|Year : 2019 | Volume
| Issue : 2 | Page : 94-99
Clinical evaluation of temporomandibular joint disorders among dental students at the University of science and technology, Sana'a, Yemen
Abdulwahab Al-Dailami1, Najwa Al-Badany1, Khaled Al-Jawfi1, Yahya Al Hadi2, Ali Al-Hudaid1, Anas Shamala1
1 Department of Biological and Preventive Sciences, College of Dentistry, University of Science and Technology, Sana'a, Yemen
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Sana'a University, Sana'a, Yemen
|Date of Submission||31-Oct-2019|
|Date of Acceptance||07-Jan-2020|
|Date of Web Publication||3-Feb-2020|
Dr. Anas Shamala
Department of Biological and Preventive Sciences, College of Dentistry, University of Science and Technology, Sana'a
Source of Support: None, Conflict of Interest: None
Aim and Objectives: The study was designed to evaluate the temporomandibular joint disorders among dental students at the University of Science and Technology (UST).
Subjects and Methods: The sample size included 267 dental students in UST aged between 18 and 27 years. The study was based on Fonseca's anamnestic index and its questionnaire, which was composed of 10 questions and an examination sheet composed of demographic data and clinical examination.
Results: Of 267 students, 178 of them were female (66.7%) and 89 of them were male (33.3%). 52.1% of the study participants were with no temporomandibular disorders (TMDs), 37.5% with mild TMDs, 9.7% with moderate TMDs, and 0.7% with severe TMDs. Regarding clinical examination findings, 81.7% of the study participants were with normal mouth opening and 18.3% were with limited mouth opening. The participants with or without tenderness during palpation were 13.1% and 86.9%, respectively. Positive participants with auscultation (clicking) were 45.3% and 54.7% were negative participants.
Conclusion: The mild TMDs were most common, then moderate TMDs were less common, and severe TMDs were rarely. The females were more affected. History of the past dental treatment and psychological stress was found in students having TMDs.
Keywords: Clinical evaluation; dental students; temporomandibular disorders; Yemen
|How to cite this article:|
Al-Dailami A, Al-Badany N, Al-Jawfi K, Hadi YA, Al-Hudaid A, Shamala A. Clinical evaluation of temporomandibular joint disorders among dental students at the University of science and technology, Sana'a, Yemen. Indian J Multidiscip Dent 2019;9:94-9
|How to cite this URL:|
Al-Dailami A, Al-Badany N, Al-Jawfi K, Hadi YA, Al-Hudaid A, Shamala A. Clinical evaluation of temporomandibular joint disorders among dental students at the University of science and technology, Sana'a, Yemen. Indian J Multidiscip Dent [serial online] 2019 [cited 2020 Sep 19];9:94-9. Available from: http://www.ijmdent.com/text.asp?2019/9/2/94/277454
| Introduction|| |
The temporomandibular joints (TMJ) is an articulation between the articulator fossa of the temporal bone and the condyle of the mandible. Most patients come to the dentist to complain of pain or dysfunction in TMJ. The muscular disorders are the most common cause. Temporomandibular disorders (TMDs) is a term that combines a subgroup of painful orofacial disorders, the patient complains of pain on the TMJ region and fatigue of the craniocervicofacial muscles, especially masticatory muscles, mandible movement limitation, and articular clicking.
The term of TMDs is involving many symptoms; also, it may be caused by multiple factors. That means it a multifactorial causes related to traumatic injury, immune-mediated systemic disease, neoplastic growths, emotional stress, occlusal interferences, malpositioning or loss of teeth, postural changes, dysfunctions of the masticatory musculature and adjacent structures, extrinsic and intrinsic changes on TMJ structure, nonfunctional movements of the mandible (bruxing), and tooth clenching habits and/or a combination of such factors. Mandibular fracture, prosthodontic treatment, orthogenetic surgery, and orthodontic treatment increasing the TMDs. The complexity of the etiology, with the presence of manifestation at a wide range of age and different diagnostic methods to give us good treatment, approaches to resolve TMDs all give the epidemiology of TMDs its important.
