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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 1-5

Prevalence of temporomandibular dysfunction in edentulous patients of Saudi Arabia


Department of Prosthodontics, College of Dentistry, AlJouf University, Skaka, AlJouf, Kingdom of Saudi Arabia

Date of Web Publication28-Feb-2017

Correspondence Address:
Bader K AlZarea
College of Dentistry, AlJouf University, Skaka, AlJouf
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_25_16

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  Abstract 

Aim: This study aimed to determine the prevalence of various temporomandibular joint dysfunction (TMD) signs in healthy asymptomatic edentulous individuals and denture wearers. Materials and Methods: Four hundred completely edentulous individuals in the age group of 45–75 years, who did not complain of any TMD and were denture bearers with varied denture-wearing span, were examined for the existence of TMD signs and symptoms. Statistical analyses were carried out with Chi-square test. Statistical significance was set at P < 0.05. Results: The total prevalence of TMD in the group was 60.5% (58.75% in males and 63.12% in females). It has been observed that more number of females (63.21%) reported signs of TMD and majority of them (23.25%) reported with two signs of TMD. The most common finding was limitation on mouth opening and the least common finding was joint sounds (crepitus and clicking). The occurrence of findings was not statistically related to edentulous span. Conclusion: The present study showed a high prevalence of signs of TMD in healthy asymptomatic completely edentulous individuals. However, the gender difference was not statistically significant.

Keywords: Complete dentures, edentulism, temporomandibular disorders


How to cite this article:
AlZarea BK. Prevalence of temporomandibular dysfunction in edentulous patients of Saudi Arabia. J Int Oral Health 2017;9:1-5

How to cite this URL:
AlZarea BK. Prevalence of temporomandibular dysfunction in edentulous patients of Saudi Arabia. J Int Oral Health [serial online] 2017 [cited 2019 May 20];9:1-5. Available from: http://www.jioh.org/text.asp?2017/9/1/1/201091


  Introduction Top


The phrase “temporomandibular disorders” grasps various clinical issues that include the muscles of mastication, the temporomandibular joint and related structures, or both. These are otherwise called temporomandibular pain dysfunction disorders.[1] Etiology of temporomandibular joint dysfunction (TMD) is multifactorial and may involve changes in occlusion (malocclusion in dentate and posterior occlusal wear producing incisal interference in complete denture [CD] wearers), faulty prosthesis (reduced vertical dimension), traumatic insult to TMJ, psychological components, and parafunctional habits such as bruxism.[1],[2],[3] Some predisposing factors which have been highlighted in recent studies are female gender and being edentulous for a long span of time without denture.[1],[4],[5] It has additionally been demonstrated that TMD changes over time, and no reasonable denouement has been arrived yet about its natural progression or about the factors contributing to the evolution of TMD. In addition, the quantity of individuals who see subjective manifestations or signs of TMD is more than the quantity of individuals looking for treatment, and females will probably look for treatment than male partners.[6],[7]

It is concurred that edentulous individuals do not present with TMDs to the extent of those having natural dentition because of the lack of proprioceptive feedback from dentition to trigger the symptom complex of TMD.[1],[3] There are some controversial issues such as overclosure of the jaws in persons with natural dentition which can predispose to TMD whereas long-standing edentulous span individuals without dentures rarely develop TMDs despite overclosure. However, it is observed that edentulous individuals who do not gripe about TMD on an arbitrary examination may hint at least one or more signs of TMD, which may later form into a conspicuous joint dysfunction.[3] Some signs of TMDs are facial pain, headache, pain over the joint, pain which aggravates while opening the mouth, muscle tenderness of musculature, pain which is to the angle of lower jaw and cervical muscles, restricted mouth opening, deviation of jaw while opening the mouth, crepitus, and clicking sounds in joint region. These signs may appear in various combinations and degrees.[3],[4]

The role of occlusion to produce muscle spasm which may result in the above-mentioned signs does not apply to CD patients since malocclusion in dentures (e.g., centric prematurities) cannot trigger any proprioceptive response. Or maybe, quick after effect of centric prematurity is displacement of the denture which acts as a buffer to secure the TMJ.[3] Another hypothesis that has been very much investigated and acknowledged is the expansion in vertical measurement of dentures which brings about brunt of the muscles in light of overextension of the jaw-closing muscles with passionate pressure, additionally assuming a part and thus prompting to TMD in edentulous individuals.[3] The restoration of physiological freeway space in remission of muscular pain in CD wearers has been discussed and proved by Monteith.[8] The present cross-sectional study was carried out to assess the prevalence of possible presence of TMD in healthy asymptomatic completely edentulous patients who were denture wearers for varied span of time. Aims and objectives of this study were:

  • To determine the prevalence of TMD signs in individuals who were healthy asymptomatic completely edentulous and denture wearers
  • To determine which sign was most frequently seen among individuals and prevalence according to gender
  • To accomplish the relationship of TMD signs with edentulous span.



