www.scielo.

br/jaos
http://dx.doi.org/10.1590/1678-775720130054

Is there an association between anxiety/

depression and temporomandibular disorders in
college students?
Letícia Bojikian CALIXTRE¹, Bruno Leonardo da Silva GRÜNINGER¹, Thais Cristina CHAVES², Ana Beatriz de
OLIVEIRA¹

1- Department of Physical Therapy, Federal University of São Carlos (UFSCar), São Carlos, SP, Brazil.
2- Department of Neurosciences and Behavioral Sciences, University of São Paulo (FMRP/USP), Ribeirão Preto, SP, Brazil.

Corresponding address: Letícia Bojikian Calixtre - Universidade Federal de São Carlos, Departamento de Fisioterapia - Via Washington Luis, Km 235 - CP
676 - 13565-905 - São Carlos - SP - Brazil - e-mail: [email protected] - Phone: +55 16 33519793 - Fax: +55 16 33612081

Submitted: January 28, 2013 - Modification: September 5, 2013 - Accepted: October 7, 2013

abstract

O bjective: Considering the high incidence of Temporomandibular Disorders (TMD) in

the population aged 15–30 years and the fact that students are exposed to stressful
psychosocial factors, the purposes of this study were: to verify clinical symptoms and jaw
functionality in college students with TMD according to the anxiety/depression (A/D) level
and to evaluate the correlation between A/D and functionality, maximum mouth opening
(MMO) and pain and muscle activity. Material and Methods: Nineteen students with TMD
diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders
underwent two assessments during an academic semester. The evaluations were based on
questionnaires (MFIQ - Mandibular Function Impairment Questionnaire; HADS - Hospital
Anxiety and Depression Scale), clinical measurements (MMO without pain, MMO and assisted
MMO; palpation of joint and masticatory muscles), and electromyography. The HADS scores
obtained in the two assessments were used to classify all data as either “high” or “low”
A/D. Data normality, differences and correlations were tested with the Shapiro-Wilk test,
Student’s t-test (or the Wilcoxon test), and Spearman test, respectively. The alpha level
was set at 0.05. Results: None of the clinical variables were significantly different when
comparing low and high A/D data. In low A/D there was a significant correlation between
HADS score and: MFIQ (P=0.005, r=0.61), and MMO without pain (P=0.01, r=-0.55).
Conclusions: Variation in A/D level did not change clinical symptoms or jaw functionality
in college students with TMD. Apparently, there is a correlation between TMJ functionality
and A/D level, which should be further investigated, taking into account the source of the
TMD and including subjects with greater functional limitation.

Keywords: Physical therapy specialty. Electromyography. Facial pain. Temporomandibular

joint. Anxiety. Depression.

Introduction parafunctional habits or alterations secondary to

stress1.
Temporomandibular disorder (TMD) is a general The prevalence of TMD symptoms among the
term that refers to disorders associated with the general population is around 40% 15. Focusing
temporomandibular joint (TMJ) and the masticatory on university students, Casanova-Rosado, et al.8
muscles1. Due to the complexity of the masticatory (2006) found a TMD prevalence of 46.9% and
system, TMD symptoms may be caused by different Shiau and Chang23 (1992) reported a prevalence
physiological and/or psychosocial factors, such as of 42.9%. These results are also applicable to
malocclusion and occlusal interferences, alterations Brazilian students: the reported TMD prevalence
in the masticatory muscles, direct trauma to the for this population ranges from 53.21%19 to 68%20.
jaw or TMJ, microtrauma caused by continuous TMD is often associated with somatic and

J Appl Oral Sci. 15 2014;22(1):15-21

 Is there an association between anxiety/depression and temporomandibular disorders in college students?

