Temporomandibular Disorders in Patients Undergoing Orthodontic Treatment: A Cross-

Sectional Study

A Master Thesis Research Proposal by:

Farah Alshami

Postgraduate Student in Master of Science in Dentistry

ID: 451200494

Submission Date: 24/12/2023

College of Dentistry, Riyadh Elm University

 Aim of the Research

The aim of this cross-sectional research will be to examine the severity and frequency of

temporomandibular disorders among first-time adult patients seeking orthodontic treatment and

determine if there is any correlation between temporomandibular disorders and malocclusion

severity. Research has shown a high prevalence of temporomandibular disorders among

adolescents, and this persists into adulthood (Bilgiç & Gelgör, 2018; Emes et al., 2020).

Christidis et al. (2019) asserted that there are increasing concerns about temporomandibular

disorders among adult patients seeking orthodontics, most likely dating to their teenage years.

Failure to assess and screen for temporomandibular disorders before initiating orthodontic

therapy has been associated with treatment complications (Diab et al., 2023; Jain et al., 2018),

resulting in medical negligence and medical-legal suits (Yap et al., 2021). While its prevalence

ranges from 15-45%, few studies have examined the frequency and severity of

temporomandibular disorders among adults seeking orthodontic treatment for the first time. The

likely anticipated results will reveal a high prevalence of temporomandibular disorders in

patients seeking orthodontic treatment for the first time. Implications of these findings will

emphasise the importance of screening patients’ masticatory systems before starting orthodontic

therapies to avoid potential medical-legal suits and treatment complications.

Introduction

Temporomandibular disorders include various neuromuscular and musculoskeletal

conditions affecting temporomandibular joints, masticatory muscles, and neighbouring surfaces

(Lai et al., 2020). Patients with TMJ problems may exhibit pain or function-related symptoms.

Although up to 40% of adults may be affected, the prevalence may be higher in teenagers,

ranging from 7% to 55%. (Karaman et al., 2022). A study by Natu et al. (2018) reported that
patients with temporomandibular disorders reported higher concerns about reduced quality of life

than oral diseases like oral cancer, cavities, and periodontal disease. Specifically,

temporomandibular disorders have been associated with occlusal conditions like maxillary

overjet, anterior open bite, and posterior cross-bite (Paço et al., 2021). Some scholars observe

that the various cases of malocclusions might be due to the result of temporomandibular

disorders rather than their cause.

Considering increased levels of temporomandibular disorders frequency during teenage

that progresses to adulthood, there are arguments that dentists need to screen for their pre-

existence before commencing orthodontic therapy (Bilgiç & Gelgör, 2018; Emes et al., 2020).

Failure to screen for temporomandibular disorders may result in poor orthodontic treatment and

patient outcomes (Christidis et al., 2019; Natu et al., 2018). Complications, repeated clinic visits,

high cost of care, and reduced patient quality of life have been noted to result during orthodontic

treatment when dentists fail to undertake pre-screening for temporomandibular disorders. A

scarcity of studies have investigated temporomandibular disorders among patients seeking

orthodontic therapy, making it difficult to develop evidence-based guidelines, thereby

necessitating the need for this research.

Literature Review

Orthodontic scholars and practitioners have researched over thirty different types of

temporomandibular disorders. There is a large consensus that these disorders contribute to pain

and jaw dysfunction, impairing joints and muscles that control jawbone movement (Pastore et

al., 2018; Paunonen et al., 2019; Yap et al., 2021). Some common painful orofacial conditions

that have been associated with temporomandibular disorders include articular clicking, limited

mandible motion, masticatory muscle fatigue (Tesic et al., 2020), and painful
temporomandibular joints (Yap et al., 2023). Assessment of the scholarly literature further

reveals that temporomandibular disorders are considered to have multifactorial impact, such as

changes in the structure of the temporomandibular joints, abnormal functions of the masticatory

muscles, and bruxing or clenching of the jaws (Zhang et al., 2020).

