CHRONIC TEMPOROMANDIBULAR DISORDER

The Professional Medical Journal

www.theprofesional.com
ORIGINAL PROF-0-3709
DOI: 10.29309/TPMJ/2019.26.10.3709

1. BDS, FCPS
Senior Registrar
“EVALUATION OF FREQUENCY OF ANXIETY AND DEPRESSION
Department of Oral and Maxillofacial
Surgery
AMONG PATIENTS WITH CHRONIC TEMPOROMANDIBULAR
Dr. Ishrat-ul-Ebad Khan Institute of
Oral Health Sciences (DIKIOHS),
DISORDER.”
Dow University of Health Sciences.
Karachi, Pakistan. Arfa Baig1, Bushra Ghani2, Oam Parkash3, Lubna Memon4, Shoaib Muhammad Chohan5,
2. BDS, FCPS-II Resident.
Department of Operative Dentistry.
Daud Sultan6
Altamash Institute of Dental ABSTRACT: The Temporomandibular Disorder (TMD) has been considered as one of the most
Medicine, Karachi, Pakistan.
3. BDS, MOMS RCSEd commonest disorder in Pakistan. In this disorder, the patient complains of pain in Temporomandibular
joint and associated anatomical muscles. This research study has been performed to evaluate
4. BDS, FCPS the frequency of Anxiety and Depression in patients with Chronic Temporomandibular Disorder
Senior Registrar (CTMD). Objectives: The objective of this research study is to evaluate the frequency of Anxiety
Department of Prosthodontics
Dr. Ishrat-ul-Ebad Khan Institute of and Depression among patients with Chronic Temporomandibular joint Disorder. Study Design:
Oral Health Sciences (DIKIOHS), A Cross-sectional Descriptive research study. Setting: This research study was conducted in
Dow University of Health Sciences. the Department of Oral and Maxillofacial Surgery at Dr. Ishrat-ul-Ebad Khan Institute of Oral
Karachi, Pakistan.
5. BDS, MDS
and Health Sciences (DIKIOHS), Dow University of Health Sciences and Dr. Ruth K.M. Pfau
Lecturer Civil Hospital, Karachi, Pakistan. Period: This research study was conducted for a respective
Department of Oral and Maxillofacial period of 1 year from 1st March 2018 to 1st March 2019. Materials and Methods: A total of 213
Surgery patients having persisting pain in Temporomandibular Joint for a time period of more than 6
Dr. Ishrat-ul-Ebad Khan Institute of
Oral Health Sciences (DIKIOHS), months were included in this study. A diagnosis of Chronic Temporomandibular Joint Disorder
Dow University of Health Sciences. (CTMD) was established if the patient demonstrated pain/discomfort in the Temporomandibular
Karachi, Pakistan. Joint (TMJ) and muscles of mastication and masticatory dysfunction for a period, exceeding
6. BDS, FCPS 6 months. After demographic questions, Hospital Anxiety and Depression Scale (HADS) was
Assistant Professor
Department of Oral and Maxillofacial administered to each patient and the intensity and severity of Anxiety and Depression were
Surgery recorded and documented by the Operator. Results: The percentage of Anxiety and Depression
Dr. Ishrat-ul-Ebad Khan Institute of among patients with Chronic Temporomandibular Disorder (CTMD) was 31.46% (67/213) and
Oral Health Sciences (DIKIOHS),
Dow University of Health Sciences.
36.15% (77/213). Conclusion: In our respective study, the Frequency of psychological disorders
Karachi, Pakistan. like Anxiety and Depression were significantly high. Our results showed that an adequate and
profound diagnosis and treatment planning is very necessary for all patients suffering from
Correspondence Address: Chronic Temporomandibular Disorder (CTMD) so that both physical and psychological factors
Dr. Bushra Ghani
Flat No: 301, Golden Palm
of patients with Chronic Temporomandibular Disorder (CTMD) should be taken into primary
Apartments, foremost consideration prior to the decision pertaining to its management respectively.
Bahadur Yar Jung Cooperative
Housing Society (B.Y.J.C.H.S),
Key words: Anxiety, Chronic Temporomandibular Joint Disorder (CTMD), Depression,
Bahaduradbad, Near EDHI Center,
Karachi, Pakistan. Hospital Anxiety and Depression Scale (HADS).
bushra.shekhani.aidm.edu@gmail.
com
Article Citation: Baig A, Ghani B, Parkash O, Memon L, Chohan SM, Sultan D. Evaluation
Article received on: of frequency of anxiety and depression among patients with chronic
11/05/2019 temporomandibular disorder. Professional Med J 2019; 26(10):1724-1732.
Accepted for publication:
25/07/2019
DOI: 10.29309/TPMJ/2019.26.10.3709
Received after proof reading:
30/09/2019

