|Year : 2022 | Volume
| Issue : 3 | Page : 287-292
Relationship between oral health status and oral health-related quality of life among patients with temporomandibular disorders in Bengaluru City: A cross-sectional comparative study
Pallavi Pawar, Manjunath P Puranik, Namita Shanbhag
Department of Public Health Dentistry, Government Dental College and Research Institute Victoria Hospital, Bengaluru, Karnataka, India
|Date of Submission||13-Jan-2022|
|Date of Decision||25-May-2022|
|Date of Acceptance||21-Jun-2022|
|Date of Web Publication||12-Sep-2022|
Department of Public Health Dentistry, Government Dental College and Research Institute Victoria Hospital, Kalasipalayam, Near City Market, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Most of the oral diseases have consequences that can affect the quality of life (QoL). Temporomandibular disorders (TMDs) constitute a series of clinical problems that affect muscles of mastication, the temporomandibular joint, along with their associated structures. The perception and feelings of these patients regarding their oral health are often ignored. Objective: The aim is to assess the relationship between oral health status and oral health-related QoL (OHRQoL) in participants with TMD compared to the Non-TMD group. Materials and Methods: A cross-sectional comparative study was conducted among 320 participants (TMD 160 and Non-TMD 160 participants, respectively) in various hospitals of Bengaluru city. The Oral Health Impact Profile for TMDs (OHIP) questionnaire was administered for evaluating the OHRQoL. Oral health status was assessed using World Health Organization Oral Health Assessment Form for Adults, 2013. Chi-square tests, Pearson's correlation tests, and one-way ANOVA were applied for statistical analysis. The value of P < 0.05 was considered statistically significant. Results: TMD patients exhibited worse OHIP-TMDs scores when compared to the Non-TMD group (63.2 ± 3.78 vs. 2.15 ± 3.21). The mean Decayed, Missing, and Filled Teeth (P < 0.001), gingival bleeding (P < 0.001), pockets P < 0.001), and loss of attachment (P = 0.677) was significantly higher in the TMD group when compared to the non-TMD group. TMDs negatively affected the OHRQoL in the TMD group when compared to the non-TMD group. Conclusions: OHRQoL and oral health status are found to be poor among the TMD group when compared to the non-TMD group. There was a relationship between OHRQoL and oral health status among the TMD group and non-TMD group.
Keywords: Oral health, oral health impact profile, oral health-related quality of life, temporomandibular disorders
|How to cite this article:|
Pawar P, Puranik MP, Shanbhag N. Relationship between oral health status and oral health-related quality of life among patients with temporomandibular disorders in Bengaluru City: A cross-sectional comparative study. J Indian Assoc Public Health Dent 2022;20:287-92
|How to cite this URL:|
Pawar P, Puranik MP, Shanbhag N. Relationship between oral health status and oral health-related quality of life among patients with temporomandibular disorders in Bengaluru City: A cross-sectional comparative study. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2022 Sep 28];20:287-92. Available from: https://www.jiaphd.org/text.asp?2022/20/3/287/355885
| Introduction|| |
Temporomandibular disorders (TMDs) represent several clinical problems that involve the masticatory muscles, the temporomandibular joints (TMJs), and associated structures. These disorders constitute clinical problems that affect muscles of mastication, the TMJ, and/or their associated structures. TMDs affects approximately 5%–12% of the population and it is the second-most common musculoskeletal condition (after chronic low back pain) resulting in pain and disability causing public health concern.
The etiology of the TMD is multifactorial. It includes oral para functions, macrotraumas like the trauma of the mandible or TMJs, microtrauma, especially bruxism, and emotional stress, anxiety, or depression which involve an increase in the head-and-neck musculature's activity, occlusal alterations due to a loss of posterior support. Women are most affected with proportions of five women for each man. The role of sleep disorders, either due to obstructive causes like obstructive sleep apnea syndrome or to sleep movement disorders like sleep bruxism has been revealed in the last few years, and they entail an inability to relax the orofacial musculature and the rest of the body.
