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https://doi.org/10.1080/08869634.2019.1694756
ORTHODONTICS
ABSTRACT KEYWORDS
Objective: To estimate the prevalence of temporomandibular disorders in adolescent orthodon- Temporomandibular
tic patients with different dental malocclusions and to assess the relationship between oral disorders; oral health impact
health-related quality of life. profile; Fonseca’s
questionnaire; quality of life
Methods: This study was carried out on 648 randomly selected individuals 14–19 years of age.
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), Fonseca Questionnaire, and Oral
Health Impact Profile-14 (OHIP-14) forms were used.
Results: TheGCPS,TMDPain,Fonseca,OHIP-14, PHQ-9, GAD-7,OBC,andPHQ-15 mean scores of female
participants were statistically significantly higher than males (p < 0.05).There was a significant
difference among the malocclusion groups in terms of their mean scores in GCPS, Fonseca, and
OHIP-14 (p < 0.05).The age values and JFLS, TMD Pain, Fonseca, OHIP-14, PHQ-9, GAD-7, and PHQ-
15 were statistically significant correlations in the positive direction.
Conclusion: The DC/TMD form allows both a physical assessment of Axis I and II that examines
psychosocial status and pain-related disorders and a more comprehensive assessment. The mean
OHIP-14 and Fonseca questionnaire scores of Class III groups were found to be significantly higher.
CONTACT Ahmet Karaman ahmeet.ka@hotmail.com Department of Orthodontics, Faculty of Dentistry, Istanbul Aydın University, Istanbul 34295,
Turkey
© 2019 Taylor & Francis Group, LLC
2 A. KARAMAN AND S. K. BUYUK
in the Class I and Class II groups. There was no However, it was found in regional distribution that,
statistically significant difference among the groups in while the highest joint sound was on the right side in
terms of their regions of TMJ sounds (p > 0.05). the Class I and Class II malocclusion groups, it was
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5
mostly distributed bilaterally in the Class III malocclu- Table 4. Comparison of GCPS, Fonseca, OHIP-14 values
sion group (Table 2). between groups according to Dunn’s Multiple Comparison test.
No statistically significant difference was found among Dunn’s Multiple Comparison Test GCPS Fonseca OHIP-14
Class I Malocclusion/Class II Malocclusion 0.029 0.827 0.504
the malocclusion groups in terms of their mean scores in Class I Malocclusion/Class III Malocclusion 0.290 0.007 0.045
JFLS, TMD Pain Scale, PHQ-9, GAD-7, PHQ-15, OBC Class II Malocclusion/Class III Malocclusion 0.004 0.008 0.018
total and OBC activities during sleep and OBC activities Graded Chronic Pain Scale Version (GCPS); Fonseca Questionnaire; Oral
while awake (p > 0.05) (Table 3). Health Impact Profile-14 (OHIP-14).
Table 3. Comparison of GCPS, JFLS, TMD pain screener, Fonseca, OHIP-14, PHQ-9, GAD-7, PHQ-15, and OBC values among
the groups.
Class I Malocclusion Class II Malocclusion Class III Malocclusion p‡
GCPS Mean ± SD 4.61 ± 14.54 Mean ± SD 1.88 ± 6.67 Mean ± SD 5.05 ± 11.66 0.009
JFLS 1.86 ± 3.97 1.88 ± 4.04 2.92 ± 4.86 0.151
TMD Pain Screener 0.95 ± 1.3 0.96 ± 1.27 1.35 ± 1.73 0.236
Fonseca 21.48 ± 16.13 21.43 ± 15.07 27.38 ± 19.43 0.013
OHIP-14 8 ± 7.96 7.96 ± 8.4 9.57 ± 8.92 0.048
PHQ-9 5.13 ± 5.5 4.17 ± 4.68 5.57 ± 6.06 0.057
GAD-7 3.25 ± 4.17 2.73 ± 4.12 3.56 ± 4.76 0.125
OBC sleep activities 0.68 ± 0.98 0.79 ± 1.05 0.79 ± 1 0.268
OBC awake activities 14.13 ± 9.82 13.8 ± 9.65 13.97 ± 11.33 0.850
OBC total score 15.49 ± 10.82 15.38 ± 10.7 15.55 ± 12.55 0.948
PHQ-15 4.32 ± 4.35 3.77 ± 3.97 4.07 ± 4 0.448
p‡: p-value from ‡Kruskal Wallis Test; SD: Standard deviation; TMD: Temporomandibular Disorders; GCPS: Graded Chronic Pain Scale Version; JFLS:
Jaw Functional Limitation Scale; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7; PHQ-15: Patient Health
Questionnaire-15; OBC: Oral Behaviors Checklist; Fonseca Questionnaire; OHIP-14: Oral Health Impact Profile-14.
