TMJ

Anamnestic Index Severity and Signs and Symptoms

of TMD
Dbora Bevilaqua-Grossi, P.T., Ph.D.; Thas Cristina Chaves, P.T., Ms.;
Anamaria S. de Oliveira, P.T., Ph.D.; Vanessa Monteiro-Pedro, P.T., Ph.D.

ABSTRACT: The aim of this study was to determine the frequency and to characterize the symptoms
and clinical signs of temporomandibular disorders (TMD) related to each severity category of Fonsecas
0886-9634/2402- anamnestic index in a sample of Brazilian young adults (mean age 21.611.91 years, 87% females and
112$05.00/0, THE
JOURNAL OF 13% males), by the application of an anamnestic index proposed by Fonseca (1992) and by clinical
CRANIOMANDIBULAR examination considering mandibular range of motion and tenderness to palpation of stomatognathic
PRACTICE,
Copyright 2006 system structures. A significant number of participants were classified with mild TMD (43.2%) and mod-
by CHROMA, Inc. erate TMD (34.8%). Pain frequency during mastication, temporomandibular joint (TMJ) pain, and TMJ
sounds were shown to be good predictors of TMD severity. Neck pain, headache, difficulty during mouth
Manuscript received
July 8, 2004; revised
opening and lateral deviation, and tenderness to palpation of masticatory sites and during protrusion
manuscript received accompanied the TMD severity but failed to demonstrate differences between moderate and severe
September 7, 2005;
accepted
groups, showing a poor ability to determine TMD severity progression. This study suggests that not only
September 8, 2005 the frequency of signs and symptoms of TMD should be determined, but also symptom severity and its
Address for reprint relationship to the presence of clinical signs in order to discriminate patients with real treatment needs in
requests:
Dr. Dbora Bevilaqua-Grossi
nonpatient samples.
Departamento de
Biomecanica
Medicina e Reabilitao do
Aparelho Locomotor
Faculdade de Medicina de
Ribeiro Preto-
Universidade de So Paulo -
USP
Ribeiro Preto 14049-900

CEP
Brazil
E-mail:
deborabg@fmrp.usp.br
Dr. Dbora Bevilaqua-Grossi received
her physical therapy degree from the
Federal University of Sao Paulo
(UFSCar), M.S. degree in 1996, and
Ph.D. in 1998, in anatomy at the
University of Campinas (UNICAMP). She
is the coordinator of physical therapy
courses at the University of So Carlos
(USP) from Ribeirao Preto, Sao Paulo,
Brazil. She founded and coordinates the
Temporomandibular Disorders Clinic at
the Clinics Hospital, Ribeirao Preto
School of Medicine (FMRP - USP).
T
emporomandibular disorders (TMD) is a collec-
tive term applied to all the problems related to the
temporomandibular joint (TMJ) and related mus-
culoskeletal structures.1 TMD may represent a cluster of
disorders characterized by pain in the preauricular area,
TMJ and masticatory muscle pain, limitation or devia-
tions during the mandibular range of motion, and TMJ
sounds during function.2 Common patient complaints
include headache, neck pain, facial pain, and earache.3
Disharmonies and occlusal interference, emotional
stress, masticatory and cervical muscle hyperactivity,
joint overloads and lesions in whiplash of the cervical
spine, as well as repetitive loading of clenching and brux-
ism,1 besides postural alterations4-8 are possible etiologi-
cal factors that should be considered in the development
of TMD.
The prevalence of TMD symptoms ranges from 16%
to 59% in studies on nonpatient populations.9-12 Solberg,
et al.13 reported TMD symptoms in 26% of the college
students they evaluated. Pedroni, et al.6 applied Fonsecas
anamnestic index and observed that 68% of the non-