psychological complaints, including fatigue, sleep the Federal University of São Carlos (UFSCar),
disturbances, anxiety, and depression 6,8,24,29 . Brazil, according to anxiety and depression level
Moreover, psychosocial factors vary according to the variation during an academic semester.
etiologic subgroup of diagnosis. In general, these
factors are more frequently observed in patients Subjects
with myogenous TMD2,21,28. In 2008, Restrepo, et All of UFSCar’s undergraduate Physical Therapy
al.21 (2008) reported that children with bruxism students were invited to participate. A total of
had a significantly higher-tension personality 116 volunteers, 32 men and 84 women (mean
and were more prone to anxiety, as well as had age 20.87, SD: 1.96 years), signed a term of
more TMD signs and symptoms, than a control informed consent and responded to the Fonseca
group. Bonjardim, et al.6 (2005) evaluated TMD Anamnesis Index (FAI)4,12. Subjects with moderate
patients and found no evidence of either anxiety or severe signs and symptoms of TMD according to
or depression symptoms according to the Hospital FAI were examined by two trained evaluators, as
Anxiety and Depression Scale (HADS), although the recommended by the Research Diagnostic Criteria
TMD level was shown to be significantly related to for Temporomandibular Disorders (RDC/TMD)
anxiety but not to depression. consortium (http://www.rdc-tmdinternational.org).
The prevalence of mental health problems and Students not diagnosed with TMD were excluded.
subsyndromal symptoms in Australian students25 Therefore, 19 subjects (18 women and 1 man;
was 19.2% and 67.4%, respectively. These rates mean age of 20.66±1.59 years-old) were evaluated
were significantly higher than those of the general at two different moments of the academic semester,
population. Psychological distress was associated with an interval of 4 months. Figure 1 shows the
with disability and lower academic achievement. study flowchart.
The identified predictors of distress were full-time The study was approved by the local Ethics
status, financial stress, age between and 18 and Committee (permission number 234/2010).
34 years-old, being female, and in a subsequent
undergraduate year of their degree. Instruments and evaluation procedures
Tsai, et al. 27 (2002) studied the influence The RDC/TMD 11 was created to establish a
of an experimental stress situation on the proper criterion for diagnosing subjects with some
electromyographic activity of masticatory muscles.
They observed increased masseter activation
during stress, which decreased in a relaxing
situation. Considering that stress is associated with
psychological disturbances such as anxiety and
depression13 and that there are no published studies
observing the modulation of signs and symptoms
of TMD according to anxiety and depression level
in college students, the objectives of the present
study were (1) to verify clinical symptoms and jaw
functionality in college students with TMD according
to the level of anxiety/depression (A/D) evaluated
in two different moments, and (2) to evaluate
the correlation between A/D and functionality,
maximum mouth opening (MMO), pain and muscle
activity.
It was hypothesized that: (1) clinical symptoms
would be greater and jaw functionality more
Figure 1- Study flowchart. The descriptions of excluded
impaired in college students with TMD when the
level of A/D is higher; (2) this could indicate a subjects are in the dashed boxes. Description of the
possible correlation between A/D and clinical instruments applied at each moment and the number of
measures of TMD. All subjects were addressed in subjects evaluated are in the dotted boxes
two different moments in order to obtain data of (M=Men, W=Women, FAI=Fonseca Anamnesis
both high and low A/D level. Index, TMD=Temporomandibular Disorders, RDC/
TMD=Research Diagnostic Criteria for Temporomandibular
Material and Methods Disorders, MFIQ=Mandibular Function Impairment
Questionnaire, HADS=Hospital Anxiety and Depression
Study design Scale, EMG=Electromyography). *Data from 3 subjects
This was a longitudinal study investigating TMD
were excluded due to technical problems identified during
in undergraduate Physical Therapy students from
EMG signal analysis

