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195]

Original Article

Prevalence of temporomandibular disorders

in Chennai population
Arvind Muthukrishnan, Gowri Shankar Sekar1
Department of Oral Medicine and Radiology, Saveetha Dental College and Hospital, Saveetha University, 1Department
of Oral Medicine and Radiology, SRM Kaatankulathur Dental College and Hospital, SRM University, Chennai,
Tamil Nadu, India

ABSTRACT

Objective: This study aimed to determine the prevalence of temporomandibular disorders (TMDs) in Chennai city population.
Materials and Methods: To obtain a representative sample, a house-to-house survey was conducted in three zones of
Chennai and a total of 4197 individuals were randomly selected for the study. Among 4197 individuals, 1158 were excluded
from the study, based on the exclusion criteria. Finally, a total of 3039 individuals were included in the study population.
Results: More than half of the study sample (53.7%) in the present study had one or more clinical signs and symptoms
of TMD. Deviation of mandible on mouth opening (42.1%) and clicking sound (38.6%) made up the highest percentage.
Females aged 18 years and older reported higher prevalence of TMD signs and symptoms than men. However, these
differences were not significant for all signs and symptoms in all age groups. Prevalence of TMD was reported in this study
according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) system of classification, and
myofacial pain dysfunction syndrome (MPDS) was reported in 0.8% of the population, internal derangement in 38.3%, and
osteoarthritis in 14.6% of the population. Conclusion: Our study, in comparison to other prevalence studies, had a higher
sample size and was representative of a cross section of the population. The results of this study show that a significant
percentage of the population has signs of TMDs and there are chances that they may develop symptoms of TMDs. Further
studies are needed for early identification and initiation of preventive measures which could prevent TMDs progressing to
advanced stages where management becomes difficult.
Key words: Epidemiology, internal derangement, MPDS, osteoarthritis, population-based study, prevalence, RDC/TMD
criteria, temporomandibular disorder

Introduction categorization of this wide group of conditions. But

each classification or category has some shortfall or

T
he terminology “temporomandibular disorders” the other. Classification has been attempted on the
(TMDs) encompasses a wide spectrum of basis of anatomical changes, etiological factors, and by
conditions. There have been a lot of attempts to some researchers on the basis of the frequency of the
formulate a universally acceptable classification for
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DOI: How to cite this article: Muthukrishnan A, Sekar GS. Prevalence of

10.4103/0972-1363.188686
temporomandibular disorders in Chennai population. J Indian Acad
Oral Med Radiol 2015;27:508-15.

Address for correspondence: Prof. M. Arvind, Department of Oral Medicine and Radiology, Saveetha Dental College and
Hospital, Saveetha University, Chennai - 600 077, India. E-mail: arvindmuthukrishnan@yahoo.com
Received: 28-05-2015  Accepted: 09-12-2015  Published: 19-08-2016

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Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai

presenting signs and symptoms. There has always been a
considerable overlap in any classification system. TMDs
affect the articulation of the condyle with the glenoid
fossa, the masticatory muscles, and the occlusion. There
is a wide interplay between the above-mentioned factors
and a thorough investigation of all possible factors
should be done before a final diagnosis of TMD is made.
To achieve a certain degree of uniformity in defining and
categorizing TMDs, the Research Diagnostic Criteria
for Temporomandibular Disorders (RDC/TMD) have
proposed the following definition and diagnostic criteria.
It is defined as a collective term describing a group of
conditions affecting either the temporomandibular joint
(TMJ), the masticatory musculature, or both. The signs
and symptoms of TMDs include:
a. Pain in the masticatory musculature and/or joint
which can radiate and refer;
b. Locking — closed lock, open lock, inability to open
fully, dislocation;
c. Noises like clicking and crepitus during joint
movement;
d. Headache;
e. Tightness around the face in the morning; and
f. Referred pain to the ear.
Epidemiological studies have estimated that
approximately 50-75% of the population exhibit some
signs of TMDs. Many a times, it may be subclinical and
the patient might not try to relate this to an underlying
jaw problem. In less than 15-20% of the patients, the signs
change into symptoms for which the patient will seek
treatment. The frequency to seek treatment increases
if the symptoms interfere with day-to-day activities.
Identification of the signs of a possible TMD is essential
to diagnose TMDs. So, this study was carried out to
determine the prevalence of signs and symptoms of
TMD diagnosed according to RDC/TMD classification
in Chennai city population.
Materials and Methods
Chennai is a major metropolitan city located in the southern
part of India. An epidemiological study was carried out
in Chennai city population. A house-to-house survey was
conducted in the three zones of Chennai, namely north
zone, central zone, and south zone, and a total of 4197
individuals were randomly selected for the study.
Inclusion criteria
Men and women above 18 years of age and permanent
residents of Chennai city were included in the study.
Exclusion criteria
People less than 18 years of age, patients whose third
molars have been extracted, patients with a history of
fracture of the TMJ and previous TMJ surgeries, non-
cooperative subjects, and individuals not native to
Chennai district were excluded. Approval for the study
was obtained from the Institutional Ethical Committee
of Saveetha University. The study group consisted of
3039 adult patients. The subjects were divided into three
groups depending on their age as follows: Group I- 18-30
years, Group II- 31-50 years, and Group III- more than
50 years. The study was conducted from September 2012
to September 2013. The demographic data and the signs
and symptoms of TMDs were recorded, which were
based on the RDC/TMD criteria.
Statistical analysis
To evaluate the differences between the genders and
age groups, the chi-square test was used with a power
of 80% and with 5% level of significance.
Results
The distribution of study subjects based on age and
gender showed that among males, 55.1% were in
18-30 years age group, 35.4% were in 31-50 years age
group, and 9.5% were in >50 years age group. Among
females, 38.1% were in 18-30 years age group, 44.8% were
in 31-50 years age group, and 17% were in >50 years
age group [Table 1]. The distribution of study subjects
according to presence/absence of TMD based on age and
gender showed that among 3039 study subjects, 1631
(53.7%) subjects had TMD. Also, 437 (29.2%) subjects
in the 18-30 years age group, 846 (72%) subjects in
the 31-50 years age group, and 348 (94.8%) subjects in
the >50 years age group had TMD. Regarding gender
wise distribution, 1014 (50.9%) males and 617 (59%)
females had TMDs [Table 2]. The distribution of study
subjects according to the RDC/TMD between age groups
and gender showed that myofacial pain dysfunction
syndrome (MPDS) was present in 24 (0.8%) subjects
consisting of 14 (0.7%) males and 10 (1.0%) females.
Internal derangement was present in 1163 (38.3%)
subjects consisting of 767 (38.5%) males and 396 (37.9%)
females, and osteoarthritis was present in 444 (14.6%)
of the subjects and among them, there were 233 (11.7%)
males and 211 (20.2%) females. MPDS was present in 22
(1.5%) study subjects in the age group 18-30 years and
Table 1: Distribution of study subjects according to age and gender
Age (years) Gender Total
Male Female n (%) 
n (%) n (%)
18-30 1098 55.1 399 38.1 1497 49.3
31-50 706 35.4 469 44.8 1175 38.7
>50 189 9.5 178 17.0 367 12.1
Total 1993 100.0 1046 100.0 3039 100.0
P value <0.001 (Chi-square test)

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Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai

in 2 (0.2%) study subjects in the age group 31-50 years. Discussion

Internal derangement was present in 412 (27.5%) subjects
in 18-30 years age group, 734 (62.5%) subjects in the age
group of 31-50 years, and in 17 individuals in the age
group of >50 years. Osteoarthritis was present in 3 (0.2%)
subjects of the age group 18-30 years, 110 (9.4%) subjects
belonging to 31-50 years age group, and in 331 (90.2%)
subjects of age >50 years [Table 3]. The distribution of
study subjects according to the presence of signs and
symptoms of TMD based on age and gender showed
that joint sounds were present in 250 (8.2%) subjects
[133 (6.7%) males and 117 (11.2%) females], crepitus in
449 (14.8%) subjects [236 (11.8%) males and 213 (20.4%)
females], clicking in 1173 (38.6%) subjects [770 (38.6%)
males and 403 (38.5%) females], muscle tenderness in 83
(2.7%) subjects [41 (2.1%) males and 43 (4%) females],
joint tenderness in 98 (3.2%) subjects [48 (2.4%) males
and 50 (4.8%) females], referred pain in 26 (0.9%) subjects
[14 (0.7%) males and 12 (1.1%) females], pain on mouth
opening in 71 (2.3%) subjects [33 (1.7%) males and 38
(3.6%) females], deviation of mandible <5 mm on mouth
opening in 1278 (42.1%) subjects [808 males (40.5%)
and 470 females (44.9%)], and limitation of mouth
opening <40 mm was present in 347 (11.4%) subjects
[202 (10.1%) males and 145 (13.9%) females] [Table 4].
The distribution of study subjects according to presence
of parafunctional habits from history based on age and
gender showed that among 3039 study samples, bruxism
was present in 157 (5.2%) samples; among them, 110
(5.5%) were males and 47 (4.5%) were females. Gum
chewing was present in 63 (2.1%) subjects consisting of
46 (2.3%) males and 17 (1.6%) female subjects [Table 5].
One important cause for chronic facial pain is TMDs. The
term TMD has been described as a cluster of disorders
characterized by pain in the preauricular area, TMJ,
or the masticator muscles; limitation or deviations in
mandibular range of motion; and clicking in the TMJ
during mandibular function, and they are not related to
growth or developmental disorders, systemic diseases,
or macrotrauma.[1] The prevalence of this type of disease,
according to the literature, varies between 28% and 88%
depending on the type of population studied as well as
the diagnosis system used.[2] The information regarding
signs and symptoms of TMD has been collected by
clinical examination and questionnaires in some studies
and by interviews in others.[3] TMDs have been observed
to be most frequent among women.[4] Various authors
have also observed that the frequency of the signs and
symptoms of TMD increases with age.[5] Parafunctional
habits like bruxism [6] and gum chewing [7] have been
associated with TMDs. The main objectives of the present
study were to determine the presence or absence of
TMD and the signs and symptoms of TMDs in the adult
population of Chennai city. As random sample method
was used, this study population can be considered
representative of the 18-77-year-old adult population of
the region under survey. It is also thus representative of
the functional status of the population’s stomatognathic
system. The representative TMD prevalence values
determined in this study were compared to those
of other studies — Exclusively studies with random
samples — That fulfilled the criteria similar to those