The signs and symptoms of the TMDs include pain (the most important one), limitation of mandibular movements, noise during jaw movement (clicking) difficulty in eating and speaking, muscle stiffness and headache. These symptoms can found in any age or gender. The importance of early diagnosis of the TMDs signs and symptoms is to help in preventing the severity of TMDs and to improve the quality of life. This study was selected to know the clinical evaluation of TMDs among undiagnosed dental students at the University of Science and Technology (UST), Sana'a, Yemen with using of Fonseca's questionnaire.
| Subjects and Methods|| |
This study was a cross-sectional study; the population was students from the first level to the fifth level in the College of Dentistry, UST, Sana'a, Yemen.
Inclusion and exclusion criteria
Inclusion criteria involved both genders of students with ages ranged from 18 to 27 years. Exclusion criteria as out of the age range, patients under treatment to TMDs or patient had previous treatment, patient with a history of TMJ trauma, patient with immunocompromised disease, and patient under orthodontic treatment.
Examination sheet and Fonseca's questionnaire
The examination sheet had questions about the age, gender, level of the study, some questions about qat chewing as (site, duration, frequency, and pain in TMJ after chewing), and other questions about medical and dental history.
Fonseca's questionnaire was composed of ten questions (Is it hard for you to open your mouth?-Is it hard for you to move your mandible from side to side? - Do you get tired/muscular pain while chewing?-Do you have frequent headaches?-Do you have pain or a stiff neck? - Do you have earaches or pain in the TMJ region?-Have you noticed any TMJ clicking while chewing or when you open your mouth?-Do you clench or grind your teeth?-Do you feel your teeth do not articulate well?-Do you consider yourself a tense (nervous) person?).
Study participants asked to reply to these questions with (Yes or Sometimes or No) and only one answer should be chosen for each question. For a detailed analysis of TMDs severity, the answers “Yes,” “No,” and “Sometimes” from each question were summed up and the total was multiplied by the value attributed to each type of answer has a value, where 0, 5, and 10 were for No, Sometimes, and Yes, respectively. Then, the participants classified by the total value (0–15 points) mean no TMDs, (20–40 points) means mild TMDs, (45–65 points) means moderate TMDs, and (70–100 values) means severe TMDs.
Limitation of the mouth opening
By the caliper (IME-type) to measure the mouth opening from the incisal edges of upper anterior teeth to the incisal edges of lower anterior teeth when the students asked to open his/her mouth slowly to the maximum. Then, recorded normal if it was 40 mm or up, limited if it was <40 mm.
Muscles examination (tenderness)
Masseter and temporalis muscles were examined by direct palpation, whereas the lateral pterygoid muscle was examined by indirect method (the examiner put his hand below the chin of student to restrict the mouth opening and asked the participant to open. That might lead to the pain in the preauricular area.
Auscultation of the sound (clicking)
It was done by using a stethoscope (Germany-Model-SM -101A-Pakistan), which put in front of the ear. Then, asked the participant to open and close his/her jaw. Then, recorded if there was sound or no.
The calculated minimum sample size was 267 students considered a population size of nearly 850 students. Confidence level 95%, power of 80%, the level of statistical significance was set at P < 0.05 and anticipated proportion 37% according to the study in Libyan dental students. Stratified sampling technique utilized then selected by sample random sampling from each stratum (male/female) for each level.
The pilot study
The pilot study was conducted to assess the intraexaminer agreement during the examination. Fifty cases were examined by the researcher twice; the second was 1 week later of the first examination. Kappa statistic was performed; the result was 0.98.
The approval was obtained from the ethical committee in the UST No.(EAC/UST128).
