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Original Article

Prevalence of Temporomandibular Dysfunction in Edentulous

Patients of Saudi Arabia
Bader K AlZarea
Department of Prosthodontics, College of Dentistry, AlJouf University, Skaka, AlJouf, Kingdom of Saudi Arabia

Abstract
Aim: This study aimed to determine the prevalence of various temporomandibular joint dysfunction (TMD) signs in healthy asymptomatic
edentulous individuals and denture wearers. Materials and Methods: Four hundred completely edentulous individuals in the age group
of 45–75 years, who did not complain of any TMD and were denture bearers with varied denture‑wearing span, were examined for the
existence of TMD signs and symptoms. Statistical analyses were carried out with Chi‑square test. Statistical significance was set at P < 0.05.
Results: The total prevalence of TMD in the group was 60.5% (58.75% in males and 63.12% in females). It has been observed that more
number of females (63.21%) reported signs of TMD and majority of them (23.25%) reported with two signs of TMD. The most common finding
was limitation on mouth opening and the least common finding was joint sounds (crepitus and clicking). The occurrence of findings was not
statistically related to edentulous span. Conclusion: The present study showed a high prevalence of signs of TMD in healthy asymptomatic
completely edentulous individuals. However, the gender difference was not statistically significant.

Keywords: Complete dentures, edentulism, temporomandibular disorders

Introduction It is concurred that edentulous individuals do not present

with TMDs to the extent of those having natural dentition
The phrase “temporomandibular disorders” grasps various
because of the lack of proprioceptive feedback from dentition
clinical issues that include the muscles of mastication,
to trigger the symptom complex of TMD.[1,3] There are
the temporomandibular joint and related structures, or
some controversial issues such as overclosure of the jaws
both. These are otherwise called temporomandibular pain
in persons with natural dentition which can predispose to
dysfunction disorders.[1] Etiology of temporomandibular joint
TMD whereas long‑standing edentulous span individuals
dysfunction (TMD) is multifactorial and may involve changes
without dentures rarely develop TMDs despite overclosure.
in occlusion (malocclusion in dentate and posterior occlusal
However, it is observed that edentulous individuals who do
wear producing incisal interference in complete denture [CD]
not gripe about TMD on an arbitrary examination may hint
wearers), faulty prosthesis (reduced vertical dimension),
at least one or more signs of TMD, which may later form
traumatic insult to TMJ, psychological components, and
into a conspicuous joint dysfunction.[3] Some signs of TMDs
parafunctional habits such as bruxism.[1‑3] Some predisposing
are facial pain, headache, pain over the joint, pain which
factors which have been highlighted in recent studies are
aggravates while opening the mouth, muscle tenderness of
female gender and being edentulous for a long span of time
musculature, pain which is to the angle of lower jaw and
without denture.[1,4,5] It has additionally been demonstrated
cervical muscles, restricted mouth opening, deviation of jaw
that TMD changes over time, and no reasonable denouement
while opening the mouth, crepitus, and clicking sounds in
has been arrived yet about its natural progression or about the
factors contributing to the evolution of TMD. In addition, the Address for correspondence: Dr. Bader K AlZarea,
quantity of individuals who see subjective manifestations or College of Dentistry, AlJouf University, Skaka, AlJouf,
signs of TMD is more than the quantity of individuals looking Kingdom of Saudi Arabia.
for treatment, and females will probably look for treatment E‑mail: bkzarea@ju.edu.sa
than male partners.[6,7]
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DOI: How to cite this article: AlZarea BK. Prevalence of temporomandibular

10.4103/jioh.jioh_25_16 dysfunction in edentulous patients of Saudi Arabia. J Int Oral Health
2017;9:1-5.

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AlZarea: Prevalence of temporomandibular dysfunction in edentulous patients

