|Year : 2021 | Volume
| Issue : 3 | Page : 245-250
A survey report of Temporomandibular Joint Disorder using fonseca’s and research diagnostic criteria during routine dental examination: A cross-sectional study
Farahnaz Muddebihal1, Hassan Alawadh2, Mohammed Salahuddin3, Shouq Saud Alrasheed4, Meshal Mohammad Maqbool Alryes5, Mohammed Ubaidullah Sayeed6
1 Preventive Dentistry, College of Dentistry, Jouf University, Sakaka, Kingdom of Saudi Arabia
2 Dar Al Razi Dental Polyclinic, Tabuk, Kingdom of Saudi Arabia
3 Department of Physiology, College of Applied Medical Sciences, Qurayyat Campus, Jouf University, Sakaka, Kingdom of Saudi Arabia
4 College of Dentistry, Jouf University, Sakaka, Kingdom of Saudi Arabia
5 Dumat Al Jandal General Hospital, Dumah Al Jandal, Kingdom of Saudi Arabia
6 Department of Pathology, College of Medicine, Jouf University, Sakaka, Kingdom of Saudi Arabia
|Date of Submission||30-Sep-2020|
|Date of Decision||30-Jan-2021|
|Date of Acceptance||03-Mar-2021|
|Date of Web Publication||18-Jun-2021|
Dr. Farahnaz Muddebihal
Preventive Dentistry, College of Dentistry, Jouf University, Sakaka.
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Aim: By using the research diagnostic criteria (RDC) and Fonseca’s questionnaire, the present study aimed at assessing the number of self-reported temporomandibular disorders (TMDs) discovered accidentally on routine dental examination and also at knowing the prevalence, severity, and awareness of patients toward TMD in Sakaka, Saudi Arabia. Materials and Methods: This is a descriptive cross-sectional epidemiological study. A sample of 100 patients with a chief complaint of pain in the temporomandibular joint (TMJ) was collected randomly; a routine examination of the TMJ using RDC was done. Fonsecas Anamnestic Index (FAI) questionnaire was used to collect and record the data. Later on, by using the SPSS software, sample t-test and ANOVA test were used; data analysis was conducted, and results were created. Results: The study revealed that 74% of participants belonged to the significant age group of 30 to 60 years (P < 0.05), with 79% male prevalence. The most common cause noted was psychological stress, filling of tooth, root canal treatment (RCT), and chewing gum. Based on the FAI questionnaire, the severity of TMD was moderate with 44% and RDC revealed 46% tenderness in masticatory muscles and 59% of clicking sound on auscultation. Orthopantomograph (OPG) evaluation showed flattening and condylar irregularities of bone. Conclusion: The number of self-reported cases of TMDs were very less. The severity of TMD was moderate, but the average population was not aware about it.
Keywords: Fonseca’s Questionnaire, Research Diagnostic Criteria, Temporomandibular Disorder
|How to cite this article:|
Muddebihal F, Alawadh H, Salahuddin M, Alrasheed SS, Alryes MM, Sayeed MU. A survey report of Temporomandibular Joint Disorder using fonseca’s and research diagnostic criteria during routine dental examination: A cross-sectional study. J Int Oral Health 2021;13:245-50
|How to cite this URL:|
Muddebihal F, Alawadh H, Salahuddin M, Alrasheed SS, Alryes MM, Sayeed MU. A survey report of Temporomandibular Joint Disorder using fonseca’s and research diagnostic criteria during routine dental examination: A cross-sectional study. J Int Oral Health [serial online] 2021 [cited 2021 Jul 30];13:245-50. Available from: https://www.jioh.org/text.asp?2021/13/3/245/318449
| Introduction|| |
The TMJ acts like a sliding hinge, linking the jawbone to the skull with one joint on each side of the jaw. For proper functioning of the jaw it contains structures such as meniscus, glenoid fossa, ligaments, mandibular condyle, and muscles. Due to any external factors, such as mechanical, psychological, and occupational ones, any habits will hamper the proper functioning of the TMJ. Usually, the human body tries to fix its defects, but if the restoration does not proceed, the capacity to fix the defect is lost by the body and ultimately appearance of the signs and symptoms commences.
