PATTERN OF TEMPOROMANDIBULAR PAIN DYSFUNCTION SYNDROME SEEN AT KMU INSTITUTE OF DENTAL SCIENCES

Abstract

The objective of this study was to see the pattern of Temporomandibular pain dysfunction syndrome
in patients attending Khyber Medical University Institute of Dental Sciences, KMU-IDS, Kohat. This
study was carried out at Department of Oral and Maxillofacial Surgery of KMU-IDS, Kohat from
January 2018 to June 2019. A total of 34 patients with clinical presentation of TMPDS were included
in the study. Data about demographics, chief complaint, etiology, stress and history of depression was
collected. In this study, out of 34 patients, 12 (35%) were males and 22 (65%) were females. Mean age
was 23.5 ± 13.4 years with 14 ( 41%) patients in age group 10-19. With regard to chief complaint, 22
out of 34 patients (65%) complained of pain. Click was reported by 5 patients (14%), 4 patients (12%)
attended OPD for limited mouth opening (LMO). Etiology was elicited as trauma to face in 2 out of
34 patients (6%). Bruxism only was documented for just 1 person (3%). Stress was the only etiology
in 9 people (26%). Stress collectively was reported in 20 patients (59%). In 11 patients (32%), etiology
could not be elicited. Of the people with stress, 8 were on psychiatric medicines for clinical depression
(23%).
In this study, TMPD was prevalent in females with a mean age of 23 years. Pain was the commonest
chief complaint. Stress was the most common main etiology. Clinical depression was also found in
23% of people with stress.
Key words: Temporomandibular pain dysfunction syndrome, stress, pain
This article may be cited as: Safi S, Qayyum Z, Aslam S. Pattern of temporomandibular pain dys-
function syndrome seen at KMU Institute of Dental Sciences . Pak Oral Dent J 2019; 39(4):341-344

Full text

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Pakistan Oral & Dental Journal Vol 39, No. 4 (October-December 2019)
1 For Correspondence: Sanna Safi, BDS, FCPS-II, Registrar,
Department of Oral & Maxillofacial Surgery, KMU-IDS, Kohat.
Cell: 0331-4304365 Email: sannasafi15@gmail.com
2 Zahid Qayyum, BDS, FCPS, Assistant Professor, Oral & Maxillo-
facial Surgery, Khyber Girls Medical College/Hayatabad Medical
Complex, Peshawar.
3 Saddique Aslam, BDS, FCPS, Professor, Oral & Maxillofacial
Surgery, KMU-IDS, Kohat.
Received for Publication: Aug 17, 2019
First Revised: Sept 18, 2019
Second Revised: Sept 30, 2019
Approved: Oct 2, 2019
Oral & MaxillOfacial Surgery
INTRODUCTION
Temporomandibular pain dysfunction syndrome
(TMPDS) is a frequently encountered musculoskeletal
disorder of orofacial region, involving the masticatory
muscles and/or temporomandibular joint. 1 TMPDS
show an increased incidence in women, relative to men.
Several studies have highlighted this gender disparity
for TMPDS. Estrogen, the female sex hormone, seems
to have an important role in this. 2 TMPDS is generally
considered a disorder of adults but various studies have
demonstrated its presence in children as well. 3
Multiple factors are involved in etiology of TMPDS.4,5
Today, mental health has an important role in TMPDS
pathogenesis. 6 Behavioral and psychologic factors are
the most significant etiology among potential causes of
TMPDS.7 Direct relation between stress and TMPDS
exist as stressors like anxiety, depression and sleep
disorders are closely related to the syndrome as shown
by various studies.8 Another possible cause of TMPDS
is trauma, both micro- and macro-trauma.9 A strong
association between bruxism and TMPDS also exist.10
TMPDS is characterized by limited mouth opening,
decreased mandibular motion and clicks, pops, crepita-
tions of temporomandibular joint (TMJ).11
A significant
clinical feature of TMPDS is pain , disturbing quality
of life and stomatognathic system function.12
In the United States, about 65-85% people, during
their lives experience some symptoms of TMPDS.
Chronic symptoms due to prolonged pain or disability is
seen in approximately 12%. Despite the high prevalence
in the population, only about 5 - 7% have symptoms
severe enough to render treatment . A study in Nigeria
showed that varying degrees of symptoms and signs of
temporomandibular disorders are exhibited in 62.8%
of population.13 To see the proportion and distribution
PATTERN OF TEMPOROMANDIBULAR PAIN DYSFUNCTION
SYNDROME SEEN AT KMU INSTITUTE OF DENTAL SCIENCES
1SANNA SAFI , 2ZAHID QAYYUM , 3SADDIQUE ASLAM
ABSTRACT
The objective of this study was to see the pattern of Temporomandibular pain dysfunction syndrome
in patients attending Khyber Medical University Institute of Dental Sciences, KMU-IDS, Kohat. This
study was carried out at Department of Oral and Maxillofacial Surgery of KMU-IDS, Kohat from
January 2018 to June 2019. A total of 34 patients with clinical presentation of TMPDS were included
in the study. Data about demographics, chief complaint, etiology, stress and history of depression was
collected. In this study, out of 34 patients, 12 (35%) were males and 22 (65%) were females. Mean age
was 23.5 ± 13.4 years with 14 ( 41%) patients in age group 10-19. With regard to chief complaint, 22
out of 34 patients (65%) complained of pain. Click was reported by 5 patients (14%), 4 patients (12%)
attended OPD for limited mouth opening (LMO). Etiology was elicited as trauma to face in 2 out of
34 patients (6%). Bruxism only was documented for just 1 person (3%). Stress was the only etiology
in 9 people (26%). Stress collectively was reported in 20 patients (59%). In 11 patients (32%), etiology
could not be elicited. Of the people with stress, 8 were on psychiatric medicines for clinical depression
(23%).
In this study, TMPD was prevalent in females with a mean age of 23 years. Pain was the commonest
chief complaint. Stress was the most common main etiology. Clinical depression was also found in
23% of people with stress.
Key words: Temporomandibular pain dysfunction syndrome, stress, pain
This article may be cited as: Safi S, Qayyum Z, Aslam S. Pattern of temporomandibular pain dys-
function syndrome seen at KMU Institute of Dental Sciences . Pak Oral Dent J 2019; 39(4):341-344.
Original article

