|Year : 2015 | Volume
| Issue : 4 | Page : 508-515
Prevalence of temporomandibular disorders in Chennai population
Arvind Muthukrishnan1, Gowri Shankar Sekar2
1 Department of Oral Medicine and Radiology, Saveetha Dental College and Hospital, Saveetha University, Chennai, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, SRM Kaatankulathur Dental College and Hospital, SRM University, Chennai, Tamil Nadu, India
|Date of Submission||28-May-2015|
|Date of Acceptance||09-Dec-2015|
|Date of Web Publication||19-Aug-2016|
Prof. Arvind Muthukrishnan
Department of Oral Medicine and Radiology, Saveetha Dental College and Hospital, Saveetha University, Chennai - 600 077
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: This study aimed to determine the prevalence of temporomandibular disorders (TMDs) in Chennai city population. Materials and Methods: To obtain a representative sample, a house-to-house survey was conducted in three zones of Chennai and a total of 4197 individuals were randomly selected for the study. Among 4197 individuals, 1158 were excluded from the study, based on the exclusion criteria. Finally, a total of 3039 individuals were included in the study population. Results: More than half of the study sample (53.7%) in the present study had one or more clinical signs and symptoms of TMD. Deviation of mandible on mouth opening (42.1%) and clicking sound (38.6%) made up the highest percentage. Females aged 18 years and older reported higher prevalence of TMD signs and symptoms than men. However, these differences were not significant for all signs and symptoms in all age groups. Prevalence of TMD was reported in this study according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) system of classification, and myofacial pain dysfunction syndrome (MPDS) was reported in 0.8% of the population, internal derangement in 38.3%, and osteoarthritis in 14.6% of the population. Conclusion: Our study, in comparison to other prevalence studies, had a higher sample size and was representative of a cross section of the population. The results of this study show that a significant percentage of the population has signs of TMDs and there are chances that they may develop symptoms of TMDs. Further studies are needed for early identification and initiation of preventive measures which could prevent TMDs progressing to advanced stages where management becomes difficult.
Keywords: Epidemiology, internal derangement, MPDS, osteoarthritis, population-based study, prevalence, RDC/TMD criteria, temporomandibular disorder
|How to cite this article:|
Muthukrishnan A, Sekar GS. Prevalence of temporomandibular disorders in Chennai population. J Indian Acad Oral Med Radiol 2015;27:508-15
|How to cite this URL:|
Muthukrishnan A, Sekar GS. Prevalence of temporomandibular disorders in Chennai population. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 Aug 11];27:508-15. Available from: http://www.jiaomr.in/text.asp?2015/27/4/508/188686
| Introduction|| |
The terminology "temporomandibular disorders" (TMDs) encompasses a wide spectrum of conditions. There have been a lot of attempts to formulate a universally acceptable classification for categorization of this wide group of conditions. But each classification or category has some shortfall or the other. Classification has been attempted on the basis of anatomical changes, etiological factors, and by some researchers on the basis of the frequency of the presenting signs and symptoms. There has always been a considerable overlap in any classification system. TMDs affect the articulation of the condyle with the glenoid fossa, the masticatory muscles, and the occlusion. There is a wide interplay between the above-mentioned factors and a thorough investigation of all possible factors should be done before a final diagnosis of TMD is made. To achieve a certain degree of uniformity in defining and categorizing TMDs, the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) have proposed the following definition and diagnostic criteria. It is defined as a collective term describing a group of conditions affecting either the temporomandibular joint (TMJ), the masticatory musculature, or both. The signs and symptoms of TMDs include:
- Pain in the masticatory musculature and/or joint which can radiate and refer;
- Locking - closed lock, open lock, inability to open fully, dislocation;
- Noises like clicking and crepitus during joint movement;
- Tightness around the face in the morning; and
- Referred pain to the ear.
