Acta Odontologica Scandinavica.

2014; 72: 1054–1065

ORIGINAL ARTICLE

Associations between craniomandibular disorders, sociodemographic

factors and self-perceived general and oral health in an adult population

NEGIN YEKKALAM & ANDERS WÄNMAN

Department of Clinical Oral Physiology, Umeå University, Umeå, Sweden

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Abstract
Objective. The aim of this study was to analyze the relationships between pain in the craniomandibular region and jaw
dysfunction, respectively, to sociodemographic factors and self-perceived general and oral health in a middle-aged and elderly
population in Västerbotten County, Sweden. Materials and methods. Six hundred individuals, 35-, 50-, 65- and 75 years
old, from inland and 600 individuals from coastal areas were randomly selected in 2002. Of these, 987 individuals completed a
questionnaire and 779 participated in a clinical examination. Thirty-five- and 50-year-olds together constituted a middle-aged
group and the rest an elderly group. Results. Among the middle-aged, craniomandibular pain was associated with impaired
general health status, signs of temporomandibular disorder (TMD) pain were associated with female gender and living alone,
jaw dysfunction symptoms were associated with university degree and chewing with caution; and signs of TMD dysfunction
were associated with female gender and living in the more densely populated coastal region. Among the elderly, cranio-
mandibular pain was more common among those living in the inland region, craniomandibular pain and signs of TMD pain
For personal use only.

were associated with impaired general health status, jaw dysfunction symptoms were associated with higher education level and
self-perceived impaired general health and oral health; and signs of TMD dysfunction were associated with female gender and
living in the coastal region. Dental status was not associated with craniomandibular pain. Conclusions. Socioeconomic factors
and impaired general state of health were related to signs and symptoms indicative of CMD. These factors may influence
demand for treatment among the affected.

Key Words: temporomandibular disorders, elderly, epidemiology, headaches, jaw dysfunction, socioeconomics

Introduction [5]. Biological issues such as age and gender seem to

influence the prevalence of TMD and headaches
Craniomandibular disorders (CMD) is an umbrella significantly [6,7]. The explanations behind these
term used to embrace pain and dysfunction in the fairly clearly observed age and gender differences
jaw–face–head region [1]. Terminology has varied remain to be identified [6]. Regarding associations
over time and the most commonly used term the between TMD and socioeconomic factors (i.e. family
last decades to capture musculoskeletal disorders in structure, occupation, education and financial
the jaw, face and temple region has been temporo- resources), the results are not conclusive [8,9].
mandibular disorders (TMD). In the presented paper Impaired general state of health has in several
we have chosen to add frequently reported headaches population-based studies emerged as an important
in the analyses and, thus, chosen the term cranioman- factor associated with presence of TMD [8–12].
dibular disorder as a heading. The etiology of CMD/ TMD symptoms can be associated with a variety of
TMD is considered multi-factorial, including local systematic diseases, such as inflammatory [13] and
factors such as trauma and biomechanical loading of hypermobility disorders [14], and can manifest as
the temporomandibular joint and muscles of masti- local pain conditions or as a part of general pain
cation, together with more general contributing conditions [10,15,16]. TMD has also been associated
aspects such as biological, psychological and social with mood disturbances and sleep disorders [11,13],
factors [2–4] summarized in a biopsychosocial model thus resembling other pain conditions and having a

Correspondence: Dr Anders Wänman, Department of Clinical Oral Physiology, University of Umeå, SE-901 87 Umeå, Sweden. Tel: +46907856082.
E-mail: [email protected]

(Received 29 January 2014; accepted 10 July 2014)

ISSN 0001-6357 print/ISSN 1502-3850 online
2014 Informa Healthcare
DOI: 10.3109/00016357.2014.949843
 CMD, sociodemography and general health 1055

significant effect on the individual’s quality-of-life cross-sectional analysis, information was used both
[17–19]. from clinical examinations regarding signs indicative
Those affected by TMD are not homogeneous with of TMD and from responses to a questionnaire
regard to main symptom, diagnosis, co-morbidities regarding headaches, symptoms indicative of TMD,
and related disability. Therefore, differences in per- sociodemographic factors and general and oral state
ceived oral health are to be expected among TMD of health.
sub-groups [18]. One major TMD cohort consists of A questionnaire, together with a pre-paid return
those with predominantly pain disorders (i.e. myo- envelope, was sent to the randomly selected indivi-
fascial pain, arthralgia and associated headaches) and duals. It included a total of 65 items. The questions
another those with predominantly symptoms of dys- regarding symptoms in the jaw–face and head region
function (i.e. TMJ sounds, TMJ locking and impaired concerned occurrence during the past 3-month
jaw function). Based on the NIH consensus confer- period and for each question participants were asked
ence and several recent studies, TMD should be to state the frequency on a 5-graded scale (never; a
viewed from these two main aspects: the pain domain few times; once a week, several times per week; daily).
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and the dysfunction domain [5]. Few studies have The following six symptoms indicative of CMD were
analyzed possible contributing factors to TMD from included: temporomandibular joint clicking or other
this perspective [12,20]. sounds, feelings of tiredness/stiffness in the jaw
In Västerbotten, Sweden, surveys of oral health region, pain in the jaw or face region, jaw locking,
based on 35-, 50- and 65-year-old people done in impaired maximal jaw opening capacity and head-
1990 and in 2002 with 75-year-olds added in, showed aches. The perceived general state of health and oral
associations between dental status and some socio- health was, respectively, stated on a single item ques-
demographic background factors [21]. An analysis of tion with a 5-graded scale (very good; fairly good;
the influence of gender and age on headaches, pain neither good nor bad; fairly bad; very bad). The
and dysfunction indicative of TMD of the sample answers were categorized into good (very good, fairly
examined in 2002 revealed an obvious age-related good), moderate (neither good nor bad) and poor
pattern of symptoms, with the highest prevalence of (fairly bad, very bad). The returned questionnaires
both pain and dysfunctions in the 35- and 50-year-old were read optically. Reported symptom frequency was
For personal use only.