Temporomandibular disorders (TMDs) are the defects that affect the TMJ; TMDs are common and are composed of mixtures of disorders. They are characterized by pain and tenderness in TMJ, masticatory muscles, adjacent soft tissues, limited mouth opening, mandibular lateral movements or deviation, protrusion, and sounds in TMJ.
The TMDs can be associated with numerous causes such as emotional stress, occlusal interferences, malpositioning or loss of teeth, postural changes, dysfunctions of the masticatory muscles and adjacent structures, extrinsic and intrinsic changes on TMJ structure, and/or a combination of such factors. Non-odontogenic orofacial pain is considered to be the most common cause of TMDs.
The TMJ disorders fall into three main categories: (i) Arthritis refers to a group of degenerative/inflammatory joint disorders. (ii) Myofascial pain dysfunction syndrome involves tenderness or pain in the muscles that control jaw function. (iii) Internal derangement of the TMJ involves anterior displacement of the meniscus with or without auto reduction, dislocated jaw, or injury to the condyle.
The diagnosis of TMDs can be done based on the history of the patient, imaging, and clinical examination of the TMJ. For excellent reliability and validity, the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) are the most commonly used standardized diagnostic criteria.
The Fonsecas Anamnestic Index (FAI) is a self-administered, simplified questionnaire that can be used for TMD evaluation in patients. To detect the signs and symptoms of TMDs, FAI gives an advantage of being easily used by general dentists or any of the epidemiologists, and it serves as a preliminary screening tool that was suggested by Campos et al. It also provides a severity index with less influence from the examiner and less variability in the measures that characterize a multidimensional evaluation. It is composed of 10 questions that display the presence of pain in the TMJ, head and back; pain while chewing; parafunctional habits; movement limitations; joint clicking; perception of malocclusion; and sensation of emotional stress. After identifying the affected population, a complete clinical examination and further use of diagnostic instruments is required to confirm the diagnosis.
Thus, using the RDC and Fonseca’s questionnaire, the present study aimed at assessing the number of self-reported TMDs discovered accidentally on routine dental examination and also at knowing the prevalence, severity, and awareness of patients toward TMD in Sakaka, Saudi Arabia.
| Materials and Methods|| |
This is a descriptive cross-sectional epidemiological study. The present study was conducted on patients attending the dental clinic of College of Dentistry, Jouf University KSA from October 2018 to December 2018, after seeking approval from the college ethical committee. The random sampling method was used to select the sample subjects. During initial screening, a total of 100 patients were examined.
Inclusion criteria for the study group included age group of 18–65 years and no previous history of orthodontic treatment. Also, patients with symptoms and without symptoms were included in the study. The symptoms included were clicking, limited mouth opening, crepitus, TMJ pain, deviation of the mandible on opening and closing, limited lateral excursions of the mandible, muscle tenderness, headaches, and earaches. Exclusion criteria for the study group included no previous history of trauma to the TMJ or no previous treatment for the TMJ.
All the patients were informed about the study aims, brief information about TMD was given to the volunteers, and formal written consent was taken before participation. First, the patients attending the dental clinic were studied by taking the demographic data along with their closed-ended medical history, dental history, and habits. Then, the questionnaire proposed by Fonseca’s was given to the patients to fill so as to classify the severity of TMDs in the study population. It is composed of 10 questions, which include checking for the presence of pain in TMJ, head and back, while chewing, parafunctional habits, movement limitations, joint clicking, perception of malocclusion, and sensation of emotional stress. The questions included in the Fonseca’s questionnaire are given in [Table 1].
The volunteers/patients were informed that the 10 questions should be answered with “yes” (10 points), “no” (0 points), and “sometimes” (5 points) and that only one answer should be marked for each question. The sum of points will be used to classify patients into four categories: TMD free (0–15), mild TMD (20–40), moderate TMD (45–60), and severe TMD (70–100). All the patients with an age around 18 to 65 years, associated with symptoms and without symptoms will undergo a screening procedure that will be evaluated further by RDC/TMD-based criteria.