Table 2: Distribution of study subjects according to presence/absence of TMD based on age and gender
TMD Age (years) Gender Total
18-30 31-50 >50 Male Female n (%)
n (%) n (%) n (%) n (%) n (%)
Present 437 29.2 846 72.0 348 94.8 1014 50.9 617 59.0 1631 53.7
Absent 1060 70.8 329 28.0 19 5.2 979 49.1 429 41.0 1408 46.3
Total 1497 100.0 1175 100.0 367 100.0 1993 100.0 1046 100.0 3039 100.0
P value <0.001 (Chi-square test)

Table 3: Distribution of study subjects according to RDC/TMD between age groups and gender
RDC/TMD Age (years) Gender Total
18-30 31-50 >50 Male Female n (%)
n (%) n (%) n (%) n (%) n (%)
Myofacial pain dysfunction syndrome Absent 1475 98.5 1173 99.8 367 100.0 1979 99.3 1036 99.0 3015 99.2
Present 22 1.5 2 0.2 0 0.0 14 0.7 10 1.0 24 0.8
Total 1497 100.0 1175 100.0 367 100.0 1993 100.0 1046 3039 3039 100.0
Internal derangement Absent 1085 72.5 441 37.5 350 95.4 1226 61.5 650 62.1 1876 61.7
Present 412 27.5 734 62.5 17 4.6 767 38.5 396 37.9 1163 38.3
Total 1497 100.0 1175 100.0 367 100.0 1993 100.0 1046 100.0 3039 100.0
Osteoarthritis Absent 1494 99.8 1065 90.6 36 9.8 1760 88.3 835 79.8 2595 85.4
Present 3 0.2 110 9.4 331 90.2 233 11.7 211 20.2 444 14.6
Total 1497 100.0 1175 100.0 367 100.0 1993 100.0 1046 100.0 3039 100.0
P value <0.001 (Chi-square test)

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Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai

Table 4: Distribution of study subjects according to the presence of signs and symptoms of TMD based on age and gender
Signs and symptoms Age (years) Level of Gender Level of Total
significance significance
18-30 31-50 >50 P value Male Female P value n (%)
n (%) n (%) n (%) n (%) n (%)
Clicking Present 423 28.3 735 62.6 15 4.1 <0.001 770 38.6 403 38.5 0.954 1173 38.6
Absent 1074 71.7 440 37.4 352 95.9 1223 61.4 643 61.5 1866 61.4
Crepitus Present 3 0.2 110 9.4 336 91.6 <0.001 236 11.8 213 20.4 <0.001 449 14.8
Absent 1494 99.8 1065 90.6 31 8.4 1757 88.2 833 79.6 2590 85.2
Other joint Present 26 1.7 79 6.7 145 39.5 <0.001 133 6.7 117 11.2 <0.001 250 8.2
sounds Absent 1471 98.3 1096 93.3 222 60.5 1860 93.3 929 88.8 2789 91.8
Muscle Present 39 2.6 35 3.0 9 2.5 0.791 41 2.1 42 4.0 0.002 83 2.7
tenderness Absent 1458 97.4 1140 97.0 358 97.5 1952 97.9 1004 96.0 2956 97.3
Joint Present 48 3.2 35 3.0 15 4.1 0.576 48 2.4 50 4.8 <0.001 98 3.2
tenderness Absent 1449 96.8 1140 97.0 352 95.9 1945 97.6 996 95.2 2941 96.8
Referred pain Present 23 1.5 2 0.2 1 0.3 <0.001 14 0.7 12 1.1 0.206 26 0.9
Absent 1474 98.5 1173 99.8 366 99.7 1979 99.3 1034 98.9 3013 99.1
Pain on mouth Present 37 2.5 21 1.8 13 3.5 0.135 33 1.7 38 3.6 0.001 71 2.3
opening Absent 1460 97.5 1154 98.2 354 96.5 1960 98.3 1008 96.4 2968 97.7
Deviation of Present 270 18.0 732 62.3 276 75.2 <0.001 808 40.5 470 44.9 0.020 1278 42.1
mandible on Absent 1227 82.0 443 37.7 91 24.8 1185 59.5 576 55.1 1761 57.9
mouth opening
Limitation on Present 25 1.7 96 8.2 226 61.6 <0.001 202 10.1 145 13.9 0.002 347 11.4
mouth opening Absent 1472 98.3 1079 91.8 141 38.4 1791 89.9 901 86.1 2692 88.6
Total 1497 100.0 1175 100.0 367 100.0 — 1993 100.0 1046 100.0 — 3039 100.0
P value <0.001 (Chi-square test)