Epidemiological studies have estimated that approximately 50-75% of the population exhibit some signs of TMDs. Many a times, it may be subclinical and the patient might not try to relate this to an underlying jaw problem. In less than 15-20% of the patients, the signs change into symptoms for which the patient will seek treatment. The frequency to seek treatment increases if the symptoms interfere with day-to-day activities. Identification of the signs of a possible TMD is essential to diagnose TMDs. So, this study was carried out to determine the prevalence of signs and symptoms of TMD diagnosed according to RDC/TMD classification in Chennai city population.
| Materials and Methods|| |
Chennai is a major metropolitan city located in the southern part of India. An epidemiological study was carried out in Chennai city population. A house-to-house survey was conducted in the three zones of Chennai, namely north zone, central zone, and south zone, and a total of 4197 individuals were randomly selected for the study.
Men and women above 18 years of age and permanent residents of Chennai city were included in the study.
People less than 18 years of age, patients whose third molars have been extracted, patients with a history of fracture of the TMJ and previous TMJ surgeries, non-cooperative subjects, and individuals not native to Chennai district were excluded. Approval for the study was obtained from the Institutional Ethical Committee of Saveetha University. The study group consisted of 3039 adult patients. The subjects were divided into three groups depending on their age as follows: Group I- 18-30 years, Group II- 31-50 years, and Group III- more than 50 years. The study was conducted from September 2012 to September 2013. The demographic data and the signs and symptoms of TMDs were recorded, which were based on the RDC/TMD criteria.
To evaluate the differences between the genders and age groups, the chi-square test was used with a power of 80% and with 5% level of significance.
| Results|| |
The distribution of study subjects based on age and gender showed that among males, 55.1% were in 18-30 years age group, 35.4% were in 31-50 years age group, and 9.5% were in >50 years age group. Among females, 38.1% were in 18-30 years age group, 44.8% were in 31-50 years age group, and 17% were in >50 years age group [Table 1]. The distribution of study subjects according to presence/absence of TMD based on age and gender showed that among 3039 study subjects, 1631 (53.7%) subjects had TMD. Also, 437 (29.2%) subjects in the 18-30 years age group, 846 (72%) subjects in the 31-50 years age group, and 348 (94.8%) subjects in the >50 years age group had TMD. Regarding gender wise distribution, 1014 (50.9%) males and 617 (59%) females had TMDs [Table 2]. The distribution of study subjects according to the RDC/TMD between age groups and gender showed that myofacial pain dysfunction syndrome (MPDS) was present in 24 (0.8%) subjects consisting of 14 (0.7%) males and 10 (1.0%) females. Internal derangement was present in 1163 (38.3%) subjects consisting of 767 (38.5%) males and 396 (37.9%) females, and osteoarthritis was present in 444 (14.6%) of the subjects and among them, there were 233 (11.7%) males and 211 (20.2%) females. MPDS was present in 22 (1.5%) study subjects in the age group 18-30 years and in 2 (0.2%) study subjects in the age group 31-50 years. Internal derangement was present in 412 (27.5%) subjects in 18-30 years age group, 734 (62.5%) subjects in the age group of 31-50 years, and in 17 individuals in the age group of >50 years. Osteoarthritis was present in 3 (0.2%) subjects of the age group 18-30 years, 110 (9.4%) subjects belonging to 31-50 years age group, and in 331 (90.2%) subjects of age >50 years [Table 3]. The distribution of study subjects according to the presence of signs and symptoms of TMD based on age and gender showed that joint sounds were present in 250 (8.2%) subjects [133 (6.7%) males and 117 (11.2%) females], crepitus in 449 (14.8%) subjects [236 (11.8%) males and 213 (20.4%) females], clicking in 1173 (38.6%) subjects [770 (38.6%) males and 403 (38.5%) females], muscle tenderness in 83 (2.7%) subjects [41 (2.1%) males and 43 (4%) females], joint tenderness in 98 (3.2%) subjects [48 (2.4%) males and 50 (4.8%) females], referred pain in 26 (0.9%) subjects [14 (0.7%) males and 12 (1.1%) females], pain on mouth opening in 71 (2.3%) subjects [33 (1.7%) males and 38 (3.6%) females], deviation of mandible <5 mm on mouth opening in 1278 (42.1%) subjects [808 males (40.5%) and 470 females (44.9%)], and limitation of mouth opening <40 mm was present in 347 (11.4%) subjects [202 (10.1%) males and 145 (13.9%) females] [Table 4]. The distribution of study subjects according to presence of parafunctional habits from history based on age and gender showed that among 3039 study samples, bruxism was present in 157 (5.2%) samples; among them, 110 (5.5%) were males and 47 (4.5%) were females. Gum chewing was present in 63 (2.1%) subjects consisting of 46 (2.3%) males and 17 (1.6%) female subjects [Table 5].