112
BEVILAQUA-GROSSI ET AL.
patients presented with TMD. Zulqarnain, et al.14 showed
a symptom prevalence of 12% among female college
students.
Self-administered questionnaires have been used to
evaluate TMD symptoms.6,14-20 The questionnaire pro-
posed by Fonseca, et al.17 is one of the instruments avail-
able in the Portuguese language for the characterization
of TMD symptoms and was designed to classify patients
according to TMD categories of severity. It has been pre-
viously tested in TMD patients, demonstrating a correla-
tion of 95% when compared to Helkimos anamnestic
index15 and has proved to be easy to use.6
The diagnostic tool currently used in the literature for
the evaluation of TMD is the Research Diagnostic Cri-
teria for Temporomandibular Disorders (RDC/TMD).21
However, this diagnostic screening does not classify
TMD into categories of severity,22 an aspect that should
not be forgotten in TMD assessment, since TMD is pri-
marily a chronic pain condition.
Few studies6,20 have determined both the presence and
severity of TMD symptoms, and the understanding of the
signs and symptoms related to the various degrees of
TMD severity obtained using anamnestic tools could
assist the practitioner to better understand TMD progres-
sion and to discriminate patients with treatment needs.
Considering that the criterion currently used to differenti-
ate patients from nonpatients in research samples is the
search for specific clinical treatment on the part of the
patient,2 the classification of severity and the determina-
tion of the signs and symptoms directly related to higher
degrees of severity could function as auxiliary tools for
the identification of patients in samples of nonpatients.
The purpose of this study was to determine the fre-
quency of symptoms and to characterize the symptoms
and clinical signs of TMD related to each severity cate-
gory of Fonsecas17 anamnestic index in a sample of non-
patients.
Materials and Methods
A total of 111 college students were randomly selected
from among students at a Brazilian university in So
Paulo, Brazil. Two were excluded because of the mini-
mum age requirements for the study. The remaining 109
students (21.611.91 yrs) were 95 females (21.481.79
yrs) and 14 males (22.432.53 yrs) ranging in age from
18 to 27 years. Exclusion criteria were the presence of
systemic joint disorders, neurological disease, cervical
spine alterations, facial paralysis, and an established
diagnosis of TMD.
The questionnaire used was developed by Fonseca, et
al.17 to evaluate symptom severity. An experienced exam-
APRIL 2006, VOL. 24, NO. 2
ANAMNESTIC INDEX SEVERITY
iner administered the questionnaire, and the volunteers
were instructed to reply to ten questions by choosing one
of the following answers indicating different degrees of
TMD: yes (10 points), no (0 points), and sometimes (5
points). The sum of the points was used to classify the
participants into four categories: TMD-free (0 to 15
points); mild TMD (20 to 40), moderate TMD (45 to 60),
and severe TMD (70 to 100). For statistical analysis, the
positive answers to the questionnaire were considered to
be equal (as one point) and the negative answer was con-
sidered to represent a zero point.
To determine the mandibular range of motion (mouth
opening, lateral deviations to the right and left, and pro-
trusion), a Boley gauge was used. Mandibular move-
ments were recorded by the Okeson, et al.23 method.
Tenderness to muscle palpation was verified bilater-
ally by the application of digital pressure to the following
anatomic points: anterior temporal, medial and posterior
masseter, medial and lateral pterygoid (intra-oral), and
lateral and posterior TMJ. The anatomic structures were
palpated bilaterally on each side by unilateral palpation
with firm pressure exerted by one (TMJ and intra-oral
muscles) or two (extra-oral muscles) fingers. Only ten-
derness that triggered reflex blinking or flinching was
considered.24
Statistical Analysis
A one-way ANOVA and the Duncan post hoc test were
used to compare the differences in the mean values of the
mandibular range of motion among the different degrees
of severity. Each measurement was made three times by
the same examiner and the mean value was considered. A
chi-square test was applied to compare the frequency of
positive answers between the male and female groups
and among the severity groups and to compare the differ-
ences in tenderness to palpation between the groups clas-
sified according to TMD severity. The level of significance
