Journal of Oral Rehabilitation 2003 30; 283–289

Prevalence study of signs and symptoms

of temporomandibular disorders in university students
C. R. PEDRONI*, A. S. DE OLIVEIRA† & M. I. GUARATINI‡ *University of São Carlos, Physiotherapy
Post-Graduated, São Carlos, SP, Brazil, University of Campinas, College of Dentistry of Piracicaba, Piracicaba, SP, Brazil and ‡College Center of
†

Araraquara, Araraquara, SP, Brazil

SUMMARY The aim of this study was to evaluate the sensation of emotional stress, and postural and
prevalence of signs and symptoms of temporoman- occlusal changes were more evident in the group
dibular disorders (TMD) in university students from with TMD, although they were also present in
19 to 25 years old, male and female, through the subjects classified as TMD-free. Limitations in the
distribution of frequency of the data obtained from mandibular movements were not found. The associ-
a questionnaire and physical examination. The ation of the obtained data allowed identifying a high
results showed that 68% of the subjects exhibited prevalence of signs and symptoms of TMD in the
some degree of TMD, and the women were the most Brazilian university population.
affected. Signs and symptoms such as articular KEYWORDS: temporomandibular disorders, evalua-
sounds, pain to palpation of the masticatory, tion, prevalence, aetiology, physical examination,
cervical and scapular girdle musculature, subjective questionnaire

the general and non-patient populations (Solberg, Woo

Introduction
& Houston, 1979; Shiau & Chang, 1992; Gray et al.,
The major difficulty for identifying the temporoman- 1994; Garcia, Lacerda & Pereira, 1997; Schiffman &
dibular disorder (TMD) arises from its complex rela- Fricton, 1988).
tionship with other structures of the head, neck and The prevalence of TMD is still obscure, and more
scapular girdle, in addition to the great variety of signs studies are necessary to allow a better understanding of
and symptoms that can be related to temporomandib- the pathological aspects so as to address effective
ular joint (TMJ) by these structures and vice-versa. therapies individually or preventive projects at the
The clear existence of a multifactorial origin for TMD is population level.
evidenced by the association of psychological, structural The aim of this study was to evaluate the prevalence
and postural factors, which disarrange the functional of signs and symptoms of TMD in university students,
balance among three fundamental elements of the sto- male and female, with no previous clinical diagnosis of
matognathic system: dental occlusion, masticatory mus- TMD, through the analysis of the subjective data
cles and TMJ, becoming impossible to recognize a single obtained from a questionnaire and clinical examina-
aetiological factor as triggering of a TMD (Silva, 1993). tion.
The importance of the epidemiology with regards to
TMD concerns the knowledge of several symptomatic
Materials and methods
complexes and the therapeutic approaches, allowing
the establishment of prevention and control pro-
Volunteers
grammes, that will lead to the actual definition of the
aetiology (De Boever & Steenks, 1996). The volunteers who participated in this study were
Some studies in non-patient population indicate a randomly selected among students of the Federal
high prevalence of signs and symptoms of TMD in both University of São Carlos, São Paulo, Brazil. The

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284 C . R . P E D R O N I et al.

analysed group consisted of 50 subjects, 18 male and 32 uninterruptedly three times, in order to observe the
female, with age ranging from 19 to 25 (21Æ5
1Æ3) presence of articular sounds.
years, with no history of systemic, musculoskeletal or The amplitude of the movements was registered by a
neurological disorder. All the volunteers were informed Boley gauge* according to Okeson (1992), and each
on the objectives of the study, and they signed a formal movement was repeated three times in order to obtain
consent of participation approved by the Ethic Com- an average of the values. The degree of mouth
mittee in Research of the Federal University of São opening, the lateral and protrusion eccentric move-
Carlos. ments were also evaluated. In addition, the classifica-
Volunteers who had a clinical diagnosis of TMD with tion of the occlusion was made according to the criteria
or without treatment, and subjects who were under- of Angle.
going orthodontic treatment during the period of data
collection were excluded.
Data analysis