joint region. These signs may appear in various combinations Results

and degrees.[3,4]
Out of the total 400 patients, majority, i.e., 32%, were in
The role of occlusion to produce muscle spasm which may result 51–55 years’ age group and a minimum of 3.25% of patients
in the above‑mentioned signs does not apply to CD patients belonged to 71–75 years’ age group [Table 1]. Table 2
since malocclusion in dentures (e.g., centric prematurities) represents the distribution of male and female patients by age
cannot trigger any proprioceptive response. Or maybe, quick groups. Of the total 400 patients, 240 patients were males
after effect of centric prematurity is displacement of the denture and 160 were females. Further, out of the 240 male patients,
which acts as a buffer to secure the TMJ.[3] Another hypothesis
that has been very much investigated and acknowledged is the
6628 patients reported to the dental outpatient
expansion in vertical measurement of dentures which brings department from August 2014 to July 2016
about brunt of the muscles in light of overextension of the
jaw‑closing muscles with passionate pressure, additionally
assuming a part and thus prompting to TMD in edentulous
individuals.[3] The restoration of physiological freeway space in Among which, 2284 patients had various
prosthodontic complaints
remission of muscular pain in CD wearers has been discussed
and proved by Monteith.[8] The present cross‑sectional study
was carried out to assess the prevalence of possible presence of
TMD in healthy asymptomatic completely edentulous patients 1268 patients were partially edentulous and
who were denture wearers for varied span of time. Aims and thus excluded (2284-1268=1016 complete
denture wearers)
objectives of this study were:
• To determine the prevalence of TMD signs in individuals
who were healthy asymptomatic completely edentulous
and denture wearers
A total of 438 participants were excluded
• To determine which sign was most frequently seen among due to various reasons as mentioned in the
individuals and prevalence according to gender methodology of the study (1016-438=578)
• To accomplish the relationship of TMD signs with
edentulous span.

Materials and Methods Out of 578 individuals, 178 were unwilling to

participate in this study. Hence, the final
sample of this study comprised (578-178)
Four hundred completely edentulous individuals attending 400 participants
College of Dentistry, AlJouf University, Skaka, AlJouf,
Kingdom of Saudi Arabia, with no complaint of any TMD and
Flowchart 1: The method used for selection of the study participants.
were denture bearers with varied denture‑wearing span were
included in this study. The study was carried out from August
2014 to July 2016 after obtaining prior informed consent Table 1: Age distribution of samples
and ethical clearance. Patients with single CD with opposing Age groups (years) Number of patients (%)
natural teeth or partially edentulous arches and individuals who
45-50 117 (29.25)
had been already diagnosed and treated as symptomatic TMD 51-55 128 (32)
patients were not incorporated in this study [Flowchart 1]. 56-60 71 (17.75)
These 400 individuals were divided into six age groups, 61-65 40 (10)
i.e., 45–50, 51–55, 56–60, 61–65, 66–70, and 71–75 years of 66-70 31 (7.75)
age. Tenderness, clicking, crepitus of the TMJ, musculatures, 71-75 13 (3.25)
the maximum mouth opening, and pathway of mandibular Total 400 (100)
opening were determined as described by Al‑Jabrah and
Al‑Shumailan.[9] The examiner underwent adequate training
and calibration exercise before collecting data to aid in proper Table 2: Age distribution of samples by gender
diagnosis, thus to avoid selection bias. Weekly training session Age groups (years) Male (%) Female (%) Total (%)
over a 4‑month period was undertaken by the examiner. The 45-50 61 (25.42) 56 (35.00) 117 (29.25)
training comprised oral presentation, discussion, and clinical 51-55 84 (35) 44 (27.5) 128 (32)
evaluation of patients under the supervision and guidance 56-60 45 (18.75) 26 (16.25) 71 (17.75)
of experienced staff of oral diagnosis. The results obtained 61-65 20 (8.33) 20 (12.5) 40 (10)
were analyzed using Statistical Package for Social Sciences. 66-70 21 (8.75) 10 (6.25) 31 (7.75)
Software (SPSS version 20.0, SPSS IBM, New York, NY). 71-75 9 (3.75) 4 (2.50) 13 (3.25)
Statistical analyses were performed using Chi‑square test. Total 240 (100) 160 (100) 400 (100)
Statistical significance was set at P < 0.05. χ2=5.0198, P=0.2853

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AlZarea: Prevalence of temporomandibular dysfunction in edentulous patients

