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ORIGINAL ARTICLE Association Between Parafunctional Habits and Signs and Symptoms of Temporomandibular Dysfunction Amon...

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ORIGINAL ARTICLE

Association Between Parafunctional Habits and Signs and Symptoms of Temporomandibular Dysfunction Among Adolescents Lara Jansiski Mottaa/Carolina Cardoso Guedesb/Tatiana Oliveira De Santisc/ Kristianne Porta Santos Fernandesd/Raquel Agnelli Mesquita-Ferrarid/ Sandra Kalil Bussadorid Purpose: To determine associations between signs and symptoms of temporomandibular disorder (TMD) and harmful oral habits. Materials and Methods: Two hundred forty-four adolescents from a public school in the city of São Roque, Brazil, were evaluated. A screening questionnaire for orofacial pain and TMD recommended by the American Academy of Orofacial Pain was used to determine signs and symptoms of TMD. Patient histories and clinical exams were used to determine harmful oral habits. Results: Eighty-three participants (34%) displayed no signs or symptoms of TMD, 161 (66%) responded affirmatively to at least one item on the questionnaire and 49 (20.1%) gave at least three affirmative responses. Headache was the most frequently reported sign or symptom of TMD (40.6%; n = 99). There was no statistically significant association between gender and signs or symptoms of TMD (P = 0.281). Twenty-five percent (n = 61) of the patients had no harmful oral habits, while 16.4% (n = 40) had only one habit, the most common of which was nail biting. A total of 20.1% (n = 49) reported two harmful oral habits and 38.5% (n = 94) reported three or more such habits. There was a statistically significant association between signs and symptoms of TMD and three or more habits. Conclusion: A statistically significant association was found between signs and/or symptoms of TMD and harmful oral habits in adolescents. Key words: adolescent health, habits, temporomandibular joint Oral Health Prev Dent 2013; 11: 3-7

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emporomandibular disorder (TMD) is defined as a set of painful and/or dysfunctional conditions involving the muscles of mastication and/or the temporomandibular joint (TMJ) (Pedroni et al, 2003). The characteristic symptoms of TMD are muscle and/or joint pain upon palpation, impaired mandibular function and joint noises. a

Professor, Department of Paediatric Dentistry, Nove de Julho University, Sao Paulo, Brazil.

b

Professor, Department of Paediatric Dentistry, Braz Cubas University, Sao Paulo, Brazil.

c

Dentist in Private Practice, Sao Paulo, Brazil.

d

Professor, Department of Rehabilitation Sciences, Nove de Julho University, Sao Paulo, Brazil.

Correspondence: Lara Jansiski Motta, Department of Paediatric Dentistry, Nove de Julho University, Sao Paulo, Brazil. Tel: +55-113665-9000, Fax: +55-11-3868-4130. Email: [email protected]

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Submitted for publication: 23.02.12; accepted for publication: 16.05.12

The term temporomandibular disorder (TMD) refers to a group of orofacial conditions that affect the physiology of the TMJ and/or muscles of mastication and adjacent tissues. According to Phillips et al (2001), TMD is a heterogeneous group of psychophysiological disorders commonly characterised by orofacial pain, chewing dysfunction or both. Epidemiological studies, such as those carried out by Egermark et al (2001) and Thilander et al (2002), have shown that signs and symptoms of TMD can be found in all age groups. However, the prevalence among children is considered low and increases with age in adolescents and young adults. As TMJ remodelling occurs in adolescence, there is a direct need for the accurate assessment of dental conditions, the joint itself and the neuromus-

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cular apparatus in this period (Pereira et al, 2010). Thilander et al (2002) analysed 4724 children from 5 to 17 years of age in groups based on chronological age and dental development. The problems recorded included functional occlusion, dental wear, mandibular mobility and pain upon palpitation of the muscles and TMJ. The results demonstrate that one or more clinical signs were recorded in 25% of the individuals and that the prevalence increased throughout the stages of dental development. Headache was the most frequently reported symptom. It is possible that TMD first appears in the initial phases of craniofacial growth. A high percentage of adolescents have non-nutritional oral habits associated with TMD (Emodi-Perlman et al, 2012). Patients need to be informed about the negative effects of harmful oral habits. The early diagnosis of signs and symptoms of TMD can help improve the course of treatment and the quality of life of adolescents. Thus, the aim of the present study was to test the hypothesis that that presence of parafunctional habits influences the manifestation of signs and symptoms of TMD and to describe the association between harmful oral habits and signs and symptoms of TMD in adolescence.