|Table 2: Distribution of study subjects according to presence/absence of TMD based on age and gender |
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|Table 3: Distribution of study subjects according to RDC/TMD between age groups and gender |
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|Table 4: Distribution of study subjects according to the presence of signs and symptoms of TMD based on age and gen |
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|Table 5: Distribution of study subjects according to the presence of parafunctional habits from history based on age |
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| Discussion|| |
One important cause for chronic facial pain is TMDs. The term TMD has been described as a cluster of disorders characterized by pain in the preauricular area, TMJ, or the masticator muscles; limitation or deviations in mandibular range of motion; and clicking in the TMJ during mandibular function, and they are not related to growth or developmental disorders, systemic diseases, or macrotrauma.  The prevalence of this type of disease, according to the literature, varies between 28% and 88% depending on the type of population studied as well as the diagnosis system used.  The information regarding signs and symptoms of TMD has been collected by clinical examination and questionnaires in some studies and by interviews in others.  TMDs have been observed to be most frequent among women.  Various authors have also observed that the frequency of the signs and symptoms of TMD increases with age.  Parafunctional habits like bruxism  and gum chewing  have been associated with TMDs. The main objectives of the present study were to determine the presence or absence of TMD and the signs and symptoms of TMDs in the adult population of Chennai city. As random sample method was used, this study population can be considered representative of the 18-77-year-old adult population of the region under survey. It is also thus representative of the functional status of the population's stomatognathic system. The representative TMD prevalence values determined in this study were compared to those of other studies - Exclusively studies with random samples - That fulfilled the criteria similar to those of the present study, and were therefore adequately comparable. These studies consisted of subjects 18 years of age or older and a sample size of >500 study subjects [Table 6].
|Table 6: Random sampling population-based TMD prevalence studies of adults |
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In our study, the sample population numbered 3039 in the age group of 18-77 years. This is a very large sample representing the population under survey, when compared to other population-based TMD prevalence studies ,,,,,,,,,, where the study population was less. Only two prevalence studies , had a larger sample size when compared to our study. In the present study, 53.7% subjects had TMD, which was statistically significant (<0.001). A review of 18 international epidemiologic TMD studies conducted primarily on adults from 1979 to 1984 showed an incidence range of 33-86% for one or more signs/symptoms of TMD and 16-59% for anamnestic symptoms.  A meta-analysis published in 1993 on 51 random samples and selected TMD prevalence studies conducted from 1974 to 1991 showed clinically determined TMD frequency in the range of 0-93% (an average of 44%) and TMD prevalence in the range of 6-93% (an average of 30%) based on the information obtained from questionnaires. 
In our study, TMDs were present in 50.9% males and 59% females. Females showed a higher prevalence of TMDs compared to males. Epidemiological studies generally document a greater frequency and severity of TMD in females than in males. In effect, TMD is observed to be up to four times more frequent in women, and women tend to seek treatment for their TMJ problems three times more often than males. It has been suggested that the presence of estrogen receptors in the TMJ of women modulates the metabolic functions in relation to laxity of the ligaments, and this could be relevant in TMD. 
