1

2

Theses studies were financially supported

By

Ministry of Health

Saudi Arabia

3

Contents

page

Introduction 4

Aims 20

Paper I 22

Paper II 47

Acknowledgements 67

4

Introduction

5

Background

In a report by Dworkin et al (1990), American Dental Association has suggested the term

Temporomandibular Disorders (TMD) to describe a cluster of related disorders characterized

by pain in the pre-auricular area, the temporomandibular joint (TMJ) or the muscles of

mastication; limitation or deviation in the mandibular range of motion and noises in the TMJ

during mandibular function.

TMD is a collective term embracing a number of clinical problems that involve the

masticatory musculature, the temporomandibular joint (TMJ) and associated structures, or

both (McNeill 1993). Because there is no single agreed-upon definition for TMD as a global

term, encompassing a variety of subtypes of the prevalence rates reported for TMD have

varied widely (LeResche 1997).

Epidemiological studies of TMD have been published from different communities in the

world. A survey of five common pain conditions, including pain in the temporomandibular

region was conducted among a stratified random sample of population (1016) in Seattle

Washington. The majority of the population of this study were between the ages of 25 and 44

years, Caucasian, married, employed, and had at least some college education. Results from

this age group showed that 10%men and 18% women reported pain in the TMJ or facial

muscles in the prior six months (Von Korff et al 1988). Data were gathered as a part of the

1989 National Health interview, which was administered by telephone to a large,

representative sample of the United States population to obtain national prevalence estimates

of five oral facial pains in 18 years of age and older. Nearly 22% of the populations were

estimated to have experienced at least one orofacial pain more than once during past six

months. The highest rates were found in 18-34-years olds, and the rates decreased with age

(Lipton et al 1993).

One early TMD prevalence study conducted in the Arab World was performed by Abdel-

Hakim (1983). It covered 215 male subjects from the Siwa oasis. The Siwian community is

representative of the Bedouin communities in the Egyptian western desert. The population

6

belongs to a characteristic ethnic group, living in a primitive way. The most prevalent

symptoms were headache (29%), pain in the ear (24%) and clicking joint sounds (19%); 84%

of the subjects suffered from tenderness of one or more of the masticatory muscles; 8% of

the subjects had painful movements of the mandible.

From the Saudi Arabian population more than ten studies have been published. In one

publication by Jagger & Wood (1992), the aim was to determine signs and symptoms of TMJ

dysfunction in 219 Saudi Arabians older than 16 years attending a dental clinic for routine

dental treatment. The authors concluded that there was a high incidence of signs and

symptoms of TMD. TMJ sounds (36%) and muscle tenderness to palpation (34%) was

common findings. Of the subjects examined, 31% reported suffering from frequent

headaches.

In a study by Nourallah & Johansson (1995), the prevalence of TMD was investigated in a

group of selected young male Saudi population, 105 dental students with a mean age of 23

years (range of 20-29 years). The Helkimo anamnestic and clinical dysfunction index,

(Helkimo 1974) was used, and around two-thirds of the individuals were found to have no

signs and symptoms of TMD, 30% reported mild symptoms (Ai I) and 6% severe symptoms

(Ai II). One-third showed mild clinical signs of dysfunction (Di I) 3% moderate signs (Di II)

and 1% severe clinical signs of dysfunction (Di III).

In 1996 Abdel-Hakim et al sent a questionnaire to adolescents regarding symptoms of

stomatognathic dysfunction, general health, peripheral joint diseases, chewing function, and

oral parafunctions. Thirty-two per cent reported at least one symptom of dysfunction. Pain

on opening was the most common 36%, followed by headache 34%, and joint sounds 32%.

Symptoms increased with impaired general health, particularly health of peripheral joints.

In a study by Zulqarnain et al (1998), symptoms of TMD reported by 705 female university

students of Riyadh, Saudi Arabia, were analyzed. Eighty–eight percent of the subjects were

Saudi citizens with a mean age of 21 years. Symptoms frequently reported were feeling of

tiredness in the jaws (34%), awareness of uncomfortable bite (31%), pain in front of the ear

(22%) and discomfort upon wide opening (22%). Symptoms frequently found were pain

interfering with activity (42%), disturbed sleep (41%), medication (28%) and pain being

frustrating or depressing (27%).

7

In a report of TMD prevalence in 502 children aged 3-7 years old, 17% presented TMD (4%

males, 18 % females; P< 0.001). Eight percent of the children had TMJ sounds, 7% muscle

tenderness, 3% pain during TMJ movement, 3% deviation of the mandible during movement

and 2% restricted mouth opening. None of the children had sought treatment for these

conditions. The authors concluded that the importance of TMJ examinations in the overall

clinical assessment of the pediatric patient should not be overlooked. (Alamoudi et al 1998)

In order to describe the prevalence of signs and symptoms of TMD in a group of patients

seeking orthodontic treatment, Akeel & Al-Jasser (1999) examined 191 consecutive

orthodontic female patients, divided into three age groups 8, 14 and 18 year. They were

examined for TMD signs, symptoms, and the index of orthodontic treatment need (IOTN).

The percentages of signs and symptoms were 41% and 30%, respectively. No significant

association was found between IOTN and TMD. Headache was associated with all TMD

symptoms and tenderness to palpation. In conclusion, the results indicated that malocclusion

could not be considered as a primary etiologic factor for TMD within the age range studied.

Prevalence of TMD signs as well as emotional status on the development of TMD among

696 female Saudi children aged 6 to 14 years was investigated in a study by Farsi (1999).

The results showed that 17% of the children had at least one sign of TMD with joint sounds

being the most frequent (14%), restricted mouth-opening second most in frequent sign (8%).

Statistically significant differences in the prevalence of TMJ tenderness between the calm

and nervous children suggested that children in emotional states run a greater risk of

developing TMD signs.

Occlusal characteristics, signs, and symptoms of TMD in children with primary dentition

were investigated in a group of 502 children 4-6 years olds (Alamoudi 2000). The results of

this study showed significant correlation between signs and symptoms of TMD and some of

the occlusal characteristics including posterior cross-bite, edge to edge-bite, anterior open-

bite and class III canine relationship and as well as asymmetrical canine relationship (canines

on one side had a different relation from the ones in the contra lateral side). The study

supported the previous conclusions about TMD being multifactorial and highlighted the

importance of an early intervention to prevent further consequences for TMD and permanent

occlusion.

8

Farsi & Alamoudi (2000) evaluated the prevalence of signs of TMD in children with and

without premature loss of primary teeth. Fifty-eight children, aged 4-6 years, with missing

primary molars, were compared with 58 age- and sex-matched control children with

complete primary dentitions. There were no statistically significant differences in the

prevalence of single or collective TMD signs between the two groups. The results of this

study show that premature loss of primary teeth, uncomplicated by other factors, does not

appear to be an etiological factor for the development of TMD.

In another study published by Alamoudi (2001), the relationship between the subjective and

objective symptoms of TMD, oral parafunctions, and emotional status were investigated.

This study was based both on a questionnaire and clinical examination. Five hundred and

two Saudi children aged 3 to 7 years old were examined for different signs and symptoms of

TMD. In addition, the parents were given questionnaires to reveal the existence of oral

parafunctions and evaluate the emotional status of the children being calm or nervous. The

results of this study showed associations between attrition and TMJ pain, muscle tenderness

and restricted opening. Significant associations were found between the emotional status and

multiple signs and symptoms of TMJ tenderness, TMJ pain and muscle tenderness.

Nassif et al (2003) performed a self administered questionnaire and screening examination

were performed on 523 males with an age range of 18-25 years (mean age = 22.4) regarding

TMD symptoms. The screening examination was performed by extra oral examination and

included range of jaw movement, digital palpation of selected masticatory muscles and

palpation over the pre-auricular TMJ area and digital palpation for TMJ sounds during jaw

movement. They reported that 59% had TMD symptoms and 50% had TMD signs. When

combined, 75% of the subjects had TMD symptoms and/or signs. There were 7%

insignificant moderate symptoms and/or signs, 51% significant moderate symptoms and/or

signs, and 17% severe symptoms and/or signs. It was recommended that subjects with

significant moderate and severe symptoms and/or signs should have a comprehensive TMD

evaluation, in order to further identify the need for TMD therapy.

In another study by Farsi (2003), 1976 stratified selected schoolchildren aged 3-15 years,

were divided into three groups, 505 with primary, 737 with mixed and 734 with permanent

dentition. The prevalence of TMD signs was found to be 21% and the most common sign of

9

TMD was joint sounds (12%). The second most common sign was restricted mouth opening

capacity (5%). TMJ sounds were significantly increasing with age (P < 0.05). TMD

symptoms as reported by the parents were evident in 24% of the returned questionnaires. The

most common symptoms were headache (14%) and pain on chewing (11%). The incidence

of headache was found to be significantly increasing from primary to permanent dentition (P

< 0.01). No sex difference in the prevalence of any symptom was reported. Nail biting was

the most common oral parafunction (28%) while bruxism was the least common (8 %). All

parafunctions except bruxism were significantly related to age. Cheek biting and thumb

sucking were reported more in females than in males. The author concluded that importance

of a screening examination for symptoms and signs of TMD should not be overlooked in the

clinical assessment of the pediatric patient.