CLINICAL RELEVANCE the frequency of Anxiety and Depression have

This research study has strongly highlighted a remarkable impact in patients with Chronic
the significance of a proper understanding Temporomandibular joint (CTMD). Moreover; this
and knowledge of Temporomandibular Joint, research study can be a valuable aid in increasing
Muscles of mastication and the related significant phenomenal success in contemporary future
anatomical muscles; that can play an imperative dentistry.
role for the General Dental Practitioner, Restorative
Dental Practitioner, Endodontists as well as an INTRODUCTION
Oral and Maxillofacial Surgeon in the Diagnosis, The Temporomandibular Disorder (TMD), also
Case selection and Treatment planning, thereby termed as Temporomandibular Joint Disorder is
leading to an excellent patient management since considered as one of the most common disorder
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CHRONIC TEMPOROMANDIBULAR DISORDER 2

that is primarily encountered in general population permit multiple diagnoses, the novel popular
with a prevalence of up to 93%, reported in an classification scheme of Temporomandibular
epidemiological clinical study.1 In this disease, Joint Disorder (TMD) offers recommended
patient complains of pain in Temporomandibular guidelines for General Dental Practitioners,
Joint and its associated anatomical muscles. Both Specialists of all respective entities and those
somatic and psychogenic conditions like Anxiety conducting clinical interventional studies.16 This
and Depression are common with any Chronic scheme was primarily applied to population with
facial pain including Temporomandibular Joint Temporomandibular Joint Disorder (TMD) and
Disorder (TMD).2 Psychological and emotional controlled patients.
factors have been predominantly closely related
to Temporomandibular Joint Disorder (TMD) Many self assessment scales have been devel-
and should be considered as an integral part oped for the evaluation of Anxiety and Depres-
of clinical presentation.3 It has been reported sion in patients with Chronic Temporomandibular
that mental state4, like Anxiety, Depression Joint Disorder (CTMD).17 One of the most reliable
and negative effects are far more common in diagnostic tool; for detecting the state of Anxiety
patients with Temporomandibular Joint Disorder and Depression in patients with Chronic Temporo-
(TMD) as compare to healthy individuals.5 It has mandibular Joint Disorder (CTMD) is the “Hospi-
been reported, that somatic factors like Stress, tal Anxiety and Depression Scale (HADS)”.18 This
Depression and Anxiety the main etiological subscale, is primarily used to measure the inten-
factors in the initiation, predisposition and sity and severity of Hospital Anxiety and Depres-
perpetuation of Temporomandibular Joint sion that helps to determine the severity of emo-
Disorder (TMD).6 tional disorder. In terms of gender aspect, there
are no significant gender differences in level of
A research study conducted on adolescent Anxiety and Depression on Hospital Anxiety and
patients having signs and symptoms of Depression Scale (HADS).19 It has been demon-
Temporomandibular Joint Disorder (TMD), strated that by the introduction of a reliable scale
showed a prevalence of Anxiety and like; Hospital Anxiety and Depression Scale, all
Depression; 16.58% and 26.71% respectively.7 the patients having Chronic Temporomandibular
An epidemiological clinical; research study has Joint Disorder (CTMD) are extremely benefitted
reported a frequency of 39.8% of patients exhibiting in the detection and management. In this way, an
Temporomandibular Joint Disorder (TMD) and emotional disorder like Anxiety and Depression
experiencing moderate to severe depression in can be properly investigated at the very first in-
the psychological status assessment.8 stance, diagnosed and managed in all medical
and surgical department.20
Many epidemiological research studies9,10 have
suggested that patients with significant signs The rationale of this research study is to find
and symptoms of Chronic Temporomandibular out the burden of co-morbid emotional factors;
Joint Disorder (CTMD) have reported a higher Anxiety and Depression among patients of
prevalence of Anxiety and Depression and are Chronic Temporomandibular Joint Disorder
thereby more common than in patients with a (CTMD) and it is important to evaluate the
controlled group;11 therefore a higher frequency somatic and emotional factors; Anxiety and
of symptoms of Anxiety and Depression are Depression in patients with Temporomandibular
common in patients with Temporomandibular Joint Disorder (TMD), as a complete and
Joint Disorder (TMD).12 thorough understanding can improve the patient
management and treatment planning; especially
Many clinical studies13,14, have reinforced a in chronic patients. We hypothesized, that Anxiety
close association of Muscular tension, Anxiety, and Depression, the two emotional parameters
Depression and symptoms of Temporomandibular have a significant remarkable association in
Joint Disorder (TMD).15 One of the first to patients with Chronic Temporomandibular Joint
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CHRONIC TEMPOROMANDIBULAR DISORDER 3

