Journal of Oral Rehabilitation

Journal of Oral Rehabilitation 2012

The role of dental loss and denture status on clinical signs

of temporomandibular disorders
K . S I P I L A * , R . N A P A N K A N G A S * , M . K O N O N E N * * , P . A L A N E N
& A . L . S U O M I N E N *Department of Prosthetic Dentistry and Stomatognathic Physiology, Institute of Dentistry, Uni-
versity of Oulu, Oulu, Institute of Dentistry, University of Eastern Finland, Kuopio, Department of Oral and Maxillofacial, Kuopio Uni-
versity Hospital, Kuopio, Department of Oral and Maxillofacial, Oulu University Hospital, Oulu, Institute of Dentistry, University of

Helsinki, Helsinki, **Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital, Helsinki, Department of Public

Health Dentistry, Institute of Dentistry, University of Turku, Turku, Unit of Living Conditions, Health and Wellbeing Helsinki, National

Institute for Health and Welfare (THL), Helsinki and Department of Environmental Health, National Institute for Health and Welfare
(THL), Kuopio, Finland

SUMMARY Studies concerning the role of denture
status on in temporomandibular disorders (TMD)
are scarce. The aim of this study was to evaluate
the association of tooth loss and denture status
with clinical findings of TMD. The data were
obtained from 6316 subjects aged  30 years from
the Finnish Health 2000 Survey. The associations
between clinically assessed TMD findings and
number of teeth, wearing of removable dentures,
need for denture repair and age of the dentures
were analysed by means of chi-square test and
logistic regression. Among women after adjusting
for age, having fewer teeth or wearing complete
dentures associated with restricted maximum
interincisal distance and pain on palpation of the
temporomandibular joints (TMJ) and masticatory
muscles. After adding education level and
depression in the model, the associations between
TMJ pain and explanatory variables were
weakened. Among men, having a higher number
of teeth associated with occurence of TMJ
crepitation. Subjective need for repair of dentures
and having a denture aged  5 years associated
with pain on palpation in masticatory muscles
among women. Among men, both the objective
and subjective need for denture repair and having
at least one denture aged  5 years or been
repaired during the past 5 years associated
negatively with the presence of TMJ crepitation. It
can be concluded that edentulousness, wearing of
complete dentures and poor condition of dentures
associate with pain-related TMD findings among
women. Psychosocial factors have a modifying
effect on these associations.
KEYWORDS: temporomandibular disorders, dental
loss, edentulousness, denture status psychosocial
factors
Accepted for publication 9 July 2012

the movement patterns of the mandible (2). The

Introduction
Temporomandibular disorders (TMD) are clinical
problems that involve the masticatory muscles, the
temporomandibular joints (TMJs) and associated
structures, or both (1). Typical signs and symptoms of
TMD are facial pain, clicking or crepitation of the
TMJs, limited jaw opening capacity and deviation in
Finnish nationally representative Health 2000 Survey
(3) included a clinical examination for TMD. Thirty-
eight percentage of the subjects studied had at least
one sign of TMD, which included pain in TMJs or
masticatory muscles, TMJ sounds (clicking or crepita-
tion) or limited mouth opening (4). All the signs stud-
ied were more common in women than in men. The