Farsi et al (2004) investigated the relationship between oral parafunctions and TMD. A

group of 1976 children aged 3-15 years old randomly selected, underwent an examination

consisting of palpation and assessment of the TMJ and associated muscles for tenderness and

joint sounds. Maximum vertical opening and deviation during jaw opening were recorded.

The parents were requested to complete a questionnaire regarding symptoms of TMD and

history of oral parafunctions. The results showed significant correlations between cheeks

biting, nail biting, bruxism, thumb sucking, and TMD

signs and symptoms.

A presentation of the above-mentioned studies is shown in Table1.

10

Table 1.Table 1.Table 1.Table 1. Presentation of studies performed in Saudi Arabian population regarding TMD

No.

STUDY NAMESTUDY NAMESTUDY NAMESTUDY NAME &&&&

(REFERENCE NO.)(REFERENCE NO.)(REFERENCE NO.)(REFERENCE NO.)

SAM

SAM

SAM

SAMPLE

PLE

PLE

PLE

SIZE

SIZE

SIZE

SIZE

AGEAGEAGEAGE

GROUGROUGROUGROUPPPP

POPULATION POPULATION POPULATION POPULATION

TYPETYPETYPETYPE ++++

GENDERGENDERGENDERGENDER Males (MMales (MMales (MMales (M))))

Females (Females (Females (Females (F)F)F)F)

METHODMETHODMETHODMETHOD

AIMSAIMSAIMSAIMS

ToToToTo Investigate :Investigate :Investigate :Investigate :

QUESTIONNA

QUESTIONNA

QUESTIONNA

QUESTIONNA

IRE

IRE

IRE

IRE

CLINICAL

CLINICAL

CLINICAL

CLINICAL

EXAMINATIO

EXAMINATIO

EXAMINATIO

EXAMINATIO

NN NN

1 Jagger & Wood 1992 (7)

219

≥ 16

Dental patients 100 M & 119 F

Yes

Yes

Signs & symptoms of TMD in Saudis

2 Nourallah & Johansson 1995 (9)

105

20 – 29

Dental students M

Yes

Yes

The prevalence of TMD

3 Abdel-Hakim et al 1996(10) 330

14– 21

Secondary school 194 M & 136 F

Yes

No

Symptoms of TMD

4

Zulqarnain et al 1998 (11)

705

17- 33

University students

F

Yes

No

The prevalence of symptoms of bruxism & TMD and study any interaction between the symptoms and social environment factors

5

Alamoudi et al 1998 (12)

502

3-7

School children 235 M & 267 F

No

Yes

The prevalence of signs & symptoms of TMD

6 Akeel & Aljasser 1999 (13) 191191191191 8,148,148,148,14----18181818 ,,,,

>>>>18181818

Seeking orthodontic treatment F

Yes

Yes

The prevalence of signs & symptoms of TMD

7

Farsi 1999 (14)

696696696696

6666----14141414

F children

Yes

Yes

The prevalence of TMD signs and effect of emotional status on development of TMD

8

Alamoudi 2000 (15)

502

4 - 6

Pre- school children

235 M & 267 F

No

Yes

The association between occlusal characteristics and signs & symptoms of TMD

9

Farsi & Alamoudi 2000 (16)

116

4 - 6

Children

Yes

Yes

Signs &symptoms of TMD in children with or without premature loss of primary teeth

10

Alamoudi 2001 (17)

502

3 - 7

Pre- school children

235 M & 267 F

Yes

Yes

The relationship between signs & symptoms of TMD and oral parafunction and emotional status

11

Nassif et al 2003 (18)

523

18 - 25

Military students M

Yes

Yes

-The prevalence of signs & symptoms of TMD - The relative significance of TMD findings

12

Farsi 2003 (19)

1976

3 - 15

School children 1034 M 942 F

Yes

Yes

The Prevalence of signs and symptoms of TMD and oral parafunctions

13

Farsi et al 2004 (20)

1976

3 - 15

School children

1034 M 942 F

Yes

Yes

The relationships between oral parafunctions and signs & symptoms of TMD among Saudi children.

11

These epidemiological studies performed in Saudi Arabia have been mainly examining signs

and/or symptoms in relation to specific conditions such as parafunctional habits and occlusal

characteristics. In the past, examining signs and symptoms was the preferred way to study

epidemiology of TMD, due to the lack of knowledge of how to gather data in order to

diagnose different subgroups of TMD. In addition, none of the above-mentioned studies was

performed according to standardized diagnostic criteria of TMD.

In 1992 the research diagnostic criteria of TMD ( RDC/TMD ) were presented by Dworkin

and LeResche (1992) .The RDC/TMD were primarily intended for research purposes ,

allowing standardized methods for gathering relevant data and making possible comparison

of findings and replication of research into the most common forms of muscle-and joint-

related TMD among diverse clinical investigators.

The major attributes of the RDC/TMD making them especially valuable in clinical research

settings are: (1) a carefully documented and standardized set of specifications for conducting

a systematic clinical examination for TMD, (2) demonstrated reliability for these

operationally defined clinical measurement methods, and (3) use of dual-axis system: Axis I

to record clinical physical findings, and Axis II to record behavioral (e.g. mandibular

functional disability), psychological (e.g. depression somatization), and psychosocial status

(e.g. chronic pain grade for assessing pain severity and life interference) through subjective

self-report (Dworkin and LeResche, 1992) (Dworkin et al , 2002).The RDC/TMD Axis II is

not intended to yield clinical psychiatric diagnosis. Instead, they assess the extent to which a

person with TMD may be so cognitively, emotionally, or behaviorally impaired that these

factors may contribute to the development or maintenance of the problem and/or interfere

with smooth acceptance of and compliance with treatment. Depression is the psychological

mood characterized by feelings of sadness, helplessness, hopelessness, guilt, despair, and

futility, while somatization is the process whereby a mental condition is experienced as a

bodily symptom (Okeson1996).

TMDs are placed within the same biopsychosocial model currently used to study and

manage all common chronic pain conditions (Dworkin & Massoth 1994). The concept of

chronic pain dysfunction has emerged as a critical consideration for chronic pain research

and management. Most chronic pain patients seem to bear their condition adequately and

12

thus maintain adaptive levels of psychosocial function. By contrast, a psychosocially

dysfunctional segment of the chronic pain population appears unable to cope as well and

demonstrate higher rates of depression, somatization, and health care use, even though

persons in this segment are not different from their functional peers on the basis of

observable organic pathology (Dworkin & Massoth 1994). Patients with TMD have been

reported to have greater experimental pain perception when compared with pain-free

controls. Common psychological features of TMD include somatization and depression

(Sherman et al 2004).

In a recent study, John et al (2005) investigating the reliability of assessment trials conducted

at 10 international clinical centers, involving 30 clinical examiners by assessing 230 subjects.

They concluded that the RDC/TMD demonstrated sufficiently high reliability for the most

common TMD diagnoses, supporting its use in clinical research and in treatment decision

making.

13

Kingdom of Saudi Arabia

Kingdom of Saudi Arabia occupies most of the Arabian Peninsula, with an area of approximately

2,250,000 square kilometers (868,730 square miles) and is bounded on the north by Jordan, Iraq and

Kuwait; on the east by the Gulf, Bahrain, Qatar and the United Arab Emirates; on the south by the

Sultanate of Oman and Yemen; and on the west by the Red Sea.

The total population is 22.673.538 with 16.529.302 (72.9%) Saudis and 6.144.236 (27.1%) non-

Saudis, 50.1 % males and 49.9 females. (National survey 2004)

Makkah (Mecca)

The Holy City of Makkah lies inland, 73 km east of Jeddah, in the narrow, sandy Valley of Abraham.

The land consists of rugged, rocky (predominantly granite) terrain, with mountain ranges on three

sides. It is 277 meters (909 feet) above sea level.

Makkah is the holiest city on Earth to Muslims. At least five times each day, the world's one billion

Muslims, wherever they may be, turn to the Holy City of Makkah to pray toward the Ka’aba.

Makkah is one of the biggest cities in the western region of the kingdom of Saudi Arabia, with

1.338.341 population (National survey 2004)

In the study by Abdul-Qader in 2004 (1424 H) the demographic, social, and economic characteristics

of Makkah population were presented. The population in Makkah included 75% Saudi Arabians with

52% males and 48% females. The mean number of persons in a family was 5.2 people. Out of the

total population, people without any education were 18% (22% females and 14 % males). Forty-nine

percent of Makkah population were 19 years or less, 41% between 20-49 years old, and 10% were

50 years old or more. Totally 44% of Makkah people are less than 18 years old. Twenty seven

percent were unemployed, out of which 18% had lost their jobs and 82% never had any job. Out of

those, who had no job, 61% were males and 39% were females.