Disorder (CTMD). The epidemiological data anxiolytics drugs, Patients who had received any
obtain from this study will create an awareness type of orthodontic treatment, Patients having
among the General dental practitioner, Oral and Temporomandibular Joint (TMJ) ankylosis,
Maxillofacial Surgeons, Endodontists and all the aplasia or hyperplasia contracture or hypertrophy
other respective Dental Specialities that both and neoplasm, Patients with pain in bone and joint
physical and psychological factors of patients disease, Radiation treatment to head and neck,
with Chronic Temporomandibular Joint Disorder Patients with previous Temporomandibular Joint
(CTMD) should be taken into consideration prior surgery, Neurological disorder, Rheumatological
to the decision of patient management. disorder and Pregnancy.

MATERIALS AND METHOD An approved consent was taken from the

This Cross-sectional Descriptive research study Ethical Review Board/Committee (ERC) of Dr.
was conducted in the Department of Oral and Ishrat-ul-Ebad Khan Institute of Oral and Health
Maxillofacial Surgery at Dr. Ishrat-ul-Ebad Khan Sciences(DIKIOHS) and Dr. Ruth K.M. Pfau
Institute of Oral and Health Sciences(DIKIOHS), Civil Hospital, Karachi, Pakistan prior to the
Dow University of Health Sciences and Dr. Ruth commencement of study. Before administration of
K.M. Pfau Civil Hospital, Karachi, Pakistan for questionnaire, the patients were briefly explained
a time period of 1 year from 1st March 2018 to about the purpose and nature of the study. They
1st March 2019 2018 respectively. A total of were ensured that their information was used for
(213) patients were selected; for this research the study purpose only and an Informed consent
study having Chronic Temporomandibular Joint was taken from them.
Disorder (CTMD); taking Confidence Interval
(C.I of 95% and Prevalence of 15.58% anxiety First of all, all demographic questions were used
and 26.71% of Depression9 and margin of error to gather information about the gender, age and
5% concluding a sample size of (213) patients marital status. After demographic questions,
including in this research study14 who attended Hospital Anxiety and Depression Scale (HADS)
the Oral and Maxillofacial Surgery Department was used on each patient to determine the
of Dr. Ishrat-ul-Ebad Khan Institute of Oral Health intensity of Anxiety and Depression. A respective
Sciences (DIKIOHS), Dow University of Health value of Depression score; ≥14 was considered
Sciences and Dr. Ruth K.M. Pfau Civil Hospital, as a profound state of “DEPRESSION” and <14
Karachi, Pakistan and fulfilling the particular was considered as Normal. An Anxiety score; ≥14
inclusion criteria. was considered as a profound state of “ANXIETY”
and <14 was considered as Normal.
The diagnosis of Chronic Temporomandibular
Joint Disorder (CTMD) was established after a All the relevant data and information were
detailed history taking procedure and a detailed collected and well documented by the Operator,
through examination of Patients. The inclusion entered into the IBM SPSS (Statistical Package
criteria for pertaining to this research study for the Social Sciences) version 25.0 and well
included patients of both genders (Males and analyzed accordingly. The Mean and Standard
Females) with 12-18 years of age; demonstrating deviation were used as quantitative variables to
pain and discomfort in the Temporomandibular evaluate the Age. Frequency and percentages
Joint (TMJ), dysfunctioning and pain of Muscles of was used for qualitative variables like Gender,
mastication for a time period, exceeding 6 months. Anxiety and Depression. A Chi-Square test
The exclusion criteria for patients participating was used with regards to Age, Gender on
in this research study included; patients with a Anxiety and Depression levels for patients with
diagnosis of any major psychiatric disorder, All Temporomandibular Joint Disorder (TMD). A P
patients who had experienced death of any of their value of <0.05 was considered significant.
close relatives within the past 3 months, Patients
taking any anti-depressants, anti-psychosis and
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CHRONIC TEMPOROMANDIBULAR DISORDER 4