2012 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2012.02345.x

2 K . S I P I L A et al.
prevalence of TMD is also related to age, with the
highest prevalence occurring at 20-40 years of age
(5), although the results from the Health 2000 Survey
showed that the prevalence of TMD signs associates
positively with higher age (4).
TMD have varying aetiology and pathology. Gen-
eral factors, such as impaired health, general joint and
muscle diseases, psychological and psychosocial fac-
tors, and local influences such as occlusal disturbances
and traumas, can exist in the background of TMD (1).
There is considerable evidence that biomedical or
physical factors alone correlate poorly with TMD (2,
6, 7). Furthermore, the current consensus is that loss
of teeth and lack of posterior occlusal support seem to
have little association with TMD (8, 9).
The role of denture status on TMD is controversial. A
study have found no statistically significant correlations
between signs and symptoms of TMD and denture
retention, stability, occlusal disturbances, freeway
space, age of present denture or the number of sets of
dentures (10). However, some studies have shown that
denture wearers have a higher prevalence of TMD
symptoms compared to the normal population (11) or
to those who still have natural teeth (12) and that the
incidence and intensity of TMD is higher in subjects
with greater tooth loss in the supporting zones (13).
Based on our earlier findings from the Health 2000
Study, there exists an association between edentulous-
ness and the local TMD pain cluster (14). It has been
suggested that factors that make the wearing of com-
plete dentures difficult may also pre-dispose to TMD
symptoms (12). Based on these previous studies, the
denture status and edentulousness may have a role in
TMD. However, their clinical relevance still needs
further study, and additional studies are required to
evaluate the associations between distinct TMD find-
ings and edentulousness, as well as denture status.
Based on our earlier findings, we hypothesise that
TMD are associated with edentulousness and poor den-
ture condition. The aim of the study was to evaluate
the association of tooth loss and denture status as well
as the condition of the dentures on clinical findings of
TMD in a nationally representative sample of adults.
Methods
The nationally representative Health 2000 Survey was
carried out in 20002001 by the National Institute for
Health and Welfare (THL, which includes the former
National Public Health Institute of Finland, KTL).
Two-stage, stratified, cluster sampling was designed
by Statistics Finland. The sampling frame comprised
8028 adults aged 30 years or over, living in mainland
Finland (3). A comprehensive health examination
included a clinical oral examination (79% of the ori-
ginal sample) (15). The data for this study were
obtained from 6316 subjects whose oral health was
clinically examined and who participated in the home
interview. The interviews prior to the health exami-
nation were carried out by trained interviewers and
included information about sociodemographic and
socioeconomic factors. Additional information about
the Health 2000 Survey is available at http://www.
terveys2000.fi/indexe.html.
Five calibrated examiners (dentists) performed a
standardised clinical oral examination as part of the
oral health study and assessed the signs of TMD and
denture status (15). Experienced specialists trained
the examiners to increase the reproducibility of the
clinical examination. The clinical examination tech-
nique for assessment of the signs of TMD was trained
and calibrated by experienced specialists in TMD.
They videotaped each examiners course of procedure
to be immediately reviewed and discussed.
The assessment of TMD signs included recording of
maximum mouth opening, auscultation of TMJ noises
and palpation of the TMJ and two masticatory mus-
cles (temporalis anterior and masseter superficialis).
Maximum mouth opening was measured with a ruler
and reported as maximum interincisal distance with-
out overbite; it was considered limited when
<40 mm. The mouth opening measurements were
taken for dentate and denture wearers. Joint noises
(clicking and crepitation) were recorded bilaterally
over the TMJ region with gentle digital palpation
when the subject opened and closed the mouth. TMJ
tenderness to palpation was assessed by applying a
force of about 5 N over the immovable condyle, and
muscle tenderness was assessed with a force of about
10 N. Attempts were made to standardise the palpa-
tion force by exerting the forces on a measuring scale
(using a letter weighing scale) between the examina-
tions. Joint and muscle pain on palpation was
recorded if the subjects reported pain when asked or
showed a protective reflex. Except for the maximum
interincisal distance, all the findings were recorded