14

Dental Health Care System

In the kingdom of Saudi Arabia, dental health care services are divided into three levels:

The first dental health care level is primary health care and is provided by dental clinics in the

primary health care centers (PHCC). In every city or town, there is many PHCC s according to the

population in the area. Until December 2005, the total number of PHCCs in the whole area of

Makkah is 72 centers and in every one there should be at least one dental chair.

The second level is the dental departments in the public hospitals, which receive complicated cases

that need help with diagnosis and managements. In every city, there are 2-4 secondary hospitals

according to population in the area. In Makkah there are four public hospitals.

The third level is the specialist care presented by only one specialized dental center in every

city/area. This specialized dental center receives patients needing more specialized dental care

referred from the dental departments in the public hospitals.

Makkah Specialist Dental Center

The dental center in Makkah city is accredited by Saudi Council for Health Specialties as a training

center for specialist training of Saudi board students in the branch of restorative dentistry. It is also

training center for dental technicians and dentists from other hospitals and PHCCs in Makkah city. It

is the place of practical training and examinations for dental assistance students from the College of

Nursing in Makkah.

The Dental Center is composed by 25 specialist dental chairs covering all specialties of dentistry. The

available specialties are:

1- Oral diagnosis & oral radiology.

2- Oral & maxillo-facial surgery.

3- Restorative dentistry.

4- Endodontics.

5- Pedodontics.

6- Fixed prosthodontics.

15

7- Removable prosthodontics.

8- Periodontics.

9- Orthodontics.

10- Implantology.

11- Dental laboratory.

After registration in the reception, all referred patients examined in the screening & diagnosis clinic

to confirm diagnosis and then referred to the appropriate specialist clinics.

16

References

1- Dworkin SF, Huggins KH, LeResche L, Von Korff M, Howard J, Truelove E, Sommers E.

Epidemiology of signs and symptoms in temporomandibular disorders:clinical signs in cases and

controls. J Am Dent Assoc 1990;120:273-81.

2- McNeill C, editor. Temporomandibular disorders. Guidelines for classification, assessment and

management.Chicago:Quintessence 1993.p11-60.

3- Le Resche L. Epidemiology of temporomandibular disorders: implications for the investigation of

etiologic factors. Crit Rev oral Biol med 1997;8:291-305.

4- Von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain

complaints. Pain.1988 Feb;32 (2):173-83.

5- Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported

orofacial pain in the United States. J Am Dent Assoc 1993 Oct;124(10):115-21.

6- Abdel-Hakim AM. Stomatognathic dysfunction in the western desert of Egypt: an epidemiological

survey. J Oral Rehabil 1983 Nov;10(6):461-8.

7- Jagger, R.G. & Wood C. Signs and symptoms of temporomandibular joint dysfunction in a Saudi

Arabian population. J Oral Rehabil 1992;19:353-9.

8- Helkimo, M. Studies on function and dysfunction of the masticatory system II. Index for anamnestic

and clinical dysfunction and occlusal state. Sven Tandlak Tidskr 1974; 67:101-21.

9- Nourallah H, Johansson A. Prevalence of signs and symptoms of temporomandibular disorders in a

young male Saudi population. J Oral Rehabil 1995;22:343-7.

17

10- Abdel-Hakim AM, Alsalem A, Khan N. Stomatognathic dysfunctional symptoms in Saudi Arabian

adolescents.J Oral Rehabil 1996;23:655-61.

11- Zulqarnain BJ, Khan N, Khattab S. Self-reported symptoms of temporomandibular dysfunction in

a female university student population in Saudi Arabia. J Oral Rehabil 1998;25:946-53.

12- Alamoudi N, Farsi N, Salako NO, Feteih R. Temporomandibular disorders among schoolchildren.

J Clin Pediatr Dent 1998;22:323-8.

13- Akeel R, Al-Jasser N.Temporomandibular disorders in Saudi females seeking orthodontic treatment.

J Oral Rehabil 1999;26:757-62.

14- Farsi NM. Temporomandibular dysfunction and the emptional status of 6-14 years old Saudi female

children. Saudi Dental J 1999;11:114-19.

15- Alamoudi N. The correlation between occlusal characteristics and temporomandibular dysfunction

in Saudi Arabian children. J Clin Pediatr Dent 2000;24:229-36.

16- Farsi NM, Alamoudi N. Relationship between premature loss of primary teeth and the development

of temporomandibular disorders in children. Int J Paediatr Dent 2000;10:57-62.

17- Alamoudi N. Correlation between oral parafunction and temporomandibular disorders and emotional

status among Saudi children. J Clin Pediatr Dent.2001;26:71-80.

18- Nassif NJ, Al-Salleeh F, Al-Admawi M. The prevalence and treatment needs of symptoms and

signs of temporomandibular disorders among young adult males. J Oral Rehabil 2003;30:944-50.

19- Farsi NM. Symptoms and signs of temporomandibular disorders and oral parafunctions among

Saudi children. J Oral Rehabil 2003;30:1200-8.

18

20- Farsi N, Alamoudi N, Feteih R, El-Kateb M. Association between temporomandibular disorders

and oral parafunctions in Saudi children. Odontostomatol Trop 2004;27:9-14.

21- Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review,

criteria, examinations and specifications,critique. J Craniomandib Disord 1992;6:301-55.

22- Dworkin SF, Sherman J, Mancl L, Ohrbach R, LeResche L, Truelove E. Reliability, validity,

and clinical utility of the research diagnostic criteria for Temporomandibular Disorders Axis II Scales:

depression, non-specific physical symptoms, and graded chronic pain. J Orofac Pain 2002;16:207-20.

23- Okeson JP, eds. Orofacial Pain. Guidelines for Assessment, Diagnosis and Management. Chicago:

Quintessence, 1996.

24- Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: disease or illness?. J

Prosthet Dent 1994;72:29-38.

25- Sherman JJ, LeResche L, Huggins KH, Mancl LA, Sage JC, Dworkin SF. The relationship of

somatization and depression to experimental pain response in women with temporomandibular disorders.

Psychosom Med 2004;66:852-60.

26- John MT, Dworkin SF, Mancl LA. Reliability of clinical temporomandibular disorder diagnoses.

Pain 2005 Sep 8; [Epub ahead of print].

27- Abdul-Qader A., Studying the Demographic, Social and Economic Characteristics of Makkah Al-

Mukaramah Population. Study survey (2004/1424 H); on the website of the High Commission For The

Development of Makkah Province. http://www.makkah-development.gov.sa/hcm/3/3-5/3-5-2.htm.

(Retrieved at 2006-05-09).

19

28- National survey done September (2004) by the Ministry of planning / Saudi Arabia.

http://www.cds.gov.sa/statistic/index.htm (Retrieved at 2006-09-09).

29- List T, Dworkin SF. Comparing TMD diagnoses and clinical findings at Swedish and US

TMD centers using research diagnostic criteria for temporomandibular disorders. J Orofac

Pain 1996 Summer;10(3):240-53.

30- Dworkin SF, LeResche L, DeRouen T, Von Korff M. Assessing clinical signs of

temporomandibular disorders: reliability of clinical examiners. J Prosthet Dent 1990 May;63(5):574.

20

Aims

21

Specific Aims

The aims of this thesis are the following:

1- To examine the frequencies of pain related TMD among adults (20 -40 years old) referred to

a specialist clinic in Makkah, Saudi Arabia by using RDC/TMD. (Paper I)

2- To compare pain related TMD symptoms in patients with and without TMD pain. (Paper I)

3- To examine the frequencies of clinical findings and subdiagnoses of TMD according to RDC/TMD

specifications in a group of adult (20-40 years old) Saudi Arabians reporting pain related TMD.

(Paper II)

22

Paper I

23

Pain Related Temporomandibular Disorders in Adult Saudi Arabians Referred For

Specialized Dental Treatment

Mohammad H. Al-Harthy 1, 2

, EwaCarin Ekberg 2, and Maria Nilner

2

1 Dental Center , Al-Noor Specialist Hospital, Holy Makkah, Saudi Arabia

2 Department of Stomatognathic Physiology, Faculty of Odontology, Malmö University, Malmö, Sweden.

Abstract

The aim of the present study was to examine the frequencies of pain-related symptoms of TMD in

patients in the age of 20-40 years referred for specialized dental treatments in Makkah, Saudi Arabia

by using Research Diagnostic Criteria for TMD (RDC/TMD).

Three hundred and twenty-five consecutive Saudi patients in the age of 20-40 years; 135 males and

190 females were interviewed according to the RDC/TMD history questionnaire. The results revealed

that pain related TMD and orofacial pain were found among 58 (18%) patients. All other patients

formed the non-pain group (267, 82%). In the pain group, there were 79% females compared to 21%

males (P< 0.001).