samples compared to the 65- and 75-year-old samples dichotomized into those occurring with a frequency of
[7]. These significant differences in distribution of once a week or more and those occurring less fre-
symptoms indicative of TMD between middle-aged quently. A pain domain (pain in the jaw–face–head
and elderly people may indicate that differences in the region) was constituted to include symptoms reported
relative importance of socioeconomic and psychoso- to occur at a frequency of once a week or more (pain
cial factors on TMD also exist. in the jaw-face region, headaches and/or feelings of
The aims of this study were to analyze the relation- tiredness in the jaws) and was used as a dependent
ships between the domains signs and symptoms of variable in the regression analysis (Table I).
pain in the jaw-face-head region (in the following A dysfunction domain (jaw dysfunction) was consti-
referred to as craniomandibular region) and jaw dys- tuted to include symptoms reported to occur at a
function, respectively, to sociodemographic factors frequency of once a week or more (TMJ sounds, jaw
and self-perceived general and oral health in a locking and/or impaired jaw opening) and was used
middle-aged and an elderly population. The hypoth- as a dependent variable in the regression analysis
esis was that sociodemographic factors and general (Table I).
and oral health are associated with signs and symp- Clinical examinations were performed from Sep-
toms of pain in the craniomandibular region and/or tember 2002 to February 2003 by four examination
jaw dysfunction in middle-aged and older adults. teams. The examinations included dental status,
function of the temporomandibular joint (TMJ)
Materials and methods and signs of muscle pain to palpation. Presence of
dull clicking, sharp clicking or crepitation sounds was
The study population was 35-, 50-, 65- and 75-year- registered during jaw opening and closing move-
olds living in the County of Västerbotten, Sweden. ments; TMJ pain to palpation was assessed by palpa-
The total population in these age groups was 11 tion over the TMJ. Only palpation that elicited a clear
324 individuals in 2002. In each age group, 300 indi- palpebral reflex in the eye or a protection reflex was
viduals were randomly selected from the population, registered as a sign of TMJ pain. TMJ pain during jaw
half from the inland and half from the coastal regions movements was registered. Maximal mandibular
(in total, 1200 individuals were thus included). The opening capacity was measured with the aid of a ruler
study included a questionnaire and a clinical exam- as the distance in millimeters between the edges of the
ination; 987 individuals completed a questionnaire upper and lower incisors during voluntary maximal
and 779 participated in a clinical examination. Details opening and with the vertical overbite added in. Jaw
have been reported in a previous paper [7]. In the muscle pain to palpation was assessed based on
 1056 N. Yekkalam & A. Wänman

Table I. Description of dependent and independent variables. The reference used for independent variables in the regression analysis is
specified first. In each row the number of included individuals is presented in Middle-aged (35 + 50 years old) and Elderly (65 + 75 years old)
groups, respectively.

Definition Middle-aged number Elderly number

Dependent variables
Frequent pain in the craniomandibular region Reported jaw/face pain or jaw tiredness or No = 367 No = 426
headache; ‡ once a week
Yes = 119 Yes = 63
Frequent jaw dysfunction Reported TMJ locking or TMJ sounds or No = 418 No = 449
difficulty to open the jaw wide; ‡ once a week
Yes = 70 Yes = 37
TMD pain signs Registered jaw muscle pain to palpation or No = 210 No = 211
TMJ pain to palpation or pain on jaw
Yes = 187 Yes = 159
movements
TMD dysfunction signs Registered TMJ sounds or jaw opening less No = 311 No = 254
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than 40 mm Yes = 86 Yes = 116

Independent variables
Gender Man (M) 255 249
Woman (W) 236 247
Region Inland (I) 255 257
Coast (C) 236 239
Education Elementary (ES) 81 356
High school (HS) 265 88
University (U) 140 43
Living condition With other (WO) 415 342
For personal use only.