Data were coded, entered, and analyzed using the Statistical Package for the Social Sciences (SPSS) version 20 (Armonk, NY: IBM Corp).
| Results|| |
Responses of the study participants to the examination sheet are summarized in [Table 1], which shows that the calculated sample size was 267 students. One hundred and seventy-eight of students were female (66.7%) and 89 were male (33.3%). The selection was from each level of the study sample, 30% from the first level, 16.1%, 17.2%, 16.1%, and 20.6% were from the second, third, fourth, and fifth levels, respectively. Qat chewers were 77 students of the study sample (28.8%). However, 199 students were non-qat chewers (71.2%).
It was also found that 9.0% had a medical history and 91.0% had not any medical history; the diseases were 2.3% and 1.5% arthritis and diabetes, respectively. No students had hypertension and 5.2% had other systemic diseases. About 74.2% of the study sample had previous dental history; however, 25.8% without previous dental treatment. The dental treatments had done were 35.6%, 7.5%, 2.6%, 19.9%, and 8.6% with filling, extraction, prosthesis, more than one treatment and other treatments as scaling, polishing, and whitening, respectively.
Responses of the study participants to Fonseca's Questionnaire are summarized in [Table 2], which shows that the high percentage among Yes was with question no. 10 (Do you consider yourself a tense “nervous” person?) and the least percentage with a question no. 1 (Is it hard for you to open your mouth?). Among the answer by sometimes, the most frequently reported problem of TMDs was frequently headaches and the least reported problem was hard to move the mandible from side to side.
Furthermore, table shows that 0.4% of the participants had limited mouth opening all the time when 13.1% of the participants had limited mouth opening sometimes, but 86.5% of the participants had not this problem. In the movement of the mandible from side to side, 4.9% of the participants sometimes had difficulty to move their mandible, and 2.2% of the participants all the time had difficulty to move their mandible from side to side. About muscular pain, nearly 18.7% of students sometimes had tenderness in the muscles of the mastication, with 3.4% of students had tenderness in the muscles of the mastication all the time. Nearly 45.3% of the sample had frequent headaches; sometimes, 11.6% of the sample all the time had frequent headaches. The participants with stiff neck were (13.5%) felt stiff neck sometimes and (5.2%) of the participants felt by stiffness all the time.
The pain of TMJ region was among 21.8% of the participants in all or sometimes. TMJ clicking found sometimes among 31.8% of the students and found all the time among 14.2% of the students. Grinding and clenching of teeth found among 19.1% of the participant sometimes. Nearly 11.6% of the students sometimes felt that their teeth did not articulate well, 23.2% of the students considered they were nervous all the time and 41.9% of the students considered themselves as nervous sometimes.
The association of gender, level of study and qat chewing with TMDs are summarized in [Table 3], which shows that there was a significant association with P = 0.036 between the gender and TMD severity. On the other hand, there was no significant association between the level of the study and qat chewing with TMDs which were (0.471) and (0.286), respectively.
|Table 3: Association of gender, level of study, and qat chewing with temporomandibular disorders severity|
Click here to view
The clinical examination findings of the study participants are summarized in [Table 4], which shows that 81.7% of the study participants were with normal mouth opening and 18.3% were with limited mouth opening. The participants with tenderness during palpation were 35 students (13.1%) and without tenderness were 232 students (86.9%). Positive participants with auscultation (clicking) were 45.3% and 54.7% were negative participants (no clicking).
| Discussion|| |
This study was a cross-sectional study on a group of dental students at UST in Sana'a city to give preliminary data on the clinical evaluation of TMDs by using anamnestic questionnaires of Fonesca and clinical examination among 267 university dental students (males and females). It got a large quantity of information in a relatively short period and at a low cost, and it was easy to understand.
About the medical history and their effects on TMDs, it found that the majority of the participants were healthy. Only 2.3% of the participants had arthritis, which considered as degenerative joint diseases that may lead to defects in the shape of the tissues of the joint, limitation of function (e.g., restricted mandibular movements), and joint pain.