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Pakistan Oral & Dental Journal Vol 39, No. 4 (October-December 2019)
Temporomandibular dysfunction syndrome
of problems associated with TMPDS, a large number
of studies have been carried out. These studies showed
variable results among different populations.14 Unfor-
tunately, local data about this common disorder in local
population is very scarce in Pakistan.
The objective of this study was to see the pattern of
TMPDS in patients attending Department of Oral and
Maxillofacial Surgery at Khyber Medical University
Institute of Dental Sciences, KMU-IDS, Kohat.
METHODS AND MATERIALS
This descriptive cross-sectional study was carried
out at Department of Oral and Maxillofacial Surgery
of KMU-IDS, Kohat from January 2018 to June 2019.
A total of 34 patients with clinical presentation of
TMPDS were included in the study. Data about demo-
graphics, chief complaint, etiology, stress and history
of depression was collected. Demographics about age
and gender were specifically noted. Chief complaint
was marked for pain, click and limited mouth opening
(LMO). Etiological causes included bruxism, trauma
to face ( road traffic accident, blow/hits to face, falls),
stress, and unknown factors.
Stress was elicited by asking about sleep quality,
appetite, and level of energy. History of clinical de-
pression and psychiatrist medications was also sought
carefully.
Data obtained was analyzed by taking out mean,
SD for age and percentages for the other variables in-
cluding age (gender, chief complaint, etiology, stress,
depression) using SPSS version 20.0.
RESULTS
In this study, out of 34 patients, 12 (35%) were
males and 22 (65%) were females with a male to female
ratio of 6:11. See table 1.
The age range was 15 – 68 years. Mean age was
23.5 ± 13.4 years with 14 ( 41%) patients in age group
10-19 followed by age group 40-49 with 8 (23%) patients.
Minimum number of 1(3%) was seen in 60-69 age group.
See table 2.
With regard to chief complaint, 22 out of 34 pa-
tients (65%) complained of pain. Click was reported
by 5 patients (14%), 4 patients (12%) attended OPD
for limited mouth opening (LMO) whereas pain along
with LMO as chief complaint was documented for 3
patients (9%).
Etiology of the patients is shown in figure 1. Stress
collectively was reported in 20 patients (59%). Of the
people with stress, 8 were on psychiatric medicines for
clinical depression (23%).
Fig 1: Etiologies
TABLE 1: GENDER DISTRIBUTION OF PA-
TIENTS
Gender Frequency Percentage
Males 12 35%
Females 22 65%
Total 34 100%
TABLE 2: AGE DISTRIBUTION OF PATIENTS
Age group Frequency Percentage
10 to 19 14 41%
20-29 6 18%
30-39 5 15%
40-49 8 23%
50-59 0 0%
60-69 1 3%
Total 34 100%
DISCUSSION
In our study, TMPDS was more prevalent in females
(65%) than males (32%). Ahuja et al study with higher
incidence of TMPDS among females (66%) relative to
male dental students is in line with our study.7 This
is also consistent with results of Kitsoulis et al study
which showed that TMPDS is not only common but
also more severe in women than men.15 Also according
to literature, women seek specialised treatment for
this disorder three times more frequently than men.
For greater prevalence in women is the hypothesis
that estrogen receptor changes metabolic functions in
women’s TMJ increasing ligament laxity. Estrogen,
by modulating limbic system, also causes increased
susceptibility to painful stimuli. 16 Increased incidence
and increased severity in women can also be due to the
low threshold of females for both depression and pain.
Age group 10 – 19 years had maximum number of
patients 14(41%) with a mean age of 23.5 years. This
is in accordance to study by Eweka et al showing prev-