J Appl Oral Sci. 16 2014;22(1):15-21

 CALIXTRE LB, GRÜNINGER BLS, CHAVES TC, OLIVEIRA AB

TMJ compromise. It is a dual-axis system that can alcohol. The signals were conditioned by the main
be used to classify and quantify both physical and amplifier (Bagnoli-8 EMG System, Delsys), which
psychosocial components of TMD. The diagnostic provided a gain of 1000, a bandwidth of 20–450
system is nonhierarchical and allows for the Hz, and noise of 1.2 µV (RMS). The signals were
possibility of multiple diagnoses for a given subject. sampled at 2000 Hz using a PC workstation with a
The three possible types are: muscle disorders (I), 16-bit A/D card (PCI-6034E, National Instruments
disc displacement (II) and joint disorders (III), with Corporation, Austin, TX, USA) and the EMGworks
types I and III being the most common among software (version 3.0, Delsys).
TMD patients17. This protocol was applied once for Muscle activity was recorded under three
diagnostic purposes. conditions: at rest, maximum voluntary isometric
The Hospital Anxiety and Depression Scale contraction (MVIC), and free chewing. Throughout
(H ADS), Mandibular Function Impairment the test, the subjects sat on a chair without head
Questionnaire (MFIQ), clinical measurements and support and were told to keep their hands on their
electromyography of masticatory muscles were knees and their trunk to the chair back with their
applied/recorded in the two evaluations. The head in a natural upright position. For the at-rest
HADS30 was translated to Portuguese and validated condition, the signal was recorded while the subjects
in 20069. Each item is scored from 0 to 3, with a maintained their mouths closed without occluding
maximum score of 42 points. A high score indicates the teeth. Three MVIC trials were then recorded
a high level of A/D. using two rolls of cotton (10 mm diameter) placed
The MFIQ14 measures the severity of functional between the upper and lower second premolars/
limitation caused by TMD. The score ranges from 0 to first molars of the subjects, who were instructed
5 – the higher the score, the greater the limitation. to bite as hard as possible for 5 seconds. Two
The Portuguese version of the questionnaire was minutes of rest were allowed between trials. For
validated by Campos, et al.7 in 2012. the chewing condition, the subjects were instructed
Some clinical measures included in the RDC/ to chew a piece of parafilm5 6 times in order to
TMD protocol were also recorded: MMO without reduce the volume and to adjust the material. The
pain, MMO and assisted MMO; bilateral palpation muscle activity was recorded over a period of 20
of TMJ structures, including masticatory muscles seconds, and normalization was based on the MVIC
(masseter, temporalis, posterior area of the jaw, recording. The baseline signal, recorded during rest,
submandibular region, lateral pterygoid area and was subtracted from the signal recorded during
tendon of the temporalis muscle) as well as joint mastication to remove the noise.
structures (TMJ lateral pole and posterior ligament).
A caliper was used for all opening measures. Based Data processing
on palpation of the TMJ structures, the variable The data collected in the HADS and MFIQ
“number of tender points” was calculated. instruments, as well as the clinical measures, were
The electromyography examination (EMG) computed according to their respective protocols.
consisted of recording the electrical activity of The EMG signals were processed using a Matlab®
the anterior temporal and masseter muscles on (version 7.0.1, MathWorks Inc., Natick, MA, USA)
the most painful side of each subject’s face. For routine. All signals were band-pass filtered by a
subjects with bilateral involvement, the side to be fourth-order zero-lag Butterworth filter at 20–400
recorded was randomized. Active single differential Hz. They were converted into RMS using 20 ms
surface electrodes (Model #DE-2.1, Delsys, Boston, windows with 50% overlap. These data were
MA, USA) with two parallel silver bars (1 mm x normalized by the highest RMS value of the three
1 cm) separated by 1 cm were attached to the MVIC. The RMS value of the signal obtained at rest
skin using a double-sided interface (Delsys). The was subtracted from the signals in order to remove
electrode characteristics included: RRMC>80 dB, the noise. The average RMS amplitude of each
input impedance>1015 W in parallel, with 0.2 pF, muscle and the activation time were also calculated
a voltage gain of 10 and noise of 1.2 µV (root (total time of muscle activity during chewing).
mean square, RMS). They were placed on the Data obtained from each subject in the two
muscle belly parallel to the muscle fibers3. On the evaluations were divided into two data sets,
anterior temporalis muscle, the electrode was fixed according to HADS score: low A/D and high A/D. The
vertically along the anterior portion near the coronal HADS scores were classified by direct comparison of
suture. On the masseter muscle, the electrode was individual data. After that, all other variables were
positioned at the portion with the highest volume, also divided in low and high A/D.
identified by palpation26. A square self-adhesive
electrode with a 5 cm side was used as a reference Statistical analysis
and fixed to the sternal notch. Before attaching the Data analysis was performed with Statistica
electrodes, the skin was shaved and cleaned with software (v7, StatSoft Inc., Tulsa, OK, USA). The

J Appl Oral Sci. 17 2014;22(1):15-21

 Is there an association between anxiety/depression and temporomandibular disorders in college students?