RESULTS and somatic complaints;9,10,11 including Mood

There were (213) patients, having a diagnosis changes, Fatigue, Extremes of tiredness and
of persisting Chronic Temporomandibular Joint disturbances in Sleep thereby; leading to two of
Disorder (CTMD) for a time period of more than 6 the most leading major problems;12,14,15 Anxiety,
months included in this research study. Out of (213) and Depression.22
patients, 129(56.34%) were Male and 93(43.66%)
were Female patients. The gender distribution of
patients is shown in Figure-1. Majority of patients
were 12-18 years of age as shown in (Graph-1).
The average age of the patients was 13.95±1.73
years. The Anxiety and Depression score is
shown in (Table-I). The Frequency of Anxiety
and Depression among patients with Chronic
Temporomandibular Joint Disorder (CTMD) was
31.46% (67/213) and 36.15% (77/213) as shown
in (Figure-2 and Figure-3) respectively. The
rate of Anxiety and Depression was above sixty
percent (60%) and a significant difference was
not observed among the different age as shown
in (Table-II and III). Similarly the rate of Anxiety
Graph-1. Age distribution of patients.
and Depression was not significant between Male
and Female patients. The Stratification was also Age Anxiety Depression
Statistics
done in order to determine the Education status (Years) Score Score
of patients and the Family income but the rate of Mean 13.95 9.32 8.99
95% Lower
Anxiety and Depression was also not significant 13.71 8.59 8.20
Confidence Bound
among patients in Chronic Temporomandibular Interval for Upper
14.18 10.05 9.78
Joint Disorder (CTMD) with respect to Education Mean Bound
and Family income as per the results of our Median 14 6 6
research study. Standard Deviation 1.73 5.39 5.87
. Interquartile Range 3 10 11
Table-I. Descriptive statistics of patients showing
anxiety and depression score.

Figure-1. Gender distribution of Patients.

DISCUSSION
The Temporomandibular Joint Disorder (TMD),
presenting itself as a therapeutic dilemma21 is Figure-2. Frequency of anxiety among patients with
mostly related with psychological5,6 emotional7,8 chronic temporomandibular disorder (CTMD).

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CHRONIC TEMPOROMANDIBULAR DISORDER 5

Age Groups Depression

Total
(Years) No Yes
12 to 14 Years 75(61%) 48(39%) 123
15 to 16 Years 49(68.1%) 23(31.9%) 72
17 to 18 Years 12(66.7%) 6(33.3%) 18
Chi-Square=1.05; p=0.59

Table-III. Frequency of depression among patients

with chronic temporomandibular disorder (CTMD) with
respect to age groups.