The Research Diagnostic Criteria for TMDs (RDC) have been the most widely employed diagnostic protocol for TMDs research since its publication in 1992. This classification system was based on the biopsychosocial model of pain that included an Axis I physical assessment, using reliable and well-operationalized diagnostic criteria, and an Axis II assessment of psychosocial status and pain-related disability. Pain is considered not only as a major factor affecting the quality of life (QoL) of patients with TMDs but also the main reason for patients to seek treatment.
QoL is one of the most important issues in patients with TMDs. QoL, involving individuals' ability to perform daily activities without problems, consists of physical, psychological, and social aspects. In most cases of TMDs, pain becomes chronic and exerts inevitable effects on patients' daily habits including chewing and eating. Like any other type of orofacial pain, for example (acute dental pain, trigeminal neuralgia, and persistent dentoalveolar pain disorder) TMDs pain can be irritating. This can have detrimental effects on the social behavior and psychological conditions of the patients.
Oral health-related QoL (OHRQoL) measurement is a well-accepted way of characterizing the impact of a disease on the subjects' perceived oral health. OHRQoL is a conceptual model targeting the patients' perception of oral health. OHRQoL characterizes structural, behavioral, and psychological consequences of oral diseases using the framework of the World Health Organization (WHO) International Classification of Impairment, Disabilities, and Handicaps. The Oral Health Impact Profile (OHIP) is the most widely used OHRQoL instrument. The OHIP used in dentistry in its two versions: the extended version, including 49 questions, and the simplified version, including 14 questions which measure both the frequency and severity of oral problems. Research suggests that OHIP-49 may contain several redundant items, which may dilute its responsiveness to change in TMDs. OHIP-14 is a valid outcome measure to assess OHRQoL, but it is not a condition-specific measure for TMDs as it is not balanced enough or domain representative for TMDs. A shortened condition-specific form of OHIP-49, OHIP-TMDs, has been developed which contains twenty items from OHIP-49 and two new items derived from qualitative research with patients with TMDs.
Earlier studies used a different instruments who assess the role of psychosocial impairments, depression, and somatization, and highlighted their impact on patients with TMDs. Studies showed the impact of anxiety and migraine on TMDs patients' OHRQoL.,, Systemic inflammatory activity was found to be an important factor behind the degree of influence of TMJ pain and affects daily activities and QoL. Diagnosis associated with limited jaw movements had a higher impact on OHRQoL, while orofacial pain negatively affected the QoL of the patients with TMDs.,,,
Many systematic reviews describing the association between TMDs and OHRQoL did not include oral health assessment. As the OHRQoL impairment is associated with TMDs experience, it might be important for oral health education and treatment-seeking considering a minority of TMDs patients are seeking professional advice. As there is a paucity of research reporting the association of OHRQoL and oral health status, this study was conducted to assess the relationship between oral health status and the OHRQoL in patients with TMDs.
The research hypothesis was TMDs affect oral health status and OHRQoL in patients with TMDs.
| Materials and Methods|| |
A cross-sectional comparative study was conducted from for 6 months among patients attending Tertiary Care Hospitals in Bengaluru city. The study was conducted following the Helsinki Declaration of 1975, as revised in 2008. The ethical clearance was obtained from Institutional Ethics Committee. Necessary permission was also obtained from the respective hospital authorities for conducting the study. A written informed consent was obtained from the participants after explaining the purpose and procedure. This study is reported adhereding to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.
The training and calibration of the investigator yielded a Kappa coefficient value (k) 0.82 reflecting a high degree of conformity in observation for intraexaminer reliability. The cross-cultural validation of the OHIP-TMDs questionnaire was performed using the back-translation (English to Kannada) method with the help of linguistic experts. It was assessed for readability and comprehension.
The sample size was calculated using G*Power 3.1. 9.2. Kiel, Germany: Kiel University based on previous literature. Considering the significance level of α = 0.05, effect size of 0.3, and power of the study of 80% the sample size obtained was 310, which was rounded off to 320 with 160 each in TMD and non-TMD groups, respectively.
