|Year : 2013 | Volume
| Issue : 1 | Page : 21-25
Prevalence of signs and symptoms of temporomandibular disorders in urban and rural children of northern hilly state, Himachal Pradesh, India: A cross sectional survey
Deepak Chauhan1, Jairam Kaundal2, Suneet Karol3, Tripti Chauhan4
1 Department of Pedodontics and Preventive Dentistry, H.P. Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Orthodontics, H.P. Government Dental College, Shimla, Himachal Pradesh, India
3 Department of Periodontics, H.P. Government Dental College, Shimla, Himachal Pradesh, India
4 Department of Community Medicine, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
|Date of Web Publication||6-Apr-2013|
Department of Pedodontics and Preventive Dentistry, H.P. Government Dental College, Shimla- 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background: Temporomandibular disorders (TMDs) have been recognized as a common orofacial painful condition. Many epidemiological studies of TMDs in children and adolescents have been performed. However, the results of such studies have varied, and a comprehensive view of the prevalence and severity of symptoms and signs is difficult to obtain. Objectives: To determine the prevalence of signs and symptoms of TMDs among school children of Himachal Pradesh and to establish a baseline for comparison with future studies. Study Design: Cross sectional. Materials and Methods: A sample of 1188 school children in the age group of 9 and 12 years (males n = 650 and females n = 538), from randomly selected schools of rural and urban areas of Himachal Pradesh were included as study subjects. The survey was done according to the WHO Oral Health Assessment Form (modified). Results: The results of TMDs, i.e., clicking, tenderness and reduced jaw mobility showed that overall prevalence was 2.5% and the rest 96.5% were not suffering from these disorders. In 9 years age group, the prevalence was 1.6% whereas it was more than double, 3.5% in 12 years age group. Signs and symptoms of TMDs were determined to assess their oral health status. Statistical Analysis: SPSS version 15. Conclusion: This study contrasts with what is found in the other societies regarding the high prevalence of TMDs disorders.
Keywords: Prevalence, signs and symptoms, temporomandibular disorders, Himachal Pradesh
|How to cite this article:|
Chauhan D, Kaundal J, Karol S, Chauhan T. Prevalence of signs and symptoms of temporomandibular disorders in urban and rural children of northern hilly state, Himachal Pradesh, India: A cross sectional survey. Dent Hypotheses 2013;4:21-5
|How to cite this URL:|
Chauhan D, Kaundal J, Karol S, Chauhan T. Prevalence of signs and symptoms of temporomandibular disorders in urban and rural children of northern hilly state, Himachal Pradesh, India: A cross sectional survey. Dent Hypotheses [serial online] 2013 [cited 2019 Dec 11];4:21-5. Available from: http://www.dentalhypotheses.com/text.asp?2013/4/1/21/110182
| Introduction|| |
Temporomandibular joint (TMJ) function and temporomandibular disorders (TMDs) have been the subject of enormous importance for many years. TMJ dysfunction is a cryptic issue even today, because of it's multifactorial etiology.  TMDs is a collective term that describes a sub-group of painful oro-facial disorders, involving complaints of pain on the TMJ region and fatigue of the cranio-cervicofacial muscles, especially mastication muscles, limitation of mandibular movement and presence of articular clicking. However, it is generally assumed that TMDs would mainly affect adult patients; nevertheless, children have also shown a similar incidence of signs and symptoms in other studies. 
Emotional stress, occlusal interferences, malpositioning or loss of teeth, postural changes, dysfunctions of the masticatory musculature and adjacent structures, extrinsic and intrinsic changes on TMJ structure and/or a combination of such factors are causes of TMDs.  prevalence is estiated between 5% and 12% and prevalence rates of TMDs are higher among younger persons. These disorders are at least twice as prevalent in women as men. 
The prevalence is low in children but increases with age. However, children rarely complain of any symptoms. It has been well established, by means of other epidemiological studies that signs and symptoms of TMDs are common in all ages. A high prevalence of such signs and symptoms have also been found in children. However, they have been judged to be milder in character and less frequency in children and young individuals.  It is therefore, important and valuable to have epidemiological data to estimate the proportion and distribution of these disorders in the hilly population also.