6 A. KARAMAN AND S. K. BUYUK
Table 6. Comparison of GCPS, JFLS, TMD pain screener, headaches in the Class III malocclusion group was found
Fonseca, OHIP-14, PHQ-9, GAD-7, OBC, and PHQ-15 values to be higher than those in the Class I and Class II groups.
between genders. Lei et al. [14] reported significantly higher levels of TMJ
Males Females
(n = 219) (n = 429) p* sounds among women. In this study, the incidence of TMJ
Mean ± SD Mean ± SD sounds was found to be higher among Class III individuals.
GCPS 1.79 ± 5.72 4.46 ± 13.29 0.019 Additionally, there was a significant difference among the
JFLS 1.62 ± 3.28 2.3 ± 4.57 0.205
TMD Pain Screener 0.86 ± 1.25 1.11 ± 1.45 0.044 groups. In addition to this, while TMJ sounds were mostly
Fonseca 18.24 ± 14.38 24.78 ± 17.11 0.0001 on the right side in Class I and Class II malocclusions, they
OHIP-14 6.66 ± 6.75 9.11 ± 8.95 0.002
PHQ-9 3.62 ± 4.53 5.43 ± 5.58 0.0001
were distributed mostly bilaterally in Class III individuals.
GAD-7 2.35 ± 3.65 3.47 ± 4.51 0.0001 Nomura et al. [16] and Kim et al. [17] reported that
OBC sleep activities 0.59 ± 0.86 0.83 ± 1.08 0.019 TMJ disorder prevalence is higher among women.
OBC awake activities 11.13 ± 9.28 15.41 ± 10.11 0.0001
OBC total score 12.32 ± 10.18 17.06 ± 11.21 0.0001 Minghelli et al. [13] studied a Portuguese population
PHQ-15 2.93 ± 3.34 4.62 ± 4.38 0.0001 with the age group of 5–19 years and showed that the
p*: p-value from Mann–Whitney-U test; SD: Standard deviation; females had higher incidence rates of temporomandibular
Temporomandibular Disorders (TMD), Graded Chronic Pain Scale
Version (GCPS), Jaw Functional Limitation Scale (JFLS), Patient Health disorders than the males, and there was a significant rela-
Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), tionship between sex and temporomandibular disorder.
Patient Health Questionnaire-15 (PHQ- 15), Oral Behaviors Checklist
(OBC), Fonseca Questionnaire, Oral Health Impact Profile-14 (OHIP-14). Kim et al. [17] stated that the reason for this prevalence
is based on biological differences, possibly including hor-
monal and psychosocial factors. Poveda et al. [1] and
There was no significant relationship between the Nomura et al. [16] suggested that the high TMD preva-
male participants’ malocclusion classifications and their lence in women may be associated with their physiologi-
Fonseca TMD group distributions (p > 0.05), while there cal characteristics, especially hormonal variations and the
was a significant relationship between the female parti- structures in the connective tissue and muscles. They
cipants’ malocclusion classifications and their Fonseca reported that these tissues relaxed more due to the level
TMD group distributions (p < 0.05) (Table 7). of estrogen, and as a result of this, they cannot support
functional pressure and, in turn, lead to temporomandib-
ular disorders. LeResche et al. [18] reported that tempor-
Discussion
omandibular disorders and the severity of pain changed
The authors conducted a comprehensive questionnaire during the menstruation cycle. In the present study, the
study with 648 adolescent patients (257 Class I, 269 authors found the mean TMD Pain score of the women
Class II, and 122 Class III malocclusion). Lei et al. [14] to be significantly higher than that of the men.
reported high rates of symptoms of temporomandibular Lei et al. [14] found the frequency of temporoman-
disorder among Chinese adolescent individuals in their dibular disorder, depression, anxiety, and stress symp-
study. They stated that the most frequently reported toms among individuals at the ages of 16–18 to be
temporomandibular disorder symptom was orofacial significantly higher than those at the ages of 12–15.
pain, which was followed by TMJ sounds and headaches. In this study, a significant relationship was found
Severe temporomandibular disorders associated between the age values and the TMD Pain values.
with pain in the head and face are seen in 1-2% of Studies have determined that facial pain and TMD
children, 5% of adolescents, and 5-12% of adults [15]. prevalence in malocclusion and dentofacial deformities
In this study, although the incidence of orofacial pain were higher than those in patients with normal occlu-
was higher among Class III individuals, the difference sion [19]. Temporomandibular disorders are associated
among the Class I, Class II, and Class III malocclusion with types of malocclusion, such as unilateral crossbite,
groups was not statistically significant. The incidence of anterior open bite, and excessive overjet. Moreover,
Table 7. Gender distribution of Class I, Class II, and Class III malocclusions according to severity of TMD.