The sample size was achieved by employing a consecutive sampling method based on the following inclusion and exclusion criteria. The TMDs group included patients in the age group of 18–60 years with at least one diagnosis to TMD according to the RDC/TMD axis I and who can read and understand English/Kannada were included. Those under treatment for TMDs and having comorbid disease or condition with limited mouth opening which make an assessment of oral health difficult were excluded. The non-TMD group included patients aged 18–60-year-old without TMDs and who can read and understand English/Kannada were included and comorbid diseases or conditions with limited mouth opening which makes an assessment of oral health difficult were excluded.
Study pro forma included general information regarding the demographic profile, dental history, dietary habits, and oral hygiene practices. Socioeconomic status (SES) was assessed using the Modified Kuppuswamy scale. The inflation rate of January 2021 is 4.06. The multiplying factor was 4.06 for income scale values of the year 2012. The scale was updated to September 2021 considering Consumer Price Index-Industrial Workers (CPI-IW) = 123.3. The conversion factor from January 2021 to September 2021 was obtained by multiplying January 2021 scales by 1.02 (CPI-IW September 2021/CPI-IW January 2021 = 123.3/120.07). OHRQoL was assessed using the OHIP-TMDs questionnaire. The OHIP-TMDs questionnaire consists of 22 items of questions distributed among seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The items are scored on a five-point Likert scale: never, hardly ever, occasionally, fairly often, and very often (scored 0–4). Higher scores indicate poorer QoL. Oral health status was assessed using the WHO Oral Health Assessment Form for Adults, 2013.
Data were collected through an interview, followed by administering OHIP-TMDs questionnaires. A single calibrated examiner carried out oral examination under natural light using autoclaved instruments. Infection control measures were observed throughout the study.
MS Excel format was used to enter data. The statistical analysis was performed with the SPSS version 25 software package (IBM Corporation, SPSS Inc., Chicago, IL, USA). The normality of data was checked using the Shapiro–Wilk test and parametric or nonparametric tests were applied accordingly. Descriptive statistics with frequency, mean, and standard deviation were computed. The Chi-square test was used to find out the differences between proportions. An independent t-test was used to find differences in mean scores. One-way ANOVA was used to find the difference between TMD subgroups.
The mean and standard deviation were computed for OHIP-TMDs questions and all the domains. Data were dichotomized for age, SES, decayed, missing, and filled teeth (DMFT) based on the median value and bleeding on probing, pocket based on the presence or absence of disease. Association between sociodemographic variables, caries experience, and periodontal diseases among study groups were computed using the Chi-square test. Pearson's correlation test was used to find out the correlation between oral health indicators with TMD characteristics and OHIP-TMDs domains of the TMD group. A P < 0.05 was considered statistically significant.
| Results|| |
The study comprised 160 TMD and 160 non-TMD groups aged between 18 and 60-year-old with the mean age being 38.73 ± 11.33 and 39.10 ± 11.14 for TMD and non-TMD groups, respectively. Majority of the study participants were women in the TMD group. Sociodemographic variables are shown in [Table 1]. Around 2/3rd of the participants in both groups visited a dentist. There was a statistically significant difference between the study groups regarding the duration, reason for the visit, and treatment received. The pain was the main reason to visit in the TMD group, while the majority of them in the non-TMD group visited were problem-oriented visits such as decayed teeth, pain, and discolored teeth. The treatment received was more of a curative type than preventive. All the participants used toothbrush and toothpaste to clean their teeth. Majority of them in both groups' followed the horizontal method of cleaning, changed their toothbrush in every 4–6 months and used a tongue cleaner. Mixed diets were preferred in both groups.
Patients were diagnosed according to RDC/TMD criteria: majority of them belonged to Group I (myofascial pain), whereas 1/5th belonged to Group II (Disc displacement), and Group III (arthralgia, osteoarthritis, and osteoarthrosis). According to duration, majority of them were diagnosed within a year. There was no statistically significant difference within the TMD groups regarding duration (P = 0.141).