Alone (A) 69 145

Employment status Working (Wk) 403 12
Not working (Nwk) 82 481
Income Level of income per month in Swedish ‡15 000 = 343 ‡15 000 = 109
Crowns (SEK) (2002)*
<15 000 = 126 <15 000 = 365
Financial resources (Resources) Able to obtain 14 000 SEK within a week Yes = 260 Yes = 358
No = 210 No = 113
Self-perceived general state of health during Good (Good) 368 352
the last year (General health)
Moderate (Mod) 70 84
Poor (Poor) 51 49
History of general arthritis No 461 434
Yes 20 37
Regular use of prescribed medicine No 336 173
Yes 155 323
Currently smoking No 417 436
Yes 73 49
Currently using snuff No 359 424
Yes 121 36
Self-perceived oral health the last year Good (Good) 338 366
Moderate (Mod) 102 91
Poor (Poor) 49 30
Oral hygiene Brushing teeth ‡ daily 475 464
Tooth brush Brushing teeth < daily 10 20
Oral hygiene ‡ weekly 179 278
Proximal cleaning < weekly 305 168
Regular dental health care <2 years between examinations 387 333
>2 years between examinations 97 117
 CMD, sociodemography and general health 1057

Table I. (Continued).

Definition Middle-aged number Elderly number

Chewing capacity of hard food No problem (NP) 441 376

With caution (WC) 47 118
Dental status Number of teeth ‡ mean 305 227
Number of teeth < mean 92 143
Occlusal supporting zones** Eichner Index A1 = 325 A1-B = 213
Other = 72 Other = 157

*Year 2002.
**The Eichner classification is based on occlusal supporting zones in premolar and molar regions on each side. Class A defined as all four
support zones. Class B contains three (B1), two (B2) or one (B3) support zone(s) or support in the front area only (B4). In Class C, there are no
antagonist contacts between the maxilla and the mandible.
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palpation of the following muscle and/or tendon sites: model. The results are presented as odds ratio
anterior and posterior parts and attachments of the (OR) with 95% confidence interval (95% CI).
temporal muscles; the body and origin of the masseter A p-value less than 0.05 was considered statistically
muscles; the area of the lateral pterygoid muscle significant.
origin; the attachment of the medial pterygoid mus-
cles. Pain criteria were the same as for TMJ pain. The Results
details of clinical examination have been presented in
a previous paper [7]. A domain with TMD pain signs The majority of the individuals had neither frequent
was constituted to include jaw muscle pain to palpa- symptoms indicative of CMD nor related signs
tion, TMJ pain to palpation and pain on jaw move- (Table I). The middle-aged sample reported a higher
ments and was used as a dependent variable in the education level compared to the older one (p < 0.001).
For personal use only.

regression analysis (Table I). A domain with TMD Almost three quarters of the participants considered
dysfunction signs was constituted to include TMJ their general health as good (75% and 72%, respec-
sounds and jaw opening of less than 40 mm and tively), with no significant difference between age
was used as a dependent variable in the regression groups. A similar figure was noted for perceived
analysis (Table I). good oral health (69% and 75%, respectively), with
significantly (p < 0.05) lower prevalence in the
Statistical method middle-aged group. Most of the 65- and 75-year-
olds (65%) used medicine on a regular basis and
The data analysis was done by STATA statistical reported a lower income level compared to the youn-
software version 10. Analysis was based on 975 indi- ger sample. The majority of 65- and 75-year-olds had
viduals who answered the questionnaire and on a reduced number of antagonist tooth contacts as
767 individuals who participated in the clinical exam- measured with the Eichner index.
ination. Owing to minor variations in missing data,
the number of individuals included in the regression 35- and 50-year-old sample
analysis varies. The maximum missing data in the
middle age-group was for question regarding their Univariate and multivariate models for symptoms and
income level (4%). In the elderly group the maximal signs indicative of CMD pain and symptoms and
missing data was for a question regarding frequency of signs indicative of TMD dysfunction are presented
using tooth picks or dental flossing (10%). The defi- in Table II. Significant associations are indicated in
nitions of dependent and independent variables used italics. In total, 25% (n = 119) of 486 individuals
are presented in Table I. The reference group for reported craniomandibular pain once a week or more
the related independent variables in the regression often and 47% (n = 187) of 397 individuals had one or
analysis is presented first in each column (Table I). more signs of pain at the clinical examination.
Descriptive information is presented as absolute num- In the univariate analysis with craniomandibular
bers in each group. Logistic regression analysis was pain as a dependent variable (Table II), female
used to estimate factors associated with the dependent gender, unemployment, low income, lack of financial
variables for 35- and 50-year-olds and 65- and resources, impaired general state of health, general
75-year-olds, respectively. After applying univariate arthritis, regular use of medicine and perceived
analysis for each of the included independent vari- moderate oral health status emerged as significantly
ables, all factors significantly associated with the related factors. In the multivariate model only
dependent variable were added into a multivariate impaired general state of health remained significant.
 1058 N. Yekkalam & A. Wänman

Table II. Univariate and multivariate models present pain in the jaw–face–head region (craniomandibular pain), signs indicative of TMD pain,
frequent dysfunction symptoms and signs indicative of TMD dysfunction in 35- and 50-year-olds.