Both genders in the pain group reported high frequencies of both migraines in the last six months and

headache moderately to extremely in the last month showing significant difference in comparison

with the non-pain group (P< 0.001). Symptoms of TMD were significantly more prevalent in the pain

group than in the non-pain group. The most common pain related TMD symptoms were TMJ

clicking, TMJ crepitation, TMJ locking, stiff jaw, tinnitus, bruxism, and uncomfortable bite.

Regarding Graded Chronic Pain severity in the pain group, most patients reported their pain to be

grade I and II. Jaw disability checklist according to RDC/TMD showed that four or more disturbed

jaw activities were found in 31 patients (53%) while 13 patients (22%) had not affected mandibular

functions.

In conclusion, the findings of the present study showed high frequencies of pain related TMD in this

Saudi Arabian patient population.

24

Introduction

Epidemiological studies on temporomandibular disorders (TMD) and orofacial pain have been

performed in several countries around the world. In 1988, a survey of five common pain conditions,

including pain in the temporomandibular region was conducted in a stratified random sample of the

population in Seattle Washington.1 The majority of the populations of this study were between the

ages of 25 and 44. They found that 8% of the men and 15% of the women reported pain in the

temporomandibular joint or facial muscles in the prior six months.

A National Health interview was made on a large, representative sample of the United States

population in 1989 to obtain national prevalence estimates of five oral facial pains in 18 years of age

and older. Nearly 22% of the populations were estimated to have experienced at least one orofacial

pain more than once during past six months. The highest rates of orofacial pain were found between

18-34 years of age.2 In an epidemiological review study it was found that pain in the

temporomandibular region appears to be relatively common, occurring in approximately 10% of the

population over the age of 18 years; it is primarily a condition of young and middle-aged adults,

rather than of children or the elderly, and is approximately twice as common in women as in men.3

Several epidemiological studies of TMD have been performed in Arabian countries.4-17 Some of them

included populations 20 years of age and above.4-8, 10 In one study which focused on a population of

20-29 years old male dental students in Saudi Arabia it was found that, around two-thirds of them had

no signs and symptoms of TMD. Mild symptoms were reported in 30% and severe symptoms in 6%.

No TMD diagnoses were presented in this study.6 The aim of the present study was to examine the

frequencies of pain related TMD among adults (20-40 years old) referred to a specialist clinic in

Makkah, Saudi Arabia by using RDC/TMD. Another aim was to compare pain-related TMD

symptoms in patients with and without TMD pain

25

Patients and Methods

Patients

Patients referred to the Specialist Dental Centre in Alnoor Specialist Hospital in Makkah, Saudi

Arabia 3 days a week during October and November 2005 were invited to take part in the study.

Three hundred and thirty five consecutive Saudi patients in the age of 20-40 years were asked to take

part in the study. This specialist dental centre has 25 dental chairs covering many specialties of

dentistry. It receives referrals from general dental clinics in primary health care centers and dental

departments in the secondary health care hospitals.

Out of the 335, 10 patients declined to participate due to that they either had no time for the

interview, or that they were suffering from acute dental pain or that they could not communicate well

enough for the interview. The total number of participating patients in the study was 325 and Table 1

presents the distribution of age and gender.

Methods

All patients were given information about the study and asked to participate. They were informed that

if they did not participate it would not influence their care at the centre. Official approval to start the

study had been taken from the director of the health affairs in Makkah, Saudi Arabia.

The patients were interviewed according to an Arabic version of RDC/TMD18 by two trained dentists.

A few questions were deleted or modified to make the history questionnaire accepted in the Saudi

(Arabic-Muslim) culture. These questions were about sexual activities, thinking of death or dying as

well as awakening early in the morning. The modifications of these questions did not affect the main

idea of the questions or RDC/TMD diagnostic criteria. These modifications will be discussed

elsewhere.

26

A secretary in the dental centre was assigned to take the patients from the Diagnosis Clinic to the

Radiology Department. During film processing the interview took part in a separate room. Due to

cultural reasons, a female dentist was trained to perform the interviews with female patients as

otherwise their husbands or male relatives insisted to attend the interview.

Patients included in the interview according to the following inclusion criteria:

• 20-40 years old.

• being able to communicate in an interview.

A subgroup of TMD related pain was formed according to the following criteria:

& reported pain in the face, jaw, temple, in front of the ear or in the ear in the past month.

& reported worst orofacial pain in the last six months that were more than 0 on the

Numeric Rating Scale (NRS).

& reported average usual orofacial pain at times of its experience in the last six months that were

more than 0 on the NRS.

27

Results

Three hundred and twenty-five patients included in this study had a mean age of 28.7 years ± 6

(S.D.). One hundred and thirty-five (42%) male patients had a mean age of 29 years ± 6 (S.D.) and

190 (58%) female patients had a mean age of 28.5 years ± 6 (S.D.). The male: female ratio was 1:

1.4. Patients in the age group from 20-24 years from both genders were the highest frequency 32%

(104). A subdivision of the patients into pain and non-pain groups with respect to age and gender is

shown in Table 1.

Most of the patients were Arabians 268 (82.5%). The distributions of national origins or ancestries

are shown in fig. 1.

Education:

Fifty-two percent (168) of all patients had received more than 12 years of education, out of them 83

(49%) were males and 85 (51%) were females. The frequency of those who had not received any

education was 17 (5%) and all females. Table 2 shows the educational levels of the 325 patients in

the two subgroups pain and non-pain.

Income:

Total combined household incomes during the last 12 months medium (25.000–34.000 $) to high

(35.000–50.000) were more frequent in the groups without significant difference between the pain

and non-pain groups (Table 3).

Marital Status:

Most of the patients were either married-living in household 171 (52%) or never married 139 (43%).

Fifteen patients (5%) from the total number of participants were separated, divorced, widowed, or

married-spouse not in household. Table 4 shows the distribution of marital status and gender in

different age groups. The last mentioned 15 patients are considered as non-married due to both their

resemblance to non-married status and by living without spouse. In Table 5, the married and non-

28

married males and females patients are subdivided into pain and non-pain groups without any

significant difference between marital status and pain or non-pain.

General and Oral Health:

All patients graded their general and oral health according to their own opinions from excellent to

poor. Most of the patients (98%) considered themselves to be in good to excellent general health

without any difference between the genders or groups. Oral health was considered to be good to

excellent by 86% of all patients without any differences between genders, see Table 6.

Headache and Migraine:

The pain group from both genders reported high frequencies of both migraines in the last six months

and moderately to extremely headache in the last month showing significant difference in comparison

with the non-pain group (P< 0.001) as shown in Table 7.

Pain and Non-Pain Groups:

The pain group comprised 58 (18%) patients according to the inclusion criteria of the subgroup. All

other patients formed the non-pain group (267, 82%). Females reporting orofacial pain were 79%

compared to 21% males (P< 0.001). The non-pain group comprised 54% females and 46% males.

Forty-nine patients (84%) were suffering from recurrent orofacial pain, 7 patients (12%), from

persistent pain and 2 (3%) patients had experienced this kind of pain once.

Regarding doctor visit, 64% (37) had never visited a health professional to get help with their

orofacial pain. In the last 6 months, 16 (27%) visited a doctor, and 5 (9%) visited more than 6

months ago a health professional.

Worst orofacial pain in the last six months in 90% (52) patients of the pain group was rated 5 or more

on the NRS as shown in fig.2. Ninety-three percent (54) patients rated their usual orofacial pain at

times of its experience in the last six months between 1 and 6 on the NRS (figure. 3).

Nineteen percent of the pain group had not been absent from their usual activities (work, school or

housework) because of the oro-facial pain, 5 patients (9%) had been absent one day, and 6 patients

(10%) 2 days or more. Twenty-seven patients (47%) stated that the orofacial pain did not interfere

with their daily activities. Thirty patients (52%) reported that the orofacial pain did not change the

29

ability to take part in social and family activities, and 36 patients (62%) reported that their orofacial

pain did not change the ability to work.

Symptoms of TMD were significantly more prevalent in the pain group than in the non-pain group.

The percentage distribution of TMD symptoms in both the orofacial pain and non-pain groups are

shown in Table 8.

Graded Chronic Pain severity in the pain group for both genders is shown in Fig.4 and showed that

most patients reported their pain to be grade I and II.

Jaw disability checklist according to RDC/TMD18 showed that four or more disturbed jaw activities

were found in 31 patients (53%) while 13 patients (22%) had no affected on the mandibular functions

(Figure 5).

30

Discussion

The results of this study showed a frequency of symptoms of TMD and orofacial pain that was 18%,

a figure that is higher than has been reported in population’s studies 2, 18, 19 but in accordance with

Magnusson et al 21 who reported 27%.