0-15 Fonseca 20-40 Fonseca 45-65 Fonseca 70-100 Fonseca
Absence of TMD Mild TMD Moderate TMD Severe TMD p*
Males Class I 45 36.59% 29 36.25% 4 26.67% 0 0.00% 0.615
Class II 53 43.09% 32 40.00% 7 46.67% 0 0.00%
Class III 25 20.33% 19 23.75% 4 26.67% 1 100.00%
Females Class I 74 45.96% 79 39.11% 24 41.38% 2 25.00% 0.026
Class II 69 42.86% 88 43.56% 17 29.31% 3 37.50%
Class III 18 11.18% 35 17.33% 17 29.31% 3 37.50%
*p-value from Chi-Square Test. TMD: Temporomandibular disorder.
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 7
deep bite and Angle Class II/III occlusal factors are also patients with severe physical symptoms/depression
argued to be risk factors for TMD [20]. In the current levels and severe disability were older than those who
study, although the TMD Pain scores of individuals had normal and moderate scores. As a result of this,
with Class III malocclusion were higher than those of the epidemiology of depression becomes higher in
the individuals with Class I and Class II malocclusions, populations of older ages in comparison to younger
the difference among the groups in terms of this vari- populations. In the current study, a positive and sig-
able was not statistically significant. nificant relationship was found between the age values
One of the possible reasons for the different degrees and the PHQ-9, GAD-7, and PHQ-15 scores.
of prevalence of temporomandibular disorders in dif- While some studies found positive relationships
ferent populations is the diversity of the criteria that between parafunctional habits and temporomandibular
are questioned and the clinical examination protocols disorders, some others could not [26]. Michelotti et al.
that are used [21]. The RDC/TMD is a clinical exam- [27] reported that there is a relationship between tempor-
ination protocol for TMD that is internationally omandibular disorders and parafunctional habits. Van der
accepted [6]. In later years, some limitations were Meulen et al. [28] could not find any difference between
found in the RDC/TMD protocol, and by revising men and women in terms of their mean OBC scores or
these, a clinical examination protocol known as the ages. Antoun et al. [11] could not find a significant differ-
Diagnostic Criteria for Temporomandibular Disorders ence in the OBC scores of hyperdivergent and normodi-
(DC/TMD) was recently developed [2]. vergent groups. Neither group displayed significant
As a result of assessment of the differences of the differences in terms of their OBC scores in cases of sleep
DC/TMD in terms of its inquisitional reliability among or being awake. In this study, the malocclusion groups did
educated and qualified research groups, because its not significantly differ based on their OBC activities during
inquisitional reliability was found to be high, it was sleep, OBC activities while awake, and total scale mean
concluded to be an adequate tool to diagnose tempor- scores. Furthermore, the OBC total, OBC activities during
omandibular disorders [22]. sleep, and OBC activities while awake scores of the women
High stress levels may lead to development of bruxism were significantly higher than those of the men.
by affecting the circulation in local muscles. They also As the Fonseca anamnestic questionnaire provides
change the ionic balance in cell membranes, and as similar results to those in studies conducted with the
a result of this, they lead to stimulation of pain receptors RDC/TMD, it may also help clinicians in their epidemio-
by causing accumulation of lactic and pyruvic acids. This is logical studies on temporomandibular disorders [5,16].
why psychosocial factors, such as anxiety, stress, and Pedroni et al. [29] conducted a study with 50
depression may be effective in the pathogenesis of Brazilian university students by using Fonseca’s ques-
TMDs [13]. tionnaire and determined that 68% of the participants
Winocur et al. [23] found somatization values to be had at least one TMD sign or symptom. They also found
significantly associated with sex, and in both cases, that the signs and symptoms were mild in 42%, moder-
women showed higher values in comparison to men. ate in 20%, and severe in 6% of participants.
No significant relationship was found between depression Nomura et al. [16] in their study that used Fonseca’s
values and sex. Komiyama et al. [24] could not find questionnaire and included 218 dentistry students, deter-
a significant relationship between somatization scores mined temporomandibular disorders with mild levels in
and age groups. Nevertheless, they found the somatiza- 35.78%, moderate levels in 11.93%, and severe levels in
tion scores among women to be significantly higher than 5.5% of the participants. Chandak et al. [30]conducted
those among men. Likewise, in this study, the mean a study with 200 participants at the ages of 18-27 years in
PHQ-9, GAD-7 and PHQ-15 somatization scores of the the population of Vidharbian in India and reported no
women were significantly higher than those of the men. TMD in 30% of the participants, while 55% had mild, 14%
Minghelli et al. [13] found that the sex and age had moderate, and 1% had severe TMD levels. Minghelli
group of individuals were significantly associated with et al. [13] carried out a study on a Portuguese population at
anxiety and depression. They reported that anxiety and the ages of 5–19 years and found the rate of the cases who
depression increased with increased age. Moreover, showed TMD symptoms as 25.2%, while they reported the
they found the anxiety and depression levels of severity of TMD in these as mild in 22.4%, moderate in
women to be higher than those of men. 2.5%, and severe in 0.3% of the cases. In their study that
Lei et al. [14] found the prevalence of depression, included a total of 409 dentistry students, Ayalı and
anxiety, and stress among individuals at the ages of Ramoglu [12] reported the severity of TMDs among the
16–18 to be significantly higher than those at the ages participants to be mild in 38.6%, moderate in 13.4%, and
of 12–15. Gatz and Hurwicz [25] determined that severe in 4.4% of the students.
