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The Journal of Craniomandibular & Sleep Practice

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Evaluation of temporomandibular disorders,

quality of life, and oral habits among dentistry
students

Ahmet Karaman & Zeynep Sapan

To cite this article: Ahmet Karaman & Zeynep Sapan (2020): Evaluation of temporomandibular
disorders, quality of life, and oral habits among dentistry students, CRANIO®, DOI:
10.1080/08869634.2020.1857615

To link to this article: https://doi.org/10.1080/08869634.2020.1857615

Published online: 16 Dec 2020.

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 ®
CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2020.1857615

TMJ

Evaluation of temporomandibular disorders, quality of life, and oral habits

among dentistry students
Ahmet Karaman DDS, MSc and Zeynep Sapan DDS
Department of Orthodontics, Istanbul Aydın University, Istanbul, Turkey

ABSTRACT KEYWORDS
Objective: To evaluate temporomandibular disorders (TMD), quality of life, and oral habits in Temporomandibular
dentistry students. disorders; oral health impact
Methods: The study was performed with 480 students (287 females, 193 males). The Fonseca profile; Fonseca’s
questionnaire; quality of life
Questionnaire, Oral Health Impact Profile-14 (OHIP-14), and Oral Behaviors Checklist (OBC) were
used.
Results: The mean scores of the fifth-year students from Fonseca TMD, OHIP-14, and OBC were
statistically significantly higher than those of the students in other years of study. The mean
Fonseca score of female students was higher than those of the males. There was a statistically
significant difference regarding the OHIP-14 scores based on the Fonseca TMD scores.
A statistically significant difference regarding OBC was present based on the Fonseca TMD scores.
Conclusion: The prevalence of TMDs was higher among the senior dentistry students. Necessary
measures should be taken in the dentistry educational system to raise students’ quality of life,
improve joint disorders, and eliminate current oral habits.

Introduction determine clinical indices that will help classify patients

based on their levels of severity [7].
According to the American Dental Association (ADA),
These questionnaires may be used simply and pro­
the concept of temporomandibular disorder (TMD)
vide faster application, reducing the practical costs.
consists of medical problems characterized by pain in
Consequently, epidemiological studies and processes of
the temporomandibular joint, pain in the preauricular
monitoring treatment become more suitable and sim­
area or masticatory muscles, and joint noises during
pler [8].
limitation of mandibular function, deviation, or move­
The Fonseca Anamnestic Index was proposed as an
ments [1].
alternative to determine and classify TMDs in
TMD is related to many factors, such as missing
research populations, owing to its certain qualities,
teeth, occlusal disorders, trauma, psychological stress,
such as low costs, short duration of application, and
masticatory muscle fatigue, malfunction, and parafunc­
easy implementation. It was developed by da Fonseca
tional habits [2].
et al. and consists of 10 items that enable researchers
The pain arising from a TMD may affect people’s
to perform a multi-directional examination on the
daily activities, psychosocial functionality, and quality of
presence of joint, head, and back pain during masti­
life [3]. Early diagnosis of TMD is critical to prevent the
catory movements, parafunctional habits, limitations
potential problems that may arise later. Accordingly,
in movement, joint noises, malocclusion, and emo­
a TMD that is diagnosed late makes the treatment
tional stress factors [6,7].
process more complicated, causing many irremediable
The Oral Behaviors Checklist (OBC) indicates oral
issues later [4]. Certain studies have reported that the
activities, such as chewing, swallowing, and speaking.
social prevalence of TMD varied between 50% and 70%,
Oral parafunctional habits, on the other hand, reflect
based on racial differences, population size, diagnostic
other sorts of habits, such as gnashing teeth while awake
criteria, and relevant methods [5,6].
or sleeping, activities like chewing gum or biting the
As simpler assessment procedures that can be com­
lips, cheeks, nails, or a pen, or playing a wind instru­
monly used on patients with TMD and can standardize
ment, all of which create a load on the jaws [3,8].
samples are needed, questionnaires are being formed to
Parafunctional habits affect the masticatory system
examine the main clinical symptoms of TMD and
on various levels due to repetitive traumas. Considered