TMDs is acknowledged as the main cause of non-dental or facial pain. Pain is generally located on the masticatory muscles in the pre-auricular area and TMDs.  Due to the high prevalence and variability of the complaints, TMDs is diagnosed by associating signs and symptoms, as some characteristics may be frequent even in a non-patient population. ,
The aim of this study was to evaluate the prevalence of TMDs in school children of both sex through the analysis of the subjective and objective data obtained from a questionnaire and clinical examination and correlation between anamnestic and clinical dysfunction index in a hilly area Himachal Pradesh.
| Materials and Methods|| |
A sample consisted of 1188 school children, in the age groups of 9 and 12 years, 650 males and 538 females. The sample size was calculated with a 95% confidence interval, a proportion of 0.42 (estimated prevalence of TMDs), and the precision was fixed at 0.05. Simple random technique was adopted so that every student had same possibility to be chosen to avoid any bias. All the subjects were allotted a number (0 to N-1); random numbers were generated from a to select both public and private schools from rural and urban areas of six districts, representing different geographical locations of the state.
All the students present on the day of examination were included. Inclusion criteria were: all mixed and permanent dentition stage, no history of orthodontic treatment, no craniofacial anomalies and all students should be of the hill population.
This study was cross sectional in design, where a descriptive survey was conducted in the state. Informed consent of the parents or school authorities was obtained prior to their inclusion in the study. The study was approved by the institutional committee for ethical considerations for research. The examination was carried out by two examiners from the Department of Pedodontics and Preventive Dentistry. Inter and intra examiners calibration and standardization was done prior to the commencement of the study. Using Cohen's Kappa statistics, the reliability tests were 0.90 and 0.94, respectively. The examinations on the students were carried out in the schools under proper lighting and students were seated upright during the examination.
Demographic information was recorded for each subject prior to the clinical examination. A thorough clinical assessment was performed according to criteria laid in WHO survey guidelines.  TMDs were assessed by three indicators like; clicking, tenderness and reduced jaw mobility (RJM). The findings are classified as symptoms and signs.  Diagnosis of TMDs is made with a history of facial pain combined with physical findings by asking the following questions like: 
- Do you have difficulty opening your mouth?
- Do you hear noises within your jaw joint?
- Do you have pain in or around your ears or your cheeks?
- Do you have pain when chewing?
- Do you have pain when opening your mouth wide or when yawning?
- Has your "bite" felt uncomfor or unusual?
- Does your jaw ever "lock" or "go out"?
- Have you ever had an injury to your jaw, head, or neck? If so, when? How was it treated?
- Have you previously been treated for a TMDs? If so, when? How was it treated?
Clinical and physical assessment of the TMJ is done by manual palpation of the muscles and TMJ to evaluate the tenderness of intraoral and extra oral jaw muscles, neck muscles and TMJ capsule. Evaluation of jaw movements including assessment of mandibular range of motion using a millimeter ruler (i.e., maximum unassisted and maximum assisted opening measured. 
The subjects and their parents were requested to answer a questionnaire that included history of frequent headache, jaw locking, hearing TMJ noises, and difficulty in opening the mouth and acute pain in the periauricular area during chewing. Other questions on parafunctional habits such as nail/check biting, bruxism, finger and thumb sucking were also included in the questionnaire.
SPSS statistical package (version 15) was used. The frequency and forms of appearances of TMDs signs and symptoms were analyzed regarding the total number of subjects, separately for females and males. Comparisons were then carried out using Pearson's Chi-square test. The level of significance was set at P < 0.05.
| Results|| |
A total of 1188 children were examined, of these 650 (54.8%) were males and 538 (45.2%) were females. 564 belonged to the 9-years age group and 624 to the 12-years age group. In the 9-years age group from rural area, there were 139 males and 136 females as compared with 165 males and 124 females from urban area. However, in the age group of 12 years, 176 males and 136 females belonged to rural area and from urban area, 170 were males and 142 were females [Table 1].
The results of TMDs i.e., clicking, tenderness and RJM showed that overall prevalence was 2.5% and the rest 96.5% were not suffering from these disorders. In 9 years age group, the prevalence was 1.6% whereas it was more than double, 3.5% in 12 years age group. Among children of 9 years; tenderness was neither presented nor found, whereas clinking and RJM was found in 0.9% and 0.5% respectively. In 12 years age group, 2.4% were found to have clicking, 1% with RJM and only.1% with tenderness. Further, age wise increase in the prevalence of TMDs among children is evident with statistically not significant results P < 0.1286 [Table 2].
|Table 2: Prevalence of (temporomandibular disorders) clicking, tenderness and reduced jaw mobility according to age |
Click here to view
Genderwise distribution showed that females were affected eight times more than the males; 4.8% to.6%. Among males, tenderness was not found; 0.2% had clicking and 0.5% had RJM. Among females, 3.3% were suffering from clicking, 0.2% with tenderness 1.3% with RJM P < 0.00004 [Table 3].
