|Year : 2016 | Volume
| Issue : 2 | Page : 139-143
Prevalence of temporomandibular disorders and its association with parafunctional habits among senior-secondary school children of Lucknow, India
Kriti Agarwal, Sabyasachi Saha, Pooja Sinha
Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||10-Jun-2016|
Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Utrathia, Raebareily Road, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Temporomandibular disorders (TMD) are defined as heterogeneous group of psychological disorders, commonly characterized by orofacial pain, chewing dysfunction, or both. Aim: To determine the prevalence of TMD and to describe the association between parafunctional habits and signs and symptoms of TMD among 15–17-year-old school children in Lucknow. Materials and Methods: This study followed a cross-sectional design, with a sample of 407 school children aged 15–17-year-old. A single, trained, calibrated investigator interviewed the participants according to Fonseca's Anamnestic Questionnaire-1994, which provided information on the prevalence of TMD, followed by the clinical examination of temporomandibular joint (TMJ) according to WHO (1997). Chi-square test and Univariate and Multivariate Logistic Regression analysis were used. Results: The prevalence of TMD was (22.4%). There was no statistically significant association was found between age, (P = 0.81) gender (P = 0.09) and TMD. Nail-biting (88.3%) was the most common habit, followed by clenching/grinding (68.4%) and mouth breathing (53.4%). However, habits and TMJ symptoms were found statistically significant P < 0.01 or P < 0.001 associated to TMD. Further, adjusted (age and gender) logistic regression analysis revealed that digit-sucking, mouth breathing, nail biting, and clenching has made a significant contribution to prediction (P < 0.001). Conclusion: The habits especially digit-sucking, mouth breathing, nail biting, and clenching had statistically significantly associated with TMD.
Keywords: Adolescent health, orofacial pain, parafunction
|How to cite this article:|
Agarwal K, Saha S, Sinha P. Prevalence of temporomandibular disorders and its association with parafunctional habits among senior-secondary school children of Lucknow, India. J Indian Assoc Public Health Dent 2016;14:139-43
|How to cite this URL:|
Agarwal K, Saha S, Sinha P. Prevalence of temporomandibular disorders and its association with parafunctional habits among senior-secondary school children of Lucknow, India. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Oct 21];14:139-43. Available from: http://www.jiaphd.org/text.asp?2016/14/2/139/183809
| Introduction|| |
Temporomandibular disorders (TMD) are considered as the common cause of orofacial pain of nondental origin. Thus, it is an enigmatic issue for dental professional all around the globe as it affects the deleterious effects on the stomatognathic system. The common symptoms of TMD are muscle and/or joint pain on palpation, impaired mandibular function, and joint noises. As temporomandibular joint (TMJ) remodeling occurs in adolescence, there is a direct need for accurate assessment of dental conditions, the joint itself and the neuromuscular apparatus in this period.
Adolescents need to be informed about the negative effects of parafunctional habits. The early diagnosis of signs and symptoms of TMD can help to improve the course of treatment and quality of life of adolescents. Thus, the aim of this study to assess the prevalence of TMD and to describe the association between parafunctional habits and signs and symptoms of TMD among 15–17-year-old school children in Lucknow.
| Materials and Methods|| |
A descriptive cross-sectional survey was designed among 15–17-year-old school going children of Lucknow from March 2014 to August 2014. Ethical clearance was obtained from the Institutional Ethical Committee. Approval was obtained from the principals of the concerning schools. Written consent was obtained from the parents for the participation of their children during parents-teachers meeting.
A pilot study was conducted on 50 school going children. The sample size was estimated using n Master software (version 2, CMC, Vellore, Tamil Nadu, India). Anticipating a 15% prevalence of TMD was obtained during the pilot study in the study population, an absolute precision of 5% and a 95% confidence interval, a sample size of 205 is found to be sufficient. As the study population was selected using multi-stage cluster sampling technique; hence, this sample size was multiplied by 2 (i.e., design effect). Thus, the minimum sample size required was 205 which was rounded off to 410.