CONTACT Ahmet Karaman zeynepsapan@stu.aydin.edu.tr Department of Orthodontics, Istanbul Aydın University, Istanbul 34295, Turkey.
© 2020 Taylor & Francis Group, LLC
2 A. KARAMAN AND Z. SAPAN
as critical during the onset of TMD, these factors are in
a strong relationship with TMD pain. Additionally, the
presence of significant psychosocial stress causes the
onset of TMD, and it may be related to chronic TMD
pain [9,10].
The aim of this study is to evaluate temporomandib­
ular disorders, quality of life, and oral habits of dentistry
students.
Materials and methods
The study was conducted with 480 students studying at
the Faculty of Dentistry at Istanbul Aydin University,
and it was approved with the decision (2020/271) made
at meeting held by the Directorate of Ethical Committee
for Clinical Studies at the same university. The sample
size specified for the Power Analysis (alpha error prob­
ability = 0.05) performed using the G*Power 3.1 pro­
gram was found to consist of 159 participants, at
minimum.
The participants of this study (n = 480) consisted of
287 female and 193 male students. Of these, 135 were in
their first year, 100 in their second year, 90 in their
third year, 85 in their fourth year, and 70 in their
fifth year. The participants were informed about the
objectives and uses of the study. Their written and
verbal consents were obtained after the information
stage (Table 1).
The questionnaires administered to the dentistry stu­
dents included the following:
1. Fonseca Anamnestic Index
2. OHIP-14 questionnaire
3. Oral Behaviors Checklist (OBC), and study objec­
tive and method.
Fonseca anamnestic index
The participants were asked to select one option for
10 items without any time limitations. The options
were scored as follows: “yes = 10,” “no = 0,” and
“occasionally = 5.” Then, the participants were clas­
sified as TMD-free (0–15), mild TMD (20–40), mod­
erate TMD (45–60), or severe TMD (70–100) [7].
Table 1. Distribution of Fonseca classification.
Fonseca classification n %
Absence 224 46.7
Mild 221 46.0
Moderate 22 4.6
Severe 13 2.7
Total 480 100
Oral Behaviors Checklist (OBC)
The participants were asked to fill out the comprehen­
sive questionnaire assessing the frequency of oral paraf­
unctional behaviors. This questionnaire was the OBC,
consisting of 21 items used to determine the excessive
activities of the masticatory muscles [3].
Each item of the OBC was scored on a 5-point Likert-
type scale, as follows: “never = 0,” “<1 night/month = 1,”
“1–3 nights/month = 2,” “1–3 nights/week = 3,” and
“4–7 nights/week = 4.” The general score of one varied
between 0 and 84. The participants were asked to fill out
the OBC based on their experiences from a previous
month. The OBC was found to have a good validity and
reliability score for the behaviors displayed when
awake [11].
Oral Health Impact Profile (OHIP)
The OHIP is one of the instruments used to assess the
quality of life regarding oral or dental health. The
instrument was developed by Slade and Spencer [12].
Additionally, its validity and reliability were demon­
strated, and it is commonly used in dentistry.
The OHIP-14, which consists of 14 items (two items
for each of seven dimensions) and is shorter than the
original OHIP, was developed. The answers to the items
were assessed on a Likert-type scale, as follows: “no = 0,”
“rarely = 1,” “occasionally = 2,” “often = 3,” and
“always = 4.”
Fourteen questions regarding the functional activity,
disability, pain, psychological state, and physical and
social insufficiency dimensions were asked, and the
aim was to extensively measure oral functional disorders
or limitations [13]. The lowest score from OHIP-14 was
0, while the highest was 56. As the score reached the
maximum value, oral health, and quality of life
decreased [14].
One hundred eighty patients were randomly selected
and reassessed 4 weeks later. According to the Kappa
statistic, the reliability between the two assessment times
was 0.925.
Statistical analysis
The IBM Statistical Package for the Social Sciences 22
(IBM SPSS, Turkey) was used for the statistical analyses
to assess the study’s results. The parameters’ goodness of
fit to normal distribution was evaluated through the
Shapiro–Wilk test. In addition to descriptive statistical
methods (mean, standard deviation, frequency), the
Kruskal–Wallis test was utilized to perform inter-
group comparisons regarding the parameters that did
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3