Diab et al. (2023) found that causes of temporomandibular disorders could be attributed

to postural changes, malocclusion, and local interferences due to occlusion. Paunonen et al.

(2019) reported that other aetiologies like neoplasm, immunological disorders, and traumatic

injury have been reported to trigger temporomandibular disorders. Mechanical stress, change in

jaw position, and loading have been noted to be standard treatment responses that trigger

morphology change in the temporomandibular joints, possibly because of its characteristic

adaptive capacity (Karaman & Buyuk, 2022; Paço et al., 2021). Despite these findings, there is

no consensus on the causation of temporomandibular disorders and malocclusion. A transversal

study by Macrì et al. (2022) reported few studies on the relationship between patients seeking

orthodontic treatment and temporomandibular disorders, making it challenging to recommend

optimal clinical practice.

A case-control study by Zúñiga-Herrera et al. (2023) concluded that temporomandibular

disorders are associated with malocclusion complexity. Therefore, it is crucial to determine the

pre-existing extent of temporomandibular disorders before commencing orthodontic

management. Such an approach can aid us in enhancing therapy planning and assessing the

aspects that can intensify or alleviate the symptoms. While examining the ongoing controversy

between temporomandibular disorders and malocclusion, Aboalnaga et al. (2019) found that a

precise diagnosis needs to be made before commencing orthodontic treatment. Robust medical
assessments are needed since functional and static dental malocclusion are not always predictors

of temporomandibular disorders.

Materials and Methods

Research Design

The question that will be investigated in this cross-sectional study relates to determining

the prevalence and severity of temporomandibular disorders among adults seeking orthodontic

treatment. The null hypotheses are (1) the prevalence of temporomandibular disorders in

potential orthodontic patients is low, and (2) there is no association between the presence of

temporomandibular disorders and malocclusion severity. Cross-sectional research design, a type

of observational study (Nicolau et al., 2023), will collect data to test the formulated hypotheses.

According to Tabatabaei and Tayebi (2023), researchers measure both the exposure and the

outcome simultaneously when conducting a cross-sectional study. This study will use clinical

data and surveys to examine correlations between the prevalence and severity of

temporomandibular disorders among patients seeking orthodontic treatment (Nicolau et al.,

2023). The independent variables will be the severity and prevalence of temporomandibular

disorders, and the dependent variable is the treatment outcome.

Methodology

Before conducting the study, approvals will be obtained from the Institutional Review

Board and Ethics Research Committee regarding the use of human subjects (Pastore et al., 2018).

The target population for this study will be limited to patients seeking orthodontic treatment. The

sample size will include 55 prospective orthodontic patients, aged 18 to 40 years, who present at

the Riyadh Elm University dental clinics. Assuming a confidence level of 95%, a margin of error
of 5%, and the estimated target population of 64 first-time patients seeking orthodontic treatment

at a local dental clinic, a sample size of 55 patients will be enough for the study. The sample size

is calculated using the sample size calculator available at calculator.net

(https://www.calculator.net/sample-size-calculator.html). Purposive sampling will be used to

recruit potential participants into the study (Nicolau et al., 2023).

Predetermined inclusion and exclusion criteria were used to recruit (1) persons 18 years

and above, (2) prospective orthodontic patients who have existing temporomandibular disorders,

and (3) first-time visitors to the Riyadh Elm University dental clinics. Participants will be

excluded on the following grounds: (1) have severe psychiatric conditions, (2) unable to

autonomously understand the questionnaire, (3) received prior orthodontic treatment, (4)

advanced periodontitis or irreversible pulpitis, (4) received prior temporomandibular disorder

therapy, and (6) has cranial facial syndrome. The Fonseca Anamnestic Index (FAI) will be used

to assess the severity and presence of temporomandibular disorders. In contrast, the Peer

Assessment Rating (PAR) index will be used to identify the severity of malocclusion (Zhang et

al., 2020).