Table 5: Distribution of study subjects according to the presence of parafunctional habits from history based on age
Parafunctional habit Age (years) Gender Total
18-30 31-50 >50 Male Female n (%)
n (%) n (%) n (%) n (%) n (%)
Bruxism Present 66 4.4 67 5.7 24 6.5 110 5.5 47 4.5 157 5.2
Absent 1431 95.6 1108 94.3 343 93.5 1883 94.5 999 95.5 2882 94.8
Gum chewing Present 30 2.0 30 2.6 3 0.8 46 2.3 17 1.6 63 2.1
Absent 1467 98.0 1145 97.4 364 99.2 1947 97.7 1029 98.4 2976 97.9
Total 1497 100.0 1175 100.0 367 100.0 1993 100.0 1046 100.0 3039 100.0
P value <0.001 (Chi-square test)

of the present study, and were therefore adequately

Table 6: Random sampling population-based TMD prevalence
comparable. These studies consisted of subjects 18 years studies of adults
of age or older and a sample size of >500 study subjects Study Year Origin Sample Age (years)
[Table 6]. Swanljung and Rantanen 1979 Finland 583 18-64
Locker and Slade 1988 Canada 677 18-65
In our study, the sample population numbered 3039 Tervonen and Knuuttila 1988 Finland 1275 25-65
in the age group of 18-77 years. This is a very large Von Korff et al. 1988 USA 677 18-75
sample representing the population under survey, when Agerberg and Bergenholtz 1989 Sweden 1578 25-65
compared to other population-based TMD prevalence Agerberg and Inkapööl 1990 Sweden 637 18-64
studies[8-18] where the study population was less. Only Duckro et al. 1990 USA 500 21-65
two prevalence studies [19,20] had a larger sample size Dworkin and LeResche 1992 USA 1016 18-75
Salonen et al. 1990 Sweden 967 20-80
when compared to our study. In the present study, 53.7%
Lipton et al. 1993 USA 42370 >18
subjects had TMD, which was statistically significant
Jensen et al. 1993 Denmark 735 25-64
(<0.001). A review of 18 international epidemiologic Goulet et al. 1995 France 897 >18
TMD studies conducted primarily on adults from Matsuka et al. 1996 Japan 672 20-92
1979 to 1984 showed an incidence range of 33-86% for Ciancaglini et al. 1999 Italy 520 18-75
one or more signs/symptoms of TMD and 16-59% for Pow et al. 2001 China 1526 18-55
anamnestic symptoms.[21] A meta-analysis published Gesch et al. 2003 Germany 4289 20-81
in 1993 on 51 random samples and selected TMD Studies based on adults 18 years of age or older, a sample size ≥500