The dental history was very common among the participants in this study; most of them had a dental filling 35.6%, then extraction 7.5%, a prosthesis 2.6%, and other dental treatments such as scaling, polishing, and whitening. Their effects on TMJ may be due to the prolong mouth opening during the treatment or by unadjusted prosthesis, which leads to micro-trauma to TMJ.
As responses of the study participants to Fonseca's questionnaire, it found that nearly half of the participants had a frequent headache and considered themselves tense (nervous) person. The muscle activity considered as a possible explanation for the association between TMDs and headache may be due to muscle activity, and hence, any activity involving the head and neck may be important in the etiology of many headaches. Also, 13.1% of the study participants showed hard to open their mouth, 4.9% of them had got hard to move their mandible from side to side, 18.7% of them had muscular pain while chewing, 46.1% of them had sound in the TMJ during open and closed the mouth as well as during chewing. This may be due to disc displacement. Furthermore, the response of the articulation of the teeth was approximately 27.4% of the study participants felt their teeth did not articulate well, the abnormality of the occlusion is often blamed for TMDs, but there was no evidence that these factors are involved.
Limited mouth opening and a feeling that the teeth are not articulated properly, these manifestations may appear due to tension, stress, and anxiety, which cause grinding of teeth and persistent muscular contraction in the face. This produces pain which causes further anxiety which sequentially causes prolonged muscular spasm at trigger points, vasoconstriction, ischemia, and release of pain mediators. The pain discourages the use of the masticatory system. This result is similar to the result of another study. However, clinical examination with auscultation (clicking) showed that 45.3% of the study participants had a positive result and this symptom was the most common with TMDs.
In the present study, it found that the females were more affected by TMDs than males. This finding is in agreement with the previous studies.,,, This result may be due to hormonal variations between the genders, especially estrogen hormone which may play a role in modulating joint inflammation, nociceptive neurons in the trigeminal nerve, muscle reflexes to pain. On the other hand, this finding in disagreement with another study in Brazil which showed no difference between genders. This may be due to the age group because their sample was among elderly persons.
As a result of this study, it found that 52.1% of the study participants were without TMDs, 37.5% of them were with mild TMDs, 9.7% of them were with moderate TMDs, and 0.7% of them were with severe TMDs. Similar results were found with previous studies.,,,
The association between TMDs with gender showed that significant association (0.036%). This finding is in agreement with previous studies.,, On the other hand, no significant association between TMDs with qat chewing; this result is in agreement with another study and in disagreement with another study, which showed that a positive correlation between the intensity of the symptoms of TMDs with the frequency and duration of qat chewing. This deference may be due to that TMD is a chronic disease that needs time to progress, while the participants of this study were (18–27) years of old, the percentage of the non-qat chewers in this study was (71.2%), and some students in this study were non-Yemenis.
| Conclusion|| |
It may be concluded that mild TMDs were the most common, then moderate TMDs were less common and severe TMDs were rarely. The females were more affected by TMDs than males. History of the past dental treatment and psychological stress was found in students having mild, moderate, and severe TMDs. The use of the Anamnestic Index was helpful, and this information can be of great importance for the early diagnosis of the dysfunction, preventing future complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ocak M, Sargon MF, Orhan K, Bilecenoǧlu B, Geneci F, Uzuner MB. Evaluation of the anatomical measurements of the temporomandibular joint by cone-beam computed tomography. Folia Morphol (Warsz) 2019;78:174-81.
Hupp JR, Ellis E, Tucker MR, editors. Contemporary Oral and Maxillofacial Surgery. 4th
ed. St. Louis, Mo: Elsevier; 2014. p. 672.
de Santis TO, Motta LJ, Biasotto-Gonzalez DA, Mesquita-Ferrari RA, Fernandes KP, de Godoy CH, et al
. Accuracy study of the main screening tools for temporomandibular disorder in children and adolescents. J Bodyw Mov Ther 2014;18:87-91.
Scully C. Oral and Maxillofacial Medicine: The Basis of Diagnosis and Treatment. 2nd
ed. Printed in China in permission of Philadelphia: Churchill Livingstone Elsevier; 2008. p. 816.