The Oral Health Impact Profile–14 (OHIP-14) and the FAI with demographic

information will be administered at the initial visit. Models for the study will then be obtained

and analysed using the Ortho Analyzer to determine patients’ PAR index scores before matching

the data with individuals’ FAI data (Pastore et al., 2018). OHIP-14 (Appendix 1) includes 14

questions with responses ranked on a 5-point Likert scale (from 1 = never to 5 = very often). The

responses help identify the different problems patients have experienced in the past 12 months

regarding their oral health. The total score is obtained by summing all responses to 14 items with

scores ranging from 0 to 56 (Tesic et al., 2020).

 The FAI questionnaire (Appendix 2) contains ten questions related to pain (measured

using headache, neck pain, masticatory muscle, and temporomandibular joints [TMJ]). The FAI

survey also includes emotional stress, temporomandibular disorder risk factors and symptoms

(poor bite or malocclusion, teeth clenching), and functional issues (jaw movement problems,

openings, and TMJ sound). A 3-point scale scores points on the ten FAI items with No = 0,

Sometimes = 5, and Yes = 10. Patients with “No TMDs” score ≤15 points, while individuals

with “With TMDs” score ≥20 points. Severe TMDs will include patients with a score of 70-100

points, moderate TMDs will consist of scores of 45-69 points, and those with mild TMD will

have 20-44 points.

The collected data will be analysed using the Statistical Package for Social Sciences

(SPSS) version 26. The significance level will be set to 0.05, with all p-values ≥0.05 considered

statistically significant. The data from OHIP-14 and FAI will not be normally distributed; the

Shapiro–Wilk test will be used to test for normality. Nonparametric tests (Mann-Whitney U and

Kruskal–Wallis tests) will compare means from the sampled populations. The tests will be used

to compare median OHIP-14 scores. At the same time, Spearman’s rho correlation (rs) will be

applied in assessing correlations between FAI and OHIP-14 scores to determine the frequency

and severity of temporomandibular disorders. Appendices 3 and 4 present the proposed study’s

time flow and research budget.

 References

Aboalnaga, A. A. et al. (2019) “Malocclusion and temporomandibular disorders: Verification of

the controversy,” Journal of oral & facial pain and headache, 33(4), pp. 440–450. doi:
10.11607/ofph.2260.

Bilgiç, F. and Gelgör, İ. E. (2018) “Prevalence of temporomandibular dysfunction and its

association with malocclusion in children: An epidemiologic study,” The journal of clinical
pediatric dentistry, 41(2), pp. 161–165. doi: 10.17796/1053-4628-41.2.161.

Christidis, N. et al. (2019) “Prevalence and treatment strategies regarding temporomandibular

disorders in children and adolescents-A systematic review,” Journal of oral rehabilitation, 46(3),
pp. 291–301. doi: 10.1111/joor.12759.

Diab, A., Elkhashab, M. and Aziz, E. (2023) “Prevalence and severity of temporomandibular
disorders among Egyptian postgraduate students: A cross-sectional study,” Advanced Dental
Journal, 5(1), pp. 166–173. doi: 10.21608/adjc.2023.180496.1218.

Emes, Y. et al. (2020) “Evaluation of occlusion types, pain severity, and onset of complaints in
127 patients with temporomandibular disorders: A retrospective study,” Cranio: the journal of
craniomandibular practice, 38(3), pp. 168–173. doi: 10.1080/08869634.2018.1509824.

Jain, S., Chourse, S. and Jain, D. (2018) “Prevalence and severity of temporomandibular
disorders among the orthodontic patients using Fonseca’s questionnaire,” Contemporary clinical
dentistry, 9(1), pp. 31–34. doi: 10.4103/ccd.ccd_689_17.

Karaman, A., DDS, MSc and Buyuk, S. K. (2022) “Evaluation of temporomandibular disorder
symptoms and oral health-related quality of life in adolescent orthodontic patients with different
dental malocclusions,” Cranio: the journal of craniomandibular practice, 40(1), pp. 55–63. doi:
10.1080/08869634.2019.1694756.