MATERIALS AND METHODS A descriptive, cross-sectional study was conducted in compliance with the Brazilian National Health Council guidelines contained in Resolution 196/96 and with the authorisation of the administration of the school at which the study was finally carried out. Parents/guardians of the children were properly informed regarding the methodology and signed a statement of informed consent. The study received approval from the Human Research Ethics Committee of the Universidade Nove de Julho (Brazil) under process number 013/2008. Initially, all students regularly enrolled in an elementary/high school in the city of São Roque, state of São Paulo, Brazil, were asked to participate in the study. Students who refused to participate, those whose parents/guardians did not sign the statement of informed consent and those undergoing orthodontic treatment were excluded from the study. Two hundred forty-four adolescents (10 to 20 years of age) from a high school in the municipal school system of the city of São Roque, Brazil, were evaluated for the determination of signs and symp-

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toms of TMD and parafunctional habits. A self-explanatory screening questionnaire recommended by the American Academy of Orofacial Pain (AAOP) was filled out by all participants. The questionnaire is composed of ten direct questions on the most common signs and symptoms of orofacial pain and TMD and uses straightforward yes/no answers. According to the AAOP, three or more ‘yes’ answers indicate TMD. Patient histories and detailed clinical exams were used to determine parafunctional habits. The frequency of signs and symptoms was analysed and the data were organised according to age and gender. The SPSS 12.0 programme was used for statistical analysis and the data were submitted to Pearson’s chi-square test.

RESULTS One hundred thirteen (46.3%) of the 244 adolescents evaluated were male and 131 (53.7%) were female. The mean age was 13.01 (standard deviation = 2.12). Eighty-three of the participants (34%) reported no signs or symptoms of TMD. One hundred sixty-one (66%) gave at least one ‘yes’ answer on the AAOP questionnaire. A total of 49 (20.1%) exhibited three or more associated habits. Headache was the most frequently reported sign or symptom of TMD (40.6%; n = 99). Noises in the TMJ constituted the second most frequently reported sign or symptom of TMD (24.6%; n = 60). A total of 13.5% (n = 33) reported difficulties speaking, chewing or using the jaws. Facial fatigue was reported by 9.8% (n = 24) and 9% (n = 22) stated that their ‘jaw locked’ at times. Facial pain was reported by 7.8% (n = 19) and 2.5% (n = 6) reported difficulty or pain upon opening the mouth. There was no statistically significant association (P = 0.281) between signs and symptoms of TMD and gender. Although there was a higher frequency of signs and symptoms among individuals aged 12 and 13 years, age was not significantly associated with signs and symptoms of TMD (P = 0.609). Participants gave yes/no answers to the following list of harmful oral habits: nail biting, clenching the teeth, grinding the teeth, lip or object biting and chewing gum. Twenty-five percent (n = 61) of the participants reported having none of the habits listed on the questionnaire; 16.4% (n = 40) reported only one of the habits; 20.1% (n = 49) reported two associated harmful oral habits and 38.5% (n = 94) reported three or more such habits (Table 1).

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Table 1 Frequency and percentage of harmful habits according to gender Gender Male N (%)

Female N (%)

Total

No

53 (41.4%)

75 (58.6%)

128 (100%)

Yes

60 (51.7%)

56 (48.3%)

116 (100%)

No

87 (45.8%)

103 (54.2%)

190 (100%)

Yes

26 (48.1%)

28 (51.9%)

54 (100%)

No

94 (45.2%)

114 (54.8%)

208 (100%)

Yes

19 (52.8%)

17 (47.2%)

36 (100%)

No

66 (45.2%)

80 (54.8%)

146 (100%)

Yes

47 (48.0%)

51 (52.0%)