Craniomandibular pain Jaw dysfunction

(symptoms) TMD pain (signs) (symptoms) TMD dysfunction (signs)

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)

Gender
Men Ref Ref Ref Ref Ref Ref Ref Ref
Women 2.0 1.6 2.3 2.1 2.0 1.5 2.0 2.0
(1.3–3.1) (0.9–2.7) (1.6–3.5) (1.3–3.2) (1.2–3.4) (0.9–2.7) (1.2–3.2) (1.2–3.3)
Region
Inland Ref Ref Ref Ref Ref Ref Ref Ref
Coast 0.9 — 1.3 — 1.0 — 2.0 1.8
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(0.7–1.5) (0.9–1.9) (0.6–1.7) (1.2–3.3) (1.1–3.1)

Education
Elementary Ref Ref Ref Ref Ref Ref Ref Ref
High school 0.8 — 0.8 — 1.6 1.9 2.0 2.0
(0.5–1.5) (0.4–1.4) (0.7–3.7) (0.8–4.6) (0.9–4.8) (0.8–4.7)
University 0.8 — 0.9 — 2.7 2.7 2.9 2.2
(0.4–1.5) (0.5–1.8) (1.1–6.5) (1.1–6.8) (1.2–7.0) (0.9–5.6)
Living condition
With other Ref Ref Ref Ref Ref Ref Ref Ref
Alone 1.2 — 2.1 2.1 1.0 — 1.1 —
(0.7–2.1) (1.1–3.8) (1.0–3.9) (0.5–2.1) (0.6–2.3)
For personal use only.

Employed
Yes Ref Ref Ref Ref Ref Ref Ref Ref
No 2.5 0.7 1.9 0.9 1.4 — 1.0 —
(1.5–4.1) (0.3–1.5) (1.1–3.2) (0.4–1.9) (0.7–2.6) (0.5–1.9)
Income/month
‡15 000 SEK Ref Ref Ref Ref Ref Ref Ref Ref
<15 000 SEK 1.8 1.5 1.8 1.3(0.8–2.3) 1.2 — 1.0 —
(1.2–2.8) (0.8–2.7) (1.1–2.9) (0.7–2.1) (0.6–1.7)
Resources
Own savings Ref Ref Ref Ref Ref Ref Ref Ref
No savings 2.1 1.6 1.7 1.3 1.2 — 0.7 —
(1.4–3.2) (0.9–2.7) (1.1–2.6) (0.8–2.1) (0.7–2.1) (0.4–1.2)
General health
Good Ref Ref Ref Ref Ref Ref Ref Ref
Moderate 3.8 3.1 1.9 1.8 2.3 1.9 1.1 —
(2.2–6.7) (1.6–5.8) (1.1–3.3) (0.9–3.3) (1.2–4.3) (0.9–3.8) (0.5–1.9)
Bad 8.2 3.5 2.5 2.2 2.1 1.8 1.1 —
(4.4–15.3) (1.4–17.0) (1.3–4.9) (0.9–4.9) (1.0–4.4) (0.8–3.9) (0.5–2.4)
General arthritis
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 3.4 1.6 1.9 — 1.5 — 1.7 —
(1.4–8.4) (0.8–4.9) (0.7–5.4) (0.5–4.8) (0.6–5.1)
Use of medicine
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 2.3 1.4 1.5 — 1.3 — 1.3 —
(1.5–3.5) (0.8–2.4) (0.9–2.2) (0.8–2.2) (0.8–2.1)
 CMD, sociodemography and general health 1059

Table II. (Continued).

Craniomandibular pain Jaw dysfunction

(symptoms) TMD pain (signs) (symptoms) TMD dysfunction (signs)

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)

Smoking
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 1.3 — 1.5 — 1.5 — 0.7 —
(0.7–2.2) (0.8–2.6) (0.8–2.9) (0.3–1.5)
Using snuff
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 1.1 — 0.7 — 0.7 — 0.9 —
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(0.7–1.8) (0.5–1.2) (0.4–1.3) (0.5–1.6)

Oral health
Good Ref Ref Ref Ref Ref Ref Ref Ref
Moderate 1.9 1.6 1.2 — 1.5 — 0.9 —
(1.2–3.1) (0.9–2.9) (0.8–2.1) (0.8–2.7) (0.5–1.6)
Bad 1.7 0.9 1.3 — 1.1 — 1.3 —
(0.9–3.2) (0.4–2.0) (0.6–2.5) (0.5–2.6) (0.6–2.7)
Oral hygiene
‡ daily brushing Ref Ref Ref Ref Ref Ref Ref Ref
< daily brushing 0.8 — 0.3 — 0.6 — 0.4 —
(0.2–3.7) (0.1–1.54) (0.1–5.2) (0.1–3.6)
Proximal cleaning ‡ weekly Ref Ref Ref Ref Ref Ref Ref Ref
For personal use only.