Dental caries experience was significantly higher in the TMD group (90%) compared to the non-TMD group (85%) (P < 0.001). The prevalence of gingival bleeding and the mean number of teeth with gingival bleeding was significantly higher in the TMD group (90%, 9.75 ± 7.78) compared to the non-TMD group (65%, 6.01 ± 7.40) (P < 0.001). The prevalence of periodontal pocket and Mean number of teeth with a periodontal pocket was significantly higher in the TMD group (40%, 0.25 ± 0.53) compared to the non-TMD group (36.25%, 0.10 ± 0.30) (P < 0.001). The prevalence of loss of attachment (LOA) was more in the non-TMD group (71.9%) compared to the TMD group (65.6%), as given in [Table 2].
OHRQoL among the TMD group was found to be poor with OHIP-TMDs mean score of 63.2. There is a significant difference between the study groups for overall OHIP-TMDs scores and in all domains [Table 3].
|Table 3: Domain wise mean oral health impact profile for temporomandibular disorders scores among study groups|
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A significant positive weak correlation was found with duration and DMFT (ρ = 0.289) (P < 0.001) and bleeding (ρ = 0.289) (P < 0.001), whereas, significant positive moderate correlation was found with pocket (ρ = 0.449) (P < 0.001) and LOA (ρ = 0.566) (P < 0.001). Total OHIP-TMDs: significant negative weak correlation was found with bleeding (ρ = −0.305) (P < 0.001) and pocket (ρ = −0.133) (P < 0.005). Whereas no significant correlation was found with DMFT (ρ = −0.073) and LOA (ρ = 0.094) [Table 4].
|Table 4: Pearson's correlation coefficient of temporomandibular disorders duration and oral health impact profile for temporomandibular disorders domains with oral health indicators|
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| Discussion|| |
Progress has occurred in many areas related to TMDs and today many experts agree that TMDs represent several clinical problems that involve the masticatory muscles, the TMJs, and associated structures. QoL is one of the most important issues in patients with TMD that involves individuals' ability to perform daily activities without problems, consisting of physical, psychological, and social aspects. OHRQoL provides an opportunity to summarize a variety of possible psychosocial impacts in relation to specific oral diseases. Using the OHRQoL instrument's summary score as the measure of overall psychosocial distress would, therefore, allow us to characterize the overall psychosocial burden from TMD and to compare this impact among specific TMD diagnoses.
Aging causes physiological changes to oral motor function and the TMJ, as well as pathological changes in teeth and periodontal tissues, with consequent loss of occlusal contacts, that lead to the conclusion that TMD is prevalent among the elderly. Studies reported in the literature presented an age group that ranged from 34.3 ± 12.4 to 72.3 ± 8.1. In the present study, the mean age of the TMD group and non-TMD group was 38.73 ± 11.33 and 39.10 ± 11.14 years, respectively, which is alike earlier studies. Gender variations are reported in TMDs. Females are predominantly affected in the years of fertility., Numerous estrogen receptors were found in the TMJ complex of females. The dominance of females (60%) was observed in the present study which is similar to most of the studies (45%–89.7%).,,,,,,,,,,,,, The gender distribution of TMD suggests a possible link between its pathogenesis and the female reproductive system.
SES was not considered in previous studies. In the present study, most of the participants belonged to the upper-middle-lower middle class this could be attributed to the fact that participants were selected from government hospitals and the difference in the social class between the study groups was not statistically significant.
In the previous studies, Axis I,,,,,,,,, and Axis II,, were used for the diagnosis. In the present study, all the participants in the TMD group belonged to axis I were the majority of them exhibited Group I, while 1/5th had Group II/Group III. Similar observations were reported in other studies.,,,,,,,,, Duration of TMD has not been reported in earlier studies. In the present study, majority of them were diagnosed within a year. This can be explained by the fact that people with chronic pain and limitation of functional activity with additional symptoms ranging from tenderness and stiffness to disorders of balance, vision, and emotions may experience impairment of functions and disability that may have a clear impact on these patients' QoL.
None of the studies considered oral health status and its relation in patients with TMDs. This could be attributed to the study sample with a limited mouth opening that might have restricted in oral health assessment. In the present study, oral health was assessed using the WHO oral health assessment form 2013 for adults. Dental caries experience and periodontal disease were significantly higher in the TMD group when compared to non TMD group. This is suggestive of little attention that has been given to oral care activities.