separately for both sides, and they were combined
and categorised as either present or absent. Five
2012 Blackwell Publishing Ltd
 DENTURE STATUS AND TEMPOROMANDIBULAR DISORDERS
dichotomous variables were formed: limited maxi-
mum mouth opening, clicking, crepitation, pain in
TMJs and pain in masticatory muscles. Masticatory
muscle pain was subclassified into the following cate-
gories: no painful muscles/at least one painful muscle.
The reference measurements were taken for 269 study
subjects by the examiner and followed immediately by
the reference examiner. The percentage agreement
between examiners and the referent examiner was
95% (j value, 0
56; 95% CI, 0
340
77) for maximum
interincisal distance, 84% (j value, 0
44; 95% CI, 0
35
0
52) for clicking, 91% (j value, 0
21; 95% CI, 0
13
0
29) for crepitation, 92% (j value, 0
26; 95% CI, 0
19
0
34) for pain in joints and 95% (j value, 0
47; 95%
CI, 0
410
53) for pain in muscles (15).
Primary explanatory variables included in the anal-
yses were the number of teeth, wearing of removable
dentures and the condition of removable dentures.
The presence of teeth and removable dentures was
recorded during the clinical oral examination. Teeth
were recorded by tooth, including all teeth and tooth
remnants visible and tactile in the mouth. The dentist
recorded the dentures by type (i.e. full denture, par-
tial denture) and location by jaw and assessed their
need for repair using the following criteria:
1 denture was fractured;
2 denture had missing tooth/teeth;
3 dentures were loosened during the maximum jaw
opening;
4 freeway space was more than 5 mm;
5 clear partial denture base movement against abut-
ment teeth was detected.
If at least one of the criteria were fulfilled, the need
for denture repair was registered.
In addition, the subjects were asked whether they
themselves thought their dentures were in need of
repair. At the end of the clinical examination, the sub-
jects were asked how old their dentures were and
whether they had been repaired or relined during the
past 5 years, the alternatives being no/yes. The need
for repair, assessed both by a dentist or the subject
him/herself, was dichotomised as no/yes (need for
denture repair in upper or lower denture or both). The
ages of the both upper and lower dentures worn by
the subject were classified as <5 years/5 years or more.
For the analyses, the number of remaining teeth
was categorised as 0, 19, 1019, 19 and 20+. The
classification was based on the current concept that
2012 Blackwell Publishing Ltd
3
minimum of 20 teeth is acceptable for assurance of
oral function (16). The classification for the <20 teeth
was based on the distribution. Denture status was tri-
chotomised as follows: edentate or with complete
dentures, dentate with removable dentures and den-
tate without removable dentures. Dichotomies were
also formed for denture age and past repairs for the
dentures as follows: subjects with at least one denture
aged  5 years (yes/no) and subjects with at least one
denture repaired during the past 5 years (yes/no).
Age, gender and level of education served as back-
ground information and were obtained from the regis-
ters and the interview. For the analyses, age was
categorised into six groups (3034, 3544, 4554, 55
64, 6574, 75+ years), and educational level as basic,
secondary or higher. Basic education category
included those with no formal vocational training or
senior secondary education, secondary education
those who had completed vocational training or
passed the matriculation examination, and higher
education comprised degrees or diplomas from higher
vocational institutions, polytechnics and universities.
As depression has been shown to associate both
with tooth loss (17) and TMD (18), it was included in
the analysis. Major depressive episodes (MDE) includ-
ing sub-threshold cases was determined by a Finnish
translation of the German, computerised version of
the M-CIDI interview which was utilised with DSM-
IV criteria (19). The M-CIDI depression has been
shown to have an excellent inter-interview reliabil-
ity (20). It has been previously reported that owing to
dropouts in the Health 2000 Survey, the prevalence
of psychiatric disorders was shown to be underesti-
mated to some extent (20). Therefore, we chose MDE
with sub-threshold cases to be used as a covariate.
Statistical methods
The complications because of the clustered data were
handled by using the SAS CALLABLE SUDAAN* software
post-stratum weights, based on gender, age, region and
language, for correcting the effects of over-sampling
people aged 80 years or more and non-response.
Owing to earlier revealed interaction between gen-
der and age in relation to clinical signs of TMD in this
same data set (4), all the analyses were performed
*RTI International, Research Triangle Park, NC, USA.
4 K . S I P I L A et al.