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Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai
prevalence studies conducted from 1974 to 1991 showed
clinically determined TMD frequency in the range of
0-93% (an average of 44%) and TMD prevalence in
the range of 6-93% (an average of 30%) based on the
information obtained from questionnaires.[22]
In our study, TMDs were present in 50.9% males and
59% females. Females showed a higher prevalence of
TMDs compared to males. Epidemiological studies
generally document a greater frequency and severity
of TMD in females than in males. In effect, TMD is
observed to be up to four times more frequent in
women, and women tend to seek treatment for their
TMJ problems three times more often than males. It has
been suggested that the presence of estrogen receptors
in the TMJ of women modulates the metabolic functions
in relation to laxity of the ligaments, and this could be
relevant in TMD.[23]
In our study, joint sounds was present in 8.2% of
the study subjects, and it was maximum in the age
group of >50 years (39.5%). Females had significantly
more joint sounds (11.2%) when compared to males
(6.7%) (P < 0.001). In a Swedish sample,[14] 13% of the
subjects complained of TMJ sounds. In a Japanese study
sample,[16] the prevalence of these symptoms was 24%,
and was thus higher than in other studies. A German
study [20] reported that 20-59-year-old women were
significantly more frequently aware of joint sounds than
men. In the 60-80-year-old age group, this difference
no longer existed. In contrast, three studies[13,14,16] found
no gender-based difference. The authors did, however,
confirm a significant reduction of the subjectively
perceived joint sounds with increasing age, which was
in contrast to our study.
TMJ crepitus and clicking was present in 14.8% and
38.6% of the subjects, respectively, in our study
(P < 0.001). Crepitus was maximum (91.6%) in the
age group of >50 years (P < 0.001). Clicking was more
prevalent (62.6%) in the age group of 31-50 years
(P < 0.001). Females showed higher prevalence of
crepitus (20.4%) (P < 0.001) when compared to males
(11.8%). Clicking was present slightly more in males
(38.6%) when compared to females (38.5%). In the
RDC/TMD,[24] clicking sounds that are reproducible
on repeated openings and occur in a reciprocal pattern,
or on excursive as well as vertical range of motion, are
considered to be indicative of disc displacement with
reduction. It should be noted that painless clicking is
also considered as pathognomonic of TMD. In a Swedish
study, [12] the overall prevalence of clicking detected
by examination was 17% in men and 27% in women.
Another study investigated persons aged 18-65 years
in the County of Stockholm, Sweden, and found clicks
to be present in 21% males and 28% females. Crepitus
512 Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2015 | Vol 27 | Issue 4
was detected in 26% men and 40% women.[25] Previous
reviews have reported wide variability, from 6 to 50%,
for the prevalence rates of TMJ sounds across studies.[26]
In all studies that examined both sexes, women showed
a slightly higher prevalence of clicks than men, and their
rates of crepitus were 1.5-2.3 times more than those of
men. The German study[20] reported clicking and crepitus
in 24.9% of the subjects, with women having joint sounds
significantly more frequently than men, almost twice as
often (31.7% vs. 17.9%). A study in Finland[10] reported
the rate as 20%; however, they did not describe either
gender- or age-dependent differences. In a Danish
sample, the rate was 15.4%, [15] with 19% of women
and 12.2% of men having the symptom. The Japanese
study[16] did not report on TMJ sounds, but prevalence of
clicking (46%) and crepitation (19%) was higher in their
sample. In a random telephonic survey,[13] 11% of the
North American subjects reported the same. Although
one may argue whether joint clicking represents a
pathologic condition or simply a normal variation in
the population,[27] it appears that the prevalence rates for
clicking are slightly higher in women than in men. The
factors more prevalent in women, such as joint laxity,[28]
have not been investigated. This may again be related
to the presence of pain or it may be a reflection of the
higher prevalence of certain systemic arthritic conditions
in women.[29]
Masticatory muscle tenderness was found in 2.7% of the
study sample and it was more (3%) in the age group of
31-50 years. Muscle tenderness was more among women
(4.1%) when compared to men (2.1%) (P < 0.002). In
contrast, in the German study,[20] masticatory muscle
tenderness was found in 12% of the subjects. The
prevalence rates reported in Swedish[14] and Japanese[16]
samples were 19% and 21%, respectively. The Finnish
study[10] and another Swedish study[12] also reported
frequency of 6-16% and 19-36%, respectively. Signs
and symptoms were significantly more frequent among
women than men (24.0% vs. 14.0% [14] and 23.3% vs.
18.2%[16]), the latter not being significant. The German
study also reported no significant difference (12.4%
vs. 78%) among the older subjects (60-80 years old).[20]
Significant age differences existed in the German study[20]
only among men aged 40-59 years who exhibited fewer
muscular symptoms. This was also the case in the Swedish
sample[14] for the men over 80 years. Significantly higher
prevalence values were documented by the Finnish and
Swedish groups[10,12] for the 65-year-old age group and