< weekly 0.9 — 0.9 — 1.5 — 1.4 —

(0.6–1.4) (0.6–1.3) (0.9–2.6) (0.8–2.4)
Dental care
<2 years Ref Ref Ref Ref Ref Ref Ref Ref
>2 years 1.3 — 1.5 — 0.9 — 0.9 —
(0.8–2.1) (0.9–2.5) (0.5–1.8) (0.5–1.7)
Chewing
No problem Ref Ref Ref Ref Ref Ref Ref Ref
With caution 1.9 – 1.6 — 2.3 2.2 1.1 —
(0.9–3.5) (0.8–3.1) (1.1–4.7) (1.0–4.8) (0.5–2.5)
Dental status
teeth ‡27 Ref Ref Ref Ref Ref Ref Ref Ref
teeth <27 1.4 — 1.2 — 0.98 — 0.92 —
(0.8–2.3) (0.6–2.2) (0.9–1.1) (0.5–1.6)
Occlusal supporting zones
A1 Ref Ref Ref Ref Ref Ref Ref Ref
Other 1.6 — 1.1 — 1.8 — 1.3 —
(0.9–2.8) (0.6–1.8) (0.9–3.3) (0.7–2.3)

Significant associations are indicated in bold-italic.

In the univariate analysis with signs of TMD pain as 397 individuals had clinical signs of jaw dysfunction.
a dependent variable (Table II) the following factors In the univariate analysis of factors related to jaw
were significantly associated: female gender, living dysfunction symptoms the following were significant:
alone, unemployment, low income, lack of financial female gender, university degree, impaired general
resources and impaired general health status. Of state of health and reduced ability to chew hard
these, female gender and living alone remained sig- food (Table II). In the multivariate model educational
nificant in the multivariate model. level and chewing impairment remained significant.
In total, 14% (n = 70) of 488 individuals reported In the univariate analysis with signs of TMD dysfunc-
symptoms of jaw dysfunction and 22% (n = 86) of tion as dependent variables the following factors were
 1060 N. Yekkalam & A. Wänman

Table III. Univariate and multivariate models present pain in the jaw–face–head region (craniomandibular pain), signs indicative of TMD
pain, frequent dysfunction symptoms and signs indicative of TMD dysfunction in 65- and 75-year-olds.

Craniomandibular pain Jaw dysfunction

(symptoms) TMD pain (signs) (symptoms) TMD dysfunction (signs)

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)

Gender
Men Ref Ref Ref Ref Ref Ref Ref Ref
Women 1.2 — 1.4 — 1.6 — 2.1 2.1
(0.7–2.1) (1.0–2.2) (0.8–3.1) (1.4–3.3) (1.3–3.4)
Region
Inland Ref Ref Ref Ref Ref Ref Ref Ref
Coast 0.5 0.5 0.6 0.6 0.9 — 1.7 2.0
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(0.3–0.9) (0.2–0.9) (0.4–0.9) (0.4–1.0) (0.5–1.7) (1.1–2.7) (1.3–3.3)

Education
Elementary Ref Ref Ref Ref Ref Ref Ref Ref
High school 1.3 — 1.1 — 2.3 2.9 0.6 —
(0.7–2.5) (0.6–1.8) (1.1– 4.9) (1.3–6.6) (0.4–1.2)
University 1.2 — 1.8 — 2.1 1.8 0.5 —
(0.5–2.9) (0.9–3.7) (0.7–5.9) (0.6–5.8) (0.2–1.2)
Living condition
With other Ref Ref Ref Ref Ref Ref Ref Ref
Alone 1.0 — 0.9 — 1.1 — 1.5 —
(0.6–1.9) (0.6–1.6) (0.5–2.3) (0.9–2.5)
For personal use only.