Shapiro-Wilk test was used to verify the normality symptoms of TMD. Fifteen (13.0%) were classified
of the data. In order to compare data from the same as having moderate and eight (7%) as having
subject at two different moments (high A/D and low severe signs and symptoms of TMD. The other 33
A/D), either Student’s t-test for paired samples or students (28.4%) were classified as healthy.
the Wilcoxon test was applied, according to data According to the RDC/TMD (Axis I and Axis
distribution. The effect size was also calculated, II), five subjects presented TMD type I (muscle
and classified as small for values between 0.20 disorders), five TMD type III (disc displacements),
and 0.49; moderate for values between 0.50 and and nine mixed TMD. No subject presented only
0.79, and large for values larger than 0.810. For both disc displacements (type II). Six subjects presented
data sets (high A/D and low A/D), the correlation unilateral compromise on the right side, seven on
between all variables and the HADS score was the left side and six presented bilateral compromise.
tested using Spearman correlation coefficients (SC). The data from the questionnaires, clinical
The strength of the relationship was considered measurements and EMG for both high and and low
“weak” when SC ranged from 0 to 0.25, “low” from A/D are shown in Table 1.
0.26 to 0.49, “moderate” from 0.50 to 0.69, “high” There was a significant difference between the
from 0.70 to 0.89 and “very high” above 0.9022. The HADS score for low and high A/D (T test, P=0.0005,
alpha level was set at 0.05 for all analyses. ES=0.83), with a mean difference of 40%. The MFIQ
score was higher for the high A/D, but there was no
Results significant difference between the low and high A/D
conditions (T test, p=0.08, ES=0.582). The same
The FAI results indicated a 70.6% prevalence was observed for the MMO measures (Table 1).
of TMD signs and symptoms (from light to severe) EMG data are shown in Table 2. Since some
among the evaluated students. Most (n=60; signals were compromised by the presence of
51.6%) were classified as having light signs and electrical noise, three subjects were excluded.

Table 1- Mean, standard deviation (SD), 95% confidence interval (CI), p-value and effect size of HADS and MFIQ scores,
MMO in millimeters and number of tender points (n=19)

Variables High A/D Low A/D P value Effect size

mean (SD) 95% CI mean (SD) 95% CI
HADS score 12.10 (6.91) 8.7-15.4 8.57 (6.25) 5.55-11.58 0.0005 0.838
MFIQ score 1.21 (1.18) 0.6-1.71 0.79 (1.08) 0.26-1.31 0.08 0.582
MMO without 31.15 (9.38) 26.6-35.6 30.21 (11.00) 24.9-35.5 0.75 0.141
pain
MMO 42.05 (6.36) 38.9-45.1 39.73 (8.25) 35.7-43.7 0.19 0.467
MMO with 45.26 (6.51) 42.1-48.3 43 (7.61) 39.3-46.6 0.23 0.492
assistance
Nº of tender 12 (5.00) 9.5-14.4 12.73 (6.59) 12.7-15.9 0.47 -0.184
points

MFIQ=Mandibular Function Impairment Questionnaire; HADS=Hospital Anxiety and Depression Scale, MMO=maximum
mouth opening

Table 2- Mean, standard deviation (SD), 95% confidence interval (CI), p-value and effect size of EMG data obtained during
free chewing, recorded on the affected side (n=16)

Variables High A/D Low A/D P-value Effect Size

mean (SD) 95%CI mean (SD) 95%CI
Mean RMS (%MVIC) AT 0.33 (0.17) 0.23-0.42 0.31 (0.13) 0.24-0.37 0.8 0.195
M 0.27 (0.16) 0.18-0.35 0.25 (0.13) 0.18-0.31 0.8 0.208
Activation time (s) AT 13.03 (4.82) 10.4-15.5 12.54 (5.01) 9.87-15.2 0.77 0.157
M 14.09 (4.42) 11.7-16.4 15.99 (5.32) 13.1-18.8 0.14 -0.59

AT=anterior temporalis; M=masseter; MVIC= maximum voluntary isometric contraction; A/D= anxiety/depression
EMG=Electromyography

J Appl Oral Sci. 18 2014;22(1):15-21

 CALIXTRE LB, GRÜNINGER BLS, CHAVES TC, OLIVEIRA AB

Figure 3- Correlation analysis of HADS score and MMO

Figure 2- Correlation analysis of HADS score and MFIQ without pain in low A/D
in low A/D HADS=Hospital Anxiety and Depression Scale,
HADS=Hospital Anxiety and Depression Scale, MMO=maximum mouth opening, A/D=Anxiety/
MFIQ=Mandibular Function Impairment Questionnaire, Depression
A/D=Anxiety/Depression

Table 3- Spearman correlation coefficient and p-values between HADS score in high and low A/D for all variables addressed