In our study, joint sounds was present in 8.2% of the study subjects, and it was maximum in the age group of >50 years (39.5%). Females had significantly more joint sounds (11.2%) when compared to males (6.7%) (P < 0.001). In a Swedish sample,  13% of the subjects complained of TMJ sounds. In a Japanese study sample,  the prevalence of these symptoms was 24%, and was thus higher than in other studies. A German study  reported that 20-59-year-old women were significantly more frequently aware of joint sounds than men. In the 60-80-year-old age group, this difference no longer existed. In contrast, three studies ,, found no gender-based difference. The authors did, however, confirm a significant reduction of the subjectively perceived joint sounds with increasing age, which was in contrast to our study.
TMJ crepitus and clicking was present in 14.8% and 38.6% of the subjects, respectively, in our study (P < 0.001). Crepitus was maximum (91.6%) in the age group of >50 years (P < 0.001). Clicking was more prevalent (62.6%) in the age group of 31-50 years (P < 0.001). Females showed higher prevalence of crepitus (20.4%) (P < 0.001) when compared to males (11.8%). Clicking was present slightly more in males (38.6%) when compared to females (38.5%). In the RDC/TMD,  clicking sounds that are reproducible on repeated openings and occur in a reciprocal pattern, or on excursive as well as vertical range of motion, are considered to be indicative of disc displacement with reduction. It should be noted that painless clicking is also considered as pathognomonic of TMD. In a Swedish study,  the overall prevalence of clicking detected by examination was 17% in men and 27% in women. Another study investigated persons aged 18-65 years in the County of Stockholm, Sweden, and found clicks to be present in 21% males and 28% females. Crepitus was detected in 26% men and 40% women.  Previous reviews have reported wide variability, from 6 to 50%, for the prevalence rates of TMJ sounds across studies.  In all studies that examined both sexes, women showed a slightly higher prevalence of clicks than men, and their rates of crepitus were 1.5-2.3 times more than those of men. The German study  reported clicking and crepitus in 24.9% of the subjects, with women having joint sounds significantly more frequently than men, almost twice as often (31.7% vs. 17.9%). A study in Finland  reported the rate as 20%; however, they did not describe either gender- or age-dependent differences. In a Danish sample, the rate was 15.4%,  with 19% of women and 12.2% of men having the symptom. The Japanese study  did not report on TMJ sounds, but prevalence of clicking (46%) and crepitation (19%) was higher in their sample. In a random telephonic survey,  11% of the North American subjects reported the same. Although one may argue whether joint clicking represents a pathologic condition or simply a normal variation in the population,  it appears that the prevalence rates for clicking are slightly higher in women than in men. The factors more prevalent in women, such as joint laxity,  have not been investigated. This may again be related to the presence of pain or it may be a reflection of the higher prevalence of certain systemic arthritic conditions in women. 