separately in men and women. Statistical differences

for frequencies were evaluated by chi-square tests. Table 1. Profile of the study group (P-values refer to chi-square
Age-adjusted prevalences for occurrence of clinical test between genders)
signs of TMD by number of teeth and denture status
were calculated by using model adjustment. In this Men Women All
n (%) n (%) n (%)
method, predicted marginals are used for assessing
differences in prevalences (or means) caused by some All 2861 (48) 3455 (52) 6316 (100)
factor while controlling the effects of confounding fac- Age group (P < 0
001)
tors by using a (logistic) regression model. Owing to 3034 322 (11) 370 (10) 692 (11)
3544 689 (25) 759 (22) 1448 (23)
high correlations between explanatory variables, six
4554 786 (28) 834 (26) 1620 (27)
separate logistic regression analyses were fitted for each 5564 510 (18) 589 (17) 1099 (18)
of the five outcome variables. These associations were 6574 344 (12) 459 (14) 803 (13)
adjusted for age as a continuous variable, level of edu- 75+ 210 (6) 444 (10) 654 (8)
cation and presence of depressive episodes during the Level of education (P < 0
001)
Basic 1092 (38) 1402 (40) 2494 (39)
past 12 months. Results are presented in terms of odd
Secondary 1074 (38) 943 (28) 2017 (33)
ratios, together with 95% confidence intervals. Higher 685 (24) 1097 (32) 1782 (29)
Missing value 10 13 23
Number of teeth (P < 0
001)
Results 0 323 (10) 592 (15) 915 (13)
The number of teeth was higher among men than 19 289 (10) 352 (10) 641 (10)
1019 309 (11) 327 (10) 636 (10)
among women (Table 1). Sixty-nine percentage of the
20+ 1940 (69) 2184 (65) 4124 (67)
men and 63% of the women had twenty teeth or Denture status (P < 0
001)
more, while 11% of the men and 17% of the women Edentulous/with 329 (11) 597 (16) 926 (13)
were edentulous and wore complete dentures. Seven- complete dentures
teen percentage of the men and 18% of the women Dentate with removable 508 (17) 623 (18) 1131 (18)
dentures
were dentate and wore removable dentures. Women
Dentate without 2024 (72) 2235 (66) 4259 (69)
showed higher prevalences of wearing at least one
removable dentures
removable denture needing repair, assessed by the At least one removable denture needing repair
dentist or themselves, compared with men. According to dentists assessment(P < 0
001)
After adjusting for age, among women, a lower Yes 397 (13) 592 (16) 989 (15)
number of teeth and edentulousness associated with No 2463 (87) 2862 (84) 5325 (84)
Missing value 1 1 2
restricted maximum interincisal distance, TMJ pain
According to subjects own assessment (P = 0
013)
on palpation and masticatory muscle pain on palpa- Yes 372 (13) 526 (15) 898 (14)
tion (Table 2). Among men, a higher number of teeth No 2488 (87) 2926 (85) 5414 (86)
or wearing a removable denture associated with TMJ Missing value 1 3 4
crepitation. Subjects wearing at least one removable denture aged  5 years
(P < 0
001)
These associations (except the association between
Yes 620 (21) 936 (26) 1556 (24)
a lower number of teeth and TMJ pain among
No 2238 (79) 2515 (74) 4753 (76)
women) remained after adding the level of education Missing value 3 4 7
and presence of depressive episodes during the past Subjects wearing at least one removable denture repaired
12 months to the model (Table 3). Regarding the during past 5 years (P < 0
001)
condition of dentures, subjective need for repair of Yes 273 (9) 401 (12) 674 (10)
No 2587 (91) 3048 (88) 5635 (90)
dentures associated with pain in masticatory muscles
Missing value 1 6 7
among women. In addition, having at least one den- Occurrence of major depressive episodes during the past
ture aged  5 years associated with masticatory mus- 12 months (P < 0
001)
cle pain among women. Among men, both objective Yes 215 (8) 425 (13) 640 (11)
and subjective need for repair, having at least one No 2515 (92) 2810 (87) 5325 (89)
Missing value 131 220 351
denture aged  5 years or repaired during the past
5 years associated negatively with TMJ crepitation.