Laskin17; for the very first time reported, that the

main cause for Temporomandibular Joint Disorder
(TMD) is Psychological rather than Physical.
Figure-3. Frequency of depression among patients with Over the past decade, many epidemiological
chronic temporomandibular disorder (CTMD). studies19,20,23 have been devoted in order to
These emotional factors considerably vary properly understand the relationship between
depending on the etiologic sub group of diagnosis. psychological factors and Temporomandibular
Patients reporting Chronic Temporomandibular Joint Disorder (TMD).12,16,22,23 It has been
Joint Disorder (CTMD) possess these etiological demonstrated that most of the patients suffering
factors and are mostly observed with myogenous from Temporomandibular Joint Disorder (TMD)24,25
subgroup.18 Bertoli3 (2016) has reported a higher have showed that their respective symptoms are
level of the emotional parameters; Anxiety, highly increased during stressful situations.26,27
Depression and Suicidal ideation in patients
with Chronic Temporomandibular Joint Disorder In our research study, we have used an excellent
(CTMD); primarily in patients exhibiting a long and a reliable diagnostic scale; commonly refer
lasting muscle pain, as compared to the general to as; Hospital Anxiety and Depression Scale
population. Bertoli (2016) strongly emphasized (HADS).12,28,29 This popular diagnostic scale17
the need for screening for suicidal tendencies is used to evaluate the levels and severity of
and other significant comorbidities in patients Anxiety  and  Depression of patients included in
suffering from Chronic Temporomandibular Joint our study. The Hospital Anxiety and Depression
Disorder (CTMD). Scale (HADS) is a total fourteen item scale23,30,31,32
that primarily generates ordinal data. Among them
Age Groups Anxiety seven of the items are linked to Anxiety and seven
Total items are linked to Depression. Giannakopoulos,
(Years) No Yes
et al6 (2010) also used the same scale to evaluate
12 to 14 Years 79(64.2%) 44(35.8%) 123 the frequency of Anxiety and Depression
in patients with type I (muscle disorders)
15 to 16 Years 54(75%) 18(25%) 72
Temporomandibular Joint Disorder (TMD), type
17 to 18 Years 13(72.2%) 5(27.8%) 18 III Temporomandibular Joint Disorder and healthy
controlled patients for a routine diagnostic and
Chi-Square=2.56; p=0.27
monitoring phase in future; Moreover as well as
the prevalence of Chronic Facial Pain.
Table-II. Frequency of anxiety among patients with
chronic temporomandibular disorder (CTMD) with
respect to age groups. Bonjardim, et al9 (2005) in his research; also
used the same Hospital Anxiety and Depression
Scale (HADS) in order to evaluate the prevalence
of Anxiety and Depression in patients with

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CHRONIC TEMPOROMANDIBULAR DISORDER 6

Temporomandibular Joint Disorder (TMD). but not to Depression.