  Materials and Methods Top


Four hundred completely edentulous individuals attending College of Dentistry, AlJouf University, Skaka, AlJouf, Kingdom of Saudi Arabia, with no complaint of any TMD and were denture bearers with varied denture-wearing span were included in this study. The study was carried out from August 2014 to July 2016 after obtaining prior informed consent and ethical clearance. Patients with single CD with opposing natural teeth or partially edentulous arches and individuals who had been already diagnosed and treated as symptomatic TMD patients were not incorporated in this study [Flowchart 1]. These 400 individuals were divided into six age groups, i.e., 45–50, 51–55, 56–60, 61–65, 66–70, and 71–75 years of age. Tenderness, clicking, crepitus of the TMJ, musculatures, the maximum mouth opening, and pathway of mandibular opening were determined as described by Al-Jabrah and Al-Shumailan.[9] The examiner underwent adequate training and calibration exercise before collecting data to aid in proper diagnosis, thus to avoid selection bias. Weekly training session over a 4-month period was undertaken by the examiner. The training comprised oral presentation, discussion, and clinical evaluation of patients under the supervision and guidance of experienced staff of oral diagnosis. The results obtained were analyzed using Statistical Package for Social Sciences. Software (SPSS version 20.0, SPSS IBM, New York, NY). Statistical analyses were performed using Chi-square test. Statistical significance was set at P < 0.05.




  Results Top


Out of the total 400 patients, majority, i.e., 32%, were in 51–55 years' age group and a minimum of 3.25% of patients belonged to 71–75 years' age group [Table 1]. [Table 2] represents the distribution of male and female patients by age groups. Of the total 400 patients, 240 patients were males and 160 were females. Further, out of the 240 male patients, majority, i.e., 35%, were in 51–55 years' age group and a minimum of 3.75% of patients belonged to 71–75 years' age group. Similarly, in 160 female patients, majority, i.e. 35% of patients belonged to 45–50 years' age group and a minimum of 2.5% of patients belonged to 71–75 years' age group. The association or difference between gender and age group was statistically nonsignificant (χ2 = 5.0198, P = 0.2853) at 5% level of significance. [Table 3] represents the distribution of male and female patients by presence or absence of signs. The total prevalence of TMD in the whole group was 60.5%. Nearly 58.75% of males had signs as compared to 63.12% of females. The difference was not found to be statistically significant (χ2 = 0.7693, P = 0.3813) at 5% level of significance. Almost 28.5% of patients had 1–3 years of edentulous span followed by 21.75% of patients who had 3–5 years of edentulous span and 10.25% had >5 years of edentulous span [Table 4]. The maximum of 24.58% of males and 21.25% of female patients had two signs and a minimum of 2.08% of males and 1.25% of females had three signs. The difference between male and female patients was statistically nonsignificant (χ2 = 2.3102, P = 0.5113) at 5% level of significance [Table 5]. A maximum of 18.33% of males and 20% of females had limitation on mouth opening followed by other signs and a minimum of 1.25% of males had crepitus and 0.63% of females had clicking. No significant association was observed between signs and gender (χ2 = 0.7642, P = 0.9798) at 5% level of significance [Table 6]. The most common sign observed in all the three edentulous spans (i.e., 1–3 years, 3–5 years, and more than 5 years) was limitation on mouth opening. The least common sign in 1–3 years, 3–5 years, and more than 5 years of edentulous span was crepitus. The association between types of sign and duration of edentulous span was found to be statistically not significant (χ2 = 5.5661, P = 0.6964) at 5% level of significance [Table 7].
Table 1: Age distribution of samples

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Table 2: Age distribution of samples by gender

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Table 3: Number and sex distribution

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Table 4: Distribution of samples according to edentulous span

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Table 5: Patients showing one or more signs of temporomandibular joint dysfunction

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Table 6: Frequency and distribution of temporomandibular disorder signs in complete denture wearers according to gender

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Table 7: Frequency and distribution of temporomandibular disorder signs in complete denture wearers in relation to edentulous span

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  Discussion Top


Studies have been conducted to determine the prevalence of TMD in dentate, completely edentulous, and partial denture wearers. Authors have reported TMD to be almost as prevalent in CDs wearers as in individuals with natural dentition.[10],[11] While others found CD with an increased prevalence of TMD symptoms in patients wearing CD than the individuals with natural dentition.[12],[13] Some researchers have also found lesser prevalence of TMD in CD wearers and contributed this finding to the fact that such individuals have reduced maximum opening levels and 5–6 times lesser bite force than in dentate patients, so, from time to time, they surpass their tissue resilience and flexibility leading to lesser prevalence of TMD.[14]