Employed
Yes Ref Ref Ref Ref Ref Ref Ref Ref
No —* — 1.5 — 0.9 — 3.8 —
(0.4–6.2) (0.1–7.2) (0.5–31)
Income/month
‡15 000 SK Ref Ref Ref Ref Ref Ref Ref Ref
<15 000 SK 1.6 — 1.6 — 0.7 — 2.0 1.5
(0.8–3.2) (0.7–2.7) (0.3–1.6) (1.1–3.7) (0.8–2.8)
Resources
Own savings Ref Ref Ref Ref Ref Ref Ref Ref
No savings 1.1 — 0.9 — 1.3 — 1.1 —
(0.6–2.0) (0.6–1.6) (0.6–2.8) (0.7–1.9)
General health
Good Ref Ref Ref Ref Ref Ref Ref Ref
Moderate 3.4 3.0 1.1 0.9 1.9 1.7 0.8 —
(1.7–6.4) (1.5–6.3) (0.6–1.8) (0.5–1.7) (0.8–4.6) (0.7–4.2) (0.4–1.4)
Bad 6.0 4.6 3.0 3.0 4.3 3.3 0.8 —
(2.9–12.2) (1.9–11) (1.5–6.1) (1.3–7.1) (1.8–10) (1.2–8.7) (0.4–1.7)
General arthritis
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 3.7(1.7–7.9) 1.8(0.7–4.7) 2.1 1.4 2.5 — 0.7 —
(1.0–4.2) (0.6–3.1) (0.9–6.9) (0.3–1.6)
Use of medicine
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 2.5 1.9 1.5 — 2.1 — 1.3 —
(1.3–4.9) (0.8–4.0) (0.9–2.3) (0.9–4.6) (0.8–2.0)
Smoking
No Ref Ref Ref Ref Ref Ref Ref Ref
 CMD, sociodemography and general health 1061

Table III. (Continued).

Craniomandibular pain Jaw dysfunction

(symptoms) TMD pain (signs) (symptoms) TMD dysfunction (signs)

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)

Yes 0.8 — 0.8 — 0.5 — 0.9 —

(0.3–2.1) (0.4–1.8) (0.1–2.1) (0.4–2.0)
Using Snuff
No Ref Ref Ref Ref Ref Ref Ref Ref
Yes 1.8 — 1.0 — 0.3 — 0.9(0.5–1.6) —
(0.8–4.4) (0.5–2.3) (0.1–2.4)
Oral health
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Good Ref Ref Ref Ref Ref Ref Ref Ref

Moderate 1.5 1.1 1.1 0.8 0.7 0.5 1.1 —
(0.8–2.9) (0.5–2.5) (0.6–1.9) (0.4–1.6) (0.2–2.0) (0.2–1.6) (0.6–1.9)
Bad 3.5 2.1(0.6–6.8) 2.9 1.5 7.3 3.9 1.4 —
(1.5–8.3) (1.2–7.1) (0.5–4.1) (3.1–18) (1.2–13) (0.6–3.2)
Oral hygiene
‡ daily brushing Ref Ref Ref Ref Ref Ref Ref Ref
< daily brushing 0.4 – 0.8 — 1.4 — 1.1 —
(0.1–2.8) (0.3–2.2) (0.3–6.2) (0.7–1.8)
Proximal cleaning ‡ weekly Ref Ref Ref Ref Ref Ref Ref Ref
< weekly 0.9 — 1.5 — 0.9 — 0.9 —
(0.6–1.7) (0.9–2.3) (0.4–1.8) (0.6–1.6)
For personal use only.

Chewing
No problem Ref Ref Ref Ref Ref Ref Ref Ref
With caution 1.8 0.8 1.7 1.4 2.4 3.3 0.5 —
(1.0–3.2) (0.4–1.9) (1.1–2.8) (0.8–2.5) (1.2–4.7) (0.7–4.5) (0.1–1.8)
Dental care
<2 years Ref Ref Ref Ref Ref Ref Ref Ref
>2 years 1.4 — 1.6 — 0.5 — 1.3 —
(0.8–2.6) (1.0–2.6) (0.2–1.4) (0.7–2.1)
Dental status
Teeth ‡14 Ref Ref Ref Ref Ref Ref Ref Ref
Teeth <14 1.3 — 1.5 — 1.35 — 2.3 1.6(0.60–4.3)
(0.7–2.2) (0.7–3.1) (0.8–2.1) (1.5–3.6)
Occlusal supporting zone
A1–B3 Ref Ref Ref Ref Ref Ref Ref Ref
Other 1.4 — 1.2 — 1.2 — 2.2 1.5
(0.7–2.5) (0.8–1.9) (0.6–2.5) (1.4–3.5) (0.6–3.7)

Significant associations are indicated in bold-italics.

significantly associated: female gender, living in the Table III. In total, 13% (n = 63) of 489 individuals
coastal region of Västerbotten and university degree. reported craniomandibular pain at least once a week
Of these, female gender and living on the coast and 43% (n = 159) of the 370 individuals had clin-
remained significant in the multivariate model (Table ically registered pain signs.
II). In the univariate analysis with craniomandibular
pain as a dependent variable, living in the inland
65- and 75-year-old sample communities of Västerbotten, self-perceived impaired
general state of health, general arthritis, regular use
Univariate and multivariate models for symptoms of medicine, perceived bad oral health status and
and signs indicative of CMD regarding pain decreased chewing ability were all significantly related
and dysfunction, respectively, are presented in factors. In the multivariate model living in the inland
 1062 N. Yekkalam & A. Wänman