In Sweden; an epidemiologic research Lajnert V26 (2010), has recommended the

study reported that 7% of 12 to 18 years old introduction of a behavioral and psychological
patients visiting the Public dental hospitals, therapy for the patients with Chronic
met the research diagnostic criteria for Temporomandibular Joint Disorder (CTMD).
Temporomandibular Joint Disorder (TMD).20 The Apart from the conventional psychotropic
substantial frequency in these young children drugs (trycyclic antidepressants), the advent
suggested that a proper diagnosis and treatment of behavioral, motivational and psychological
of Paediatric Temporomandibular Joint Disorder intervention and other management strategies
is considered as an important treatment dilemma, such as stress management and modification
thereby providing a comfort to its sufferers and of habits can be an excellent treatment strategy
efforts, to take the advance action for this long- in the complete reduction of Depression,
lasting pain and disability. Anxiety and Tension in patients with Chronic
Temporomandibular Joint Disorder (CTMD).34
A research study in adolescent patients with
significant features of signs and symptoms Our research study has reported a significantly
of Temporomandibular Joint Disorder (TMD) higher incidence of level of Anxiety and Depression
reported that the frequency of Anxiety and in Male patients. This greater incidence in men
Depression was reported in 16.58% and as compare to women has been allocated to an
26.71%, of patients respectively.8 In a sample interaction of a variety of multidisciplinary factors
of adolescent, the psychological and emotional ranging from hormonal and biological factors
status evaluation showed that 39.8% of patients to social and psychological parameters.27,29,30
with Temporomandibular Joint Disorder (TMD); In contrast to our current research findings,
reported moderate to severe levels of marked many clinical and interventional epidemiological
Depression, and 47.6% had moderate to studies have concluded that a greater number of
severe nonspecific physical symptom scores Female patients, suffer from Temporomandibular
(somatization).10 Joint Disorder (TMD) as compare to Male
patients.21,23,25,28 These result concludes the
Dohrenwend et al;21 have considered the pain as a fact that approximately two to three times level
causal stressor hypothesis, that has emphasized of stress is much more common in women as
the fact that the stress and trauma of leading a compare to men.23,24,26,31,32 In a community study
life with symptoms of chronic pain leading to conducted by Dworkin et al;24, 84% of patients,
and moreover is highly associated with intense determining the treatment and 75% of patients
psychological and emotional distress. not determining the treatment were primarily the
women; thereby showing that Temporomandibular
In contrast to these studies; Dworkin et al;33 Joint Disorder (TMD) is considered to be as a
reported that patients with a single pain habitual therapeutic disorder among women in
condition, such as Temporomandibular Joint their childbearing years respectively.35
Disorder (TMD), thereby did not reveal a greater
prevalence of signs and symptoms of Depression LIMITATIONS OF OUR RESEARCH STUDY
than persons with no present pain condition, but The limitations of our research study were that
those with a number of pain conditions were at there was an unequal distribution of gender (Male
greater risk of Depression. Bonjardim et al;9 (2005) and Female) patients that were selected primarily
evaluated that patients with Temporomandibular by a non-probability convenience sampling
Joint Disorder (TMD) had no affirmation of either technique. A larger sample size should be used
Anxiety or Depression symptoms although the in more future epidemiological and clinical
Temporomandibular Joint Disorder (TMD) level interventional research studies in a generalized
was shown to be highly associated with Anxiety larger population in order to determine the
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CHRONIC TEMPOROMANDIBULAR DISORDER 7

significant impact of Anxiety and Depression in to all the respective patients participating in
patients with Chronic Temporomandibular Joint this research study; their cooperation was
Disorder (CTMD). Furthermore, more additional highly commendable. The authors are graceful
incorporation of quantitative and qualitative and thankful to the Head of institution, entire
variables should be considered as a primary focus Department of Oral and Maxillofacial Surgery,
of attention and consideration. These can surely Fellow Residents and Colleagues and lastly, to all
prove to be a highly valuable aid in modifying the the Dental assistants of Dr. Ishrat-ul-Ebad Khan
contemporary and novel zones of modern and Institute of Oral and Health sciences(DIKIOHS),
future dentistry. Dow University of Health Sciences and Dr. Ruth
K.M. Pfau Civil Hospital, Karachi, Pakistan for
CONCLUSION their tremendous support and active cooperation
The following conclusions are made from the throughout the execution of our research study.
present respective study conducted, keeping the A special thanks, appreciation and dedication
limitations of our research study in mind: of our research article to Mr. Abdul Ghani
Shekhani for all the support and encouragement
There is a strong association and impact of the throughout the writing, designing and drafting of
two most important; psychological and somatic the respective research manuscript article.
emotional factors, Anxiety and Depression in Copyright© 25 July, 2019.
patients with Chronic Temporomandibular Joint
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AUTHORSHIP AND CONTRIBUTION DECLARATION

Sr. # Author-s Full Name Contribution to the paper Author’s Signature
1 Arfa Baig Original research article conception,
Designing manuscript article, Research
Drafting, Accountable for all aspects of
the work.
2 Bushra Ghani Research Manuscript Article Designing
and Writing, Drafting, Data Collection
with Interpretation and Analysis,
Literature Review, Critical Review,
Expert Research Opinion, Finalization
of Research Manuscript Article, Final
Proof Reading and Final Approval of
Research. Accountable for all aspects
of the Work.
3 Oam Parkash Statistical data analysis and
intepretation of data.
4 Lubna Memon Data collection.

5 Shoaib Muhammad Data collection and drafting.

Chohan Data collection and drafting.
6 Daud Sultan

Professional Med J 2019;26(10):1724-1732. www.theprofesional.com 1732