|Table 3: Prevalence of (temporomandibular disorders) clicking, tenderness and reduced jaw mobility according to gender |
Click here to view
This study also showed that, children belonging to urban background were affected more, 3.2% as compared with 2% of rural children. Among children from urban area, 1.7% had clicking, 2% had tenderness and 1.2% had RJM. Among children from rural area 1.5% had clicking, 0.5% had RJM, the result was not statistically significant, P < 0.2106 [Table 4].
|Table 4: Prevalence of (temporomandibular disorders) clicking, tenderness and reduced jaw mobility according to location |
Click here to view
| Discussion|| |
A number of studies on the prevalence of TMDs among children have been reported from different parts of the world. Present study was first to be conducted on a larger sample population of both rural and urban school
children of Himachal Pradesh with the aim to evaluate the prevalence of signs and symptoms of TMDs through clinical examination and subjective data obtained from questionnaires was used to compare the findings with other national and international studies, to establish a baseline for comparison with future studies. In the present study; out of total 1188, 96.5% were found to be free from the signs and symptoms of TMDs and the rest 2.5% of children were suffering from the signs and symptoms of TMDs. A study conducted in Sweden in the age groups of 10 and 15 year olds, 5-9% of the participants reported more severe symptoms, up to 50% showed one or more TMDs signs. Several symptoms and signs increased with age but no gender differences seen. Increasing age, general health factors and oral para-functions were associated with TMDs symptoms and signs in 10- and 15-year-olds.  Similarly, this study has also reported an increase in the prevalence of TMDs with the increase in age.
Another study conducted among Turkish children, the prevalence of signs and symptoms related to TMDs showed that there was an increase in signs and symptoms from the primary to the mixed dentition group, but only the joint sounds were found significantly different between the two groups. This shows the similar trend to our study. 
Other study conducted among Caucasian children for prevalence of the signs and symptoms of TMDs in a population of 1134 subjects (593 males and 541 females; age range 5-15 years) The percentages of signs and symptoms were compared using the Chi-square test to determine the differences among the groups for the rates of TMDs symptoms, bruxism, joint sounds, deviation during opening, reduced opening, protrusive movements, and myofascial pain. Subjects who were 12-15 years old showed a significantly higher prevalence of myofascial pain than those who were 5-11 years old. Females showed a significantly higher prevalence of myofascial pain than males. Subjects with posterior, unilateral crossbite showed a significantly higher prevalence of TMDs symptoms and reduction of functional movements than those with no crossbite or with anterior or posterior bilateral crossbite. Signs and symptoms of TMDs seem to be associated to some definite characteristics such as female gender, young age, and presence of posterior unilateral crossbite. 
Study conducted among Saudi children to record the prevalence of signs and symptoms of TMDs and oral parafunction on 1940 stratified randomly selected school children. The sample was divided into three groups, 505 with primary, 737 with mixed and 734 with permanent dentition. The prevalence of TMDs signs was found to be 20.7% and the most common sign of TMDs was joint sounds (11.8%). This showed similar trend as in our study. The second most common sign was restricted mouth opening (5.3%). Muscle and TMJ pain as well as deviation upon jaw opening appeared infrequently. TMJ sounds were significantly increasing with age (P < 0.05). The most common symptoms were headache (13.6%) and pain on chewing (11.1%). All para-functions were significantly related to age. 
Considering the results of the present investigation as well as those of other studies on TMDs in children, it is concluded that the frequency of TMDs differ in various geographic regions and among different races.  Epidemiological studies in different regions of India, are thus needed to determine the prevalence of and to preventthe progress of TMDs in adulthood. In view of numerous epidemiological reports on TMDs in adults, limited studies on children and the lack of a corresponding uniform physical examination form and charting, attempts must be made to prepare a uniform standardized charting for interview and physical examination of children, in order to compare the results of different studies on TMDs.