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Pakistan Oral & Dental Journal Vol 39, No. 4 (October-December 2019)
Temporomandibular dysfunction syndrome
alence of TMPDS in adults. 13 Manfredini et al findings
showed a similar peak incidence between 20 and 40
years. 17 Adulthood is an age of initial exposure to the
stress of education, selection of profession, employment,
and different kinds of social pressures, predisposing
young adults to TMPDS.
Pain was the most common chief complaint (22
patients, 65%). In addition to this, pain together with
limited mouth opening was also seen (3 patients, 9%).
A study by Ogunlewe et al also reported pain as the
most common presenting complaint. 18 Similarly, Kit-
soulis et al study documented pain as the most common
TMPDS symptom. 15 Pain is a symptom which can not
be ignored by a person and thus, becomes the most
common presenting complaint.
Joint click (14%) as presenting complaint was
followed by limited mouth opening (12%). Motta LJ
et al showed a similar pattern of symptoms with pain
as most common complaint followed by joint noises
and finally, limited mouth opening. 19 Eweka et al
documented clicking as presenting complaint in 35%
and pain in 95.2% of subjects. 13 Clicking and limited
mouth opening are two other frequently seen features
of TMPDS as reported by Eweka et al and others.
Stress was the most common known aetiology
(26%) with 32% patients of unknown cause. Stress,
collectively, was seen in 59% patients. Similarly, in
Patil et al study, stress and depression were present
in 60% and 53.3% of TMPDS patients respectively, as
compared to controls. 20 Stress and TMPDS symptoms
usually have a very close relationship. Its difficult to
ascertain that whether chronic TMPDS symptoms lead
to stress or prolonged stress results in TMPDS. Its a
common notion that pain has psychological sequele
like depression and somatization. 21 It can affect the
emotional and mental health by interfering with day to
day activities and social life of a patient. On the other
hand, dental clamping occurs as a result of extreme
tension which changes local circulation of muscles and
affects the ion exchange in cell membranes. This causes
lactic and pyruvic acid accumulation which stimulates
the pain receptors. 22
Ogunlewe et al study revealed parafunction habits
in 5.3% which is consistent with our finding of 3% sub-
jects with bruxism. 18 Bruxism, grinding or clenching,
induces microtrauma in TMJ and sets the stage for
TMPDS. Bruxism and stress together were seen in
15% patients which can be correlated to the reports of
studies showing bruxism in 7.4 % to 27.2% of TMPDS
subjects. 23
Stress, anxiety, and psychological factors stimulate
excessive jaw-muscle activity identified as bruxism,
and thus may result in initiating TMPDS.
In our study, trauma was seen as cause in 6%, stress
and trauma in 15% with stress, trauma and bruxism
together in 3%. Also in Kolk et al study, osteoarthri-
tis occurred in 9.1-11.5% of intracapsular fractures.
24 Similarly, Wang et al study showed that in acute
mandibular injury without condylar fracture resulted
in 18-66% of cases with displaced disc. 25 Direct blow
to joint, or trauma to jaw can occur in road traffic ac-
cidents, assault and sports and can end up in TMPDS.
Traumatic episode can lead to post traumatic stress
disorder as well. Thus trauma and stress together can
unite to cause TMPDS.
TMPDS individuals, as compared to controls, exhibit
increased levels of stress, anxiety, depression, somatic
awareness, pain catastrophizing and kinesiophobia. 9
In our study, clinical depression was present in 23% of
patients. In contrast, Majumder et al observed 66.2%
patients of TMPDS with anxiety and depression. 22
Celic et al also demonstrated an increased level of
depression and somatization in TMPDS patients. 21
This difference in our study may be due to the patients
with undiagnosed clinical depression who had not yet
been labelled depressed by psychiatrist and were not
on any psychiatric medication.
The limitation of our study was small sample size.
This is probably due to study was carried out in a single
center.
As TMPDS and biopsychosocial factors like in-
creased anxiety, depression, stress are closely related,
therefore consultation with a psychologist or psychi-
atrist should always be considered whenever dealing
with TMPDS patients.
CONCLUSION
In this study, TMPD was prevalent in females
with a mean age of 23 years. Pain was the commonest
chief complaint. Stress was the most common etiology.
Clinical depression was also found in 23%. Trauma to
face and bruxism were other reported causes.
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CONTRIBUTIONS BY AUTHORS
1 SannaSa: Conception of study idea, study design, collection of data, analysis of
data, manuscript writing, nal draft of the manuscript.
2 Zahid Qayyum: Literature review, discussion.
3 Saddique Aslam: Recommendation, review and edition of the manuscript writing.