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Original Article

Cheek Bite Keratosis among Temporomandibular Disorder Patients
Abdullah Mohammed Alzahem1,2

Department of Medical Introduction: Cheek biting commonly reported by patients with

Education, College of
Medicine and Director of
temporomandibular disorders (TMDs). This cheek biting may cause cheek bite
Quality Assurance, Deanship keratosis. This research aims to study the prevalence of cheek bite keratosis among
of Quality Management, TMD patients. Materials and Methods: A  cross‑sectional survey was conducted
King Saud Bin Abdulaziz on 373 TMD patients seen in the temporomandibular joint (TMJ) clinic by one
University for Health TMJ specialist since 2013. Convenient sampling technique was followed where all
Sciences, 2Department screened patients having TMDs were included in the study. Results: TMD patients
of Dental Services, King
Abdulaziz Medical City,
who have cheek‑bite keratosis are 226 patients (60.6%). Female TMD patients are
Riyadh, Saudi Arabia the majority (75.60%) and 78.8% of TMD patients with cheek bite keratosis were
female. The highest number of TMD patients (4.6%) was at the age of 20 years
old. Conclusion: Cheek bite keratosis is an important sign for TMD screening for
the general dentist in the first dental visit. Dentist who finds cheek bite keratosis
during intraoral examination advised to ask more screening questions and do more
clinical examination for TMDs.

Keywords: Cheek bite keratosis, cheek biting, temporomandibular disorders,
temporomandibular joints

Clinical Relevance to Interdisciplinary Dentistry
• Temporomandibular disorder patients need to be managed by multidisciplinary
• Cheek bite keratosis as a sign should act as alert for different dental disciplines
• Diagnosing temporomandibular disorders as early as possible is important for
all dental disciplines.

Introduction opening entrapped buccal mucosa between teeth during
the chewing cycle, which in turn can lead to further
T emporomandibular disorders (TMDs) are a group
of conditions and cause pain and dysfunction of the
jaw joints and the muscles of mastication. TMDs affect
injury of the mucosa.[7] Cheek biting existed in 3.05% of
normal adults and 0.97% of normal children and youth.[8]
women more than men, and mostly, the symptoms are Removable prosthesis introduced in the literature to
self‑limited with little or no treatment. However, some prevent the injury of cheek biting but requires enough
people develop significant long‑term symptoms and compliance by a patient.[9] An adolescent with a history
need treatment.[1] TMDs are related to mixed etiologic of hydrocephalus and developmental delay successfully
factors.[2] One of these etiological factors reported treated with a modified standard maxillary orthodontic
in the literature was the oral parafunctions as cheek
biting.[3] Cheek biting influenced dysfunctional opening Address for correspondence: Dr. Abdullah Mohammed Alzahem,
and pain on opening.[4] Other oral habits did not affect College of Medicine, King Saud Bin Abdulaziz University for
Health Sciences, King Abdulaziz Medical City, Ministry of
TMD symptoms in a period of about 5 years by getting National Guard‑Health Affairs, PO Box 22490 (MC 1243),
worse or change.[5] Cheek biting was the most common Riyadh 11426, Saudi Arabia.
parafunctional habit among patients with TMDs and did E‑mail: zahema@ksau‑
affect 41% of them.[6] TMD patients with limited mouth
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DOI: How to cite this article: Alzahem AM. Cheek bite keratosis among
10.4103/jid.jid_33_17 temporomandibular disorder patients. J Interdiscip Dentistry

© 2017 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow 87

and 147 TMD patients (39.785 patients. NY: IBM Corp). keratosis are 178 patients (63. Seventeen TMD patients (4. Data were categorized according to age into four groups. and the male TMD patients who have cheek bite keratosis are Referred patients with TMD symptoms and signs were screened by one temporomandibular joint (TMJ) specialist in TMJ clinic then given appointment for comprehensive TMJ examination.[12] The largest study to compare age and gender in TMD patients and their of 23. A Chi‑square statistic was used may cause cheek bite keratosis. literature to the best of my knowledge. group (30–42 years old) has the highest prevalence for Every patient has medical record with consent for routine cheek bite keratosis  (65.47%) TMD patients presence percentage of cheek bite keratosis to age and seen in 2015.35%). 78 (20. All calculations were carried emphysema but rarely. There Results is a need to investigate the significance of the cheek All 373 TMD patients with age 7–76 years bite as a sign for screening TMDs by investigating the old (mean = 32) were distributed according to their prevalence of cheek bite keratosis among TMD patients. the first group was patients with age below 22 years old. TMJ evaluation form was filled for each patient. the study determined the and 15 (4. and cheek bite keratosis availability as a sign.59%) have diagnosed with TMDs to determine the prevalence of cheek bite keratosis. The study objectives TMD patients were seen in the past 5 years. (below 22 years old) has the lowest prevalence of cheek bite keratosis (54.12%). attending a Mexican dental school association with cheek-bite keratosis. During the comprehensive TMJ examination. Observation recording form was developed and used as data collection form.0 (Armonk. Moreover. and the fourth group was patients with age above 42 years old.05) with both TMDs mucosa was very frequent injury and could cause facial and cheek‑bite keratosis.91%) TMD patients seen in 2016.41%) cheek bite keratosis among TMD patients. Convenient do not have cheek bite keratosis [Table 3]. the third group was patients with age 30–42 years old. The third age Board and no additional patient consent was required. sampling technique was used. Three hundred and seventy‑three bite keratosis among TMD patients.02%) TMD patients seen this year 2017. and each group Ethical clearance was granted by the Institutional Review has 91–93 TMD patients [Table 2].40%). where were to calculate the presence percentage of cheek bite 109 (29. usually unhurt.[13] Biting of the buccal were significantly associated (P < 0. Figure 1: Age of temporomandibular disorders patients’ distribution 88 Journal of Interdisciplinary Dentistry  ¦  Volume 7  ¦  Issue 3  ¦  Sepetember-December 2017 . percentage of female and male TMD patients. the second group was patients with age 22–29 years old. Statistics Data were categorized in groups according to age and gender. but what has been mentioned was the cheek biting as a symptom. Our sample had 282 female TMD patients (75. Logistic regression clinic.6%) at the age of 20 years old were the highest number among This research aimed to study the prevalence of cheek all ages [Figure 1]. Version Cheek bite as a sign has not been discussed in the 21.60%) Materials and Methods and 91 male TMD patients (24. Study design A cross‑sectional survey was conducted on 373 patients Two hundred and twenty‑six patients (60.59%). self‑inflicted injury[11] and patients was calculated.22%) TMD patients seen in 2013. and the first age group examination in dental clinics.38%) keratosis among TMD patients and to correlate the TMD patients seen in 2014. age [Table 1]. patient age.7 cases per 1000 patients.[10] Cheek biting The prevalence of cheek‑bite keratosis among TMDs is a chronic. patient gender. gender of patients.[14] out with the IBM SPSS Statistics for Windows. The sample has Ethics been divided into four age groups. 76 (20. Alzahem: Cheek bite keratosis among TMDs patients retainer to prevent cheek biting injury. containing the following fields: medical record number. where all diagnosed The female TMD patients who have cheek bit patients with TMDs were included since 2013. found that cheek biting lesions were ranked fifth models were used to assess the impact of variables that or 21. 95 (25.