8 A. KARAMAN AND S. K. BUYUK
Pedroni et al. [29] and Nomura et al. [16] reported In their study, de Oliveira and Sheiham [32] found
that women have a higher prevalence of TMD. Ayalı a significant relationship between sex and OHIP-14
and Ramoglu [12] also found the prevalence of TMD scores among adolescents. Additionally, the OHIP-14
in women to be higher than men and stated that this values among female individuals were higher than those
difference was statistically significant. Furthermore, among males. They also found a significant relationship
they concluded that, in addition to factors such as between age and OHIP-14 scores in adolescents.
ethnic origin and sample size, sex distribution may Likewise, in the current study, the female participants
also be associated with the changes in TMD prevalence. had significantly higher OHIP-14 scores than the male
In this study, the Fonseca’s questionnaire mean score participants. Moreover, there was a positive and signifi-
of the women was significantly higher than that of men. cant correlation between age values and OHIP-14 scores.
According to Poveda et al. [1] and Nomura et al. [16],
this high TMD prevalence in women may be associated
with their physiological characteristics, especially hor- Conclusion
monal variations and the structures in their connective The DC/TMD form allows both a physical assessment
tissues and muscles. They reported that these tissues of Axis I and Axis II that examine psychosocial status
relaxed more due to the level of estrogen, and as and pain-related disorders and a more comprehensive
a result of this, they cannot support functional pressure assessment. Therefore, the authors believe that it
and, in turn, lead to temporomandibular disorders. should be utilized for comprehensive evaluation of
There was no significant relationship between the individuals with different malocclusions.
male participants’ malocclusion classifications and their In the current study, the results of the Class III mal-
Fonseca TMD group distributions, while there was occlusion group in the Fonseca questionnaire were signif-
a significant relationship between the female participants’ icantly higher than those of the other groups. Additionally,
malocclusion classifications and their Fonseca TMD the Fonseca questionnaire, since it is lower-cost and easily
group distributions. The malocclusion groups differed applicable in a shorter time on patients with different
based on their mean scores in the FAQ. The mean malocclusions in comparison to the RDC/TMD or DC/
Fonseca questionnaire score of the Class III group was TMD questionnaire forms, may be implemented as an
significantly higher than those of the other groups. alternative in clinical settings for diagnosis and classifica-
Fonseca’s questionnaire contributes to clinical tion of temporomandibular disorders.
examination of the stomatognathic system in daily The results of this study showed that there is
practice. Additionally, this questionnaire may also a strong relationship between malocclusion and oral
be used as a preliminary TMD screening instru- health-related quality of life. The OHIP-14 results of
ment. This questionnaire is a useful temporoman- the Class III group were significantly higher than those
dibular disorder screening instrument in terms of of the other malocclusion groups. As the severity of
early diagnosis of temporomandibular disorders and malocclusion increased, the participants’ mean OHIP-
prevention of complications caused by these disor- 14 scores increased, while their oral health-related
ders [30]. quality of life decreased.
Malocclusions and dentofacial deformities are highly
prevalent in society; they may affect physical, social,
and psychological functionality. The concept of quality Acknowledgments
of life related to oral health shows the effects of oral
This study was conducted as a master thesis in Ordu
health or disorders on the person’s daily functioning, University Faculty of Dentistry. Also, this study was pre-
health, or general quality of life [31]. sented as an oral presentation in 95th European
As a result of their statistical analysis, Chen et al. [31] Orthodontic Society Congress in France.
found that more severe malocclusion had a stronger effect
on the quality of life of individuals. de Oliveira and
Sheiham [32] reported that malocclusion had a negative Disclosure statement
effect on oral health-related quality of life in patients with The authors have stated explicitly that there are no conflicts
TMD. In the current study, a statistically significant dif- of interest in connection with this article.
ference was observed among the different malocclusion
groups in terms of their mean OHIP-14 scores. The main
OHIP-14 score of the Class III group was found to be Funding
significantly higher than those of the Class I and Class II No funding agency provided a significant amount of money
groups. in support of this research.
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 9