The results of this study have shown that females are affected more than boys with the statistically significant difference (P < 0.00004). Moreover, it also indicates greater need for treatment in girls than boys. This is consistent with the findings of another studies, where the prevalence of TMDs sign and symptoms were found to be more among girls than boys. The difference between genders is attributed to the fact that girls are more sensitive to tenderness and pain on palpation of the TMJ and adjacent muscles mainly in older age due to hormonal changes. ,,
| Conclusion|| |
This study has primarily been a description of the clinical signs and symptoms of TMDs in children with special reference to age, gender and location differences. The prevalence of more severe TMDs symptoms and signs in children was generally low but Increasing age, general health factors and other oral parafunctions were associated with TMDs symptoms and signs in 9- and 12-year-olds.
| Acknowledgment|| |
We acknowledge cooperation of all the individuals who participated in the study.
| References|| |
|1.||Vojdani M, Bahrani F, Ghadiri P. The study of relationship between reported temporomandibular symptoms and clinical dysfunction index among university students in Shiraz. Dent Res J (Isfahan) 2012;9:221-5. |
|2.||Muhtaroðullari M, Demirel F, Saygili G. Temporomandibular disorders in Turkish children with mixed and primary dentition: Prevalence of signs and symptoms. Turk J Pediatr 2004;46:159-63. |
|3.||Carlson DS. Growth of the temporomandibular joint. In: Zarb GA, Carlsson GE, Sessle BJ, Mohl ND, editors. Temporomandibular Joint and Masticatory Muscle Dis-orders. 2 nd ed. Copenhagen: Munksgaard; 1994. p. 128-50. |
|4.||NICDR National institute of dental and craniofacial research. Improving the Nation's Oral Health, 2011. Available from: http://www.nidcr.nih.gov/datastatistics/finddatabytopic/facialpain/prevalencetmjd.htm. [Last accessed on 2012 June 20]. |
|5.||Dunstan K. Prevalence of Signs and Symptoms of Temporomandibular Joint Dysfunction in Subjects with Different Occlusions using the Helkimo Index, 2005. Available from: http://etd.uwc.ac.za/usrfiles/modules/etd/docs/etd_init_5852_1173686029. [Last accessed on 21 June 2012]. |
|6.||Dixon Ad. Formation of the cranial base. In: Dixon AD, Howyte DA, Rönning O, editors. Fundamentals of Craniofacial Growth. Boca Raton, Fl: CRC press; 1997. p. 100-29. |
|7.||Dibbets JM, van der Weele LT. Prevalence of structural bony change in the mandibular condyle. J Craniomandib Disord 1992;6:254-9. |
|8.||Griffiths R. Report of the president's conference on the examination, diagnosis, and management of temporomandibular disorders. J Am Dent Assoc 1983;106:75-77. |
|9.||World Health Organization. Oral Health Survey, Basic Methods. 4 th ed. Geneva: WHO; 1997. p. 31. Available from: http://www2.paho.org/hq/dmdocuments/2009/OH_st_Esurv.pdf. [Last accessed on 2012 Oct 20]. |
|10.||McDonald RE, Avery DR, Dean JA. Examination of the mouth and other relevant structures. In: Dean JA, Avery DR, McDonald RE, editors. McDonald and Avery's Dentistry for the Child and Adolescent. 9 th ed. Maryland Heights Mo: Mosby Elsevier; 2011. p. 1-18. |
|11.||Brooks SL, Brand JW, Gibbs SJ, Hollender L, Lurie AG, Omnell KA, et al. Imaging of the temporomandibular joint: A position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:609-18. |
|12.||Pahkala R, Qvarnström M. Can temporomandibular dysfunction signs be predicted by early morphological or functional variables? Eur J Orthod 2004;26:367-73. |
|13.||Köhler AA, Helkimo AN, Magnusson T, Hugoson A. Prevalence of symptoms and signs indicative of temporomandibular disorders in children and adolescents. A cross-sectional epidemiological investigation covering two decades. Eur Arch Paediatr Dent 2009;10:16-25. |
|14.||Tecco S, Crincoli V, Di Bisceglie B, Saccucci M, Macrí M, Polimeni A, et al. Signs and symptoms of temporomandibular joint disorders in Caucasian children and adolescents. Cranio 2011;29:71-9. |
|15.||Farsi NM. Symptoms and signs of temporomandibular disorders and oral parafunctions among Saudi children. J Oral Rehabil 2003;30:1200-8. |
|16.||Widmalm SE, Christiansen RL, Gunn SM. Race and gender as TMD risk factors in children. Cranio 1995;13:163-6. |
|17.||Dao TT, LeResche L. Gender differences in pain. J Orofac Pain 2000;14:169-84. |
|18.||List T, Wahlund K, Wenneberg B, Dworkin SF. TMD in children and adolescents: Prevalence of pain, gender differences, and perceived treatment need. J Orofac Pain 1999;13:9-20. |
[Table 1], [Table 2], [Table 3], [Table 4]