was set at 5% (p0.05). All analyses were performed with
the SPSS software, Ver. 10.0 (SPSS, Inc. Chicago, IL).
Results
More than 87% of the volunteers demonstrated TMD
symptoms and the great majority (78%) showed mild
(43.2%) and moderate (34.8%) TMD symptoms (p
<0.0001) according to Fonsecas anamnestic index
(Table 1). Previous painful episodes involving the cervi-
cal and stomatognathic systems were reported by 40% of
the volunteers even though the study was conducted on a
nonpatient sample.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 113
ANAMNESTIC INDEX SEVERITY
Table 1
Characterization of the Sample Studied according to Age and
Gender and TMD Severity Degrees (n=109)
Total TMD-free
(n=109) (n=14)
Age (SD) 21.611.91 21.792.01
Sample (%) 109 (100%) 14 (12.8%)
Females 87% (n=95) 8.4% (n=8)
Males 13% (n=14) 43%* (n=6)
*p0.05, 2 - test
Differences Between TMD, TMD-Free, and TMD Severity
Groups
Pain during mastication was observed in more than
50% of the participants. More than 60% of the volunteers
reported cervical pain and frequent headaches. Para-
functional habits and perception of stress were mentioned
by more than 80% of the volunteers, although these ques-
tions were not able to differentiate the TMD-free group
from the groups with different degrees of TMD severity
(Table 2).
Positive answers to the questions about pain during
mastication, TMJ pain, and TMJ sounds were signifi-
cantly more frequent in the severe TMD group than in the
other TMD severity groups (Table 2). As shown in Table
2, difficulty during mouth opening, difficulty during lat-
eral deviation, headache, neck pain and malocclusion
perception were not able to distinguish volunteers with
moderate and severe TMD according to the anamnestic
index.
Differences in Tenderness to Palpation of Masticatory
Structures and Mandibular Range of Motion
As shown in Table 3, tenderness to palpation of medial
and lateral pterygoid muscles and posterior TMJ was
reported by more than 50% of the participants, and more
than 40% of the volunteers reported tenderness to palpa-
tion of the masseter and lateral TMJ. Only tenderness to
palpation of the posterior temporal and posterior TMJ
was significantly more reported by both the severe and
moderate TMD groups. The frequencies of tenderness to
palpation of the medial and lateral pterygoid muscles
were significantly reduced in the TMD-free group com-
pared to the other severity groups. Conversely, the fre-
quencies of tenderness to palpation of the lateral TMJ
were similar in the TMD-free and moderate TMD groups
114 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
BEVILAQUA-GROSSI ET AL.
Mild TMD Moderate TMD Severe TMD
(n=47) (n=38) (n=10)
21.771.77 21.452.21 21.201.14
47 (43.2%*) 38 (34.8%*) 10 (9.2%)
43%* (n=41) 38% (n=36) 10% (n=10)
43%* (n=6) 14% (n=2) 0% (n=0)
and were significantly reduced in mild TMD volunteers
compared to the other groups (Table 3).
Mean values of range of motion during mouth opening
for all participants (women and men) was 48.91 mm, lat-
eral deviation to the right was 9.49 mm, lateral deviation
to the left was 9.32 mm, and deviation for protrusion was
6.05 mm. No significant differences in mouth opening or
lateral deviations were observed among the various
severity groups, although the mild and moderate groups
showed a significant reduction in mandibular protrusion
(one-way ANOVA) compared to the other severity
groups (Figure 1).
Differences Between Genders
We observed a significant frequency of female volun-
teers (91.5%, n=87) classified with at least one symptom
of TMD (considering all groups of severity) compared to
male volunteers (57%, n=8, p=0.004) (Table 1). A sig-
nificant percentage of women were classified as mild
TMD, while the TMD-free and mild TMD categories
were more frequent among men (Table 1).
Comparisons between genders showed a significant
percentage of female volunteers (p<0.04) who reported
difficulty during mouth opening, headache, neck pain,
TMJ pain and stress perception (Table 4). The percent-
ages of positive answers given by women to the other
questionnaire items were always greater than mens per-
centages, although the difference was not significant.
Discussion
The aim of this study was to determine and to charac-
terize the signs and symptoms of TMD severity based on
Fonsecas anamnestic index17 in a population of non-
patients. Eighty-seven percent (87%) of the volunteers
APRIL 2006, VOL. 24, NO. 2
BEVILAQUA-GROSSI ET AL. ANAMNESTIC INDEX SEVERITY