High A/D Low A/D

r p-value r p-value
MFIQ score 0.21 0.38 0.61 0.005
MMO without pain (mm) -0.13 0.58 -0.55 0.01
MMO (mm) -0.07 0.75 -0.45 0.053
MMO with assistance (mm) -0.14 0.54 -0.44 0.053
Nº of tender points 0.07 0.76 0.24 0.3
Mean RMS - AT (%MVIC) 0.2 0.44 0.21 0.41
Mean RMS - M (%MVIC) -0.04 0.87 0.23 0.37
Activation time - AT (s) -0.14 0.58 -0.01 0.95
Activation time - M (s) -0.33 0.2 -0.01 0.95

AT=anterior temporalis; M=masseter; MMO=maximum mouth opening; MFIQ=Mandibular Function Impairment

Questionnaire; HADS=Hospital Anxiety and Depression Scale, A/D=Anxiety/Depression

Thus, the data from 16 subjects were used in this Discussion

analysis. No difference was found in EMG data when
comparing high and low A/D (P>0.05). The results of this study showed that even
There was no correlation between the variables though college students with TMD presented A/D
in high A/D. Otherwise, as presented in Table 3, changes during the semester according to the
the correlation between HADS and MFIQ scores HADS, clinical variables directly related to TMD
for low A/D condition was positive and moderately did not change during the same period. This
significant (SC, P=0.005, r=0.61) - Figure 2. In result refutes the first hypothesis of the study.
low A/D, a negative and moderately significant Furthermore, in the low A/D condition, a significant
correlation was also observed between HADS correlation was found between the level of A/D
score and MMO without pain (SC, P=0.01, r=- and some clinical measurements (MFIQ and MMO
0.55) - Figure 3. Moreover, two variables presented without pain), which partially confirms the second
borderline p-values: MMO and number of tender hypothesis.
points (Table 3). The significant variation of anxiety and depression
levels identified between the two evaluations was
expected, which may reflect emotional oscillations

J Appl Oral Sci. 19 2014;22(1):15-21

 Is there an association between anxiety/depression and temporomandibular disorders in college students?

due to personal and academic activities that the instrument applied to measure anxiety and
affected anxiety and depression levels during depression does not evaluate the same psychological
the semester. However, based on the available dimension as other studies that have investigated
literature, we expected that the clinical variables the association between EMG and stress. Future
related to TMD would also change. A coexistence studies intending to explore the variation of
of signs and symptoms of TMD and psychological psychological factors and their influence on clinical
complaints is reported in the literature, and some TMD variables should use other questionnaires
studies dealing with this subject have already than the HADS or create stressful situations, just
been briefly described above 6,8,24,29. Moreover, as studies reported in the literature27.
Monteiro, et al.18 (2011) also identified a significant Even though difference in clinical TMD measures
correlation between anxiety levels and degree of at different A/D levels was not identified, the
orofacial pain in university students, although they data did indicate a correlation between A/D level
used different instruments to classify and quantify and some variables, particularly in the low A/D.
the observed variables. Giannakopoulos, et al.14 A moderate negative correlation between MMO
(2010) used HADS to investigate the prevalence of without pain and HADS score was observed, as well
anxiety and depression in subjects with TMD type I as a moderate positive correlation between TMJ
(muscle disorders), TMD type III (joint disorders) functionality (MFIQ score) and HADS score. The fact
and healthy controls, as well as the prevalence of that the correlations were observed only in those
chronic facial pain. Although the anxiety scores of with low A/D may be related to the heterogeneity
both TMD groups were similar, there was a higher of the sample. Considering that women with
prevalence of depression in those with TMD type clinical symptoms of TMD type I have higher rates
I than with type III, particularly among women. of depression14, the correlation between A/D and
Finally, Bonjardim, et al.6 (2005) evaluated TMD TMD clinical variables would be better investigated
patients and found no evidence of either anxiety if taken into account the type of TMD. The relatively
or depression among the subjects in their sample. small number of subjects did not allow the sample
However, they found that TMD level was significantly to be divided according to TMD type. Furthermore,
related to anxiety. it should be pointed out that even though all of the
Bearing in mind the positive relationship between subjects were diagnosed with TMD, most of them
TMD and psychological factors, higher levels of did not present relevant functional impairment
anxiety and depression should lead to a lower of the TMJ. We believe that the investigation of
MMO, reduced functionality and a greater number subjects with greater functional limitation could
of tender points, as well as greater electrical activity provide additional and more conclusive information.
in the masticatory muscles27. This, however, did not Finally, the study has certain limitations that
turn out to be the case in our sample, which could should be considered. The first is the size and
be explained by the HADS scores of subjects in the heterogeneity of the sample. A larger sample
the high A/D condition. According to the literature, would probably bring up more conclusive results
HADS scores over 13 points indicate the presence regarding TMJ functionality (evaluated by the
of anxiety and depression16. The high A/D reported MFIQ). Moreover, further studies should consider
in this study refers to a mean HADS score of 12.10: the type of TMD (according to RDC/TMD) in order
seven of the 19 subjects scored over 13. So, even to assess the influence of anxiety and depression on
though the subjects in the high A/D condition had clinical indicators of dysfunction. The evaluation of
elevated HADS scores, most of them did not present subjects without TMD would also provide additional
anxiety or depression according to HADS. In most of information and help to interpret the results.
the subjects, the variation observed between “high” Another limitation is the fact that the subjects
and “low” A/D occurred in a “healthy” condition. were not severely anxious/depressed. It is possible
Therefore, the variation of A/D was probably not that the variation in psychosocial indicators was
enough to change clinical TMD measures (MMO, not enough to influence the clinical TMD variables
functionality, number of tender points and muscle analyzed in the study. The subjects were recruited
activation). from a sample of students who were not under
Considering the association between stress and treatment for orofacial pain and had not been
psychological disturbances such as anxiety and referred for rehabilitation by a doctor or a dentist.
depression13, it was expected a variation of the Therefore, further studies should evaluate subjects
masseter and temporal electrical activity according with higher levels of anxiety and depression and
to the level of A/D. However, this behavior was not functional impairment.
observed, probably due to the small variation in
A/D. It is likely that the variation observed among
the subjects was not enough to change muscular
activation. In addition to that, we believe that