The estimated sample was selected by multistage cluster random sampling technique. In the first stage, Lucknow city was divided geographically into five areas, that is, East, West, North, South, and Central. List of all the wards from the five geographic areas was obtained from census enumeration areas data. A list of schools located within the Lucknow municipality was obtained from District School Officer. Approximately, 22 wards came under each of these geographic areas. In the second stage, one ward was randomly selected from each of these geographic areas. In the third stage, two schools from each of the 5 wards were randomly selected. This was followed by a school survey in which all the students aged 15–17 years meeting the following inclusion and exclusion criteria.
- School children who were present on the day of examination
- Parents of children who gave consent.
- Children with special health care needs like physically handicapped children
- Students undergoing orthodontic treatment
- Students with a history of trauma or dental pain.
Three students were absent on the day of the examination, hence final sample size was attained 407.
Method of data collection
The single investigator was trained and calibrated in the department before the commencement of the survey, and the kappa coefficient was estimated to be 0.86. The study proforma had two parts: The first part consisted of the demographic characteristics of subjects included the name, age, gender, address, and name of the school. The second part consisted of The Fonseca Anamnestic Questionnaire (FAQ) (1994) to assess the severity of the TMD symptoms and clinical examination of TMJ as per WHO 1997. FAQ (1994) consists of 10 questions, whose answer options are no, sometimes, and yes. The questionnaire included questions on the presence of TMJ pain, head and neck pain, pain while chewing, questions on parafunctional habits, limitation of joint movement, the perception of malocclusion, and emotional stress. Each answer has a value; answer “NO” = 0, “SOMETIMES” = 5, and “YES” = 10. The sum of the values obtained provides an index that classifies individuals in the absence of TMD (0–15), mild TMD (20–45), moderate TMD (50–65), and severe TMD (70–100). Participants' history and clinical examination was used to determine parafunctional habits like attrition on mandibular incisors, etc., Each parafunction was reported as either present or absent.
The children were interviewed and examined by single, trained calibrated examiner as per American Dental Association Type III criteria  using mouth mirrors while seated on chair under natural light.
Data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0 (SPSS, Inc., Chicago, IL, USA). Results were subjected to statistical analysis using descriptive statistics, were made to all variables in the study. Chi-square Test was applied to evaluate the association between the occurrence of TMD and gender, age group, and parafunctional habits. The influence of the variables use in this study with the presence of TMD was assessed using Univariate and Multivariate-Logistic regression analysis. For all the tests, the level of significance was set up at P < 0.05.
| Results|| |
Out of 407 students, who were interviewed and examined, 158 were 15-year-old (38.8%), 173 were 16-year-old (42.5%) and 76 were 17-year-old (18.7%). Among children further, 190 were female children (46.7%) and 217 were male children (53.3%) [Table 1]. The overall prevalence of TMD (mild and moderate) was found to be 21.4%. A total of 19.2% had mild TMD and 2.2% had moderate TMD, none of the children had severe TMD and majority of school children (78.6%) did not have TMD [Table 2].
|Table 2: Distribution of children according to different grades of temporomandibular disorders according to the Fonseca's Anamnestic Questionnaire|
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There was statistically significant association was found between sign and symptoms of TMD (P< 0.001). The most common symptom was frequent headache which was most prevalent in both with TMD (86.2%) and without TMD (12.2%), morning facial pain was common in cases of TMD (86.2%) but was less common in cases not having TMD (3.4%), among cases of TMD pain in ear or about the ear was the most common item (89.7%) [Table 3]. The most common habit was nail biting (88.3%), clenching (68.4%), mouth breathing (53.4%), thumb/digit sucking (21.4%), lip biting (19.4%), and tongue thrusting (1.3%), respectively [Table 4]. In the present study, we used a clinical examination of TMJ as per WHO (1997). [Table 5] depicts TMJ examination as per the WHO (1997) evaluation. Among all participants, majority of children did not have any sign or symptoms. There were 22.6% symptomatic children. The most common sign was clicking 22.4%, followed by tenderness 2.5% and reduced jaw mobility 2.2%, respectively.