Goldstein BH. Temporomandibular disorders: A review of current understanding. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:379-85.
Boever J, Steenks M. Epidemiology, Symptomatology and Etiology of the Craniomandibular Dysfunction. Craniomandibular Dysfunction of the Point of View of the Physiotherapy and of the Dentistry-diagnosis and Treatment. São Paulo: Santos; 1996. p. 35-43.
Mujakperuo HR, Watson M, Morrison R, Macfarlane TV. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Syst Rev 2010; CD004715.
Nassif NJ, Hilsen KL. Screening for temporomandibular disorders: History and clinical examination. American Dental Association. J Prosthodont 1992;1:42-6.
Fonseca DM, Bonfante G, Valle AL, Freitas SF. Diagnóstico pela anamnese da disfunção craniomandibular. Rev Gauch Odontol 1994;42:23-8.
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.
Coulthard P, Horner K, Sloan P, Theaker ED. Master Dentistry E-book: Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine. 3rd
ed., Vol. 1. Printed in China in permission of Philadelphia: Elsevier Health Sciences; 2013.
Bugaighis IS, Elgehani R, Orafi M, Elatrash A. The prevalence of temporomandibular disorders among a group of Libyan dental students. Libyan Int Med Univ J 2017;2:64-73. [Full text]
Cairns BE. Pathophysiology of TMD pain – Basic mechanisms and their implications for pharmacotherapy. J Oral Rehabil 2010;37:391-410.
Majumder K, Sharma S, Dayashankara Rao J, Siwach V, Arya V, Gulia S. Prevalence and sex distribution of temporomandibular disorder and their association with anxiety and depression in Indian medical university students. Int J Clin Med 2015;6:570.
Cawson RA, Odell E. Cawsons Essentials of Oral Pathology and Oral Medicine. 7th
ed. Edinburgh: Churchill Livingstone; 2002.
Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J. Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database Syst Rev 2011; CD008456.
Chisnoiu A, Lascu L, Pascu L, Georgiu C, Chisnoiu R. Emotional stress evaluation in patients with temporomandibular joint disorder. Hum Vet Med 2015;7:104-7.
Zwiri AM, Al-Omiri MK. Prevalence of temporomandibular joint disorder among North Saudi University students. Cranio 2016;34:176-81.
Al-sanabani J, Al-Moraissi E, Almaweri A. Prevalence of temporomandibular joint disorders among Yemeni university students: A prospective, cross-sectional study. Int J Oral Craniofac Sci 2017;3:052-9.
Karthik R, Hafila MI, Saravanan C, Vivek N, Priyadarsini P, Ashwath B. Assessing prevalence of temporomandibular disorders among university students: A questionnaire study. J Int Soc Prev Community Dent 2017;7:S24-9.
Pinto RG, Leite WM, Sampaio LD, Sanchez MD. Association between temporomandibular signs and symptoms and depression in undergraduate students: Descriptive study. Rev Dor 2017;18:217-24.
Dallanora AF, Grasel CE, Heine CP, Demarco FF, Pereira-Cenci T, Presta AA, et al
. Prevalence of temporomandibular disorders in a population of complete denture wearers. Gerodontology 2012;29:e865-9.
Modi P, Shaikh SS, Munde A. A cross sectional study of prevalence of temporomandibular disorders in university students. Int J Sci Res Publ 2012;2:1-3.
Al Moaleem MM, Okshah AS, Al-Shahrani AA, Alshadidi AA, Shaabi FI, Mobark AH, et al
. Prevalence and severity of temporomandibular disorders among undergraduate medical students in association with Khat Chewing. J Contemp Dent Pract 2017;18:23-8.
Al-Maweri SA, Warnakulasuriya S, Samran A. Khat (Catha edulis
) and its oral health effects: An updated review. J Investig Clin Dent 2018;9:1-9.
[Table 1], [Table 2], [Table 3], [Table 4]