Table 2
Percentage of Volunteers Who Answered Postively to Items
On the Anamnestic Index in the Groups Studied (n=109)
Total TMD-free Mild TMD Moderate TMD Severe TMD
Anamnestic index % (n=109) % (n=14) % (n=47) % (n=38) % (n=10)
Difficulty during mouth
opening 34.86 14.29 29.79 44.74* 50.00*
Difficulty during lateral
deviations 12.84 7.14 4.26 21.05* 30.00*
Pain during mastication 53.21 35.71 42.55 68.42 70.00*
Headache 63.30 35.71 57.45 73.68* 90.00*
Neck pain 63.30 42.86 51.06 84.21* 70.00*
TMJ pain 35.78 28.57 23.40 42.11 80.00*
TMJ sounds 48.62 14.29 44.68 55.26 90.00*
Parafunctional habits 80.73 78.57 74.47 86.84 90.00
Malocclusion perception 36.70 28.57 29.79 42.11* 60.00*
Perception of stress 82.57 78.57 74.47 92.11 90.00
*p0.05, 2-test, comparisons between the TMD-free group and the other severity groups

were classified as having some degree of TMD, i.e., only
13% of the volunteers were classified as TMD-free. Our
data agree with those reported by Zulqarnain, et al.,14 who
observed that only 12% of female college students had no
TMD symptoms. In contrast, Pedroni, et al.6 reported a
32% frequency of TMD-free subjects among Brazilian
college students.
In the present study, the great majority of the volun-
teers (78%) were classified as having mild and moderate
TMD, in agreement with Pedroni, et al.,6 who reported a
62% frequency of mild and moderate TMD among col-
lege students. On the other hand, Conti, et al.,20 who also
evaluated Brazilian college students, observed that most
of the students (58.71%) were classified as TMD-free and
a total of 40% of the volunteers were classified as having
mild and moderate TMD.
We found few studies6,20 that determined the relation-
ship between signs and symptoms and TMD severity.
Fonsecas anamnestic index17 is a simple tool that consid-
ers the severity of TMD symptoms and was not designed
with diagnostic pretensions. However, it could be applied
as a tool for prevention, since the study of these volun-
teers in longitudinal investigations could identify the pro-
gression of dysfunction and the signs and symptoms

Table 3
Differences in TMD Severity Groups According to Tenderness
to Palpation of Masticatory Muscles (n=109)
Total TMD-free Mild TMD Moderate TMD Severe TMD
Masticatory muscles % (n=109) % (n=14) % (n=47) % (n=38) % (n=10)
Masseter 43.12 21.43 42.55* 55.26* 20.00
Anterior temporal 28.44 21.43 29.79* 39.47* 0.00
Posterior temporal 23.85 7.14 17.02 34.21* 40.00*
Medial pterygoid 53.21 35.71* 51.06 57.89 70.00
Lateral pterygoid 74.31 57.14* 74.47 84.21 70.00
Lateral TMJ 44.95 50.00 34.04* 55.26 40.00
Posterior TMJ 73.39 64.29 63.83 84.21* 70.00*
*p0.05, 2-test, comparisons between the TMD-free group and the other severity groups

APRIL 2006, VOL. 24, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 115
ANAMNESTIC INDEX SEVERITY BEVILAQUA-GROSSI ET AL.

Figure 1
Mandibular range of motion (ROM)
values (mm) in the different severity
groups (n=109).
*p0.05, ANOVA one-way.

directly related to this progression. Consequently, the
definition of severity categories could be of help in the
determination of subgroups with more severe signs and
symptoms and in the understanding of trends in the sam-
ples studied.
Thus, the establishment of TMD severity symptoms in
epidemiologic studies can play an important role in the
determination of TMD patients in research samples, or
can differentiate volunteers classified with TMD with
real treatment needs.20 This could suggest that the greater
the severity of symptoms, the greater the chance of
selecting patients with real treatment needs in a sample
of nonpatients.
Standardized criteria of diagnosis such as the RDC/
TMD do not consider the classification of TMD sever-
ity,22 and this is a limitation, since TMD is defined by the
proper criterion as a chronic pain condition. RDC axis-II
considers only the evaluation of pain chronicity and
related symptoms.

Table 4
Differences Between Genders Based on the Percentage of Volunteers Who Answered Positively
to the Items of the Anamnestic Index Proposed by Fonseca (n=109)
Females Males
Anamnestic index % (n=95) % (n=14)
Difficulty during mouth opening 38.95* 7.14
Difficulty during lateral deviations 13.68 7.14
Pain during mastication 54.74 42.86
Headache 69.47* 21.43
Neck pain 67.37* 35.71
TMJ pain 37.89* 21.43
TMJ sounds 49.47 42.86
Parafunctional habits 82.11 71.43
Malocclusion perception 37.89 28.57
Perception of stress 86.32* 57.14
*p0.05, 2-test