J Appl Oral Sci. 20 2014;22(1):15-21

 CALIXTRE LB, GRÜNINGER BLS, CHAVES TC, OLIVEIRA AB

Conclusions 12- Fonseca DM, Bonfante G, Valle AL, Freitas SF. Diagnóstico pela
anamnese da disfunção craniomandibular. RGO (Porto Alegre).
1994;42:23-8.
Although the college students’ anxiety and 13- Gameiro GH, Silva Andrade A, Nouer DF, Ferraz de Arruda
depression level changed over the 4 month Veiga MC. How may stressful experiences contribute to the
academic semester, no difference in TMD signs development of temporomandibular disorders? Clin Oral Investig.
and symptoms was observed in subjects with 2006;10:261-8.
14- Giannakopoulos NN, Keller L, Rammelsberg P, Kronmüller
either high or low levels of anxiety and depression.
KT, Schmitter M. Anxiety and depression in patients with chronic
The correlation identified between anxiety and temporomandibular pain and in controls. J Dent. 2010;38:369-76.
depression and some clinical variables in the low 15- Gonçalves DA, Dal Fabbro AL, Campos JA, Bigal ME, Speciali
A/D condition suggests an association between JG. Symptoms of temporomandibular disorders in the population:
these factors, which should be better investigated, an epidemiological study. J Orofac Pain. 2010;24:270-8.
16- Hinz A, Brähler E. Normative values for the hospital anxiety
taking the origin of TMD into consideration, in
and depression scale (HADS) in the general German population.
subjects with greater functional impairment. J Psychosom Res. 2011;71:74-8.
17- Manfredini D, Arveda N, Guarda-Nardini L, Segù M, Collesano
Acknowledgments V. Distribution of diagnoses in a population of patients with
temporomandibular disorders. Oral Surg Oral Med Oral Pathol
Oral Radiol. 2012;114:e35-41.
The authors are grateful to Professor Débora
18- Monteiro DR, Zuim PR, Pesqueira AA, Ribeiro PP, Garcia
Bevilaqua Grossi for a careful reading of the AR. Relationship between anxiety and chronic orofacial pain of
research project and for suggestions, and to São temporomandibular disorder in a group of university students. J
Paulo Research Foundation (FAPESP) for financial Prosthodont Res. 2011;55(3):154-8.
support (grant 2010/15872-5). 19- Nomura K, Semprini M, Siéssere S, Eduardo J, Hallak C,
Cecilio S, et al. Use of the Fonseca´s questionnaire to assess
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