The male-female ratio in the pain group was in accordance with the ratio in the study by Anastassak

&Magnusson 22, Yap et al 23 and Reiter et a l 24 who presented a ratio of 1:3 to 1:5. The number of

women has, however been found to be even higher in pain patients.21-25 Although the difference in

TMD prevalence between males and females is still not well understood, some theories have been

proposed to explain why females are more affected than males.26 In many studies, TMD pain has

been found to be 1.5 to 2 times more common in women than men and gender differences in pain

report can be attributed to a number reasons: of biologic, occupational, psychologic, and social

factors.4, 27 Interestingly, some researchers stated that variations in estimated prevalence rate of

reported pain symptoms suggest that various sociodemographic characteristics may be related to the

onset, course or outcome of particular types of orofacial pain. In addition to gender, possible factors

may include age, race/ethnicity, and place of residence.2

The patients visiting the Specialist Dental Centre in Makkah, Saudi Arabia were referred for

specialized dental treatments from primary health care dental clinics and dental departments in

secondary care hospital.

Many dental specialties were available except for a specialist in TMD and orofacial pain. Therefore,

it was decided to include all consecutive patients in the study within the age span of 20-40 years

which has been shown in several studies to be the age at which TMD pain has its peak of frequencies

in the general population. 24

At the interview of the second patient, it was noticed that the patient was answering most of the

questions negatively and without thinking. This was probably due to a feeling of shame especially

when answering depression and somatization questions in the presence of at least five persons in the

clinic in the same time (diagnoses clinic dentist, training dentist, dental assistance, training dental

assistance, and interviewing dentist). It was therefore decided to interview patients who met the

inclusion criteria in a separate room. It was, however, also noticed from the first female patient who

31

was accompanied by her husband that she felt uncomfortable and answered the questions negatively,

especially when answering the questions about depression and somatization. When a husband insisted

to attend the interview it was carried out with the help of a trained female dentist.

Married patients did not show higher values in TMD symptoms in comparison to non-married ones.

Even if the married females in the pain group presented the highest percent (57%) among all groups,

there was no difference and this is in disagreement with a previous study done on Saudi university

females in another region of the country in which many TMD symptoms were significantly higher in

married females.8

Education in Saudi Arabia is free and the percentages of patients in both the pain and non-pain

groups having 12 years of education or more were high. In the pain group 45% and in the non-pain

group 53% had an education of ≥12 years. These results disagree with data reported in an earlier

study from Al-Ahsa province in the east region of Saudi Arabia.28 They reported university education

of 14% and 21% in the TMD and control groups respectively.28 Illiterates in the present study were

only females with a percentage of 5%, while in the last mentioned study they reported total of 18%

and 8% illiterate people from both TMD group and control group respectively 28 and these differences

may be due to the absence of a university in Al-Ahsa province in contrast to two universities in

Makkah province.

Migraine in the last six months in this study was frequent in women (47%) twice that in men (25%)

and these findings are in accordance with other studies 21, 29 and agree with a discussion study

regarding frequency of migraine without aura.27 However, more information from the patients needed

in the history questionnaires of RDC/TMD 18 about the nature, onset, location as well as duration of

headache and/or migraine to confirm diagnosis. This may explain the high figures of migraine

reported by the patients in the present study in comparison with low reported findings of a specific

diagnosed headache in a study done on Saudi population in another region of the country.30 Headache

within the last month in pain group were significantly higher than in non-pain group in this study. In

addition, this is in agreement with many studies, which mentioned high frequencies of headache

and/or had been considering headache as a symptom of TMD.4, 5, 8, 15, 21, 31 It seems to be due to

cultural behavior in headaches pain expressions.

The frequencies of TMD symptoms were found to be statistically significantly different between the

pain and non-pain groups regarding all symptoms studied. Regardless the methods of data collection

32

by the past studies done on Saudi people above the age of 18 years old, a presentation of frequencies

of TMD symptoms in these studies 5, 6, 8, 10, 15 and the present study is presented in Table 9.

The frequency of chronic pain severity grade scores for females in the pain group were 57% in grade

II followed by 41% in grade I and only one female patient with grade III and none in grade IV. These

scores of Saudi Arabian females were in disagreement with scores of pain grade severity of Arabian

females in another study.24 In the last mentioned study, they used RDC/TMD and found Arabian

females in the grade III followed by nearly equal scores of both grade II and I. This difference

between our study and this study can be perhaps possibly explained by the more stable and secure

lives of Saudi Arabian females. When comparing our findings with those of a study done in other

non-Arab Asian community, we found no difference in the chronic pain severity grade scores

distribution.23

In conclusion, the findings of the present study showed high frequencies of pain related TMD in this

Saudi Arabian population. A consequence of the results and that in Saudi Arabia today there is no

special clinics for treating patients with TMD, there is a need to start revaluations of future plans in

the field of TMD and orofacial pain from the health workers and decision makers in the country.

To the author’s knowledge, this is the first paper using RDC/TMD history questionnaire in Saudi

Arabia and this will make it possible to compare with TMD prevalence in other communities.

Acknowledgments

The authors wish to extend their warm thanks to Dr.Linda Mirza for her help in interviewing some

female patients and to the former director of the Specialist Dental Center in Alnoor Hospital Dr.

Mohammad Wahbi for his assistance before and during the study conduction, and to secretary Nor

Haya for her guidance of patients before the interviews and for all staff of the centre.

33

Figure legends

- Figure 1: Distribution of different national origins or ancestries in the study population of 325

patients.

- Figure 2: Distribution of worst orofacial pain rated by the pain group (58 patients) in the last 6

months rated on the NRS.

- Figure 3: Distribution of usual orofacial pain at times of its experience in the last 6 months rated by

58 patients on the NRS.

- Figure 4: Distribution of chronic pain severity grades with regard to gender in 58 TMD pain

patients according to RDC/TMD 18:

- Grade 0= No TMD pain in the prior 6 months

- Grade l = Low Disability-Low Pain Intensity

- Grade II = Low Disability-High Pain Intensity

- Grade III = High Disability-Moderately Limiting

- Grade IV= High Disability-Severely Limiting,

- Figure 5: Distribution of mandibular activities that were affected by TMD pain according to jaw

disability checklist in 58 TMD pain patients.

34

Figure 1

157

248 1

111

22

2 00

20

40

60

80

100

120

140

160

180

Arabian Asian Black White

National Origin / Ancestry

Number of

patients

Male

Female

Figure 2

0 0 0

2

0

1

2 2

3

1 1

0

1

0

1

2

6

4 4

10

3

15

0

2

4

6

8

10

12

14

16

0 1 2 3 4 5 6 7 8 9 10

Numeric Rating Scale

Worst pain in the

Number of

patients

Male

Female

35

Figure 3

0

2

1

2

3

2

1 1

0 0 0

1

5

7

10

5

3

0 0

2

0

13

0

2

4

6

8

10

12

14

0 1 2 3 4 5 6 7 8 9 10

N

Number of

patients

Male

Female

Numeric Rating Scale

Figure 4

0

75

0 00

19

26

10

0

5

10

15

20

25

30

Grade 0 Grade I Grade ll Grade lll Grade IV

Chronic pain Severity Grade

Number of

patients

Male

Female

36

Figure 5

7 7

10

6

3

5

7

13

0

2

4

6

8

10

12

14

0 2 3 4 5 6 7 8

Number of affected Jaw Activities

Number of

patients

37

&&&& Table 1. Distribution of age groups with respect to gender, Pain / Non-Pain groups in 325 patients.

Age

Groups

(Years)

Males Females

Total

Pain (n=58)

Total

non-pain (n=267)

Grand Total

n=325 Pain

(n=12)

Non-pain (n=123)

Total (n=135)

Pain (n=46)

Non-pain (n=144)

Total (n=190)

n % n % n % n % n % n % n % n % n %

20 – 24 4 33 36 30 40 30 11 24 53 37 64 34 15 26 89 33 104 32

25 – 29 2 17 31 25 33 24 12 26 37 25 49 26 14 24 68 26 82 25

30 – 34 5 42 25 20 30 22 5 11 24 17 29 15 10 17 49 18 59 18

35 – 40 1 8 31 25 32 24 18 39 30 21 48 25 19 33 61 23 80 25

38

&&&& Table 2. Years of education of both genders among Pain and Non-Pain groups (n=325).

&&&& Table 3. Total combined household income during the last 12 months for both genders among Pain

and Non-Pain groups (n=325).

Income

Pain Group

Males Females

Total

(n=58)

Non-Pain Group

Males Females

Total

(n=267)

(n=12) (n=46) (n=123) (n=144) n % n % n % n % n % n %

Very low 1 8 1 2 2 3 2 2 6 4 8 3

Low - - 4 9 4 7 - - 16 11 16 6

Medium 3 25 16 35 19 33 29 23 49 34 78 29

High 3 25 20 43 23 40 53 43 54 38 107 40

Very high 5 42 5 11 10 17 39 32 19 13 58 22

Very low = 0-14.999 $ , Low = 15,000-24,999 $ , Medium = 25.000-34,999$ , High = 35,000-50,000$ , Very high = ≥ 50,000$

according to RDC/TMD17.