by the Japanese group[16] for the 20-39 year old subjects.
Other studies[5,30,31] reported 20% pain in the masticatory
system. Women tended to report symptoms more
frequently (P < 0.10) than did men and had more severe
symptoms (23% vs.12%); 73% of the men and 63% of the
women were symptom-free, in accordance with others
findings.[22,30,32] Contradictory studies suggest, however,
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Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai
that symptoms of TMD occur equally often in men and
women, or more often in men.[33-35]
Joint tenderness was present in 3.2% of the population
and was maximum in the age group of >50 years.
Females showed a higher prevalence of joint tenderness
(4.8%) when compared to males (2.4%), with a high
significance (P < 0.001). TMJ tenderness upon palpation
was reported to be 4.9% in the German study,[20] 5% in
the Finnish sample,[10] 2% in Swedish subjects,[14] and 6%
of the sample in Japanese subjects.[16] Overall, there was a
significant gender difference: Women were significantly
more often affected than men. The German study found
the proportion to be 6.4% versus 3.3% in 20-59 year
old subjects. [20] The Japanese study [16] found 7.6% of
the women and 3.6% of the men to be affected. Only
in the Swedish sample, no gender-related differences
(5%) were reported. [14] None of the studies reported
significant age differences. As part of the national health
interview survey, which was administered by telephone
to a large representative sample of the US population,
joint tenderness was reported in 7% of women and 3.5%
of men.[19] The highest rates were found in 18-34-year-
old subjects, and the rates declined with age. Another
study in Sweden[12] showed joint tenderness to range
from 0.5% to 7.9% with an overall rate of 2.5% for men
and 4.9% for women and the highest rates of joint pain
were found in the oldest age group, which corresponds
to the findings of our study.
Referred pain was present in 0.9% of the study subjects
and was more prevalent (1.5%) in the age group of
18-30 years, which showed high significance. Referred
pain was more among females (1.1%) than males (0.7%).
In a telephone survey of adult residents of Toronto,
Ontario, [9] 9.5% of women and 5% of men reported
experiencing pain in the face just in front of the ears.
Prevalence rates of pain were slightly higher in those
under age 45 years (8.3%) than in those 45 years of age
and older (7.2%). An American study[11] demonstrated
that 8% of men and 15% of women reported such pain.
Rates peaked in the age group of 25-44 years, with 10% of
men and 18% of women in this age group reporting pain;
rates were quite low (0% for men and 2% for women)
in those above 65 years of age. A telephone survey of
the French-speaking population reported pain around
the temporomandibular region which was found to be
highest among 35-54 year olds, with 6.8% of men and
10.4% of women reporting frequent episodes of pain.[15]
Pain on mouth opening was evident in 2.3% of our
study population. Also, 3.5% of those in the age group
of >50 years experienced maximum pain on mouth
opening. Females experienced more pain on mouth
opening (3.6%) when compared to men (1.7%), and it
was statistically significant (P = 0.001). The German
Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2015 | Vol 27 | Issue 4
study[20] reported pain upon mouth opening in 1.2% of
the subjects and this symptom was more frequent among
women than men in the age group of 40-59 years (2.1%
vs. 0.4%), which corresponds to the findings of our study.
Swedish studies[10,14] reported the prevalence of pain on
mouth opening to be 3% and 0.7% in females and males,
respectively, in their samples. Both these studies detected
no significant age- and gender-based differences.
Deviation of mandible on mouth opening was reported
by 42.1% of individuals in the present study; 75.2%
of individuals in the age group of >50 years reported
deviation of mandible on mouth opening more
frequently. Deviation on mouth opening was prevalent
in 62.3% of the subjects in 31-50 years age group, with the
least rate being reported in those belonging to 18-30 years
age group (18%) (P < 0.001). Females showed a slightly
higher prevalence of deviation (44.9%) when compared
to males (40.5%) (P = 0.020). Our study reported the
highest prevalence of deviation of mandible on mouth
opening (42.1%) when compared to the German and
Danish studies, [4,20] which reported irregular jaw
movements such as deviation and deflection in 28.3%
and 28.9% of the population, respectively, and women
were found to be significantly more affected than men
(33% vs. 23.5% and 34.8% vs. 23.4%, respectively).
Limitation of mouth opening of <40 mm was present in
11.4% of the subjects in our study. Very high prevalence
was found (61.6%) in >50 years age group (P < 0.001).
Females reported higher prevalence of limitation of
mouth opening (13.9%) when compared to males
(10.1%) (P = 0.002). The German study[20] reported the
rate of limited mouth opening to be 9.1% in its sample.
Similar results were found in the Swedish (6% and
5.2%, respectively) studies.[10,14] The Danish sample[4]
and the Japanese sample[16] showed rates of 8.1% and
5%, respectively. The study performed in Germany[20]
reported gender-related differences for this variable in
the 40-59 years age group, in which women exhibited
limited mouth opening more frequently than men (9.6%
vs. 6.1%). With the exception of the Swedish study [14]