The results were analysed using the distribution of

Questionnaire
frequency of the data obtained from physical examina-
The questionnaire adopted by Fonseca (1994) was used tion and questionnaire answers according to the
to evaluate the degree of TMD in the volunteers of this anamnesis index proposed by Fonseca (1994), so that
study, as it demonstrates a high efficiency in obtaining a the volunteers were divided into groups classified as
diagnosis and because of its proven application. This light TMD, moderate TMD, severe TMD or without
questionnaire contained an anamnesis index that was TMD-free.
just verified after the physical examination. Thus, the
volunteers were classified as light TMD, moderate TMD,
Results
severe TMD or TMD-free. The questionnaire consisted
of 10 questions, and the possible answers were ‘SOME- The results obtained from the questionnaire showed
TIMES’, ‘YES’ and ‘NO’, with a single answer to be that 68% of the subjects exhibited some degree of
marked for each of the questions. disorder. In order to study the prevalence between the
sexes, the data concerning the anamnesis indexes of the
questionnaires answered by men and women were
Physical examination
analysed in parallel (Fig. 1).
The physical examination by physical therapist consis- From the questions included in the questionnaire,
ted of inspection, palpation, evaluation of the active one particularly deserved more attention. All the
articular mobility and articular sound auscultation, in volunteers classified by the anamnesis index as severe
addition to the fulfilling of an evaluation register. At the and moderate TMD reported that they regarded them-
inspection, the volunteer posture was observed on the selves as tense people (Fig. 2). The statement of the
anterior, posterior and lateral aspects. The head, cervi- emotional behaviour considered as emotional stress by
cal spine and shoulder postures were evaluated accord- the volunteer was proportional to the severity of TMD.
ing to the criteria proposed by Kendall, Mccreary and The observation of the shoulder posture showed that,
Provance (1997). in all the groups, some type of posture deviation could
The presence of sensitive points in the head, cervical be evidenced. However, in the group classified as severe
region and scapular girdle musculature was evaluated TMD, a strong association between the protrusion
by performing a moderate digital pressure on the points deviations and asymmetric shoulder height was found
as indicated by Menell (1994). (Fig. 3).
The palpation of the masticatory musculature was According to the anamnesis index proposed by
performed on the temporalis and masseter muscle belly. Fonseca (1994), all the groups exhibited varied per-
The medial pterygoid muscle was palpated intraorally. centages of inadequate head postures (Fig. 4). How-
Auscultation of articular sounds was carried out with ever, the evaluation of the head posture among the
the aid of a stethoscope positioned on the TMJ lateral groups allowed the observation that the percentage of
region, while the volunteer was performing mouth
opening and closing movements, consecutively and *Mitutoyo, Aurora, USA.

ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 283–289

 SIGNS AND SYMPTOMS OF TEMPOROMANDIBULAR DISORDERS 285

Fig. 1. Classification of the total

(n ¼ 50), male (n ¼ 18) and
female (n ¼ 32) volunteers accord-
ing to the anamnesis index proposed
by Fonseca (1994).

Fig. 2. Distribution of frequencies of

the reports on subjective sensation of
emotional stress with regard to the
groups classified by the anamnesis
index in a total of 50 cases.

Fig. 3. Distribution of frequencies

related to the shoulder posture with
regard to the groups classified by
questionnaire in a total of 50 cases.

Fig. 4. Distribution of frequencies

related to the head posture with
regard to the groups classified by
questionnaire in a total of 50 cases.

volunteers with normal positioning decreases as the ation among the individuals of the group classified as
severity of the disorder increases. severe TMD.
By evaluating the cervical spinal posture, it was The results obtained from auscultation on the TMJ
observed that the normality values were similar in all showed that in all the groups some articular sound was
the volunteer groups and were always > 50% (Fig. 5). identified, and even in the group classified as TMD-free,
The cervical rectification was the most prevalent devi- 43Æ7% of the subjects exhibited audible sounds (Fig. 6).

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286 C . R . P E D R O N I et al.

Fig. 5. Distribution of frequencies

related to the cervical spinal posture
with regard to the groups classified
by questionnaire in a total of 50
cases.

Fig. 6. Distribution of frequencies

related to the occurrence of TMJ
sound with regard to the groups
classified by questionnaire in a total
of 50 cases.