Years

Of

Education

Pain Group

Total

(n=58)

Non-Pain Group Total

(n=267) Males

(n=12)

Females (n=46)

Males (n=123)

Females (n=144)

n % n % n % n % n % n %

0 - - 5 11 5 9 - - 12 8 12 4

1 – 8 1 8 11 24 12 20 13 10 29 20 42 16

9 – 12 4 33 11 24 15 26 34 28 37 26 71 27

> 12 7 59 19 41 26 45 76 62 66 46 142 53

39

&&&& Table 4. Marital Status, gender and age groups. Percentages of subgroups in relation to total

males(n=135) and females (n=190). (M= Males, F=Females)

Marital status

Years of Age Total

(n=325) 20–24 (n=104)

25–29 (n=82)

30–34 (n=59)

35–40 (n=80)

n % n % n % n % n %

Married spouse (in household)

M 2 1 9 7 25 19 29 21 65 20

F 15 8 26 14 22 12 43 23 106 33

Never Married M 36 27 20 15 4 3 2 1 62 19

F 48 25 21 11 5 3 3 1 77 24

Married spouse ( not household)

M 2 1 4 3 1 1 1 1 8 2

F 1 0.5 - - - - - - 1 0.3

Widowed

M - - - - - - - - - -

F - - - - - - 1 0.5 1 0.3

Divorced

M - - - - - - - - - -

F - - 2 1 2 1 - - 4 1

Separated

M - - - - - - - - - -

F - - - - - - 1 0.5 1 0.3

&&&& Table 5. Distribution of Pain and Non-Pain groups with marital status for both genders (n=325). (Married spouse not living in household widowed, divorced and separated were included in non-married).

Marital

status

Pain Group

Total

(n=58)

Non-pain Group Total

(n=267)

Total

Males (n=135)

Total

Females (n=190)

Males (n=12)

Females (n=46)

Males (n=123)

Females (n=144)

n % n % n % n % n % n % n % n %

Married 5 42 26 57 31 53 60 49 80 56 140 52 65 48 106 56

Non-married 7 58 20 43 27 47 63 51 64 44 127 48 70 52 84 44

40

&&&&Table 6. Reported general and oral health of both genders among Pain and Non- Pain groups (n=325).

&&&& Table 7. Distribution of reported migraine in the last six months and headache in the last month in both genders among Pain and Non-Pain groups (n=325).

Chi-square: * = <0.05, ** = <0.01, *** = <0.001

Pain Group Total

(n=58)

Non-Pain Group Total

(n=267)

Males (n=12)

Females (n=46)

Males (n=123)

Females (n=144)

n % n % n % n % n % n %

General health grade

Good – Excellent 11 92 44 96 55 95 123 100 140 97 263 99

Fair – Poor 1 8 2 4 3 5 - - 4 3 4 1

Oral health grade

Good – Excellent 11 92 36 78 47 81 104 85 125 87 229 86

Fair – Poor 1 8 10 22 11 19 19 15 19 13 38 14

Pain Group Non-Pain Group

Total (pain)

(n=58)

Total (non-pain)

(n=267)

Significance level Males

(n=12) Females

(n=46) Males

(n=123) Females (n=144)

n % n % n % n % n % n % Migraine 11 92 43 94 72 59 110 76 54 93 182 68 ***

Headache: -

Moderately – Extremely 6 50 35 76 24 20 51 71 41 71 75 28 ***

A little bit 5 42 8 17 53 43 51 22 13 22 104 39 -

41

&&&& Table 8. Distribution of percentages of TMD symptoms in the Pain and Non-Pain groups.

Chi-square: * = <0.05, ** = <0.01, *** = <0.001

TMD

SYMPTOMS

Pain Group (n=58)

Non-Pain (n=267)

Significance

level

Total (n=325)

n % n % n %

TMJ lock 32 55 25 9.4 *** 57 18

TMJ clicking 31 53 59 22 *** 90 28

Stiff jaw 29 50 26 10 *** 55 17

Crepitation 18 31 20 8 *** 38 12

Tinnitus 35 60 80 30 *** 115 35

Bruxism:

daytime 27 47 37 14 *** 64 20

sleeping 23 40 35 13 *** 58 18

Uncomfortable bite 27 47 58 22 *** 85 26

42

&&&& Table 9. Presentation of frequencies of TMD symptoms in studies performed in young adult Saudi Arabian population.

Study name: Sample size

Jagger& Wood (1992)

(n=219)

Nourallah & Johansson

(1995)

(n=105)

Zulqarnain et al

(1998)

(n=705)

Akeel & Al-Jasser

(1999)

(n=191)

Nassif et al

(2003) (n=523)

Present

Study

(2007)

(n=325)

Age (years) ≥ 16 20-29 17-33 >18 18-25 20–40

TMD Symptoms (%): Headache 31 - 31 12 12 36

TMJ noise / Clicking 15 34 4 19 16 28

TMJ Pain/Painful mouth opening 8 2 22 18 17 18

Opening difficulty / Jaw lock 5 4 13 9 14 18

Bruxism - - 10 - 6 19

Uncomfortable bite - - 31 - 18 26

Clenching - - 27 - - 20

43

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47

Paper I I

48

Diagnoses and Clinical Findings of TMD according to Research Diagnostic Criteria for

Temporomandibular Disorders in 20-40 years old Saudi Arabians

Mohammad H. Al-Harthy 1, 2

, Maria Nilner 2, and EwaCarin Ekberg

2

1 Dental Center , Al-Noor Specialist Hospital, Holy Makkah, Saudi Arabia

2 Department of Stomatognathic Physiology, Faculty of Odontology, Malmö University, Malmö, Sweden.

Abstract

The aim of this study was to examine the frequencies of clinical findings and subdiagnoses of TMD

according to RDC/TMD specifications in a group of adult (20-40 years old) Saudi Arabians reporting

pain related TMD. Forty-six patients clinically examined had a mean age of 30 years ± 6.6 (S.D.).. The

male: female ratio was 1: 5.6.

TMJ pain on both sides during maximum unassisted and assisted openings was common with the percentages

52% and 48% respectively. Muscles pain from both sides during maximum unassisted opening and maximum

assisted opening was 46% and 44% respectively. Different kinds of sounds from TMJ were registered only in

females while only one male patient had a crepitus sound. Tenderness to palpation of the TMJ was found in

62% of the TMJs.Tenderness to palpation of extra and intra oral muscles were most frequently found in the

lateral pterygoid area (80%) and least frequent in the Submandibular region (17%).

Subdiagnoses of TMD showed that all patients had myofascial pain only or in combination with other

diagnoses. All patients were suffering from at least one subdiagnoses of TMD.According to the results of this

study; it is likely that all of the subjects met the criteria of subdiagnoses of TMD. These results support the

usefulness of the RDC/TMD and in comparing data from different international TMD studies.The group of

population in this study is closely similar to the whole country adult population statistics regarding education

levels, incomes, and marital status. The clinical findings and subdiagnoses of TMD found in the present study

should make researchers, community health planners, and oral health workers considering TMD as a field of

preference in dentistry in Saudi Arabian.

49

Introduction

American Dental Association has suggested the term Temporomandibular Disorders (TMD) to

describe a cluster of related disorders characterized by pain in the pre-auricular area, the

temporomandibular joint (TMJ) or the muscles of mastication; limitation or deviation in the

mandibular range of motion and noises in the TMJ during mandibular function.1 TMD is a collective

term embracing a number of clinical problems that involve the masticatory musculature, the

temporomandibular joint (TMJ) and associated structures, or both.2

Two critical shortcomings which severely limit the generalizability of epidemiological studies are: (1)

lack of operational criteria with demonstrated scientific reliability for measuring or assessing clinical

signs and symptoms of TMD, and (2) absence of clearly specified criteria for the muscle and/or joint

conditions or subtypes of TMD.3, 4 Another issue is that, comparisons of data from many

epidemiological studies are limited by the absence of taxonomic homogeneity between different

studies.3, 4 As an initial step to address these shortcomings, Research Diagnostic Criteria for

Temporomandibular Disorders (RDC/TMD) were presented in 1992.3

Attributes of the RDC/TMD making them especially valuable in clinical research settings are: (1) a

carefully documented and standardized set of specifications for conducting a systematic clinical

examination for TMD, (2) demonstrated reliability for these operationally defined clinical

measurement methods, (3) use of dual-axis system: Axis I to record clinical physical findings, and

Axis II to record behavioral ( e.g. mandibular functional disability ), psychologic ( e.g. depression

somatization ) , and psychosocial status ( e.g. chronic pain grade for assessing pain severity and life

interference ) through subjective self-report.3, 4, 5

After registration of signs and symptoms, diagnoses can be considered as the most useful clinical

summary for classifying subtypes of TMD as well as in clinical decision-making and research. Using

reliable diagnoses are critical in establishing a clinical condition and a rational approach to treatment

and RDC/TMD are the most widely used TMD diagnostic system for conducting clinical research .6

The RDC/TMD demonstrates sufficiently high reliability for the most common TMD diagnoses,

supporting its use in clinical research and decision-making.6

To the authors' knowledge, frequency studies of TMD diagnoses according to RDC/TMD have not

previously been performed in Saudi Arabia. It was therefore, of interest to examine patients referred

to a specialized clinic to analyze to what extent TMD diagnoses could be found.