which did not report any pronounced gender-based
differences, all the other studies documented a higher
prevalence for women than for men (8.0% vs. 3.0%[10]
and 11.0% vs. 5.5%[4]). In the Japanese population, these
differences were not significant. With the exception of
the latter, all studies including this study described a
significant increase in prevalence with age or a more
frequent occurrence of symptoms in the older age
groups. In the nine variables that were compared
between studies, significantly higher prevalence
was reported for women than for men. Statistically
significant age- and gender-based differences were
found in four out of the nine variables studied by us:
Joint sounds, crepitus, deviation of mandible on mouth
513
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Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai
opening, and limitation on mouth opening. A review on
epidemiological literature about TMD found TMD to be
approximately twice as common in women as in men.[23]
Parafunctional habits like bruxism and gum chewing
are associated with TMDs.[36] The prevalence of bruxism
and gum chewing was 5.2% and 2.1%, respectively, in
our study. Prevalence of bruxism was higher in those
>50 years of age (6.5%), while gum chewing was higher
among those in the age group of 31-50 years (2.6%). Males
showed a higher prevalence of bruxism (5.5% vs. 4.5%)
and gum chewing (2.3% vs. 1.6%) as parafunctional habits
when compared to females. No significant difference was
found. Two studies[5,37] found a significant association
between bruxism and TMD, which reported that subjects
with any degree of bruxism had a higher rate of TMD than
those who showed no degree of bruxism. On the other
hand, two studies[2,38] did not find significant differences
between bruxism and TMDs.
Research diagnostic criteria (RDC) have grouped three
main conditions of TMD:
a. MPDS,
b. Disc disorders or internal derangement, and
c. Osteoarthritis. Our study was based on the RDC/
TMD system of classification of TMDs.
In our study, the prevalence of MPDS was 0.8%
(P < 0.001). MPDS was most prevalent in the age group
of 18-30 years. Females showed higher prevalence of
MPDS (1%) than males (0.7%). Prevalence of internal
derangement was 38.3%, and it was more in the age
group of 18-30 years (62.5%) (P < 0.001). Regarding
gender wise distribution, internal derangement was
more prevalent in males (38.5%) when compared to
females (37.9%). Osteoarthritis was reported in 14.6%
of the study sample, with more than 90% occurring in
people >50 years of age (P < 0.001). Females exhibited
higher prevalence of osteoarthritis (20.2%) when
compared to males (11.7%) (P < 0.001). In a retrospective
study, [39] the prevalence of MPDS was 35.2%, disc
disorders 44.8%, and osteoarthritis 13.4%. In another
study by the same author,[40] the prevalence of MPDS was
18.1%, disc disorders 31.4%, and osteoarthritis 27.2%.
Conclusion
A significant percentage of the population has signs
of TMDs. In our study, more than half of the study
sample (53.7%) had one or more clinical signs and
symptoms of TMD. Deviation of mandible on mouth
opening (42.1%) and clicking sound (38.6%) made up
the highest percentage. Females >18 years reported
higher prevalence of TMD signs and symptoms than
men. However, these differences were not significant
for all signs and symptoms in all age groups. The
514 Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2015 | Vol 27 | Issue 4
influence of age on signs and symptoms of TMD was less
pronounced, with the exception of crepitation as well as
limited maximum mouth opening, which significantly
increased with age in both males and females. This is the
first field-based study to record the symptoms of TMDs
without the patient actually reporting to have them. The
results of this study show that a significant percentage of
the population has signs of TMDs and there are chances
that they may develop symptoms of TMDs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Casanova-Rosado JF, Medina-Solís CE, Vallejos-Sánchez AA,
Casanova-Rosado AJ, Hernández-Prado B, Ávila-Burgos L.
Prevalence and associated factors for temporomandibular
disorders in a group of Mexican adolescents and youth adults.
Clin Oral Invest 2006;10:42-9.
2. Shiau Y, Chang C. An epidemiological study of temporomandibular
disorders in university students of Taiwan. Community Dent Oral
Epidemiol 1992;20:43-7.
3. Farsi NM. Symptoms and signs of temporomandibular disorders
and oral parafunctions among Saudi children. J Oral Rehabil
2003;30:1200-8.
4. Jensen R, Rasmussen BK, Pedersen B, Lous I, Olesen J. Prevalence
of oromandibular dysfunction in a general population. J Orofac
Pain 1993;7:175-82.
5. Koidis PT, Zarifi A, Grigoriadou E, Garefis P. Effect of age and sex
on craniomandibular disorders. J Prosthet Dent 1993;69:93-101.
6. Magnusson T, Egermark I, Carlsson GE. A longitudinal
Epidemiologic study of signs and symptoms of temporomandibular
disorders from 15 to 35 years of age. J Orofac Pain 2000;14:310-9.
7. Gavish A, Halachmi M, Winocur E, Gazit E. Oral habits and their
association with signs and symptoms of temporomandibular
disorders in adolescent girls. J Oral Rehabil 2000;27:22-32.
8. Swanljung O, Rantanen T. Functional disorders of the masticatory
system in southwest Finland. Community Dent Oral Epidemiol
1979;7:177-82.
9. Locker D, Slade G. Prevalence of symptoms associated with
temporomandibular disorders in a Canadian population.