|Table 3: Association between Fonseca Anamnestic Questionnaire and temporomandibular disorders according to Fonseca criteria|
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|Table 4: Association between parafunctional habits and temporomandibular disorders among children|
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|Table 5: Temporomandibular joint examination as per World Health Organization (1997) evaluation|
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A univariate and multivariate logistic regression analysis was depicted in [Table 6] for the presence of TMD by different variables conducted to predict the occurrence of TMD among adolescents using age, gender, thumb/digit sucking, mouth breathing, nail biting, lip biting, and clenching as predictors. Tongue thrusting was not included in the model as there was only one case found among the study population. The Wald criterion demonstrated that thumb sucking, mouth breathing, nail biting, and clenching has made a significant contribution to prediction (P< 0.001). Age, gender, and lip-biting were not appeared as significant predictors.
|Table 6: Logistic regression analysis for presence of temporomandibular disorders with different variables|
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| Discussion|| |
This survey identified the prevalence of TMD was 22.4% among 15–17-year-old school children of Lucknow. A similar observation was reported by Feteih  also revealed TMD prevalence of 21.3% in 385 adolescents aged between 12 and 16 years. Some studies , have shown a higher prevalence than in the present study, such as Gazit et al. which evaluated 369 Israeli students in the age group of 10–18 years (56.4%).
Study done by Motta et al., and Thilander et al., showed the prevalence was 20% and 25% among adolescents, Morinushi et al., showed the prevalence was 31% among aged between 12 and 14 years and 39.6% among 15–17 years and Magnusson et al., assessed through Helmiko index concluded that 34% adolescents showed mild symptoms of TMD.,,, The diversity of TMD prevalence among different studies have been attributed to the differences in the age group studied, the sample size and its composition, the numbers of examiners as well as diagnostic criteria used between different studies.
In the present study regarding severity, most students exhibited mild TMD (19.2%) as there is repitition, (2.2%) had moderate TMD and (0%) had severe TMD. Almost similar findings were also reported in a longitudinal study done by Magnusson et al., which evaluated 119 children at intervals of 4 years and found that in most cases, the signs were mild; however, moderate TMD was noted in 11% of the 11-year-old children and 17% of the 15-year-old children.
For all the items of FAQ, the most common symptom observed was frequent headaches (28%), followed by morning facial pain (21.1%), pain in ear or about the ear (20.4%), respectively. Clenching or grinding teeth (15.7%) and using only one side of mouth while chewing (11.5%) were the other less commonly reported symptoms.
In the present study, we used a clinical examination of TMJ as per WHO (1997). Among all participants majority of children did not have any sign or symptoms. There were 22.6% symptomatic children. The most common sign was clicking 22.4%, followed by tenderness 2.5% and reduced jaw mobility 2.2%, respectively.
The most common parafunction reported was nail biting (23.3%), clenching/grinding (15.0%), mouth breathing (14.5%), thumb/digit sucking (5.7%), lip biting (4.7%), and tongue thrusting (1.3%). These data are similar to the study done by Motta et al. in 244 adolescents in the age group of 10–20 years from the city of Sao Roque, Brazil.
This survey highlighted no statistically significant association was found between age (P = 0.81), gender (P = 0.09) and signs and symptoms of TMD. which was in accordance with the study done by Motta et al. they also found that signs and symptoms of TMD were not associated with age and gender.
A statistically significant association was found between parafunctional habits and TMD. The results were in accordance to study done by Winocur et al., Troeltzsch et al. and Motghare et al. These parafunctional habits should be considered as risk factor for TMD as they act as triggering point for the appearance of TMD due to its effect on the stomatognathic system.