2012 Blackwell Publishing Ltd

 DENTURE STATUS AND TEMPOROMANDIBULAR DISORDERS 5

Table 2. Age-adjusted prevalences of clinical signs of temporomandibular disorders (TMD) in males (M) and females (F)

Maximum
interincisal
distance < 40 mm Clicking Crepitation TMJ Muscle
(%) (%) (%) pain* (%) pain (%)

M F M F M F M F M F

All 6 12 13 18 5 10 2 5 8 19
Number of teeth
0 8 17 17 18 3 8 3 8 9 26
19 9 11 17 18 2 9 5 4 10 21
1019 6 10 14 23 5 12 3 5 9 19
20+ 5 10 12 17 7 11 2 4 6 17
P-value 0
042 <0
001 0
087 0
107 0
016 0
096 0
155 0
026 0
072 <0
001
Denture status
Edentulous/ 7 17 16 18 3 8 3 8 9 26
with full
dentures
Dentate with 7 11 14 21 3 11 3 4 8 20
removable
dentures
Dentate without 5 10 12 18 7 11 2 4 7 17
removable
dentures
P-value 0
144 <0
001 0
242 0
073 0
001 0
086 0
560 0
015 0
377 <0
001

*Either at least one of the temporomandibular joints (TMJ).

In one of the following: right or left m. masseter superficialis or m. temporalis anterior.

Chi-square test between the explanatory and outcome variables separately in females (F) and males (M).

The findings of the present study are supported by

Discussion
The present study showed that edentulousness, com-
plete denture wearing as well as poor condition of the
dentures associated with TMJ and masticatory muscle
pain on palpation, as assessed clinically. However,
these associations hold true only among women.
After adding level of education and occurrence of
MDE in the model, the associations between TMJ
pain and explanatory variables were weakened, which
emphasises the role of psychosocial factors as a modi-
fying effect (21). Among men, the only associations
were related to TMJ crepitation and were reversed
with the number of teeth and denture wearing. Based
on the findings of the present study, the associations
between local background factors and TMD findings
differ between genders, and the connection should be
observed separately in women and men, as was sup-
posed in a recent study (22). Additionally, the signs
studied here represent five distinct TMD signs with
different aetiological and risk factors and should
therefore be analysed separately, if possible.
the recent studies that have shown associations
between wearing of complete dentures and TMD
(23, 24). The reason for the vulnerability especially
among women may derive from several factors.
Women in the present study sample may have poorer
conditions regarding the stabilisation and retention of
the dentures than men, which may in turn lead to
pain in TMJs and masticatory muscles. In addition, the
repaired of relined dentures might present a different
occlusal situation compared to new dentures. The pres-
ent study supports the earlier findings that have shown
edentulousness to be more common among women
than among men (25). Women also have more resid-
ual ridge resorption than men (26, 27). This may, at
least partly, be due to the fact that women in general
have been edentulous for a longer period of time than
men of the same age, because it has been suggested
that the duration of edentulousness increases the
extent of resorption (23, 28).
In this study, retention or stability of the dentures
was not assessed clinically, whereas the need for

2012 Blackwell Publishing Ltd

 6

Table 3. Associations of number of teeth, denture status and condition of removable dentures with clinical signs of temporomandibular disorders by means of logistic regres-
sion models, fitted separately for males (M) and females (F). All associations were adjusted for age as continuous and level of education, and occurrence of major depressive
episodes during the past 12 months
K . S I P I L A et al.

Odds ratio (95% confidence interval)

Maximum interincisal
distance < 40 mm Clicking Crepitation TMJ pain* Muscle pain

M F M F M F M F M F

Number of teeth (ref. 20+)

