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EVIDENCE LEVELS OF PARAFUNCTIONAL HABITS AS PROMINENT ETIOLOGY

IN FACIAL ARTHROMYALGIA: A SYSTEMATIC REVIEW
1
S Gowri Shankar, 2M Arvind
1
Postgraduate student, Saveetha Dental College and Hospital, Saveetha University Chennai, India.
2
Professor and Academic Head, Saveetha Dental College and Hospital, Saveetha University Chennai, India.
Correspondence: M Arvind, MDS, Department of Oral Medicine, Professor and Academic Head, Department of Oral Medicine and
Radiology Saveetha Dental College and Hospital, Saveetha University Chennai, India. Email: arvindmuthukrishnan@yahoo.com
Received Apr 10, 2013; Revised May 23, 2013; Accepted Jun 28, 2013

ABSTRACT
Background:
Myofascial pain dysfunction syndrome is a painful condition arising from trigger points in a muscle that occur due
to the facial muscles going into spasm. There are numerous etiological factors responsible, and one among them is
Para functional habits.
Objective: To determine the most predominant Oral Parafunctional habit resulting in facial arthromyalgia.
Methods: Electronic search of scientific papers were carried out on EntrezPubMed and the Science direct databases
using specific keywords. PubMed search yielded 913 papers and Science direct search yielded 628; after excluding
the common search articles, 72 articles were found to be irrelevant based on the title and abstract. After going
through 61 relevant articles, 41 were excluded based on the inclusion and exclusion criteria. Twenty one articles were
finally selected that formed the base for this review.
Conclusion: Bruxism and Gum chewing are the predominant Oral parafunctional habits in the etiology of facial
arthromyalgia/ temporomandibular disorders.
Keywords:
“Temporomandibular disorders, Myofascial pain dysfunction syndrome, Facial arthromyalgia, Chronic myofascial
pain, Bruxism, Gum chewing, Teeth clenching, Lip biting, Chewing foreign objects, Jaw play, Parafunctional habits,
Parafunctional oral habits.”

Introduction and Background:
The term Temporomandibular disorder (TMD) is
defined as a collective term embracing a number of clinical
problems that involve the masticatory musculature, the
temporomandibular joint (TMJ) and associated structures,
or both. Research diagnostic criteria (RDC) have grouped
3 main conditions of TMD – (a). Myofacial pain dysfunction
syndrome (MPDS), (b). Disc disorders or internal
derangement, (c) Osteoarthritis. Factors predisposing to
TMDs are either psychological (anxiety, tension), dental
articulation (occlusion), Para functional habits (bruxism)
and external trauma. Of the 3 common TMD disorders,
incidence and prevalence of MPDS is the maximum. MPDS
is also referred as facial arthromyalgia, mandibular stress
syndrome.
Adverse oral habits or parafunctional habits are
defined as any oral non-functional activity or behavior
involving the masticatory system, are neither uncommon
nor are they always harmful. Its only when such activities
exceed an individual’s physiologic tolerance the continuous
chronic micro trauma or stress leads to changes in
masticatory system.
The term of Oral Para function was introduced
into dental literature in 1950 by Drum (1969) who defined it
as abnormal, fixed motor activities of the masticatory system
differing qualitatively and quantitatively from normal
functions of the system. According to Van der Meulen et
al. (2006) oral Para functions may be divided into 3 scales:
a BRUX scale for bruxism activities; a BITE scale for biting
activities (eg chewing gum, nails) and a SOFT scale for soft
tissue activities (e.g. Tongue, lips). Oral Para functions may
also be classified as non-occlusal or occlusal (involving
contact of opposing teeth) and including: biting of labial
and buccal mucosa, involuntary tongue pushing, biting