The present study was a cross-sectional survey. Since TMD is a fluctuating disorder, hence further longitudinal study relating stress and occlusal interferences are needed for better associations. The questionnaire employed here can be useful to determining the complex diagnosis of TMD to send affected adolescents for further clinical diagnosis and preventive treatment.
| Conclusion|| |
The results of this study revealed that there was an association between signs and symptoms of TMD and parafunction habits. These data highlighted the need to carry out screening to send affected adolescents for further treatment. This can help to prevent problems that predispose individuals to TMJ pain as this could manage orofacial pain in a large contingent of people.
All the participants' and their parents' and school authorities and faculty mem'bers of our department.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Motta LJ, Guedes CC, De Santis TO, Fernandes KP, Mesquita-Ferrari RA, Bussadori SK. Association between parafunctional habits and signs and symptoms of temporomandibular dysfunction among adolescents. Oral Health Prev Dent 2013;11:3-7.
Bonjardim LR, Lopes-Filho RJ, Amado G, Albuquerque RL Jr., Goncalves SR. Association between symptoms of temporomandibular disorders and gender, morphological occlusion, and psychological factors in a group of university students. Indian J Dent Res 2009;20:190-4.
Pereira LJ, Pereira-Cenci T, Del Bel Cury AA, Pereira SM, Pereira AC, Ambosano GM, et al.
Risk indicators of temporomandibular disorder incidences in early adolescence. Pediatr Dent 2010;32:324-8.
Nomura K, Vitti M, Oliveira AS, Chaves TC, Semprini M, Siéssere S, et al.
Use of the Fonseca's questionnaire to assess the prevalence and severity of temporomandibular disorders in Brazilian dental undergraduates. Braz Dent J 2007;18:163-7.
World Health Organization. Oral Health Surveys – Basic Methods. 4th
ed. Geneva: World Health Organization; 1999.
American Dental Association. Official Policies of the American Dental Association on Dental Health Programmes. Chicago: American Dental Association; 1957.
Feteih RM. Signs and symptoms of temporomandibular disorders and oral parafunctions in urban Saudi Arabian adolescents: A research report. Head Face Med 2006;2:25.
Minghelli B, Cardoso I, Porfírio M, Gonçalves R, Cascalheiro S, Barreto V, et al.
Prevalence of temporomandibular disorder in children and adolescents from public schools in southern portugal. N
Am J Med Sci 2014;6:126-32.
Nilner M. Functional disturbances and diseases of the stomatognathic system. A cross-sectional study. J Pedod 1986;10:211-38.
Gazit E, Lieberman M, Eini R, Hirsch N, Serfaty V, Fuchs C, et al.
Prevalence of mandibular dysfunction in 10-18 year old Israeli schoolchildren. J Oral Rehabil 1984;11:307-17.
Thilander B, Rubio G, Pena L, de Mayorga C. Prevalence of temporomandibular dysfunction and its association with malocclusion in children and adolescents: An epidemiologic study related to specified stages of dental development. Angle Orthod 2002;72:146-54.
Morinushi T, Ohno H, Ohno K, Oku T, Ogura T. Two year longitudinal study of the fluctuation of clinical signs of TMJ dysfunction in Japanese adolescents. J Clin Pediatr Dent 1991;15:232-40.
Magnusson T, Egermark I, Carlsson GE. A longitudinal epidemiologic study of signs and symptoms of temporomandibular disorders from 15 to 35 years of age. J Orofac Pain 2000;14:310-9.
Winocur E, Gavish A, Finkelshtein T, Halachmi M, Gazit E. Oral habits among adolescent girls and their association with symptoms of temporomandibular disorders. J Oral Rehabil 2001;28:624-9.
Troeltzsch M, Troeltzsch M, Cronin RJ, Brodine AH, Frankenberger R, Messlinger K. Prevalence and association of headaches, temporomandibular joint disorders, and occlusal interferences. J Prosthet Dent 2011;105:410-7.
Motghare V, Kumar J, Kamate S, Kushwaha S, Anand R, Gupta N, et al.
Association between harmful oral habits and sign and symptoms of temporomandibular joint disorders among adolescents. J Clin Diagn Res 2015;9:ZC45-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]