Masticatory muscle tenderness was found in 2.7% of the study sample and it was more (3%) in the age group of 31-50 years. Muscle tenderness was more among women (4.1%) when compared to men (2.1%) (P < 0.002). In contrast, in the German study,  masticatory muscle tenderness was found in 12% of the subjects. The prevalence rates reported in Swedish  and Japanese  samples were 19% and 21%, respectively. The Finnish study  and another Swedish study  also reported frequency of 6-16% and 19-36%, respectively. Signs and symptoms were significantly more frequent among women than men (24.0% vs. 14.0%  and 23.3% vs. 18.2%  ), the latter not being significant. The German study also reported no significant difference (12.4% vs. 78%) among the older subjects (60-80 years old).  Significant age differences existed in the German study  only among men aged 40-59 years who exhibited fewer muscular symptoms. This was also the case in the Swedish sample  for the men over 80 years. Significantly higher prevalence values were documented by the Finnish and Swedish groups , for the 65-year-old age group and by the Japanese group  for the 20-39 year old subjects. Other studies ,, reported 20% pain in the masticatory system. Women tended to report symptoms more frequently (P < 0.10) than did men and had more severe symptoms (23% vs.12%); 73% of the men and 63% of the women were symptom-free, in accordance with others findings. ,, Contradictory studies suggest, however, that symptoms of TMD occur equally often in men and women, or more often in men. ,,
Joint tenderness was present in 3.2% of the population and was maximum in the age group of >50 years. Females showed a higher prevalence of joint tenderness (4.8%) when compared to males (2.4%), with a high significance (P < 0.001). TMJ tenderness upon palpation was reported to be 4.9% in the German study,  5% in the Finnish sample,  2% in Swedish subjects,  and 6% of the sample in Japanese subjects.  Overall, there was a significant gender difference: Women were significantly more often affected than men. The German study found the proportion to be 6.4% versus 3.3% in 20-59 year old subjects.  The Japanese study  found 7.6% of the women and 3.6% of the men to be affected. Only in the Swedish sample, no gender-related differences (5%) were reported.  None of the studies reported significant age differences. As part of the national health interview survey, which was administered by telephone to a large representative sample of the US population, joint tenderness was reported in 7% of women and 3.5% of men.  The highest rates were found in 18-34-year-old subjects, and the rates declined with age. Another study in Sweden  showed joint tenderness to range from 0.5% to 7.9% with an overall rate of 2.5% for men and 4.9% for women and the highest rates of joint pain were found in the oldest age group, which corresponds to the findings of our study.
Referred pain was present in 0.9% of the study subjects and was more prevalent (1.5%) in the age group of 18-30 years, which showed high significance. Referred pain was more among females (1.1%) than males (0.7%). In a telephone survey of adult residents of Toronto, Ontario,  9.5% of women and 5% of men reported experiencing pain in the face just in front of the ears. Prevalence rates of pain were slightly higher in those under age 45 years (8.3%) than in those 45 years of age and older (7.2%). An American study  demonstrated that 8% of men and 15% of women reported such pain. Rates peaked in the age group of 25-44 years, with 10% of men and 18% of women in this age group reporting pain; rates were quite low (0% for men and 2% for women) in those above 65 years of age. A telephone survey of the French-speaking population reported pain around the temporomandibular region which was found to be highest among 35-54 year olds, with 6.8% of men and 10.4% of women reporting frequent episodes of pain. 
Pain on mouth opening was evident in 2.3% of our study population. Also, 3.5% of those in the age group of >50 years experienced maximum pain on mouth opening. Females experienced more pain on mouth opening (3.6%) when compared to men (1.7%), and it was statistically significant (P = 0.001). The German study  reported pain upon mouth opening in 1.2% of the subjects and this symptom was more frequent among women than men in the age group of 40-59 years (2.1% vs. 0.4%), which corresponds to the findings of our study. Swedish studies , reported the prevalence of pain on mouth opening to be 3% and 0.7% in females and males, respectively, in their samples. Both these studies detected no significant age- and gender-based differences.
Deviation of mandible on mouth opening was reported by 42.1% of individuals in the present study; 75.2% of individuals in the age group of >50 years reported deviation of mandible on mouth opening more frequently. Deviation on mouth opening was prevalent in 62.3% of the subjects in 31-50 years age group, with the least rate being reported in those belonging to 18-30 years age group (18%) (P < 0.001). Females showed a slightly higher prevalence of deviation (44.9%) when compared to males (40.5%) (P = 0.020). Our study reported the highest prevalence of deviation of mandible on mouth opening (42.1%) when compared to the German and Danish studies, , which reported irregular jaw movements such as deviation and deflection in 28.3% and 28.9% of the population, respectively, and women were found to be significantly more affected than men (33% vs. 23.5% and 34.8% vs. 23.4%, respectively).