During the past few years, interest in OHRQoL has increased considerably. Oral diseases have consequences that can affect various aspects of life and impair QoL. TMDs have been shown to impact patients' daily lives. The previous studies have considered (OHIP-14 and 49),,,,,,,,,,,,,, and general oral health assessment index were used, whereas the present study OHIP-TMDs-22 was used.
OHIP-TMDs scores were significantly higher among the TMD group as compared to the non-TMD group. Study participants in the TMD group had significantly worse scores across all seven domains of OHIP-TMDs as compared to the non-TMD group. The most affected domain was physical pain and psychological disability. This indicates the greater impact of orofacial pain has on the QoL among TMD patients.
TMD duration had a positive correlation with “DMFT,” “bleeding” “pocket,” and “LOA” which is suggestive of the cumulated nature of the disease coupled with little attention paid to oral health care. This may have an influence of the duration of TMD on oral health status.
To the authors' knowledge, this is the first study assessing oral health and its association with OHRQoL among the TMD group. This study is limited by its design (cross-sectional). The bias inherent in a questionnaire study and sociodemographic characteristics of the sample might also have influenced the results of the study and malocclusion was not assessed. The study was conducted in Government hospitals and the participants were from lower socioeconomic strata of society. However, these hospitals are tertiary care centers with referrals from all over the Bengaluru district. Hence, the results of the current study might be extrapolated to similar populations and conditions.
OHRQoL differs in many dimensions in patients diagnosed with TMDs. Therefore, not only physical but also psychosocial factors should be considered more closely when evaluating the different aspects of TMDs. This study provides insight into the prevalence of oral diseases among the TMD group. Therefore, TMD should be considered as a component of oral health status when conducting OHRQoL research. Hence, promoting the QoL of patients with TMD requires an emphasis on pain management and maintaining good mental health. Lower OHRQoL was observed in patients who reported TMD experience but with small clinical importance which might support considering TMD in regular dental care. The higher impairments observed in all the domains of OHRQL can help clinicians and researchers focus their attention on these domains.
| Conclusions|| |
OHRQoL and oral health status are found to be poor among the TMD group when compared to the Non-TMD group. OHRQoL in TMD patients is a multidimensional phenomenon influenced by diagnosis, and duration of TMDs. There was a relationship between OHRQoL and oral health status among both groups in the present study.
- As OHRQoL is often an outcome of oral health-care services, health service providers need to consider TMD in the overall assessment of oral health of patients receiving dental care
- Assessment for TMD when providing regular dental care similar to the current practice for caries and periodontitis experiences should be done. Individual variation has to be considered during the decision-making process about the need to provide an intervention (conservative or invasive). From this standpoint, a multi-professional approach would be necessary to form adequate diagnoses and provide relief for the patients' TMDs symptoms
- OHIP-TMDs item profiles may be of value in interpreting OHRQoL information. This insight into patients' perceived oral health provided by OHIP-TMDs item profiles would be important for patient diagnosis and outcome assessment in any clinical setting
- The cornerstone of the progressive management of the disease is prevention. Minor jaw trauma has also been proposed as an etiologic mechanism of TMDs, and it may be avoidable via educational strategies. Dentists have to offer a simple bite prop during longer dental treatments that require wide mouth opening
- Another prevention strategy is early recognition and management and requires close collaboration between the individual and his or her health-care professional to avoid overtreatment, iatrogenic harm, or an aggravation of a TMD and to identify self-care or other interventions that may decrease the negative impact on that individual.
Public health significance
- Patients and stakeholders in the public are increasingly being valued in all facets of research and in policy development that can foster the implementation of efforts to improve health in communities. Increased efforts are also needed to improve education and training on TMDs for a range of health-care professionals
- A public education campaign can educate the public and health-care professionals about this complex condition
- September is designated as pain awareness month by the World Health Assembly. Designating a specific month or day to focus on TMD and planning community-based activities or campaigns at that time would be needed.