An RDC/TMD included Axis I and Axis II. In the present study, only Axis I was used, which includes a structured diagnosis of TMD and clinical examination. Palpation of masticatory and cervical muscles to check for tenderness was included for the clinical examination. The joints were auscultated for clicking and crepitus sound. The opening pattern was observed for deviation. At the interincisal distance between the upper and lower incisors, maximal mouth opening was measured and the distance between the maxillary and mandibular midlines on moving the mandible to the right and left the lateral excursions was measured. Using the 10-point visual analogue scale (VAS), pain intensity was measured (0 indicating the absence of pain and 10 indicating the worst pain). OPG (if necessary) was taken along with the clinical examination of the patient.
Evaluation with OPG
- Fattening: loss of an even convexity or concavity of the joint outlines.
- Osteophyte: local outgrowth of bone arising from a mineralized joint surface.
- Ely’s cyst (sub-corticalcyst): rounded radiolucent area that may be just below the cortical plate or deep in trabecular bone.
The panoramic radiographs were obtained with Orthophos plus. As per the operating instructions, the head of the patients was exposed in an optimum position. The films that could be clearly visualized for mandibular condyles were considered in the study. The radiographic criteria were categorized as either present or not present for flattening, osteophyte, Ely’s cyst, and condylar irregularities.
The interpretation for the OPG was done by the two observers. Sample t-test and ANOVA test were used for data analysis and results by using SPSS software (version 16.0, SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant, and degree of freedom was n – 1 with a 95% confidence interval.
| Results|| |
The demographic data of the study revealed that 74% of the participants belonged to the significant age group of 30 to 60 years (P < 0.05). From among the 100 investigated patients, it was significantly found that 79% were males and 21% were females (P < 0.05). The most common medical history and dental history of patients were psychological stress with 51% and filling and RCT of teeth with 81%, which were statistically significant (P < 0.05). The most common habits of the patients were chewing gum with 78% followed by bruxism with 49%; the least associated habits were adult thumb sucking with 13%, which were statistically significant (P < 0.05) [Table 2]. Based on Fonseca’s questionnaire, the severity of TMDs was checked. Out of 100 patients, the severity of TMD was moderate with 44% followed by mild with 26%, then severe with 23%, and free with 7%, which were statistically significant (P < 0.05) [Figure 1], [Table 3].
Using Axis I, RDC/TMD assessment, the structured diagnosis and clinical examination of TMD revealed that 46% of patients had tenderness in masticatory muscles on palpation. 59% of patients showed clicking sound while 41% of patients showed crepitus on auscultation of the joint. Only 9% of patients had a mouth opening less than 30 mm and also lateral deviation of jaw was noted in only 20% of patients. The characteristic pain intensity level was zero (79%), followed by level 10 (21%). All these factors were statistically significant (P < 0.05) [Table 4].
The analysis of OPG evaluation revealed a statistically significant interobserver agreement for flattening, osteophyte, condylar irregularities. On examination of OPG, flattening was noted in 46% and 42% followed by osteophyte with 12% and 10% and then condylar irregularities with 48% and 50%, respectively, by observer 1 and observer 2 (P < 0.0001) [Table 5].
| Discussion|| |
TMD is a set of symptoms characterized by pain, clicking, difficulty with mouth opening, and mastication. Early diagnosis of this disorder is based on TMD signs and symptoms.
The present study was conducted to determine the number of self-reported TMDs discovered accidentally on routine dental examination and also to know the prevalence, severity, and awareness of patients toward TMD in Sakaka, Saudi Arabia.
Of 100 participants, 74% of participants belonged to the age group of 30–60 years, which was in contrast to the studies done by AlShaban et al. and Jain et al.
Among 100 participants 79% were male patients and 21% were female patients, which indicated that TMD was more common among male patients. This was in contrast to the study done by Jain et al., Mohammed Nadershah, and Saeed et al., which reported that females have a larger tendency toward the risk of developing TMDs as compared with males.,, This study reported that 51% of patients considered themselves as stressful, which was in accordance with the studies carried out by Rakhi et al., Karthik et al., and You-Sung Choi et al.,, The most common cause for TMDs was previous dental treatments such as filling and RCT with 81%, which specify a history of long-duration mouth opening for dental treatments. This was mentioned in accordance with a study done by AlShaban et al. The second most common cause reported was habits such as chewing gum (78%), bruxism (49%), and thumb sucking (13%), which were similar to studies done by AlShaban et al. and Fernandes et al., [Figure 1], [Table 2].