majority, i.e., 35%, were in 51–55 years’ age group and a

Table 3: Number and sex distribution
minimum of 3.75% of patients belonged to 71–75 years’ age
group. Similarly, in 160 female patients, majority, i.e. 35% of Male (%) Female (%)
patients belonged to 45–50 years’ age group and a minimum With signs 141 (58.75) 101 (63.12)
of 2.5% of patients belonged to 71–75 years’ age group. Without signs 99 (41.25) 59 (36.88)
The association or difference between gender and age group Total 240 (100) 160 (100)
was statistically nonsignificant ( χ2 = 5.0198, P = 0.2853) at χ2=0.7693, P=0.3813
5% level of significance. Table 3 represents the distribution
of male and female patients by presence or absence of Table 4: Distribution of samples according to edentulous
signs. The total prevalence of TMD in the whole group was span
60.5%. Nearly 58.75% of males had signs as compared
to 63.12% of females. The difference was not found to be Edentulous span (years) Number of patients (%)
statistically significant ( χ2 = 0.7693, P = 0.3813) at 5% level 1-3 114 (28.50)
of significance. Almost 28.5% of patients had 1–3  years of 3-5 87 (21.75)
edentulous span followed by 21.75% of patients who had >5 41 (10.25)
3–5 years of edentulous span and 10.25% had >5 years of
edentulous span [Table 4]. The maximum of 24.58% of males
Table 5: Patients showing one or more signs of
and 21.25% of female patients had two signs and a minimum
temporomandibular joint dysfunction
of 2.08% of males and 1.25% of females had three signs. The
difference between male and female patients was statistically Number of signs Males (%) Females (%) Total (%)
nonsignificant ( χ2 = 2.3102, P = 0.5113) at 5% level of One sign 51 (21.25) 30 (18.75) 81 (20.25)
significance [Table 5]. A maximum of 18.33% of males and Two signs 59 (24.58) 34 (21.25) 93 (23.25)
20% of females had limitation on mouth opening followed by Three signs 5 (2.08) 2 (1.25) 7 (1.75)
other signs and a minimum of 1.25% of males had crepitus and More than three signs 21 (8.75) 6 (3.75) 27 (6.75)
0.63% of females had clicking. No significant association was χ2=2.3102, P=0.5113
observed between signs and gender ( χ2 = 0.7642, P = 0.9798)
at 5% level of significance [Table 6]. The most common sign Table 6: Frequency and distribution of temporomandibular
observed in all the three edentulous spans (i.e., 1–3 years, disorder signs in complete denture wearers according to
3–5 years, and more than 5 years) was limitation on mouth gender
opening. The least common sign in 1–3 years, 3–5 years,
and more than 5 years of edentulous span was crepitus. The Signs Males (%) Females (%) Total (%)
association between types of sign and duration of edentulous Pain during mouth opening 31 (12.92) 17 (10.63) 48 (12.00)
span was found to be statistically not significant ( χ2 = 5.5661, Limitation on mouth 44 (18.33) 32 (20.00) 76 (19.00)
opening
P = 0.6964) at 5% level of significance [Table 7].
Deviation 18 (7.50) 11 (6.88) 29 (7.25)
Tenderness of TMJ 9 (3.75) 7 (4.38) 16 (4.00)
Discussion TMJ pain on movement 7 (2.92) 4 (2.50) 11 (2.75)
Studies have been conducted to determine the prevalence of Tenderness of muscles of 6 (2.50) 6 (3.75) 12 (3.00)
mastication
TMD in dentate, completely edentulous, and partial denture
Crepitus 3 (1.25) 2 (1.25) 5 (1.25)
wearers. Authors have reported TMD to be almost as prevalent
Clicking 4 (1.67) 1 (0.63) 5 (1.25)
in CDs wearers as in individuals with natural dentition.[10,11] χ2=0.7642, P=0.9798. TMJ: Temporomandibular joint
While others found CD with an increased prevalence of
TMD symptoms in patients wearing CD than the individuals
present study as more number of females (63.12%) reported
with natural dentition.[12,13] Some researchers have also found
signs of TMD as compared to males (58.75%). No conclusive
lesser prevalence of TMD in CD wearers and contributed
results have been drawn to clarify these distinctions as far
this finding to the fact that such individuals have reduced
as behavioral, psychosocial, hormonal, and constitutional
maximum opening levels and 5–6 times lesser bite force than
contrasts are concerned. The existence of estrogen receptors in
in dentate patients, so , from time to time, they surpass their
the TMJ of females balances metabolic capacities in connection
tissue resilience and flexibility leading to lesser prevalence
to laxity of the ligaments, which could be pertinent in TMD.
of TMD.[14]
Estrogens would play a role by enhancing the diligence in
Most of the studies assessing TMD in dentate individuals, connection to pain stimuli, tweaking the activity of the limbic
partial denture wearers, and CD wearers have found system neurons.[16] Some reports in people have demonstrated
significantly more iterated and more severe TMD signs and that the presence of pain in connection to TMD escalates nearly
symptoms in females than in males, and females look for 30% in individuals receiving hormone substitution treatment
treatment for their TMJ issues 3 times more frequently than in postmenopause (estrogens) and around 20% among females
their male counterparts.[3‑5,15] This is in accordance with the who utilize oral contraceptives.[17]