In all the groups of volunteers, reports of some Figure 9 demonstrates the results concerning the
degree of discomfort to palpation of the masticatory occlusal classification. All the volunteers of the severe
musculature were noted. In addition, the percentage of TMD group showed class II occlusion according to
individuals with no pain to palpation decreased as the Angle.
severity of TMD increased. As demonstrated in Fig. 7, in Although the results of the anamnesis index have
the group with severe TMD, the pain was always indicated that 68% of the subjects showed some degree
located in more than one of the palpated muscles. of TMD, limitations among the investigated mandibular
Also in all the studied groups, some degree of movements were not found, not even when the cases
discomfort to palpation of specific points on the cervical were analysed according to sex (Table 1).
musculature and scapular region was observed, and the
prevalence of subjects with no pain decreased as the
Discussion
degree of severity of TMD increased. In the severe TMD
group, all the individuals reported discomfort to palpa- The aim of this study was to evaluate the prevalence of
tion of at least a studied specific point (Fig. 8). signs and symptoms of TMD in university students

Fig. 7. Distribution of frequencies

related to the occurrence of pain in
the masticatory musculature with
regard to the groups classified by
questionnaire in a total of 50 cases.

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 SIGNS AND SYMPTOMS OF TEMPOROMANDIBULAR DISORDERS 287

Fig. 8. Distribution of frequencies

related to the occurrence of sensitive
points in the cervical musculature
and scapular region with regard to
the groups classified by questionnaire
in a total of 50 cases.

TMD, similar to the findings of Garcia et al. (1997) who

found 61% of the subjects had some TMD, when
evaluating a sample of 200 university students and
using the same questionnaire.
In this study the prevalence of TMD found in women
was almost four times more than for men. Although
Gray et al. (1994) has reported that the prevalence of
signs and symptoms of TMD in non-patients should be
considered at proportion 1:1 with regards to sex, our
results agree with the findings of Garcia et al. (1997),
Solberg et al. (1979), Klineberg et al. (1998), Shiau and
Fig. 9. Distribution of frequencies related to the occlusal type
with regard to the groups classified by questionnaire in a total of Chang (1992). They reported the occurrence of a higher
50 cases. prevalence of signs associated with mandibular disorder
among women. The highest prevalence of women
classified with some degree of TMD may be related to
Table 1. Mean amplitude values of the mandibular movements
typical physiologic differences of the feminine sex, such
measured in the total (n ¼ 50), male (n ¼ 18) and female (n ¼ 32)
evaluated volunteers
as regular hormonal variations, muscular structure and
different characteristics of the conjunctive tissue. These
Jaw Jaw Lateral right Lateral left matters need to be investigated fully.
opening protrusion movement movement In the individuals classified by the anamnesis index
Male 55Æ28 6Æ48 8Æ87 8Æ49
as TMD-free, the presence of some signs and symptoms
Female 45Æ94 5Æ86 8Æ16 7Æ82 related to the disorder was observed, such as changes in
Total 49Æ30 6Æ08 8Æ41 8Æ06 the posture, pain to palpation of the masticatory
musculature and even TMJ sounds.
Although the results demonstrated that 68% of the
through the distribution of frequency of the data volunteers had some degree of TMD, the mean ampli-
obtained from a questionnaire and physical examination. tude values of the mandibular movements were in
The anamnesis index used provided a substantial agreement with the means found in the literature
amount of information in little time and was demon- (Gillings, Grahana & Duckmanton, 1973; Lundeen
strated to be sensitive for the degree of TMD in the et al., 1988; Molina, 1989; Sidelsky & Clayton, 1990;
studied population. The index showed itself as a simple Okeson, 1992; Garcia et al., 1997). Only two volunteers
and suitable tool with easy understanding for the showed amplitude values of mouth opening less than
volunteers, thus allowing a smaller influence of the the normal values proposed in the literature, and
examiner on the individuals and their answers. according to the questionnaire, these individuals were
The prevalence of subjects with TMD according to the classified as moderate and severe TMD.
anamnesis index is in agreement with the literature. In The report on subjective sensation of emotional stress
this study, 68% of the subjects had some degree of was considered an important characteristic of TMD,

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288 C . R . P E D R O N I et al.