region and impaired general state of health remained expression have also been suggested for this trend [6].
significant (Table III). Lately, the focus of interest has been on the role of
In the univariate analysis with signs indicative of genetic variation and the search for candidate genes
TMD pain as dependent variables the following related to development of TMD pain is an ongoing,
factors were significantly associated: living in the interesting and challenging project [27]. Middle-aged
coastal region, impaired general health status, general women also had an ~2-fold risk of having both signs
arthritis, self-perceived bad oral health and impaired and symptoms of TM dysfunction compared to men,
chewing ability. Of these, impaired general health while only signs of TM dysfunction (i.e. TMJ sounds
remained significant in the multivariate model or impaired jaw opening) remained more common
(Table III). among women in the older age groups. In a previous
In total, 8% (n = 37) of 486 individuals reported analysis [7], presence of TMJ sounds did not differ
symptoms of jaw dysfunction and 27% (n = 116) of significantly between men and women among the
370 individuals had clinical signs of jaw dysfunction. elderly, but impaired jaw opening did. It may,
In the univariate analysis of factors related to jaw thus, be questioned whether a maximal jaw opening
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dysfunction symptoms the following were significant: capacity not exceeding 40 mm should be regarded as a
high school education, impaired general state of significant clinical sign of dysfunction in elderly
health, perceived bad oral health and reduced ability women.
to chew hard food (Table III). In the multivariate
model high school education, impaired general state Socioeconomic status
of health and perceived bad oral health remained
significant (Table III). In the univariate analysis the Educational level, employment status, income and
following factors were significantly associated with financial resources may in part mirror an individual’s
signs of TMD dysfunction: female gender, living financial situation. Financial constraints can be a
on the coast of Västerbotten, low income, dental barrier to obtaining regular dental care and, conse-
status and occlusal stability. Of these, female gender quently, individuals may refrain from seeking dental
and living on the coast remained significant in the care [28]. A significant relationship between tooth
multivariate model (Table I). mortality and fewer occlusal supporting zones, on one
For personal use only.

hand, and low education level, unemployment and

Discussion lack of financial resources, on the other, was found in
a previous analysis of this study population [21].
This study indicates that female gender and lower A poorer dentition status among Japanese adults
economic status as well as self-perceived impairment with a lower educational level was recently reported
of general and oral health status are associated with [29], supporting a relationship between socioeco-
pain and dysfunction in the jaw, face and head region nomic conditions and dental status. The relationship
in middle-aged adults. The most consistent pattern in between socioeconomic status and TMD is, however,
the total study population was the relationship not conclusive. Significant associations of pain in the
between CMD and self-perceived impaired general orofacial region have been found with both higher and
health status, indicating that signs and symptoms of lower educational levels [9]. In this study a higher
CMD should be regarded as a part of a general health educational level was associated with dysfunction
problem. symptoms in both age groups but not with CMD
pain. In a large European survey, chronic pain of
Gender and age moderate-to-severe intensity was associated with sub-
jects’ impaired social and working lives, including loss
The study confirms previous observations that of employment, changed responsibilities in their
women during their fertile period in life have an working lives and change of employment status, as
~2-fold risk of incurring frequent pain in the jaw– a consequence of their pain condition [30]. In the
face–head region symptoms as well as signs of TMD univariate analysis several factors indicating a vulner-
pain compared to men before the age of retirement able economic position (unemployment, low income
[7,22,23]. In another Swedish study population, and no savings) were associated with both signs and
women also reported more multiple localizations of symptoms of pain in the jaw, face and head region
pain in neck, shoulder and arm regions compared to among people in the middle-aged population. The
men [24]. The observed peak of TMD symptoms same pattern was not found among the elderly and the
during women’s fertile period in life and reduction of association ceased in the former group after the mul-
symptoms in later age may be related to changes in the tivariate analysis. The results may still indicate that
central processing of nociceptive stimulus and reflect- subjects with TMD are in a more vulnerable socio-
ing a period of neuronal hyperexcitability [25]. economic position, but, owing to the cross-sectional
Hormonal factors [26], different levels of sensitivity design, no conclusions can be drawn about cause and
and different psychosocial roles with regard to pain effect; for that, prospective studies are needed. The
 CMD, sociodemography and general health 1063

analyses did not reveal any differences in regular (at an increased impairment of health status, which may
least, biennial) dental healthcare utilization between indicate effects from central sensitization. A self-rated
individuals with or without signs and symptoms of impaired oral health status was associated with
TMD. In a survey of 50-year-olds a high utilization of reported CMD pain, signs of TMD pain and reported
dental care was associated with TMJ pain [8]. The dysfunction, especially in the elderly sample. In
authors speculated that the result might be related assessments using oral health-related quality-of-life
either to their having sought treatment related to their (OHRQoL), patients with TMD have indicated
TMJ pain condition or to tooth fractures inflicted by high levels of related impairment [17–20]. Higher
bruxism. Patients with TMD disorders have been functional and psychosocial impact was observed in
found to utilize more medical care services [31]; it those with TMD pain compared to a non-pain con-
may, thus, not be surprising that many referrals to dition (disc displacement), which still was higher than
TMD specialists come from physicians [32]. in the general population without signs or symptoms
of TMD [20]. The study also found that patients with
Residence area two pain-related diagnoses had significantly higher
Acta Odontol Scand Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 03/17/15