Most of the studies assessing TMD in dentate individuals, partial denture wearers, and CD wearers have found significantly more iterated and more severe TMD signs and symptoms in females than in males, and females look for treatment for their TMJ issues 3 times more frequently than their male counterparts.[3],[4],[5],[15] This is in accordance with the present study as more number of females (63.12%) reported signs of TMD as compared to males (58.75%). No conclusive results have been drawn to clarify these distinctions as far as behavioral, psychosocial, hormonal, and constitutional contrasts are concerned. The existence of estrogen receptors in the TMJ of females balances metabolic capacities in connection to laxity of the ligaments, which could be pertinent in TMD. Estrogens would play a role by enhancing the diligence in connection to pain stimuli, tweaking the activity of the limbic system neurons.[16] Some reports in people have demonstrated that the presence of pain in connection to TMD escalates nearly 30% in individuals receiving hormone substitution treatment in postmenopause (estrogens) and around 20% among females who utilize oral contraceptives.[17]

The results of the present study, i.e., more percentage of patients showing two signs of TMD (24.58% of males and 21.25% of females) followed by patients presenting with one sign (21.25% of males and 18.75% of females) [Table 5], are in accordance with another study which also found more percentage of healthy asymptomatic edentulous individuals showing two signs of TMD (29%) followed by one sign (25%). However, they also found joint sounds (47%) to be the most prevalent joint dysfunction which is different from findings in the present study as we have found limitation of mouth opening to be the most prevalent sign [Table 6].[3] CD wearers may be relied upon limited jaw opening levels because of the muscular co-ordination needed to counteract relocation of the lower denture amid this exercise.[14] Joint sounds are very frequent among individuals with TMD. A variety of different causes have been attributed to these sounds such as arthritic alterations in the TMJ, anatomical deviations, muscular incoordination, and disc displacement. Recent researchers have related clicking to a sudden acceleration of condylar and internally displaced disc tissues.[18] In the present study, the least common finding was joint sounds. Joint noises in completely edentulous patients wearing denture have been related to abnormal condylar surface forms.[19] The results are also not in accordance with another study which found joint sounds (11.54%), muscle tenderness (7.69%), joint tenderness (5.77%), deviation of mandible (3.85%), and limitation on mouth opening (2.88%) in decreasing order of frequency.[4]

Studies have also found that, in comparison to CD wearers with partially edentulous patients wearing acrylic removable partial dentures, the latter group had a higher prevalence of TMD signs (36% compared to 17%).[9] Another study which assessed the prevalence of temporomandibular disorders in completely edentulous patients found a significant correlation between the prevalence of TMDs' clinical positive signs and wearing denture as the prevalence of TMDs' clinical positive signs in denture-wearing group was 38.6% (91/236) and that in no denture group was 52.6% (61/116).[5] We have found a significant decrease in signs and symptoms of TMDs as the edentulous span increased, with lesser number of more than 5 years' edentulous span patients reporting TMDs, but this finding was not statistically significant [Table 7]. This finding is in accordance with another study which also reported that TMD prevalence decreased with increasing age and its prevalence was not related to denture experience, number of dentures used, and age of the present denture.[20] However, there is still squabble with respect to the pervasiveness of TMD signs and symptoms in various gatherings of people. There could be many explanations behind this, however the most as often as possible recommended are contrasts in diagnostic criteria, clinical evaluation, and the universe of the study populace.[21] The limitation of the study is that no validated instrument (research diagnostic criteria [RDC]/TMD, Helkimo index) was used to assess TMD prevalence and it did not differentiate TMD signs and symptoms. This was a cross-sectional study and also no control group involved. The strengths of this study were the prevalence of TMD signs was categorized and represented according to gender, and the relationship of TMD signs with edentulous span was very well depicted.

Future studies with control group and using Axis I of RDC/TMD – Research Criteria were may be of more helpful in giving conclusions which can be applied to a broader category.


  Conclusion Top


TMD serve as a noteworthy reason for non-odontogenic pain in the orofacial location and are thought to be a subclass of musculoskeletal dysfunctions including tissue damage secondary generation of disproportionate force or pressure. The total prevalence of TMD in healthy asymptomatic completely edentulous patients was 60.5% (58.75% in males and 63.12% in females). More number of females reported signs and symptoms of TMD which was not statistically significant. The most common finding was limitation on mouth opening and the least common finding was joint noises (crepitus and clicking). However, a longitudinal follow-up study is recommended to know the desirable course of these signs. The occurrence of findings was not significantly related to the duration of being edentulous.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Alzarea BK. Temporomandibular disorders (TMD) in edentulous patients: A review and proposed classification (Dr. Bader's classification). J Clin Diagn Res 2015;9:ZE06-9.  Back to cited text no. 1
    
