TMD tended to chewing to the side away of the lesion. These patterns of characteristic movements seemed to be an adaptive responses that allow for the work of chewing to be handled with the least amount of pain and damage. Although the alterations observed in the chewing patterns of patients with TMD are probably direct consequences of TMD and/or muscular disorders, this did not eliminate the possibility that chronic unilateral chewing during developmental stages and while growing up could predispose an individual to certain disc derangement disorders. Because of this, unilateral chewing could be a factor that was highly associated with TMD and might even be a cause of the problem [8]. Recently, sleep disorders are often associated with the occurrence of TMD [9], therefore one expert proposed to add some questions (items) in the domain of bad habits i.e: Do you snore while sleeping?, Do you have day time sleepiness? Several studies have shown relationships between major life stressors and TMD [10,11]. A high incidence of exposure to stressful life-events and elevated levels of stress-related somatic symptoms in TMD patients have been reported [12,13]. Patients with TMD experienced twice as many undesirable stressful life events in a 6-month period than the control group did, and that life events contributed to the onset of TMD in almost 50% of the patients [12]. An increase in stress excites the limbic structures and hypothalamic-pituitary-adrenal axis activating the gamma efferent system, resulting in partial stretching of the sensory regions of the muscle spindles. When spindles are partially stretched, less stretching of the overall muscle is necessary to elicit a reflex action. This affects results in an increase in muscle tonus, which often leads to further increases in muscle tonicity. This effect lead to an increase in the interarticular pressure of the TMJ [14,15]. There were initial challenges on how to explore the subject s emotional state, but after in-depth interviews, 6 subjects were able to express some complaints which included emotional lability, feelings of loneliness, insomnia, excessive worry, and others. Parafunctional habits such as grinding and clenching of the teeth have been suggested as initiating and/or perpetuating factors in TMD patients by increasing the intra articular pressure [6,16]. These actions may result in a variety of pathologic conditions, but the most common effect reported is excessive tooth wear [8]. In this study the details of the questions were excavated in patients with excessive tooth wear. Among the 8 subjects with parafunctional habits, the most common complaints were someone heard his/her grinding frequently during sleep and clench the teeth during the day. As previously stated, the aim of this study was to produce a questionnaire which could determine the etiology of TMD in Indonesia. When the etiology is known, early intervention could be done, thus alleviating the symptoms at the early stage. This study was limited by the fact that it is a qualitative study, thus making the results more subjective rather than objective, besides Indonesian people tend to ashamed express their feelings. The future direction is to test the reliability and validity of this questionnaire. Conclusion The questionnaire could be used as a screening tool to determine the etiology of the TMD, although it requires further study to test the reliability and validity of it. Acknowledgements The authors acknowledge the financial support received from Dana Hibah Awal University of Indonesia, which funded this research, and thank all the patients whose individual stories made this article possible. 106 Vol. 10, No. 2, June 2014

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