impaired OHRQoL than patients with a single diag-

The prevalence of jaw pain was statistically lower in nosis. An interpretation of the results may be that
rural compared to urban areas of Canada [22]. TMD should be considered a part of a general mus-
Johansson et al. [8] did not find any significant culoskeletal health problem and handled accordingly.
difference in TMJ pain in a large Swedish sample Since pain emerging in the trigeminal sector also may
of 50-year-old people, but the prevalence of TMJ contribute to spread of pain in spinal sectors [37], it
sounds was significantly higher in the rural areas. may be of both individual and societal concern to
In a study from Iran, the prevalence of facial pain, regard TMD pain also from this perspective.
TMD, disc displacement and degenerative disorders
was higher in rural compared to urban areas [33]. In Chewing and dental occlusion
this study, clinical signs of dysfunction were more
commonly registered in the more densely populated One of the first epidemiological studies on mandib-
coastal areas of Västerbotten compared to the more ular dysfunction in Västerbotten was done in the early
For personal use only.

sparsely populated inland communities in both age 1970s. An analysis of the subjects’ reported chewing
groups. In the elderly sample, however, the preva- ability in relation to dental and general health [38]
lence of craniomandibular pain was, at the same time, showed that impaired chewing ability was closely
significantly lower in the more densely populated related to number of residual teeth, symptoms of
regions. The results regarding prevalence of TMD mandibular dysfunction and impaired general state
signs and symptoms among people living in rural of health. From the early 1970s to the early 2000s the
compared to urban areas are, thus, not conclusive. dental status among adults in Västerbotten has
These inconsistent results are probably related to improved significantly [21], but still approximately
other differences in living conditions. one quarter of those in the elderly sample had to be
cautious when chewing hard food. In a previous
Self-rated general and oral health status study, based on a Japanese population, chewing abil-
ity correlated with presence of TMJ pain, impaired
Self-perceived health has been used as a valid health mouth opening capacity and age [39]. The results
indicator for many years [34]. Self-rated impaired from the Japanese population as well as from the
general health status was identified as one of the previous study from Västerbotten, Sweden, are thus
strongest factors associated with CMD in both age supported in this study, since self-reported
groups, confirming results in previous studies [9– impairment of chewing capacity was related to both
11,35]. In the multivariate analysis, impaired general signs and symptoms of CMD/TMD, especially
state of health was the only factor that remained to among the elderly. In the cross-sectional analyses,
explain the presence of pain in the jaw–face–head dental status (i.e. number of teeth and occlusal sup-
region in the 35- and 50-year-olds and one of two porting zones) did not show a significant relationship
factors among the 65- and 75-year-olds. The results to CMD pain. The relationship to signs of TMD
also indicate a dose–response-like pattern, with a dysfunction among the elderly disappeared after a
higher odds ratio with a more severe rating of their multivariate analysis.
general health status. TMD pain has been related to
pain conditions in other parts of the body Strengths and limitations
[3,9,10,13,16,36]. In this study, general arthritis
also emerged as a co-morbid condition in both age In this population-based study, participants were
groups in the univariate models, confirming the result selected randomly in four so-called indicator ages
of a previous study [3]. In another study [11] the to ensure representativeness of the population under
number of painful areas was positively associated with study. Based on the presence of signs and symptoms
 1064 N. Yekkalam & A. Wänman

indicative of TMD, the sample was categorized into [3] Mundt T, Mack F, Schwahn C, Bernhardt O, Kocher T,
Biffar R. Association between sociodemographic, behavioral,
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different aspects of socioeconomic status, living con- Dworkin SF. Review of aetiological concepts of temporoman-
ditions, general health and oral status. The participa- dibular pain disorders: towards a biopsychosocial model for
tion rate was high in the questionnaire part (82%) and integration of physical disorder factors with psychological and
psychosocial illness impact factors. Eur J Pain 2005;9:613–33.
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Acknowledgment ments of the temporomandibular joint. Int J Oral Maxillofac
Surg 2012;41:1046–50.
The study was supported by grants from the Public [15] Macfarlane TV, Blinkhorn AS, Davies RM, Ryan P,
Dental Health, Västerbotten County. Worthington HV, Macfarlane GJ. Orofacial pain: just another
chronic pain? Results from a population-based survey. Pain
Declaration of interest: The authors report no 2002;99:453–8.
[16] Plesh O, Adams SH, Gansky SA. Temporomandibular joint
conflicts of interest. The authors alone are responsible and muscle disorder-type pain and comorbid pains in a
for the content and writing of the paper. national US sample. J Orofac Pain 2011;25:190–8.
[17] Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J,
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