Fonseca’s questionnaire is a scale that proposes to measure the “severity of temporomandibular disorders.” This helps to collect a large amount of information in a short period at a low cost and also recognizes the symptoms of TMJ. Based on Fonseca’s questionnaire, out of 100 patients, the severity of TMD was moderate with 44% followed by mild with 26%, then severe with 23%, and free with 7%. This report was in contrast to studies done by Rakhi et al, Riffel et al., and Rokaya et al.,, Different studies have reported variations in the prevalence of TMD due to differences in methodologies, populations, criteria for diagnosis, and examination procedures. Reliable results are provided by both radiological and clinical examinations. History, clinical examination, and OPG were considered as the primary diagnosis for the present study.
RDC/TMD is used widely for the diagnosis of TMD. However, one of its dimensions (Axis I) requires the presence of the patient for clinical examination, which revealed that 46% of patients had tenderness in masticatory muscles on palpitation. The joint showed 59% of clicking sound followed by 41% of crepitus on auscultation. Only 9% of patients had the mouth opening less than 30 mm and also lateral deviation of jaw was noted in only 20% of patients. This result was in accordance with the studies conducted by Talaat et al., Al-Gadhaan et al., and Giane da Silva et al.,, The characteristic pain intensity level was zero (79%), followed by level 10 (21%), which was in contrast to a study done by Choudhary et al.
In our study, interpretation for radiological examination by OPG was done by two observers. Results of the present study show that the most common bony changes noted by the two observers were condylar irregularities (48% by observer 1 and 50% by observer 2) followed by flattening (46% by observer 1 and 42% by observer 2), which was in contrast to a study done by Shetty et al.
After the affected population is identified, a more thorough investigation can be conducted, which would include a complete clinical examination and use of diagnostic instruments to confirm the diagnosis. Fonseca’s questionnaire can be used as an effective tool in the prevalence of signs and symptoms of TMDs along with RDC. The TMJ screening should be done on routine basis in all dental clinics, which can contribute toward early diagnosis and treatment modalities by using FAI/RDC. The study limits the use of cone beam computed tomography systems (CBCT) and magnetic resonance imaging (MRI) as a radiographic tool for proper diagnosis. Further studies can be done by using these tools. In our study, no treatment was offered to patients diagnosed with TMDs but still patients showed interest in pursuing the treatment as noted by the provided questionnaire. The FAI/RDC are useful screening tools for TMDs for the early diagnosis and prevention of future complications.
| Conclusion|| |
TMD is a complex disease that may affect the quality of life of patients due to its different signs and symptoms. The numbers of self-reported cases of TMDs were very less. The majority of people were suffering from TMD, but the average population was not aware about it. Hence, it is important for a general practitioner to examine TMJ during the screening procedure so that patients can become aware. However, it is noted that dental graduates are not receiving a proper training program for the diagnosis of TMDs because the screening of TMDs is not yet recognized as a tool for initial dental screening.
So, according to our research, male patients were more prevalent for TMD. Also, stress, past dental treatment, and incorrect habits were considered to be the main cause for TMDs. Hence, educating the patients is very important for successful TMJ rehabilitation.
The authors would like to thank their colleagues for their kind insight and knowledge that greatly assisted the research.
Financial support and sponsorship
Conflict of interest
The authors declare that they have no conflict of interest.
All authors have equally contributed to the conception of the study, data collection, data acquisition and analysis, data interpretation, article writing, and final reviewing; all the authors approved the final version of the article for publication.
Ethical policy and institutional review board statement
Ethical clearance has been obtained from the Jouf University Ethical Committee, Approval No. 6-2-4/40, and date of approval: 12/12/2018.
Patient declaration of consent
Data availability statement
Data can be obtained on written correspondence to the corresponding author on a valid request.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]