98 (100%)

No

40 (50.0%)

40 (50.0%)

80 (100%)

Yes

73 (44.5%)

91 (55.5%)

164 (100%)

Harmful habit Nail biting

P-value 0.069

Clenching teeth

0.439

Grinding teeth

0.254

Biting lip/objects

0.385

Chewing gum

0.251

Table 2 Frequency and percentage of harmful habits according to the presence of signs and symptoms of TMD Signs and symptoms up to 2 N (%)

3 or more N (%)

Total

No

109 (85.2%)

19 (14.8%)

128 (100%)

Yes

30 (25.9%)

86 (74.1%)

116 (100%)

No

163(85.8%)

27 (14.2%)

190 (100%)

Yes

22 (40.7)

32 (59.3%)

54 (100%)

No

171 (82.2%)

37(17.8%)

208 (100%)

Yes

12 (33.3%)

24 (66.7%)

36 (100%)

No

124 (84.9%)

22 (15.1%)

146 (100%)

Yes

27 (27.6%)

71 (72.4%)

98 (100%)

No

65 (81.3%)

15 (18.8%)

80 (100%)

Yes

130 (79.9%)

34 (20.7%)

164 (100%)

Harmful habit Nail biting

P-value 0.023*

Clenching teeth

< 0.001*

Grinding teeth

0.031*

Biting lip/objects

0.014*

Chewing gum

0.428

*Statistically significant, P < 0.05

A statistically significant association was found between having harmful oral habits and three or more signs and symptoms of TMD (Table 2). Moreover, there was a statistically significant association between patients with TMD and three or more signs/symptoms, such as headache, noises in the TMJ, chewing difficulties and facial fatigue (P < 0.0001) (Table 3).

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DISCUSSION The present study reports the screening of adolescents in a public school in the city of São Roque, Brazil, for signs and symptoms of TMD and associations with parafunctional habits. A questionnaire was distributed on a large scale in order to identify patients, organise the need for a more accurate di-

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Table 3 Frequency and percentage of TMD according to the presence of signs and symptoms

Without TMD N (%)

With TMD N (%)

Total

No

137 (94.5%)

8 (5.5%)

145 (100%)

Yes

58 (58.6%)

41 (41.4%)

99 (100%)

No

167 (90.8%)

17 (9.2%)

184 (100%)

Yes

28 (46.7%)

32 (53.3%)

60 (100%)

No

185 (87.7%)

26 (12.3%)

211 (100%)

Yes

10 (30.3%)

23 (69.7%)

33 (100%)

No

188 (85.5%)

32 (14.5%)

220 (100%)

Yes

7 (29.2%)

17 (70.8%)

24 (100%)

No

181 (81.5%)

41 (18.5%)

222 (100%)

Yes

14 (63.6%)

8 (36.4%)

22 (100%)

No

192 (85.3%)

33 (14.7%)

225 (100%)

Yes

3 (15.8%)

16 (84.2%)

19 (100%)

No

193 (81.1%)

45 1(8.9%)

238 (100%)

Yes

2 (33.3%)

4 (66.7%)

6 (100%)

Signs and symptoms Headache

< 0.001*

Joint noise

Difficulty or pain upon masticating Tired feeling in face

< 0.001*

< 0.001*

< 0.001*

‘Locked’ jaw

0.049*

Facial pain Difficulty or pain upon opening mouth

P-value

0.049*

0.016*

*Statistically significant, P < 0.05

agnosis of TMD and establish early care and treatment, thereby minimising the negative effects on the quality of life of affected patients. The questionnaire recommended by the AAOP was chosen for this study. Manfredi et al (2001) determined the sensitivity of this questionnaire compared to an accurate clinical exam. The results confirmed that the questionnaire is sensitive and correlates to pathologies, although it does not define severity, which needs to be determined by other means. TMD exhibits a classic triad of signs and symptoms. The first sign/symptom is pain (joint and/or muscle), followed by noises in the joints and finally, difficulties upon opening the mouth. The results of the present study followed this same pattern. Ninety-nine (40.6%) participants reported headaches, followed by noises in the joints (24.6%) and difficulties speaking, chewing or using the jaws (13.5%). Thilander et al (2002) recorded one or more clinical signs in 25% of individuals. This figure was even higher in the present study. Cross-sectional studies in a specific population reveal that 75% of individuals exhibit at least one