- Identifying high-profile individuals with a connection to TMDs who can share their personal stories and act as spokespeople
- Website content, listservs, videos, and social media; fact sheets and leaflets distributed to target audiences and available at multiple locations, including schools, health facilities, workplaces, wellness classes, places of worship, and other public venues; informational reports and studies; signs at health facilities and in health professionals' offices; and media outreach including to television and movie scriptwriters can raise public awareness and improving knowledge regarding TMDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dahlström L, Carlsson GE. Temporomandibular disorders and oral health-related quality of life. A systematic review. Acta Odontol Scand 2010;68:80-5.
Bayat M, Abbasi AJ, Noorbala AA, Mohebbi SZ, Moharrami M, Yekaninejad MS. Oral health-related quality of life in patients with temporomandibular disorders: A case-control study considering psychological aspects. Int J Dent Hyg 2018;16:165-70.
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al
. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications: Recommendations of the international RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache 2014;28:6-27.
Rener-Sitar K, Celebić A, Stipetić J, Marion L, Petricević N, Zaletel-Kragelj L. Oral health related quality of life in Slovenian patients with craniomandibular disorders. Coll Antropol 2008;32:513-7.
Blanco-Aguilera A, Blanco-Aguilera E, Serrano-Del-Rosal R, Biedma-Velázquez L, Rodriguez-Torronteras A, Segura-Saint-Gerons R, et al
. Influence of clinical and psychological variables upon the oral health-related quality of life in patients with temporomandibular disorders. Med Oral Patol Oral Cir Bucal 2017;22:e669-78.
Almoznino G, Zini A, Zakuto A, Sharav Y, Haviv Y, Hadad A, et al
. Oral health-related quality of life in patients with temporomandibular disorders. J Oral Facial Pain Headache 2015;29:231-41.
Durham J, Steele JG, Wassell RW, Exley C, Meechan JG, Allen PF, et al
. Creating a patient-based condition-specific outcome measure for temporomandibular disorders (TMDs): Oral health impact profile for TMDs (OHIP-TMDs). J Oral Rehabil 2011;38:871-83.
Schierz O, John MT, Reissmann DR, Mehrstedt M, Szentpétery A. Comparison of perceived oral health in patients with temporomandibular disorders and dental anxiety using oral health-related quality of life profiles. Qual Life Res 2008;17:857-66.
Ahmed N, Mustafa HM, Catrina AI, Alstergren P. Impact of temporomandibular joint pain in rheumatoid arthritis. Mediators Inflamm 2013;2013:597419.
Rener-Sitar K, Celebić A, Mehulić K, Petricević N. Factors related to oral health related quality of life in TMD patients. Coll Antropol 2013;37:407-13.
Reissmann DR, John MT, Schierz O, Wassell RW. Functional and psychosocial impact related to specific temporomandibular disorder diagnoses. J Dent 2007;35:643-50.
Faul FG. G Power 3.1. 9.2. Kiel, Germany: Kiel University; 2014.
John MT, Reissmann DR, Schierz O, Wassell RW. Oral health-related quality of life in patients with temporomandibular disorders. J Orofac Pain 2007;21:46-54.
Saleem SM, Jan SS. Modified Kuppuswamy socioeconomic scale updated for the year 2021. Ind J Forensic Community Med 2021;8:1-3.
World Health Organization. Oral Health Surveys – Basic Methods. 5th
ed. Geneva: WHO; 2013.
Abud MC, Dos Santos JF, Da Cunha VD, Marchini L. TMD and GOHAI indices of Brazilian institutionalised and community-dwelling elderly. Gerodontology 2009;26:34-9.
Warren MP, Fried JL. Temporomandibular disorders and hormones in women. Cells Tissues Organs 2001;169:187-92.
Barros Vde M, Seraidarian PI, Côrtes MI, de Paula LV. The impact of orofacial pain on the quality of life of patients with temporomandibular disorder. J Orofac Pain 2009;23:28-37.
[Table 1], [Table 2], [Table 3], [Table 4]