ORIGINAL RESEARCH & CONTRIBUTIONS

Influence of Psychosocial Factors and Parafunctional Habits in

Temporomandibular Disorders: A Cross-Sectional Study
Utkarsh Yadav, MDS1,2; Junaid Ahmed, MDS1,2; Ravikiran Ongole, MDS1,2;
Nandita Shenoy, MDS1,2; Nanditha Sujir, MDS1,2; Srikant Natarajan, MDS2,3 Perm J 2020;24:19.144
E-pub: 04/22/2020 https://doi.org/10.7812/TPP/19.144

ABSTRACT of anxiety, depression, and bruxism with

Introduction: Temporomandibular disorders (TMDs) are abnormalities affecting the TMD symptoms and their correlation
temporomandibular joint, jaw muscles, or both. An intrinsic relationship reportedly exists with age and sex.
between TMDs and psychosocial factors, including stress. Parafunctional habits such as
bruxism and clenching are also known to be responsible for TMDs. METHODS
Objective: To determine the association of anxiety, depression, and bruxism with TMD Patients
symptoms and their relationship with age and sex. This cross-sectional study was conduct-
Methods: Patients included in the study reported, as their chief concern, pain lasting for ed in patients reporting to the Department
more than a week in the temporomandibular joint area and/or masticatory muscles. The of Oral Medicine and Radiology, Manipal
patients were divided into age groups as follows: Younger than 20 years, 21 to 30 years, College of Dental Sciences, Mangalore,
31 to 40 years, 41 to 50 years, 51 to 60 years, and above 60 years. Patients were examined India. Ethical clearance was obtained
clinically and were asked to complete an anamnestic questionnaire (modified version of from the institutional ethical committee
Helkimo Anamnestic Index) and the Hospital Anxiety and Depression Scale (HADS). (MCODSMLR/2017.1414).
Results: Seventy-five patients (55 women, 20 men) were included in the study. The Patients with pain lasting for 1 week or
prevalence of TMDs was higher in female patients, of whom 33 (60%) had moderate to more in the TMJ region and/or the masti-
severe TMDs. Of the 20 male patients, 12 (60%) had signs and symptoms of moderate TMDs. catory muscle and absence of any systemic
Anxiety and depression scores were higher in female patients. No significant correlation conditions were included in the study. The
was found between degree of malocclusion and TMDs. exclusion criteria were as follows:
Discussion: We found correlations between the degree of TMD with age, sex, parafunc- 1. History of trauma or congenital abnor-
tional habits, and psychosocial factors. Symptoms of TMD seemed to increase in patients malities to the TMJ
with parafunctional habits, from younger to older age groups, and with increased anxiety 2. Odontogenic infections or any other
and depression scores. pathologic swellings in relation to the
Conclusion: The degree of TMDs is higher in women, and TMDs are associated with TMJ
higher anxiety and depression scores. Correlation between these factors paves the way for 3. Metastatic tumors, cysts, or carcinomas
preventive actions aimed at those with moderate and severe signs of TMDs. of the oral cavity affecting the TMJ
4. Regular intake of medicines such as
INTRODUCTION in women than in men, TMDs are most analgesics or antianxiety drugs.
Temporomandibular disorders (TMDs) prevalent in the 20- to 40-year age group With a 95% confidence level and 80%
are a group of abnormalities affecting the and are least common in children and power, the sample size was estimated to
temporomandibular joint (TMJ), jaw mus- elderly individuals. be 75.a
cles, or both. Pain, malocclusion, deviated Various studies have provided an irre-
mouth opening, limited jaw function, and futable evidence of a significantly appre- Procedures
headache are some of the most commonly ciable relationship between bruxism and The study participants were asked to fill
noticed signs and symptoms of TMDs. A TMDs.6-8 A clear and decisive relationship out an anamnestic questionnaire contain-
multifactorial etiology of pain and dys- was found between TMDs and bruxism in ing 10 questions (a modified version of
function resulting from biopsychosocial a case-control study conducted by Molina
factors has been proposed.1-3 Alteration et al.6 In a study done by Michelotti et al,7
of form can cause changes in the sto- a habit such as sustained contact between
matognathic system, eventually leading the teeth was seen to be an important Author Affiliations
to malocclusion, which is recognized risk factor in triggering myofascial pain. 1
Department of Oral Medicine & Radiology, Manipal College of Dental
as one of the primary causes of TMDs. Kanehira et al8 concluded that stress is an Sciences, Mangalore, Manipal Academy of Higher Education (MAHE),
Manipal Karnataka, India
Several authors have studied the different important factor and is intimately con- 2
Manipal Academy of Higher Education (MAHE), Karnataka, India
types of malocclusion, including posterior nected with parafunctional habits such 3
Department of Oral Pathology, Manipal College of Dental Sciences,
crossbite, anterior open bite, and horizon- as bruxism during sleep and daytime Mangalore, India
tal and vertical overlap. The authors have clenching. Considering the complexity
concluded that these changes can cause of TMDs involving psychosocial factors Corresponding Author
various degrees of TMD symptoms.4,5 Ap- and parafunctional habits, our study was Junaid Ahmed, MDS ([email protected])
proximately 1.5 to 2 times more common undertaken to determine the association
Keywords: Hospital Anxiety and Depression Scale, parafunctional habits,
psychosocial factors, temporomandibular disorder