Lai, Y. C., Yap, A. U. and Türp, J. C. (2020) “Prevalence of temporomandibular disorders in

patients seeking orthodontic treatment: A systematic review,” Journal of oral rehabilitation,
47(2), pp. 270–280. doi: 10.1111/joor.12899.

Macrì, M. et al. (2022) “Prevalence of temporomandibular disorders and its association with
malocclusion in children: A transversal study,” Frontiers in public health, 10, p. 860833. doi:
10.3389/fpubh.2022.860833.

Natu, V. P. et al. (2018) “Temporomandibular disorder symptoms and their association with
quality of life, emotional states and sleep quality in South‐East Asian youths,” Journal of oral
rehabilitation, 45(10), pp. 756–763. doi: 10.1111/joor.12692.

Nicolau, B. et al. (2023) “How to use mixed methods in oral health research,” Community
dentistry and oral epidemiology, 51(1), pp. 71–74. doi: 10.1111/cdoe.12801.
Paço, M., Duarte, J. A. and Pinho, T. (2021) “Orthodontic treatment and craniocervical posture
in patients with temporomandibular disorders: An observational study,” International journal of
environmental research and public health, 18(6), p. 3295. doi: 10.3390/ijerph18063295.

Pastore, G. P. et al. (2018) “Comparison of instruments used to select and classify patients with
temporomandibular disorder,” Acta odontologica latinoamericana: AOL, 31(1), pp. 16–22.

Paunonen, J. et al. (2019) “Temporomandibular disorders in Class II malocclusion patients after

surgical mandibular advancement treatment as compared to non‐treated patients,” Journal of oral
rehabilitation, 46(7), pp. 605–610. doi: 10.1111/joor.12790.

Tabatabaei, F. and Tayebi, L. (2023) Research methods in dentistry. 1st ed. Cham, Switzerland:
Springer Nature.

Tesic, M. et al. (2020) “Validation of the oral health impact profile - 14 in patients with head and
neck cancer,” Medicina oral, patologia oral y cirugia bucal, pp. e739–e744. doi:
10.4317/medoral.23765.

Yap, A. U. et al. (2021) “Temporomandibular disorders in prospective orthodontic

patients:,” The Angle orthodontist, 91(3), pp. 377–383. doi: 10.2319/010720-863.1.

Yap, A. U., Ho, H. C. W. and Lai, Y. C. (2023) “Analysing the psychosocial construct of
temporomandibular disorders: Implications for orthodontics,” Seminars in orthodontics. doi:
10.1053/j.sodo.2023.11.006.

Zhang, M.-J. et al. (2020) “Psychometric evaluation of the Chinese version of the Fonseca
anamnestic index for temporomandibular disorders,” Journal of oral rehabilitation, 47(3), pp.
313–318. doi: 10.1111/joor.12893.

Zúñiga-Herrera, I. D. et al. (2023) “Malocclusion complexity as an associated factor for

temporomandibular disorders. A case-control study,” Cranio: the journal of craniomandibular
practice, 41(5), pp. 461–466. doi: 10.1080/08869634.2020.1868907.
 Appendices

Appendix 1: Oral Health Impact Profile–14 Survey

Appendix 2: Fonseca Anamnestic Index

Appendix 3: Time-Flow Chart
Tasks Duration
Literature Review 14 days
Research Design 10 days
Methodology 35 days
Results Analysis 20 days
Thesis Writing 30 days
Submission and Revisions 21 days

Appendix 4: Research Budget

Equipment / materials #Items Costs
Outsourcing tests 1 300 SAR
Reagents 4 800 SAR
Lab techniques and measurements 2 800 SAR
Liquids and solids 2 850 SAR
Travel costs 10 800 SAR
Sample collection 4 300 SAR
Materials for analysis 2 300 SAR
Thesis write up materials 5 100 SAR
Software and laptop programs 2 1000 SAR
Miscellaneous - 300 SAR`