50

The aim of this study was to examine the frequencies of clinical findings and subdiagnoses of TMD

according to RDC/TMD specifications in a group of adult (20-40 years old) Saudi Arabians reporting

pain related TMD.

51

Patients and Methods

Patients

Patients referred to the specialist dental centre in Alnoor Specialist Hospital in Makkah, Saudi Arabia

3 days a week during October and November 2005 were invited to take part in the study.

The inclusion criteria were:

• 20-40 years old.

• being able to communicate in an interview.

Three hundred and thirty five consecutive Saudi patients in the age of 20-40 years were asked to take

part in the study. Out of the 335 patients, 10 patients declined to participate due to that they either had

no time for the interview, or that they were suffering from acute dental pain or that they could not

communicate well enough for the interview. Out of the 325 patients, 58 patients reported TMD

related pain and were included in this study according to the following criteria:

& reported pain in the face, jaw, temple, in front of the ear or in the ear in the past month.

& reported worst orofacial pain in the last six months that were more than 0 on the

Numeric Rating Scale (NRS).

& reported average usual orofacial pain at times of its experience in the last six months that were

more than 0 on NRS.

Official approval to start the study had been taken from the director of the health affairs in Makkah,

Saudi Arabia. All patients were given information about the study and asked to participate. They

were informed that if they did not participate it would not influence their care at the centre

Twelve patients out of the 58 patients reporting TMD related pain declined to be clinically examined

due to no time, no interest, acute pain, and/or communication problems. Thus, forty-six patients

remained and were included in the present study (figure 1).

52

Methods

After completion of RDC/TMD history questionnaire in an interview described in more details

elsewhere 7, all 46 patients reported orofacial pain and agreed to participate in the clinical

examination. A calibrated dentist according to the specifications of the RDC/TMD protocols

examined all patients. The RDC/TMD clinical examination involves clinical assessment of TMD

signs and symptoms, summarized 4 as follows:

Pain Site Assessments of presenting pain as ipsilateral or contralateral to pain provoked by clinical

examination of masticatory muscles and by tests of jaw function were done.

Mandibular Range of Motion (in mm) and Associate Pain: Jaw opening patterns were assessed for

corrected/uncorrected deviations in jaw excursions during vertical jaw opening. The vertical ranges

of motion of the mandible (extent of unassisted opening without pain, maximum unassisted opening,

and maximum assisted opening) were measured; the extent of mandibular excursive movements

(extent of lateral and protrusive jaw excursions) was recorded.

TMJ Sounds. Assessments by palpation of clicking, and/or crepitus joint sounds during vertical ,

lateral, and protrusive jaw excursions was done.

Muscle and Joint Palpation for Pain or Tenderness. The masticatory muscles (n=20 muscle sites)

and the TMJ (n=4 joint sites) were palpated bilaterally. These clinical variables have been found

reliable with kappa values from acceptable to good levels. 8

The RDC/TMD protocol divides the most common forms of TMD into three groups of diagnoses

myofascial pain, disc displacements and other joint conditions such as arthralgia, arthritis, and

arthrosis and allow multiple Axis I diagnoses to be made for a given patient.

The clinical diagnoses according RDC/TMD were:

Group I Muscle Disorders:

Myofascial pain Myofascial pain with limited mouth opening

Group II Disc Displacements:

Disc displacement with reduction, Disc displacement without reduction (with limited opening) Disc displacement without reduction (without limited opening)

Group III TMJ Degenerative Disease Disorders:

Arthralgia Osteoarthritis Osteoarthrosis

53

Results

The forty-six clinically examined patients had a mean age of 30 years ± 6.6. Out of the 46 patients, 7

(15%) were males with a mean age of 25 ± 4.8 and 39 females (85%) with a mean age of 31 ± 6.6.

The male: female ratio was 1 : 5.6. Distribution of clinically examined patients with pain related

TMD and not clinically examined patients in different age groups is shown in figure. 2. A high

number of clinically examined patients was found in the ages between 35-40 years, a percentage of

20% of the total number of all patients clinically examined and not clinically examined (80 patients).

Areas of orofacial pain pointed out by the patients, showed that having pain from both the TMJs and

the muscles was between 30% and 41% on the right and left side respectively (Table 1).

Measurements of the vertical range of the mandible –unassisted opening without pain, maximum

unassisted opening, and maximum assisted opening- are shown in table 2. Pain reported during

unassisted and assisted maximum openings in the 46 patients were frequently found on both TMJs

and muscles and on both sides (Table 3).

Both clickings and crepitations of the TMJ were registered in females, but crepitation was the only

TMJ sound registered among the males (Table 4). In 62% of all joints, the sound was found

bilaterally. Having both lateral and posterior tenderness to palpation of the TMJs was found in 29%

of the patients and in 27% laterally only (Table 5). Pain with palpation at extra and intra-oral

masticatory muscles was frequently found in the lateral pterygoid area (80%) and least frequently at

the submandibular region (17%) (Table 6).

The subdiagnoses of TMD according to RDC/TMD are shown in Table 7a. All patients had a

diagnosis of myofascial pain. Pain diagnoses of arthrogenous origin were found in 69% of the

patients. Myofascial pain only or combined with disc displacement with reduction was registered in

29% of the patients. A more detailed description of subdiagnoses is presented in Table 7b.

54

Discussion

The results of this study showed that RDC/TMD subdiagnoses groups, myofascial pain with or

without limited opening was found in 100% of the patients. The high frequency of myofascial pain in

the present study is in accordance with other studies.4, 9, 10

A comparison of the results of the present study with previous studies is limited due to differences in

age groups, cross-cultural differences, and different examination methods. To the author's knowledge,

this is the first TMD study using RDC/TMD clinical examination protocols in Saudi Arabia, which

make it difficult to compare our results with previous studies performed to asses TMD signs and

diagnoses in this country. Regarding the male-female ratio in the present study however, it was 1: 5.6

and in accordance with the male-female ratio of many other studies.4, 11, 12

A high number of the clinically examined patients who reported pain related TMD was between 35-

40 years of age and as a part of the total number of patients they were 20% with a predominance of

females. This is a similar finding as in the study by List et al (1996), where a high number and female

predominance was found in the age groups 25-44 years. 4

Areas of orofacial pain on either one or both sides pointed out by the patients showed that pain from

both TMJ and muscles was the most frequently found. This finding is not in accordance with the

study by Rantala et al (2003) 13 where it was reported that muscles pain most often pointed out by the

examined subjects . The difference in result between our study and the study by Rantala et al (2003)13

could be explained by that the later study included non-patients.

TMJ pain during maximum unassisted and assisted openings was found with the same percentages.

These frequencies of pain during mandibular movements were higher than reported in a previous

study of Saudi Arabian dental students in the ages between 20-29 years where the percentages were

lower.14 These divergating results were probably due to not only the different subjects but also

different ages.

TMJ tenderness to palpation was frequently found both laterally and posteriorly in 29%. These

frequencies are surprising and not in accordance with previous studies.9, 10 However, our results was

well in accordance with the findings of Dworkin et al (1990)1 who found that TMJ tenderness

posteriorly was 5% which is around one-fifth of that registered laterally only (27%).

Palpating masticatory muscles were reported from mild (1) to severe (3) tenderness according to

RDC/TMD specification in at least three muscles in all patients and the frequently found muscles

55

tender to palpation were intra oral muscles; lateral pterygoid with a total percentage of 80% and

tendon of temporalis 68% (Table 6). This higher frequency of intra oral muscle pain on palpation

compared with extra oral muscles is in accordance with reports in other studies.1, 13

The next most frequent subdiagnosis after myofascial pain was arthralgia with the total percentage of

59%. This high frequency of arthralgia was found in studies by List & Dworkin (1996)4 and Plesh et

al (2005).10

The percentages of patients diagnosed with disc displacement with reduction was well in accordance

with other studies 4, 9 -11, 13, 15 of patients materials as well as the diagnoses of osteoarthritis in TMJ.4,

10, 11, 15

According to the results of this study, all patients met the criteria for subdiagnoses of TMD. These

results support the usefulness of the RDC/TMD in comparing data from different international TMD

studies. All patients were suffering from at least one subdiagnoses of TMD. The group of population

in this study is closely similar to the whole country adult population statistics regarding education

levels, incomes, and marital status.7, 16 The subdiagnoses of TMD found in the present study should

make researchers, community health planners, and oral health workers to considering TMDs and

orofacial pain as a field of preference in dentistry in Saudi Arabia.

Acknowledgements

The authors wish to extend their warm thanks to Dr.Linda Mirza for her help in interviewing some

female patients and to the former director of the Specialist Dental Center in Alnoor Hospital Dr.

Mohammad Wahbi for his assistance before and during the study conduction, and to secretary Nor

Haya for her guidance of patients before the interviews and for all staff of the centre.

56

Figure Legends

Figure 1: Basis for selection of patients in the study.