Community Dent Oral Epidemiol 1988;16:310-3.
10. Tervonen T, Knuuttila M. Prevalence of signs and symptoms
of mandibular dysfunction among adults aged 25, 35, 50, and
65 years in Ostrobothnia, Finland. J Oral Rehabil 1988;15:455-63.
11. Von Korff M, Dworkin SF, LeResche L, Kruger A. An epidemiologic
comparison of pain complaints. Pain 1988;32:173-83.
12. Agerberg G, Bergenholtz A. Craniomandibular disorders in
adult population of West Bothnia, Sweden. Acta Odontol Scand
1989;47:129-40.
13. Duckro PN, Tait RC, Margolis RB, Deshields TL. Prevalence
of temporomandibular symptoms in a large United States
metropolitan area. Cranio 1990;8:131-8.
14. Salonen L, Helldén L, Carlsson GE. Prevalence of signs
and symptoms of dysfunction in the masticatory system:
An epidemiology study in an adult Swedish population.
J Craniomandib Disord 1990;4:241-50.
[Downloaded free from http://www.jiaomr.in on Tuesday, April 14, 2020, IP: 139.192.99.195]
Muthukrishnan A and Sekar GS: Prevalence of TMDs in Chennai
15. Goulet JP, Lavigne GI, Lund JP. Jaw pain prevalence among
French-speaking Canadians and related symptoms of
temporomandibular disorders. I Dent Res 1995;74:1738-44.
16. Matsuka Y, Yatani H, Kuboki T, Yamashita A. Temporomandibular
disorders in the adult population of Okayama City, Japan. Cranio
1996;14:158-62.
17. Ciancaglini R, Testa M, Radaelli G. Association of neck pain with
symptoms of temporomandibular dysfunction in the general
adult population. Scand J Rehabil Med 1999;31:17-22.
18. Pow EH, Leung KC, McMillan AS. Prevalence of symptoms
associated with temporomandibular disorders in Hong Kong
Chinese. J Orofac Pain 2001;15:228-34.
19. Lipton IA, Ship JA, Larach-Robinson D. Estimated prevalence
and distribution of reported orofacial pain in the United States.
I Am Dent Assoc 1993;124:115-21.
20. Gesch D, Bernhardt O, Alte D, Schwahn C, Kocher T, John U,
et al. Prevalence of signs and symptoms of temporomandibular
disorders in an urban and rural German population: Results of
a population-based Study of Health in Pomerania. Quintessence
Int 2004;35:143-50.
21. Carlsson GE. Epidemiological studies of signs and symptoms of
temporomandibular joint-pain-dysfunction. A literature review.
Aust Prosthodont Soc Bull 1984;14:7-12.
22. De Kanter RJ, Truin GJ, Burgersdijk RC, Van’t Hof MA,
Battistuzzi PG, Kalsbeek H, et al. Prevalence in the Dutch adult
population and a meta-analysis of signs and symptoms of
temporomandibular disorder. J Dent Res 1993;72:1509-18.
23. LeResche L, Saunders K, Von Korff MR, Barlow W, Dworkin SF.
Use of exogenous hormones and risk of temporomandibular
disorder pain. Pain 1997;69:153-60.
24. Dworkin SF, LeResche L. Research diagnostic criteria for
temporomandibular disorders: Review, criteria, examinations
and specifications, critique. J Craniomandib Disord
1992;6:301-55.
25. Agerberg G, Inkapööl I. Craniomandibular disorders in an urban
Swedish population. J Cranomandib Disord 1990;4:154-64.
26. Carlsson GE, LeResche L. Epidemiology of temporomandibular
disorders. In: Sessle BI, Bryant PS, Dionne RA, editors.
Temporomandibular Disorders and Related Pain Conditions.
Seattle: IASP Press; 1995. p. 211-26.
Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2015 | Vol 27 | Issue 4
27. Goyer RA, Rogan WI. When is biologic change an indicator of
disease? In: Underhill DW, Radford EP, editors. New and Sensitive
Indicators of Health Impacts of Environment Agents. Pittsburgh:
University of Pittsburgh; 1986. p. 17-25.
28. Westling L. Temporomandibular joint dysfunction and systemic
joint laxity. Swed Dent J Suppl 1992;81:1-79.
29. Wolfe F. Rheumatoid arthritis and osteoarthritis: Pain facts. Am
Pain Soc Bull 1994;4:15.
30. Osterberg T, Carlsson GE, Wedel A, Johansson U. A cross-sectional
and longitudinal study of cranio mandibular dysfunction in an
elderly population. J Craniomandib Disord 1992;6:237-45.
31. Nordström G, Eriksson S. Longitudinal changes in
craniomandibular dysfunction in an elderly population in
northern Sweden. Acta Odontol Scand 1994:52:271-9.
32. Johansson A, Unell L, Carlsson GE, Söderfeldt B, Halling A.
Gender difference in symptoms related to temporomandibular
disorders in a population of 50-year-old subjects. J Orofac Pain
2003;17:29-35.
33. Osterberg T, Carlsson GE. Symptoms and signs of mandibular
dysfunction in 70-year-old men and women in Gothenburg,
Sweden. Community Dent Oral Epidemiol 1979;7:315-21.
34. Helkimo M. Epidemiological surveys of dysfunction of the
masticatory system. Oral Sci Rev 1976;7:54-69.
35. Ow RK, Loh T, Neo J, Khoo J. Symptoms of craniomandibular
disorder among elderly people. J Oral Rehabil 1995;22:413-9.
36. Magnusson T, Carlsson GE, Egermark I. Changes in subjective
symptoms of craniomandibular disorders in children and
adolescents during a 10-year period. J Orofac Pain 1993;7:76-82.
37. Wabeke KB, Spruijt RJ. Dental factors associated with
temporomandibular joint sounds. J Prosthet Dent 1993;69:401-5.
38. Lobbezoo F, Lavigne GJ. Do bruxism and temporomandibular
disorders have a cause-and-effect relationship. J Orofac Pain
1997;11:15-23.
39. Poveda-Roda R, Bagán JV, Jiménez-Soriano Y, Fons-Font
A. Retrospective study of a series of 850 patients with
temporomandibular dysfunction (TMD). Clinical and radiological
findings. Med Oral Patol Oral Cir Bucal 2009;14:e628-34.
40. Poveda-Roda R, Bagan JV, Sanchis JM, Carbonell E. Enrique
Carbonell Temporomandibular disorders. A case-control study.
Med Oral Patol Oral Cir Bucal 2012;17:e794-800.
515