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ORIGINAL RESEARCH & CONTRIBUTIONS
Influence of Psychosocial Factors and Parafunctional Habits in Temporomandibular Disorders: A Cross-Sectional Study

the Helkimo Anamnestic Index) consist- Two investigators participated in the RESULTS
ing of TMD symptom-related questions study. The first investigator (UY) performed A total of 75 patients who reported
(see Sidebar: Anamnestic Questionnaire), the clinical examination of patients and with a chief complaint of pain in the
which was validated by a professor in the evaluation of the modified anamnestic TMJ region were included in the study;
Department of Community Medicine, questionnaires, and the second investigator 55 patients (80%) were women and 20
Kasturba Medical College, Mangalore. ( JA) evaluated anxiety and depression using (20%) were men. Of these 75 patients, 63
The participants were later asked to com- the HADS questionnaire in the Depart- (84%) had Angle class 1 malocclusion and
plete the Hospital Anxiety and Depression ment of Psychiatry, KMC Hospital, At- the remaining 12 (16%) had Angle class 2
Scale (HADS) questionnaire (developed tavar, Mangalore. Both investigators were malocclusion (Table 1).
by Zigmond and Snaith9 in 1983), consist- unaware of each other’s findings. The patients were divided into 6 groups
ing of 14 questions, equally distributed for by age as follows: 1) 20 years and younger,
anxiety and depression. Data Analysis 2) 21 to 30 years, 3) 31 to 40 years, 4) 41
The patients were then examined clini- Association of the role of bruxism with to 50 years, 5) 51 to 60 years, and 6) more
cally and the findings, especially the hard- the severity of TMD cases was performed than 60 years.
tissue findings (for parafunctional habits), using χ2 test. According to the DC/TMD criteria,10
were recorded in a case history pro forma. Simple linear regression analysis to patients were categorized into these 4
Palpation of the muscles of mastication predict the TMD score with the variables subgroups:
was done using the 2014 Diagnostic Cri- of age, sex, bruxism, anxiety and depres- 1. Mild TMD: Mild myofascial pain, re-
teria for Temporomandibular Disorders sion was conducted to derive the equation. curring in nature
(DC/TMD),10 followed by a thorough 2. Moderate TMD: An intra-articular
examination of the TMJ. mechanical disturbance that interfered
with a joint’s smooth action
3. Severe TMD: Signs and symptoms
of arthralgia and arthritis (clinically
Table 1. Distribution of participants with temporomandibular disorder (TMD) by age, evident joint pain with inflammation
sex, Malocclusion, bruxism, and anxiety and depression scores or swelling)
TMD free, Mild TMD, Moderate TMD, Severe TMD, Chi square 4. TMD free: Only occasional pain with
Variable no. (%) no. (%) no. (%) no. (%) value p valuea a duration of less than 1 year.
Age, y Bruxism was most prevalent among
≤ 20 1 (33.3) 4 (14.8) 8 (23.5) 1 (9.1) 16.3 0.365 women aged 21 to 30 years and 31 to
21-30 1 (33.3) 15 (55.6) 13 (38.2) 2 (18.2) 40 years (Table 1). Of 11 patients who
31-40 0 (0) 4 (14.8) 6 (17.6) 2 (18.2) had a diagnosis of severe TMD, 10 had
41-50 0 (0) 1 (3.7) 3 (8.8) 3 (27.3) bruxism, a significant finding (p = 0.001;
51-60 1 (33.3) 1 (3.7) 4 (11.8) 2 (18.2) Table 1). Our study findings revealed that
> 60 0 (0) 2 (7.4) 0 (0) 1 (9.1) the degree of TMDs increased from the
Sex youngest group to the oldest group and
Female 2 (66.7) 21 (77.8) 22 (64.7) 10 (90.9) 3.3 0.338 was significant (p = 0.04; Table 2).
Male 1 (33.3) 6 (22.2) 12 (35.3) 1 (9.1)
In the present study, female participants
had an increased degree of TMDs com-
Occlusion
pared with male participants (Table 1).
Class 1 2 (66.7) 23 (85.2) 29 (85.3) 11 (100) 2.8 0.417
Results for the anxiety and depression
Class 2 1 (33.3) 4 (14.8) 5 (14.7) 0 (0)
score revealed higher scores among the 21-
Bruxism
to 30-year age group vs other age groups
Absent 0 (0) 19 (70.4) 12 (35.3) 1 (9.1) 16.5 0.001
and an increased rate of prevalence among
Present 3 (100) 8 (29.6) 22 (64.7) 10 (90.9) female patients compared with male pa-
Anxiety score tients (Table 1).
Normal 2 (66.7) 17 (63) 13 (38.2) 3 (27.3) 9.9 0.354 In our study, patients with TMDs
Mild 0 (0) 2 (7.4) 11 (32.4) 4 (36.4) showed moderate depression scores, nota-
Moderate 1 (33.3) 7 (25.9) 9 (26.5) 3 (27.3) bly seen among women in the age group of
Severe 0 (0) 1 (3.7) 1 (2.9) 1 (9.1) 31 to 40 years. In the severe TMD group,
Depression score 12 patients had raised HADS scores and
Normal 1 (33.3) 21 (77.8) 22 (64.7) 7 (63.6) 8.2 0.221 10 had normal HADS scores, which was
Mild 2 (66.7) 5 (18.5) 11 (32.4) 2 (18.2) a clinically significant finding but not sta-
Moderate 0 (0) 1 (3.7) 1 (2.9) 2 (18.2) tistically significant (Figure 1).
Severe 0 (0) 0 (0) 0 (0) 0 (0) Linear regression analysis was con-
a Boldface indicates significant. ducted to derive a formula to calculate the
TMD score as follows:

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 ORIGINAL RESEARCH & CONTRIBUTIONS
Influence of Psychosocial Factors and Parafunctional Habits in Temporomandibular Disorders: A Cross-Sectional Study

Table 2. Correlation of degree of temporomandibular disorder (TMDs) with age, sex, concluded that TMD primarily affects
bruxism, anxiety, and depression women, because more than 84% of those
affected were women. Bonjardim et al16
Unstandardized 95% Confidence
coefficientsa interval for B
conducted a study in 217 patients and
Standardized
found that women were more commonly
B Standard coefficients,a Lower Upper
Model 1 error β t p valueb bound bound affected by TMDs. In the present study, we
(Constant) 7.482 1.869 4.003 <0.001 3.754 11.211 found that 73.3% of patients having signs
Age 0.747 0.357 0.256 2.093 0.040 0.035 1.459
and symptoms of TMDs were women. Ac-
cording to a study by Syed et al17 in 2012,
Sex -0.608 1.039 -0.067 -0.585 0.561 -2.680 1.465
women were seen to have higher degree
Bruxism 2.335 0.927 0.286 2.519 0.014 0.486 4.184
of TMDs, attributed to higher anxiety
Anxiety 0.086 0.144 0.081 0.595 0.554 -0.202 0.373
and depression scores with the habit of
Depression -0.116 0.172 -0.094 -0.672 0.504 -0.460 0.228
bruxism. The authors state that because
a Dependent variable: TMD Score = 7.482 + 0.747 (Age) - 0.608 (Sex [male 2, female 1]) + 2.335 (Bruxism 1, 0) + 0.086 bruxism results in overuse of masticatory
(Anxiety) - 0.116 (Depression)
b Boldface indicates significant. muscles, it can eventually lead to a higher
possibility of developing TMDs.17 In the
our study, with an increase in anxiety score,
TMD score = 7.482 + 0.747(Age) - clinical criteria used among various stud- it was noticed that the degree of TMDs
0.608{Sex [Female(1)] [Male(2)} + 2.335 ies, there appears to be an irregularity in also increased.
{Bruxism [Absent(1)], Present(0)} + the literature regarding the prevalence of The results of our study reinforce the
0.086(Anxiety) - 0.116(Depression) clinical signs and symptoms. Studies have assumption that there is an association
where the score for male sex = 2 and for suggested that between 1% and 75% of between TMD and bruxism. Although the
female sex = 1, and the score for having the population showed at least 1 objec- association between psychological factors
bruxism = 0, and no bruxism = 1. tive TMD sign, and 5% to 33% reported and TMD is inconsistent in the literature,
subjective symptoms.12 there is biological plausibility for this as-
DISCUSSION A peak incidence for TMD symptoms sociation in our study.
TMDs are distinctively identified as was recorded between age 20 and 40 years, Bonjardim et al18 conducted a study
a triad of clinically apparent signs and with a lower incidence seen in younger or in 196 young adults in which 101 were
symptoms that include muscle and/or elderly patients.13 Graff-Radford et al,14 women and 95 were men. They noted that
TMJ pain, TMJ sounds, and restriction in a 1989 study, found that patients had participants who had moderate or severe
and deviation of the mouth in its open- TMDs prevalent at ages 21 to 30 years TMD exhibited class 1 malocclusion,
ing path.11 followed by above 50 years. In the present which was seen to be nonsignificant.18
The prevalence of TMD is debatable, study, among 75 patients aged between 0 Similar findings were observed in our
owing to the lack of uniformity in the and 70 years, it was noted that 80% of the study, wherein the patients with class
diagnostic criteria adapted by various in- patients had TMDs, and most of these 1 malocclusion had moderate to severe
vestigators. Evidence toward an increasing patients were in the 21- to 30-year group TMD symptoms but the results were
prevalence of TMD signs and symptoms followed by 20 years of age or younger. nonsignificant.
in the general population has been noted Esposito et al15 reviewed records of 425 Wieckiewicz et al19 conducted a study in
in several studies. Because of the dissimilar consecutive patients having TMDs. They 456 Polish university students to assess the