1019 1
0 (0
61
8) 1
0 (0
71
5) 1
1 (0
71
6) 1
5 (1
12
0) 0
6 (0
41
1) 1
1 (0
71
7) 1
2 (0
62
6) 1
0 (0
61
7) 1
4 (0
92
2) 1
1 (0
81
6)
119 1
8 (1
12
8) 1
1 (0
71
6) 1
4 (0
92
1) 1
1 (0
81
6) 0
2 (0
10
6) 0
7 (0
51
1) 2
2 (1
04
6) 0
9 (0
51
6) 1
6 (1
02
8) 1
2 (0
91
7)
0 1
5 (1
02
4) 1
8 (1
32
4) 1
4 (0
92
0) 1
1 (0
81
5) 0
4 (0
20
8) 0
7 (0
51
1) 1
3 (0
44
0) 1
6 (1
02
6) 1
4 (0
92
3) 1
6 (1
22
2)
P-value 0
105 0
001 0
328 0
078 0
002 0
136 0
306 0
110 0
205 0
011
Denture status (ref. dentate without removable dentures)
Dentate with 1
4 (1
01
9) 1
2 (0
91
7) 1
2 (0
91
6) 1
3 (1
01
7) 0
3 (0
20
6) 0
9 (0
71
3) 1
5 (0
83
0) 0
8 (0
51
4) 1
3 (0
91
9) 1
1 (0
91
5)
removable dentures
Edentulous/with 1
4 (0
92
2) 1
9 (1
42
5) 1
3 (0
91
9) 1
1 (0
81
4) 0
4 (0
20
8) 0
7 (0
51
0) 1
2 (0
43
6) 1
5 (1
92
5) 1
2 (0
82
0) 1
6 (1
22
1)
complete dentures
P-value 0
205 0
001 0
318 0
110 <0
001 0
184 0
506 0
072 0
377 0
009
At least one removable denture needing repair
According to dentists own assessment (ref. no)
Yes 1
1 (0
71
6) 1
1 (0
81
4) 1
1 (0
81
7) 1
0 (0
81
3) 0
5 (0
31
0) 1
0 (0
81
4) 1
4 (0
63
3) 0
7 (0
41
3) 1
2 (0
81
8) 1
1 (0
91
5)
P-value 0
728 0
451 0
503 0
826 0
036 0
753 0
432 0
288 0
339 0
439
According to subjects own assessment (ref. no)
Yes 0
9 (0
61
4) 1
1 (0
81
4) 1
1 (0
81
7) 1
2 (0
91
5) 0
4 (0
20
8) 1
0 (0
71
4) 1
0 (0
52
2) 1
5 (1
02
2) 1
2 (0
81
8) 1
6 (1
31
9)
P-value 0
618 0
736 0
538 0
223 0
006 0
929 0
991 0
050 0
400 <0
000
Subjects wearing at least one denture aged  5 years (ref. no)
Yes 1
3 (0
91
8) 1
0 (0
71
3) 1
2 (0
91
6) 1
2 (1
01
5) 0
4 (0
30
7) 0
8 (0
61
1) 1
6 (0
83
2) 1
0 (0
71
4) 1
2 (0
81
7) 1
4 (1
11
7)
P-value 0
153 0
896 0
227 0
077 0
000 0
114 0
199 0
915 0
388 0
002
Subjects with at least one denture repaired during past 5 years (ref. no)
Yes 1
1 (0
71
7) 1
1 (0
81
5) 0
9 (0
61
4) 1
1 (0
81
6) 0
5 (0
21
0) 0
9 (0
71
3) 1
6 (0
73
5) 0
9 (0
51
4) 1
1 (0
71
8) 1
1 (0
91
4)
P-value 0
707 0
478 0
713 0
460 0
045 0
667 0
263 0
585 0
760 0
484

*In at least one of the temporomandibular joints (TMJ).

In at least one of the following: right or left m. masseter superficialis or m. temporalis anterior.

Statistical significance (p < 0.05) marked as bolded.