7) 2 8 The cheek bite keratosis is an important sign for TMD 47 3 (0.8) 1 2 patients during examination in the first dental visit.5) 2 0 opening direction.. earache. 24 16 (4.5) 4 9 prevalence of cheek bite keratosis among TMD patients.59% 25 14 (3.9) 6 1 53 3 (0.2) 4 8 Conclusion 46 10 (2.1) 4 4 TMDs by non‑TMJ specialist.3) 2 3 showed the cheek bite keratosis more than male TMD 40 12 (3.8) 1 2 TMD is more prominent in female patients than male 32 6 (1.4) 4 5 TMDs including history of frequent headache.5) 1 1 11 2 (0. The 37 7 (1.9) 0 7 third age group (30–42 years old) showed the cheek bite 38 9 (2.5) 2 0 Total 373 (100..3) 1 0 67 2 (0.5) 1 1 This study is the first to the best of our knowledge Contd.5) 1 1 TMJs for click or crepitation sound. the dentist may 56 1 (0.3) 1 0 7 1 (0.0) 10 5 Discussion 22 12 (3.1) 1 3 31 3 (0..5) 4 9 linked to physiological and psychological status. and cheek bite Table 1: Contd. and auscultate 61 2 (0. and the female TMD patients 39 5 (1.75%) [Table 3]. pain upon opening 52 7 (1.1) 1 7 Dentist who finds cheek bite keratosis during intraoral 49 1 (0. keratosis Age Frequency (%) Cheek bite keratosis Age Frequency (%) Cheek bite keratosis No Yes No Yes 65 1 (0.2) 8 4 cheek bite keratosis to a specialized dentist in TMDs for 29 7 (1.8) 2 1 and closing.6) 1 5 more prone to the cheek bite keratosis.3) 1 0 76 1 (0.5) 0 2 inspect teeth for significant occlusal wear. but there is a significant correlation between the 36 5 (1. ear sound. 44 7 (1.6) 6 11 21 15 (4.6) 1 5 patients and affects people at the age of 20 years old the 33 9 (2.3) 9 7 The cheek bite keratosis as a sign existed in 60. which might be 43 13 (3.9) 2 5 16 10 (2. 19 13 (3.3) 0 1 do further clinical examination as palpation of the TMJs 57 1 (0.0) 147 226 15 7 (1. measure range of mouth opening.5) 2 0 13 1 (0. 48 8 (2.2) 3 9 The objective of this study was to investigate the 23 13 (3. joint sound.5) 6 7 20 17 (4.3) 1 0 neck pain. In addition.5) 0 2 clenching or grinding teeth.5) 1 1 70 2 (0. discussing the prevalence of cheek bite keratosis among Journal of Interdisciplinary Dentistry  ¦  Volume 7  ¦  Issue 3  ¦  Sepetember-December 2017 89 .7) 4 6 found.3) 1 4 age of the TMD patients and the cheek bite keratosis.. to refer the patient with 28 12 (3. 62 2 (0. inspect mouth 58 2 (0. The number of female 17 7 (1.7) 5 5 48 patients (52. This makes 26 13 (3. 30 4 (1.2) 2 10 41 6 (1.4) 3 6 most.9) 2 5 further evaluation. difficult mouth opening.4) 6 3 keratosis more than others.9) 2 5 TMD patients showed that cheek bite keratosis is more 18 15 (4.9) 5 2 45 12 (3.3) 0 1 14 2 (0.6) 1 5 patients.3) 0 1 examination should ask more screening questions for 50 9 (2.3) 0 1 12 2 (0. 60 2 (0. No significant correlation between the prevalence 34 11 (2.9) 4 7 of cheek bite keratosis and the age of TMD patients 35 10 (2.5) 2 0 69 1 (0. This makes middle age female TMD patients 42 6 (1.3) 0 1 and masticatory and cervical muscles. 51 1 (0. Alzahem: Cheek bite keratosis among TMDs patients Table 1: Age of patients.0) 4 11 than the number of male TMD patients.5) 6 7 cheek bite keratosis as an important sign for screening 27 8 (2.8) 4 10 of TMD patients according to this study. and history of 55 2 (0. frequency.

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