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pencils, pens and nails as well as chewing gums. Extensive
studies have suggested that oral parafunctional habits are
a major cause of temporomandibular disorders (TMD).There
are limited reviews on the existing literature providing
information on parafunctional habits and its role as an
etiological factor in facial arthromyalgia. Hence this
systematic review aims to analyze the existing literature on
the “evidence of parafunctional habits as prominent
etiology in facial arthromyalgia”
Aim:
To analyze the existing literature on the “evidence
of parafunctional habits as prominent etiology in facial
arthromyalgia”
Objective:
To determine the most predominant parafunctional
habit resulting in facial arthromyalgia.
Structured questions:
1. What is the prevalence frequency of parafunctional habits
in facial arthromyalgia / temporomandibular disorders?
2. Does parafunctional habit have an etiological role in facial
arthromyalgia/ temporomandibular disorders?
review includes cross sectional studies, observational and
descriptive studies, prospective and retrospective cohorts,
case control studies. There was no restriction imposed on
the date of the published articles and articles published in
English were only selected
Inclusion criteria:
Studies of association between parafunctional
habits and facial arthromyalgia. Diagnosis of
temporomandibular joint disorders were made based on the
criteria set by RDC/TMD type of classification
Exclusion criteria:
Etiological factors for temporomandibular joint
disorders other than parafunctional habits were excluded.
Case reports and case series, letters, reviews, animal study
and in-vitro studies and literature in other languages were
excluded.
Figure 1: Search Flow Chart showing flow chart and
final short listed articles

Review methodology:
Search strategy for identification of studies:
A systematic literature search was done to identify
articles describing parafunctional habits in facial
arthromyalgia with no time limit using the key words listed:
“Temporomandibular disorders, Temporomandibular joint
disorders, Temporomandibular joint dysfunction,
Temporomandibular joint dysfunction syndrome,
Myofascial pain dysfunction syndrome, Mandibular stress
syndrome, Facial arthromyalgia, Chronic myofascial pain,
Bruxism, Gum chewing, Teeth clenching, Nail biting, Cheek
biting, Lip biting, Chewing foreign objects, Jaw play,
Parafunctional habits, Parafunctional oral habits.” The
search strategy was in accordance with Cochrane
guidelines. The article search included only those listed in
English literature. The search results were short listed using
preset inclusion and exclusion criteria. The articles were
screened on the basis of title and abstract. Full text was
then procured for the relevant articles which fulfilled the
inclusion criteria.

Online resources:
EntrezPubMed
Science direct
Selection criteria:
The articles were short listed based on the
following inclusion and exclusion criteria. This systematic

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Evidence Levels of Parafunctional Habits as Prominent Etiology in Facial Arthromyalgia: A Systematic Review
Table 1 Depicts the Level of Evidence of Selected Studies
Results:
The included articles were investigated for
evidence levels of various parafunctional habits and
temporomandibular disorders. The following parafunctional
oral habits were found to be associated with
temporomandibular disorders or facial arthromyalgia:
Bruxism, Clenching of teeth, Gum chewing, Cheek
or lip biting, Biting foreign objects, Leaning on palm, Nail
biting, Jaw play, Chewing on one side, Mouth breathing,
Thumb sucking.
The search methodology used in this review
revealed 913 publications of which 21 articles were included
and the remaining 760 articles were excluded from the review.
The prevalence percentages of oral parafunctional
habits used in the included studies with facial arthromyalgia
is presented. The prevalence percentages of different oral
parafunctional habits like Bruxism,Clenching,Gum chewing,
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Cheek or Lip biting, Biting foreign objects, Leaning on palm,
Nail biting, Jaw play, Chewing on one side, Mouth breathing
presented in the table.
Different studies in our systematic review suggest
that oral parafunctional habits are related to facial
arthromyalgia. Of 21 studies, 11 studies of gum chewing is
reported, 5 studies have higher prevalence percentage
compared to other parafunctional habits, the highest being
recorded by Gavish et al as 92.3%.
The most common parafunctional habit among
different studies is bruxism, the prevalence almost recorded
in all studies, but with lesser intensity compared to gum
chewing. The highest recorded as 66% by Panek et al in
2010; Bruxism was significantly higher in girls with TMJ
dysfunction. Nail biting recorded in 13 studies, of which
55.2% were recorded as highest by Widmalm et al,
1995.Studies show that this parafunctional habit is more
common among adolescent girls. Teeth clenching was
recorded in 6 studies and Fumaiki et al 2006 & Hamed
Mortazavi et al 2010 recorded teeth clenching as the most
predominant habit to be 52.4% & 64.1% Biting foreign
objects were recorded in 6 studies of which 72% recorded
by Schiffman.
The other parafunctional habits which were
minimally recorded were, recorded by Winocur et al 2001,
which showed that continuous leaning of the head on the
arm was (55.1%). Gavish et al reported 40.2% of Jaw play
habit in adolescent girls. Winocur et al, 2001 showed
chewing on one side to be 41.2 % in adolescent girls.
S.Sari & H.Sonmez et al, 2002, showed Thumb
sucking(17.07%- mixed dentition& 14.63%- permanent
dentition) was significantly higher in girls with TMJ
dysfunction than those without TMJ dysfunction
(P<0.05).So parafunctional habits like Bruxism, Gum
chewing, Nail biting are commonly involved as etiological
factor in facial arthromyalgia, more common among
adolescent girls group.
In addition to these common oral Para functional
habits, other habits like chewing ice, taking games apart w/
teeth, opening bottles w/teeth, lying on one side, atypical
swallowing, mouth breathing have also been mentioned as
risk for development of Temporomandibular disorders.
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Table 2: Depicts The Data Extracted From Various Individual Articles Based On Above Parameter