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 DENTURE STATUS AND TEMPOROMANDIBULAR DISORDERS
repair was evaluated both subjectively and clinically.
Subjectively assessed need for denture repair showed
an association with pain in masticatory muscles and
TMJ among women. This finding supports the earlier
results that problems in denture wearing may pre-dis-
pose to TMD (11, 12). On the other hand, women are
more prone to both pain and TMD (29) compared to
men, which may also have an effect on the associa-
tions between edentulousness and TMJ and muscle
pain.
Among women, also the higher age of the dentures
associated with pain in masticatory muscles. The
cross-sectional study design did not resolve the causal-
ity between these variables. It can be supposed that
subjects having TMD may be more vulnerable to seek
treatment, including preparing new dentures, com-
pared with those without TMD.
Edentulousness and complete denture wearing
associated also with restricted mouth opening among
women. The explanation may be that among women
the restricted mouth opening may be due to the poor
stability and retention of the dentures. As a conse-
quence of denture instability, inaccuracy in measure-
ments may also exist in edentulous subjects.
The findings of the present study support the role of
local influences on TMD, although the connections
were relatively weak and seen only among women. In
this study, the associations between occlusal relation-
ships and TMD were not analysed, and the question
on the role occlusal discrepancies in TMD remains
obscure. The study showed that particularly total
edentulousness associated with pain-related TMD
findings, rather than partial edentulousness. These
results are in contrast to those by Al-Jabrah and
Al-Shumailan (30), who found that partially edentu-
lous patients (wearing removable partial dentures)
exhibited more TMD signs when compared with the
complete denture wearers, in a sample of 200 patients.
The discrepancies may be due to the differences in
study samples. The sample in our study consisted of
general population, whereas the above-mentioned
study sample consisted of patients, among whom care-
seeking behaviour may have affected the results.
An interesting finding of the present study was the
association between the occurrence of TMJ crepitation
and higher number of teeth among men, who also
showed that wearing of dentures and poor condition
of dentures (including the variables removable den-
tures needing repair, as assessed both subjectively
2012 Blackwell Publishing Ltd
7
and clinically, at least one denture aged  5 years
and at least one denture repaired during past
5 years) associated negatively with the presence of
TMJ crepitation. This finding may possibly been
linked with masticatory forces, which have shown to
be stronger among completely dentate subjects than
edentulous ones (31), which may in turn pre-dispose
to degenerative alterations in TMJs among dentate
subjects. In contrast, a population study with 1646
Japanese older adults showed that the presence of
TMJ sounds associated with impairment of mastica-
tory function in subjects with reduced occlusal sup-
port (32). Traditionally, it has been thought that TMD
are caused by loss of occlusal support and an increase
in joint loading, which in turn pre-disposes to disc
displacements and degenerative joint diseases. How-
ever, today it has been concluded that loss of occlusal
support does not necessarily lead to overload in TMJ
(8). Based on the results of the present study, it can
be suggested that the association is reverse. However,
the association between TMJ sounds and occlusal
force is still unclear and needs further investigations.
The present study was a part of a comprehensive
and nationally representative health survey. Because
of the sampling design and high response rates, it was
possible to obtain information about signs of TMD in
the adult population as a whole. The study design also
allowed the use of several outcome variables, includ-
ing the main signs of TMD. As differences have been
found in both the prevalence of TMD and edentulous-
ness between genders and age groups, their con-
founding effect was also considered. However, owing
to practical reasons, all signs examined in the proper
clinical examination for TMD, that is, pain on man-
dibular movements or measurements of ranges of lat-
erotrusion and protrusion movements as well as pain
on palpation in all masticatory muscles, could not be
included in the present study. Also owing to practical
reasons, the clinical examinations were not performed
by specialists but general dentists, which may have
led to errors in measurements. This measurement
error most likely indicates that the true associations
could be stronger than those observed in this study.
It can be concluded that edentulousness and com-
plete denture wearing as well as subjectively assessed
need for denture repair associate with pain-related
TMD findings, especially among women. Psychosocial
factors have a modifying effect on these associations.
However, partial edentulousness does not seem to
8 K . S I P I L A et al.
associate with TMD. Prevention of total dental loss is
important to minimise the local risk factors for TMD.
Enhancing denture retention and stability, possibly by
implant-supported overdentures, may relieve TMD
among edentate subjects.
Acknowledgments
The Health 2000 Health Examination Survey in Fin-
land was organised by the National Institute for
Health and Welfare (former National Public Health
Institute) of Finland (http://www.ktl.fi/health2000)
and partly supported by the Finnish Dental Society
Apollonia and the Finnish Dental Association. A per-
sonal grant to Kirsi Sipila by the Academy of Finland
is gratefully acknowledged. Our sincere thanks are
extended to docent Miira Vehkalahti for her critical
review of the manuscript before submission.
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Correspondence: Kirsi Sipila, Department of Prosthetic Dentistry and
Stomatognathic Physiology, Institute of Dentistry, University of
Oulu, PO Box 5281, FIN-90014 Oulu, Finland.
E-mail: kirsi.sipila@oulu.fi