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sign of TMD (noises in the joints, muscle fatigue, etc.) and 33% exhibit at least one symptom (Okeson, 1996). The present study found that 66% of individuals exhibit at least one sign of TMD. In a previous study on TMJ disorder and pain syndrome where the Helkimo index was administered in questionnaire form to 200 individuals from 14 to 20 years of age, 34% exhibited mild symptoms (47% with noises in the TMJ and 46% with muscle pain), 20% reported joint pain, 6% reported difficulty upon opening the mouth and 5% reported ‘lockjaw’ (Nunes et al, 1987). The study cited was carried out by means of a census at a public school, the results of which corroborate those of the present investigation. Morinushi et al (1991) determined signs and symptoms of TMD among 160 students from 12 to 14 years of age and among 480 students from 15 to 17 years of age over a two-year period and found that 31% of the former group and 39.6% of the latter group exhibited one or more signs of TMD. These results underscore the importance of screening adolescents. The diagnosis and treatment of stomatognathic disorders are defined after a thorough integration

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has been carried out of all contributing factors found in the patient history, clinical exam and radiographs. The screening questionnaire employed herein can be very useful when determining the complex diagnosis of TMD. The responses provided by the self-explanatory questionnaire can identify adolescents that should be sent for clinical diagnosis and preventive treatment. Twenty percent of the adolescents who participated in the present study exhibited three or more signs/symptoms, which, according to the AAOP, indicates TMD (Okeson, 1996; Nunes et al 1997). These data highlight the need to carry out screening in order to send affected adolescents for treatment and facilitate the organisation of the demand for care. Such screening can help prevent problems that predispose individuals to craniofacial abnormalities, joint pain and muscle disorders. Further studies relating stress and occlusal interferences are needed for a better understanding of these associations.

CONCLUSION The results of the present study reveal a significant association between three or more harmful oral habits – such as nail biting, lip/object biting and grinding of the teeth – and signs and symptoms of TMD in adolescents.

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REFERENCES 1. Egermark-Eriksson I, Carlsson GE, Magnusson T. A 20-year longitudinal study of subjective symptoms of temporomandibular disorders from childhood to adulthood. Acta Odontol Scand 2001;59:40–48. 2. Emodi-Perlman A, Eli I, Friedman-Rubin P, Goldsmith C, Reiter S, Winocur E. Bruxism, oral parafunctions, anamnestic and clinical findings of temporomandibular disorders in children. J Oral Rehabil 2012;39:126–135. 3. Manfredi APS, Silva AA, Vendite LL. Avaliação da sensibilidade do quesrtionário de triagem para dor orofacial e desordens temporomandibulares recomendado pela Academia Americana de Dor Orofacial. Rev Bras Otorrinolaringol 2001;67:763–768. 4. Morinush 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;15:232–240. 5. Nunes R, Martins MC, Martins EA. Prevalência da Síndrome da Disfunção em jovens de 14 a 20 anos de idade. Utilização do Índice de Helkimo. Rev Facu Odontol Porto Alegre 1986–1987;28/29:10–13. 6. Okeson JP. Orofacial Pain. Guidelienes for assessment, diagnosis and management. Chicago: Quintessence, 1996:113–184. 7. Pedroni CR, Oliveira AS, Guaratini MI. Prevalence study of signs and symptoms of temporomandibular disorders in university students. J Oral Rehabil 2003;30:283–289. 8. Pereira LJ, Pereira-Cenci T, Del Bel Cury AA, Pereira SM, Pereira AC, Ambosano GM, Gavião MB. Risk indicators of temporomandibular disorder incidences in early adolescence. Pediatr Dent 2010;32:324–328. 9. Phillips JM, Gatchel RJ, Wesley AL, Ellis E. Clinical implications of sex in acute temporomandibular disorders. J Am Dent Assoc 2001;132:49–57. 10. 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;72:146–154.

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