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Evidence Levels of Parafunctional Habits as Prominent Etiology in Facial Arthromyalgia: A Systematic Review
Discussion:
A growing number of individuals have
musculoskeletal pain that affects their daily activities and
function and has a significant impact on their quality of life
causing a financial burden on our healthcare system.
Muscles in general, and Myofascial pain in particular, have
received less attention as a major source of pain and
dysfunction 3.
Precipitating factors of MPDS may cause the
facilitated release of acetylcholine at motor end plates,
sustained muscle fiber contractions, local ischemia with
release of vascular and neuro active substances, and
muscle pain4,5.
Emodi et al in his study gives data regarding the
prevalence of oral Para functions as 78.8% corresponding
closely with Konenen et al and Widmalm et al who reported
that 75% of their studies children described at least one
oral parafunction.
The three most claimed reasons for gum chewing
are causes pleasure, keeps the mouth busy when bored,
prevents bad mouth odor.
Schiffmann et al found that the most common
parafunction among female nursing student was gum
chewing (87%), biting foreign objects 72%, diurnal teeth
clenching (59%),nail biting(48%).
Mivakke et al, in a group of 3557 university
students found that chewing gum on one side of the mouth;
tooth clenching increased the risk of TMD. Panek et al, in
his study 95%of students revealed various parafunctional
habits such as Chewing gum (89%), Bruxism (45%), Biting
nails (41%), Biting mucosa of lip or cheek (29%). Winocur
et al, among 323 females aged 15-16 yrs. Intense habit of
chewing gum (62%) associated pain in the ear region.
In the study reported by R. Akhter et al 2011,
showed that female subjects who reported experiencing
Bruxism had 10.56 fold higher risks of TMJ sound,
respectively, than the risk for female subjects who had not
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experienced Bruxism. H.Panek et al 2010 reported that
subjects were seldom aware of Bruxism habit. He also
indicated that TMD’s were more prevalent in the presence
of Bruxism than any other oral parafunction.
In this study the prevalence of Bruxism (66%) was
significantly higher than in those with other oral Para
functions. Najlaa Alamoudi et al 2001 reported the habit of
lip and cheek biting to be 4.2% in correlation between oral
parafunction and temporomandibular disorders and
emotional status. A.Gavish et al, 2000 reported 48.4% of
biting foreign objects habit in adolescent girls. Jaw play is
the parafunctional habit with the greatest deleterious
potential, and that chewing gum contributes to joint sound
and pain. R.Miyake et al, 2004 showed that chewing on one
side was present in 21.8% of the population.
In contrast to our review, Gavish et al 2000 found
no relation between the presence of bruxism and muscle
sensitivity to palpation in adolescent girls. Meulen et al,
2006 in a group of patients with TMD found no clinically
relevant relationship between different types of oral
parafunction and TMD complaints.
Conclusion:
Facial arthromyalgia or Myofacial pain
dysfunction syndrome form the majority of
temporomandibular disorders. The exact etiology is unclear
and various hypotheses have been put forth.
Parafunctional habits are indicated as one of the most
favorable predisposing factors. Various such habits exist.
Previous research and our systematic review also confirm
this with bruxism as the most common cause followed by
gum chewing. This would help us to initiate the appropriate
treatment methodology to cause pain relief and cure in
patients with facial arthromyalgia.
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Source of Support : Nil, Conflict of Interest : Nil

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