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AlZarea: Prevalence of temporomandibular dysfunction in edentulous patients

Table 7: Frequency and distribution of temporomandibular disorder signs in complete denture wearers in relation to
edentulous span
Signs 1-3 years 3-5 years >5 years Total
Pain during mouth opening 17 24 7 48
Limitation on mouth opening 27 31 18 76
Deviation 12 9 8 29
Tenderness of TMJ 7 5 4 16
TMJ pain on movement 5 2 4 11
Tenderness of muscles of mastication 4 5 3 12
Crepitus 2 1 2 5
Clicking 3 2 0 5
χ2=5.5661, P=0.6964. TMJ: Temporomandibular joint

The results of the present study, i.e., more percentage of
patients showing two signs of TMD (24.58% of males and
21.25% of females) followed by patients presenting with one
sign (21.25% of males and 18.75% of females) [Table 5],
are in accordance with another study which also found more
percentage of healthy asymptomatic edentulous individuals
showing two signs of TMD (29%) followed by one sign (25%).
However, they also found joint sounds (47%) to be the most
prevalent joint dysfunction which is different from findings in
the present study as we have found limitation of mouth opening
to be the most prevalent sign [Table 6].[3] CD wearers may be
relied upon limited jaw opening levels because of the muscular
co‑ordination needed to counteract relocation of the lower
denture amid this exercise.[14] Joint sounds are very frequent
among individuals with TMD. A variety of different causes
have been attributed to these sounds such as arthritic alterations
in the TMJ, anatomical deviations, muscular incoordination,
and disc displacement. Recent researchers have related clicking
to a sudden acceleration of condylar and internally displaced
disc tissues.[18] In the present study, the least common finding
was joint sounds. Joint noises in completely edentulous patients
wearing denture have been related to abnormal condylar
surface forms.[19] The results are also not in accordance with
another study which found joint sounds (11.54%), muscle
tenderness (7.69%), joint tenderness (5.77%), deviation of
mandible (3.85%), and limitation on mouth opening (2.88%)
in decreasing order of frequency.[4]
Studies have also found that, in comparison to CD wearers
with partially edentulous patients wearing acrylic removable
partial dentures, the latter group had a higher prevalence of
TMD signs (36% compared to 17%). [9] Another study which
assessed the prevalence of temporomandibular disorders in
completely edentulous patients found a significant correlation
between the prevalence of TMDs’ clinical positive signs and
wearing denture as the prevalence of TMDs’ clinical positive
signs in denture‑wearing group was 38.6% (91/236) and that
in no denture group was 52.6% (61/116).[5] We have found a
significant decrease in signs and symptoms of TMDs as the
edentulous span increased, with lesser number of more than
5 years’ edentulous span patients reporting TMDs, but this
finding was not statistically significant [Table 7]. This finding
is in accordance with another study which also reported
that TMD prevalence decreased with increasing age and its
prevalence was not related to denture experience, number of
dentures used, and age of the present denture.[20] However,
there is still squabble with respect to the pervasiveness of
TMD signs and symptoms in various gatherings of people.
There could be many explanations behind this, however
the most as often as possible recommended are contrasts in
diagnostic criteria, clinical evaluation, and the universe of
the study populace.[21] The limitation of the study is that no
validated instrument (research diagnostic criteria [RDC]/TMD,
Helkimo index) was used to assess TMD prevalence and it
did not differentiate TMD signs and symptoms. This was a
cross‑sectional study and also no control group involved.
The strengths of this study were the prevalence of TMD signs
was categorized and represented according to gender, and the
relationship of TMD signs with edentulous span was very
well depicted.
Future studies with control group and using Axis I of RDC/
TMD – Research Criteria were may be of more helpful in
giving conclusions which can be applied to a broader category.
Conclusion
TMD serve as a noteworthy reason for non-odontogenic pain
in the orofacial location and are thought to be a subclass
of musculoskeletal dysfunctions including tissue damage
secondary generation of disproportionate force or pressure. The
total prevalence of TMD in healthy asymptomatic completely
edentulous patients was 60.5% (58.75% in males and 63.12%
in females). More number of females reported signs and
symptoms of TMD which was not statistically significant. The
most common finding was limitation on mouth opening and the
least common finding was joint noises (crepitus and clicking).
However, a longitudinal follow‑up study is recommended to
know the desirable course of these signs. The occurrence of
findings was not significantly related to the duration of being
edentulous.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

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AlZarea: Prevalence of temporomandibular dysfunction in edentulous patients
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