Anxiety score Depression score

100% 100%
90%
80% 80%
70%
60%
60%
50% 40%
40%
30% 20%
20%
0%
10%
TMD FREE MILD TMD MODERATE TMD SEVERE TMD
0%
TMD FREE MILD TMD MODERATE TMD SEVERE TMD NORMAL MILD MODERATE SEVERE

NORMAL MILD MODERATE SEVERE

Figure 1. Correlation of degree of temporomandibular disorders with anxiety and depression score.

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ORIGINAL RESEARCH & CONTRIBUTIONS
Influence of Psychosocial Factors and Parafunctional Habits in Temporomandibular Disorders: A Cross-Sectional Study

occurrence of TMDs and parafunctional habit of bruxism among patients with in women, increases with the increase in
habits and their correlation with psycho- such parafunctional habits and the start anxiety and depression scores. The existing
logical and emotional factors. Symptoms of relaxation therapy. It is important to correlation between these factors paves the
of TMDs were noticed in 246 students. A explain to the patient the background of way for preventive actions aimed at those
total of 164 female students were found to the disorders, especially the role of one’s with moderate and severe signs of TMD.
have TMDs, anxiety, and depression. The emotional stress, and to prescribe coun- An interdisciplinary approach should be
authors observed a significant correlation seling and behavioral therapy to reduce created for this population to reduce para-
between TMD and psychological prob- anxiety.20 functional habits and TMDs. v
lems. The incidence of TMD symptoms As explained in the Results section, we a Using the formula n = Zα2 p q/E2, where Zα = 95%
was seen to be higher in women, and emo- performed linear regression analysis to confidence level, p = Proportion from reference, q = 100 –
tional issues appeared to be an important derive a formula to calculate the TMD p, and E = 20/100 × p.
predisposing factor for the occurrence of score using the variables age, sex, brux-
muscular disorders.19 ism, anxiety, and depression. Association Disclosure Statement
In our study, we found that 73.3% of of the prediction of the TMD score with The author(s) have no conflicts of interest to
disclose.
patients with TMD diagnosis were female. the variables showed a significant asso-
Bruxism was more common in female pa- ciation with age (p = 0.040) and bruxism
Acknowledgments
tients than in male patients. Hence, female (p = 0.014) with anxiety and depression
Kathleen Louden, ELS, of Louden Health
patients appeared to have higher chances .However sex did not appear to play a Communications performed a primary copy edit.
of TMDs compared with male patients. significant role. In a study by Montero-
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