2.
Rostamkhani F, Najjaran NT, Madani A. The relationship between temporomandibular disorders (TMDs) and overall denture conditions in complete denture wearers. J Dent Mater Tech 2015;4:101-10.  Back to cited text no. 2
    
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Shetty R. Prevalence of signs of temporomandibular joint dysfunction in asymptomatic edentulous subjects: A cross-sectional study. J Indian Prosthodont Soc 2010;10:96-101.  Back to cited text no. 3
    
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Kirov DN, Krastev DS. Prevalence of signs and symptoms of temporomandibular disorders in patients wearing complete dentures. Int J Sci Res 2014;3:947-9.  Back to cited text no. 4
    
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Shi Q, Wang YY. Investigation of the prevalence of temporomandibular disorders in 352 aged edentulous individuals. Zhonghua Kou Qiang Yi Xue Za Zhi 2012;47:19-21.  Back to cited text no. 5
    
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Witzel AL, Costa JE, Bolzan MC, Carli ML, Nunes TB, Di Matteo RC, et al. Correlation between gender, temporomandibular joint disc position and clinical findings in patients with temporomandibular disorder. Med Express (São Paulo, Online) 2015;2:M150402.  Back to cited text no. 6
    
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Ahmed LI, Abuaffan AH. Prevalence of temporomandibular joint disorders among Sudanese university students. J Oral Hyg Health 2016;4:200.  Back to cited text no. 7
    
8.
Monteith B. The role of the free-way space in the generation of muscle pain among denture-wearers. J Oral Rehabil 1984;11:483-98.  Back to cited text no. 8
    
9.
Al-Jabrah OA, Al-Shumailan YR. Prevalence of temporomandibular disorder signs in patients with complete versus partial dentures. Clin Oral Investig 2006;10:167-73.  Back to cited text no. 9
    
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Zissis AJ, Karakazis HC, Polyzois GL. The prevalence of temporomandibular joint dysfunction among patients wearing complete dentures. Aus Dent J 1988;33:299-302.  Back to cited text no. 10
    
11.
Ribeiro JA, de Resende CM, Lopes AL, Farias-Neto A, Carreiro Ada F. Association between prosthetic factors and temporomandibular disorders in complete denture wearers. Gerodontology 2014;31:308-13.  Back to cited text no. 11
    
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Mercado MD, Faulkner KD. The prevalence of craniomandibular disorders in completely edentulous denture-wearing subjects. J Oral Rehabil 1991;18:231-42.  Back to cited text no. 12
    
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Divaris K, Ntounis A, Marinis A, Polyzois G, Polychronopoulou A. Loss of natural dentition: Multi-level effects among a geriatric population. Gerodontology 2012;29:e192-9.  Back to cited text no. 13
    
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Al Shumailan YR, Al Manaseer WA. Temporomandibular disorder features in complete denture patients versus patients with natural teeth: A comparative study. Pak Oral Dent J 2010;30:254-9.  Back to cited text no. 14
    
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Shet RG, Rao S, Patel R, Suvvati P, Sadar LR, Yadav RD. Prevalence of temporomandibular joint dysfunction and its signs among the partially edentulous patients in a village of North Gujarat. J Contemp Dent Pract 2013;14:1151-5.  Back to cited text no. 15
    
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Poveda Roda R, Bagan JV, Díaz Fernández JM, Hernández Bazán S, Jiménez Soriano Y. Review of temporomandibular joint pathology. Part I: Classification, epidemiology and risk factors. Med Oral Patol Oral Cir Bucal 2007;12:E292-8.  Back to cited text no. 16
    
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LeResche L, Saunders K, Von Korff MR, Barlow W, Dworkin SF. Use of exogenous hormones and risk of temporomandibular disorder pain. Pain 1997;69:153-60.  Back to cited text no. 17
    
18.
Sakurai K. Judgment of abnormal condylar surface forms in edentulous patients by temporomandibular joint noise. Bull Tokyo Dent Coll 1998;39:263-6.  Back to cited text no. 18
    
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Elfving L, Helkimo M, Magnusson T. Prevalence of different temporomandibular joint sounds, with emphasis on disc-displacement, in patients with temporomandibular disorders and controls. Swed Dent J 2002;26:9-19.  Back to cited text no. 19
    
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Yannikakis S, Zissis A, Harrison A. The prevalence of temporomandibular disorders among two different denture-wearing populations. Eur J Prosthodont Restor Dent 2009;17:35-40.  Back to cited text no. 20
    
21.
Bordin TB, Conci RA, Pezzini MM, Pezzini RP, Mendonça MJ. Prevalence of signs and symptoms of temporomandibular disorders (TMD) in patients wearing bimaxillary complete dentures, removable partial dentures and in students with natural dentition. Acta Odontol Latinoam 2013;26:173-80.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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