Figure 2: Distribution of all interviewed patients from both genders with respect to clinical

examination among different age groups.

57

Figure 1

1. All consecutive patients between 20-40 years old.2. Patients refused to participate due to either no time or in severe dental pain or due to difficult communication.3. Patients attended and completed questionnaire interview.4. Patients not fulfilling the inclusion criteria of reporting pain related TMD.5. Patients fulfilling the inclusion criteria of pain-related TMD.6. Patients did not attend clinical examination due to either no time or no interest.7. Patients clinically examined and included in this study.

335 1

3253

46 7

58 5

10 2

12 6

267 4

58

Figure 2

41 2

0

911

3

16

36

32

28

32

55

38

26

32

0

10

20

30

40

50

60

20 - 24 25 - 29 30 - 34 35 - 40

Years of Age

Number of patients

Interviewed &Examinedmales

Interviewed &Examinedfemales

Interviwedmales

Interviewedfemales

59

&&&& Table 1. Distribution of pain areas pointed out by the 46 patients in both genders (right and/or left for each patient).

Pain areas

Males (n=7)

Females (n=39)

Total (n=46)

n % n % n %

Right side:

TMJ only 1 14 2 5 3 7

Muscle only 3 43 7 18 10 22

Both - - 14 36 14 30

No 3 43 16 41 19 41

Left side:

TMJ only 1 14 4 10 5 11

Muscle only 4 57 9 23 13 28

Both 2 29 17 44 19 41

No - - 9 23 9 20

&&&& Table 2. Distribution of vertical range of motion of the mandible during unassisted opening without pain, maximum unassisted opening, and maximum assisted opening in 46 patients reporting pain related TMD.

Total (n=46)

Females (n=39)

Males (n=7)

Mouth openings n % n % n %

41 41 41 (mean,mm)

unassisted without pain:

24 52 19 51 5 71 ≥40 mm

22 48 20 49 2 29 <40 mm

48 48 49 (mean,mm)

maximum unassisted:

43 93 36 92 7 100 >35 mm

3 7 3 8 - - ≤35 mm

51 50 54 (mean,mm)

maximum assisted:

43 93 36 92 7 100 ≥40 mm

3 7 3 8 - - <40 mm

60

&&&& Table 3. Distribution of registered TMJ pain and muscles pain during maximum unassisted and maximum assisted openings in 46 patients.

Pain at:

Males (n=7)

Females (n=39)

Total (n=46)

TMJ

pain

Total (n=46)

Muscle

pain

TMJ pain

Muscle pain

TMJ pain

Muscle pain

n % n % n % n % n % n %

Maximum unassisted - opening.

One side 1 14 1 14 7 18 6 15 8 18 7 15

Both sides 5 72 5 72 19 49 16 41 24 52 21 46

No 1 14 1 14 13 33 17 44 14 30 18 39

Maximum assisted-opening.

One side 1 14 1 14 5 13 6 15 6 13 7 15

Both sides 1 14 1 14 21 54 19 49 22 48 20 44

No 5 72 5 72 13 33 14 36 18 39 19 41

&&&& Table 4. Distribution of registered TMJ sounds during opening, closing and lateral movements in 46 patients.

TMJ Sounds

Males (n=7)

Females (n=39)

Total (n=46)

n % n % n %

Clicking - - 16 41 16 35

Reciprocal clicking - - 6 15 6 13

Crepitation 1 14 7 18 8 17

61

&&&& Table 5. Distribution of number of TMJs tender to palpation in 46 patients (n=92 TMJs).

TMJ pain with palpation

Males (n=14)

Females (n=78)

Total (n=92)

n % n % n %

Laterally only 2 14 23 29 25 27

Posteriorly only - - 5 6 5 5

Both laterally and posteriorly 4 29 23 29 27 29

Total 6 43 61 78 57 62

&&&& Table 6. Distribution of 46 patients with muscles sites tender to palpation on one or both sides (n=92).

Muscles tender

to

palpation

Pain grade

Total

(n=92) 1

(n=92) 2

(n=92) 3

(n=92)

n % n % n % n %

Temporalis muscle

posterior 15 16 12 13 3 3 30 32

middle 26 28 16 17 9 10 51 55

anterior 20 22 30 33 12 13 62 68

Masseter muscle

superior 21 23 26 28 16 17 63 68

middle 14 15 27 29 19 21 60 65

inferior 20 22 9 10 10 11 39 43

Posterior mandibular region 17 18 22 24 9 10 48 52

Submandibular region 3 3 11 12 2 2 16 17

Lateral pterygoid area 17 18 24 26 33 36 74 80

Tendon of temporalis 20 22 28 30 15 16 63 68

1111= mild pain, 2222= moderate pain, 3333= severe pain.

62

&&&& Table 7a. Distribution of subdiagnoses according to RDC/TMD in 46 patients reporting pain related TMD. A patient can be assigned from zero diagnosis to five diagnoses (one muscle diagnosis plus one diagnosis from Group II and one from Group III for each joint).

Subdiagnoses of TMD Males (n=7)

Females (n=39)

Total (n=46)

n % n % n %

Myofascial pain (only)

without limited opening 3 43 3 8 6 13

with limited opening 2 28.5 2 5 4 9

Myofascial pain combined with:

arthralgia 1 14 26 67 27 59

osteoarthritis 1 14 5 13 6 13

osteoarthrosis - - 3 3 3 6

disc displacement:

with reduction - - 11 28 11 24

without reduction:

with limited opening - - - - - -

without limited opening 1 14 4 10 5 11

63

&&&& Table 7b. A detailed description of the subdiagnoses in 46 patients reporting pain related TMD.

Subdiagnoses of TMD

Males

(n=7)

Females

(n=39)

Total

(n=46)

n % n % n %

Myofascial pain (only) 3 43

3 8

6 13 without limited opening

with limited opening 2 29 2 5 4 9

Myofascial pain combined with: arthralgia only

1 14

16 38

17 37

osteoarthritis - - 3 8 3 7

osteoarthrosis - - 1 3 1 2

osteoarthritis & osteoarthrosis - - 1 3 1 2

arthralgia & disc displacement with reduction - - 5 13 5 11

arthralgia & osteoarthrosis &disc displacement with reduction

- - 1 3

1 2

arthralgia & disc displacement without reduction without limited opening

- - 1 3

1 2

arthralgia & osteoarthritis & disc displacement without reduction without limited opening

- -

1 3

1 2

arthralgia & disc displacement with reduction & without reduction without limited opening

- -

2 5

2 4

osteoarthritis & disc displacement without reduction without limited opening

1 14

- -

1 2

disc displacement with reduction - - 3 8 3 7

64

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14- Nourallah H, Johansson A. Prevalence of signs and symptoms of temporomandibular

disorders in a young male Saudi population. J Oral Rehabil 1995;22:343-7.

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66

Acknowledgements

67

Acknowledgements

First and foremost, I thank Allah, the Generous, for having finally made this effort a reality

and all praise are due to him.

I wish to express my deepest sincere gratitude to all those who made this work possible, in

particular:

Professor Maria Nilner, Head of the Department of Stomatognathic Physiology, Faculty of

Odontology, Malmö University, my primary supervisor and co-author for her unlimited

support, encouragements, skillful guidance, and valuable discussions with her common sense

throughout my research and clinical training.

Associate Professor EwaCarin Ekberg, Department of Stomatognathic Physiology, Faculty of

Odontology, Malmö University, co-supervisor and co-author, for her skillful guidance,

enormous support, and valuable discussions throughout my research and clinical training.

Professor Thomas List and Associate professor Danila Vallon for sharing their knowledge in

TMD and orofacial pain and continuous encouragement and support.

Assisting professor Mahmoud Eskafi for his artistic contribution for the master thesis and

continuous encouragement.

Dental assistants and secretaries of the Department of Stomatognathic Physiology for their

valuable help with the administration.

68

My colleague, Yasser Al-Thobaiti, specialist training dentist, Oral Surgery Department,

Faculty of Odontology, Malmö University for his skillful help in finishing of cover page of

master thesis.

All my colleagues in Dental Center in Alnoor Hospital, Makkah, Saudi Arabia in particular:

Dr. Mohammad Wahbi former director of the Dental Center and Dr.Awwad Al-bishri Head of

Maxillo-facial Department and later director of The Dental Centre, for their assistance before

and during the study conduction in the centre and valuable discussions.

Dr.Linda Mirza for her excellent collaboration in interviewing some female patients and

valuble discussions throughout data collection.

Miss.Nor Haya, dental centre secretary for her guidance of patients before the interviews.

My wife Nawal, for unlimited love, patience, support, and for providing a loving environment

for me with our lovely children, Somayya, Abdullah, and Tala to keep me happy and active

throughout my studies.

Lastly, and most important, I wish to thank my parents Hasan and Aisha for their guidance for

me throughout my life and for their unlimited support, love and prayers throughout my studies

and my life. To them I dedicate this thesis.

Mohammad H. Al-Harthy