because all the individuals with moderate and the articular structures, because of overload on the
severe TMD reported that were tense people, although articular surfaces, leading to changes in the TMJ
occasionally. This information is supported by studies biomechanics.
on the influence of the emotional stress on changes of In this study, from the individuals that had some
the muscular activity and occlusion (Solberg, Clark, & degree of TMD, more than 52% showed habits of
Rugh, 1975; Kampe, 1987). clenching or grinding the teeth. However, 25% of the
The emotional influence on the mastication muscles individuals classified as without TMD-free also men-
has been studied. The reported conclusion was that tioned to have such habits. This finding is supported by
when the individual is submitted to an emotional the statements of Steeks and De Wijer (1996), who
overload, teeth clenching may develop, producing pointed out that theses habits can be highly destructive,
circulatory changes in the mastication muscles or fluid but are considered common, and generally do not affect
increase in the muscular tissues with consequent the mouth structures in some individuals.
compression of the pain receptors (Christensen, The influence of occlusal factors in the aetiology of
1971). TMD is controversial. When analysing university
Although all the studied groups demonstrated varied students, Shiau and Chang (1992) did not find a
percentages of disturbed cervical, shoulder and head relationship among the different occlusion types in
postures, the changes were more evident in individuals the group with TMD.
with TMD. In our study, the results showed that Angle class II
Several studies (Gelb & Bernstein, 1983; Boyd, 1987; malocclusion was present in 100% of the cases of
Darling & Kraus, 1994; De Wijer et al., 1996; Kovero & severe TMD suggesting a relationship between the
Könönem, 1996; Rodrigues et al., 1999) have con- occlusal type and TMD, despite the reduced number of
firmed that the changes in posture interfere with the volunteers included in this group.
mandible position. Similarly, the results of the present Henrikson, Ekberg and Nilner (1997) concluded that
study indicate that posture becomes an important factor a normal occlusions has a lower chance of presenting
in the aetiology of TMD. signs and symptoms of TMD, while some occlusal
Therefore, our results suggest the need to evaluate characteristics, such as posterior condylar displacement
the structures of the scapular and cervical girdle as with consequent typical changes in the condylar form
indispensable for the diagnosis of TMD because this and more frequently found in the individuals with class
cannot be understood as a local disorder. II malocclusion, increase the chances of signs and
The pain on palpation of the masticatory muscula- symptoms of TMD. These characteristics influence the
ture was less frequent in the individuals without muscular activity and consequently the mandibular
TMD, and when present, isolated muscles were movement with predisposition to TMD.
affected. On the other hand, in the individuals with
some degree of TMD, the involvement of two or more
Conclusions
muscles was proportional to the level of severity of
the disorder. Based on the obtained results and the proposed
The prevalence of audible articular sounds, in this experimental conditions, it can be concluded that:
study, was higher according to the severity of TMD. 1. The association of the data obtained from the
From the total of individuals classified by the anam- physical examination and questionnaire identified a
nesis index with some degree of TMD, 52Æ94% high prevalence of signs and symptoms of TMD in
exhibited articular sounds, as much clicking and as Brazilian university population.
crackling. These results are in agreement with the 2. Most of the volunteers classified by the anamnesis
findings of Shiau and Chang (1992) and Solberg et al. index as severe and moderate TMD reported high
(1979). emotional stress and had audible articular sounds at the
Some authors reported that the parafunctional habits physical examination, this being the most evident
are one of the most important factors in the aetiology of aspects of TMD in the study.
TMD (Rugh & Ohrbach, 1989; Austin, 1997). According 3. The prevalence of pain on palpation of the masti-
to Okeson (1988), the habit of pressing or grinding the catory musculature, inadequate head, neck and shoul-
teeth produces changes in the lubrication mechanism of der postures, and presence of sensitive points to

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 SIGNS AND SYMPTOMS OF TEMPOROMANDIBULAR DISORDERS 289

palpation of the head, scapular girdle and cervical KLINEBERG, I., MCGREGOR, N., BUTT, H., DUNSTAN, H., ROBERTS, T. &
region were proportionally higher according to the ZERBES, M. (1998) Chronic orofacial muscle pain: a new
approach to diagnosis and management. Alpha Omegan, 91, 25.
severity of TMD.
KOVERO, O. & KÖNÖNEM, M. (1996) Signs and symptoms of
temporomandibular disorders in adolecent violin players. Acta
Odontologica Scandinavica, 54, 271.
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