116 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2006, VOL. 24, NO. 2
BEVILAQUA-GROSSI ET AL.
In the present study, we detected no significant differ-
ences in the frequency of parafunctional habits and per-
ception of stress between the TMD-free group and the
groups of different TMD severity. The persistence of
parafunctional habits (like bruxism) causing continuous
microtraumas to the stomatognathic system could be
associated with the development of painful events and
alterations in such system. 3,18 However, Lobezzo and
Lavigne,26 in a careful review of the literature, found no
clear cause-effect relationship between bruxism and
TMD. The results of the cited study suggest that para-
functional habits and stress perception could not be used
as good predictors of TMD severity.
Significantly higher frequencies of TMJ pain, pain
during chewing and TMJ sounds were detected in the
group classified as severe TMD, although not in the
group as a whole (n=109). Our findings suggest that
TMJ pain and TMJ sounds could function as good pre-
dictors of TMD progression and pain during chewing
suggesting that, the greater the TMD severity according
to Fonsecas anamnestic index, the greater the functional
damage involved. In contrast to our findings, Conti, et
al. 20 reported higher frequencies of TMJ sounds and
headache in a sample of young Brazilians. However,
these authors did not mention differences in symptoms
regarding TMD severity. Since no significant differences
were observed for the questions regarding difficulty
during mouth opening and lateral deviation, headache
and neck pain between moderate and severe TMD groups,
these items appear to have a poor ability to discriminate
severe stages of dysfunction. Associations between TMD
symptoms and cervical alterations were previously
reported in the literature.4,6,27,28
Tenderness to palpation of lateral and posterior TMJ
was observed in 44.95% and 73.39% of the sample eval-
uated, respectively. Posterior TMJ palpation elicited pain
at a proportion almost twice greater than lateral TMJ pal-
pation. An inverse relationship was verified by Dworkin,
et al.,2 who reported a proportion of 5:1 for pain during
lateral palpation with regard to pain during posterior pal-
pation. Our data are not in agreement with the results of
previous studies that verified frequencies of less than
10% in nonpatient populations.29 Tenderness to masseter
and temporal muscles palpation was verified in more than
28% of volunteers, confirming the findings of Gavish, et
al.,30 who reported a frequency of 23.4%. Krogstad, et
al.31 reported a frequency of 40%.
Mandibular range of motion values could be consid-
ered normal according to Helkimos15 and Szentpeterys34
classification. However, a mean protrusion value reduc-
tion in the mild and moderate TMD groups may indicate
an inversely proportional relationship between TMD
APRIL 2006, VOL. 24, NO. 2
ANAMNESTIC INDEX SEVERITY
severity and protrusion range of motion. Such results sug-
gest that reduction in mandibular protrusion could differ-
entiate patients from nonpatients. It is important to
consider that mean protrusion range of motion was
reduced only in the mild and moderate TMD groups.
Both pain elicited by palpation and mandible range of
motion failed to distinguish the most severe TMD groups,
whereas intra-oral muscle palpation (lateral and medial
pterygoid muscles) was able to discriminate volunteers
with and without TMD. These results disagree with those
obtained by Dworkin, et al.,2 who reported equal frequen-
cies of tenderness to lateral pterygoid muscle palpation
for both groups.
The TMD frequency in this study conducted on an
adult population was almost twice as high in women than
in men (1.6:1). Macfarlane, et al.36 also detected a similar
proportion of TMD symptoms in a population of 2504
volunteers. Several explanations are suggested for the
differences between sexes in the frequency of TMD signs
and symptoms. Differences between females and males
regarding the ability to deal with stress episodes,37 differ-
ences in the presence of estrogen receptors in the TMJ38
or hormonal differences39 are suggested to be important
for gender differences. The small number of male volun-
teers in the present study impaired possible comparisons
between gender and TMD severity, mainly in moderate
and severe TMD groups.
Conclusion
According to the anamnestic index proposed by
Fonseca,17 the items pain during mastication, TMJ pain
and TMJ sounds showed a better ability to distinguish
more severe TMD volunteers. However, difficulty during
mouth opening and lateral deviation, neck pain and
headache proved to be poor predictors of TMD severity.
Similarly, tenderness to palpation of masticatory sites
and mandibular range of motion could not be considered
good predictors of TMD severity, although they showed
ability to distinguish volunteers with and without TMD
classification. A significant percentage of volunteers
were classified into the mild and moderate TMD groups,
suggesting that not only the frequency of TMD symp-
toms should be considered, but also symptom severity to
discriminate patients with real treatment needs in non-
patient studies.
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Thais Cristina Chaves received her degree in physical therapy from the
Federal University of Sao Carlos (UFSCar) and her M.S. degree in
medical sciences in orthopedics, traumatology, and rehabilitation of the
locomotor apparatus, Ribeirao Preto, School of Medicine USP, Sao
Paulo, Brazil. She is a physiotherapist from the Temporomandibular
Disorders Clinic at the Clinics Hospital, Ribeirao Preto School of
Medicine (FMRP-USP).
Dr. Anamaria Siriani de Oliveira received her degree in physical
therapy and M.S. degree in 2000 from Federal University of Sao Carlos
(UFSCar). In 2002, she received a Ph.D. in anatomy at the University of
Campinas (UNICAMP). She is a professor in the Department of
Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus,
Ribeirao Preto School of Medicine, USP - Brazil.
Dr. Vanessa Monteiro-Pedro is a physiotherapist and received her
Ph.D. degree in anatomy at the University of Campinas (UNICAMP),
Sao Paulo, Brazil in 1995. Prior to that, she was a professor of physio-
therapy in orthopedics and traumatology at the Federal University of Sao
Carlos (USFCar), Sao Paulo, Brazil. She is a member of the
International Association for the Study of Pain (IASP), Brazilian
Chapter.
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