Limitation of mouth opening of <40 mm was present in 11.4% of the subjects in our study. Very high prevalence was found (61.6%) in >50 years age group (P < 0.001). Females reported higher prevalence of limitation of mouth opening (13.9%) when compared to males (10.1%) (P = 0.002). The German study  reported the rate of limited mouth opening to be 9.1% in its sample. Similar results were found in the Swedish (6% and 5.2%, respectively) studies. , The Danish sample  and the Japanese sample  showed rates of 8.1% and 5%, respectively. The study performed in Germany  reported gender-related differences for this variable in the 40-59 years age group, in which women exhibited limited mouth opening more frequently than men (9.6% vs. 6.1%). With the exception of the Swedish study  which did not report any pronounced gender-based differences, all the other studies documented a higher prevalence for women than for men (8.0% vs. 3.0%  and 11.0% vs. 5.5%  ). In the Japanese population, these differences were not significant. With the exception of the latter, all studies including this study described a significant increase in prevalence with age or a more frequent occurrence of symptoms in the older age groups. In the nine variables that were compared between studies, significantly higher prevalence was reported for women than for men. Statistically significant age- and gender-based differences were found in four out of the nine variables studied by us: Joint sounds, crepitus, deviation of mandible on mouth opening, and limitation on mouth opening. A review on epidemiological literature about TMD found TMD to be approximately twice as common in women as in men. 
Parafunctional habits like bruxism and gum chewing are associated with TMDs.  The prevalence of bruxism and gum chewing was 5.2% and 2.1%, respectively, in our study. Prevalence of bruxism was higher in those >50 years of age (6.5%), while gum chewing was higher among those in the age group of 31-50 years (2.6%). Males showed a higher prevalence of bruxism (5.5% vs. 4.5%) and gum chewing (2.3% vs. 1.6%) as parafunctional habits when compared to females. No significant difference was found. Two studies , found a significant association between bruxism and TMD, which reported that subjects with any degree of bruxism had a higher rate of TMD than those who showed no degree of bruxism. On the other hand, two studies , did not find significant differences between bruxism and TMDs.
Research diagnostic criteria (RDC) have grouped three main conditions of TMD:
- Disc disorders or internal derangement, and
- Osteoarthritis. Our study was based on the RDC/TMD system of classification of TMDs.
In our study, the prevalence of MPDS was 0.8% (P < 0.001). MPDS was most prevalent in the age group of 18-30 years. Females showed higher prevalence of MPDS (1%) than males (0.7%). Prevalence of internal derangement was 38.3%, and it was more in the age group of 18-30 years (62.5%) (P < 0.001). Regarding gender wise distribution, internal derangement was more prevalent in males (38.5%) when compared to females (37.9%). Osteoarthritis was reported in 14.6% of the study sample, with more than 90% occurring in people >50 years of age (P < 0.001). Females exhibited higher prevalence of osteoarthritis (20.2%) when compared to males (11.7%) (P < 0.001). In a retrospective study,  the prevalence of MPDS was 35.2%, disc disorders 44.8%, and osteoarthritis 13.4%. In another study by the same author,  the prevalence of MPDS was 18.1%, disc disorders 31.4%, and osteoarthritis 27.2%.
| Conclusion|| |
A significant percentage of the population has signs of TMDs. In our study, more than half of the study sample (53.7%) had one or more clinical signs and symptoms of TMD. Deviation of mandible on mouth opening (42.1%) and clicking sound (38.6%) made up the highest percentage. Females >18 years reported higher prevalence of TMD signs and symptoms than men. However, these differences were not significant for all signs and symptoms in all age groups. The influence of age on signs and symptoms of TMD was less pronounced, with the exception of crepitation as well as limited maximum mouth opening, which significantly increased with age in both males and females. This is the first field-based study to record the symptoms of TMDs without the patient actually reporting to have them. The results of this study show that a significant percentage of the population has signs of TMDs and there are chances that they may develop symptoms of TMDs.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]