not show normal distribution during the evaluation of Table 2. Comparison of Fonseca, OHIP-14, and OBC values
the quantitative data. Dunn’s test was used to determine among the classes.
the group causing the difference. Additionally, the Oral Behaviors
Fonseca OHIP-14 Checklist Total
Mann–Whitney U test was used during the inter-
(Min-Max)-(mean (Min-Max)-(mean (Min-Max)-(mean
group comparisons of the parameters that did not Group ± SD (median)) ± SD (median)) ± SD (median))
show normal distribution. For comparison of the quali­ First year (0–40)- (0–23)- (0–44)-
tative data, the chi-square test was used. To examine the (19.04 ± 11.87 (2.28 ± 4.12 (1)) (12.39 ± 11.15
(20)) (11))
relationships between the parameters that did not dis­ Second year (0–50)- (0–28)- (0–47)-
play normal distribution, Spearman’s Rho correlation (16.95 ± 13.82 (3.28 ± 5.23 (0)) (11.59 ± 11.35
(15)) (10))
analysis was used, and the significance was evaluated at Third year (0–60)- (0–27)- (0–49)-
p < 0.05. (19.61 ± 15.14 (5.66 ± 5.99 (4)) (14.51 ± 13.23
(15)) (11.5))
Fourth year (0–85)- (0–34)- (0–46)-
(24.24 ± 20.9 (6.54 ± 7.17 (4)) (14.32 ± 11.43
Results (20)) (13))
Fifth year (5–85)- (0–37)- (3–44)-
The study was performed with 480 students (36.14 ± 20.56 (12.39 ± 8.6 (19.7 ± 9.97
(35)) (10.5)) (18))
[female = 287 (59.8%), male = 193 (40.2%)] whose Total (0–85)- (0–37)- (0–49)-
ages ranged from 18 to 25 years. The mean age of the (22.13 ± 17.26 (5.35 ± 6.91 (2)) (14.03 ± 11.74
participants was 21.12 ± 1.85 years. This study was (20)) (12))
p 0.000* 0.000* 0.000*
examined under the following five groups: first-year p*: p-value from Kruskal–Wallis test; SD: standard deviation; OBC: Oral
students (n = 135, 28.1%, mean age: Behaviors Checklist; OHIP-14: Oral Health Impact Profile-14; (p < 0.05).
19 ± 0.52 years), second-year students (n = 100, 20.8%,
mean age: 20 ± 1.17 years), third-year students (n = 90,
Table 3. Comparison of Fonseca values between the classes.
18.8%, mean age: 21 ± 1.09 years), fourth-year students Fonseca classification
(n = 85, 17.7%, mean age: 22 ± 1.11 years), and fifth-year Absence Mild Moderate Severe
students (n = 70, 14.6%, mean age: 23 ± 1.25 years). Group n (%) n (%) n (%) n (%)
Of these students, 46.7% did not have TMD, while First year 60 (44.4) 75 (55.6) 0 (0) 0 (0)
46% had mild TMD, 4.6% had moderate TMD, and Second year 58 (58.0) 40 (40.0) 2 (2.0) 0 (0)
Third year 50 (55.6) 35 (38.9) 5 (5.6) 0 (0)
2.7% had severe TMD (Table 1). Fourth year 41 (48.2) 32 (37.6) 7 (8.2) 5 (5.9)
There was a statistically significant difference regard­ Fifth year 15 (21.4) 39 (55.7) 8 (11.4) 8 (11.4)
ing the mean scores from Fonseca TMD, OHIP-14, and Total 224 (46.7) 221 (46.0) 22 (4.6) 13 (2.7)
p 0.000*
OBC between the class years (p < 0.05). As a result of the Chi-square test; *p < 0.05.
pairwise comparisons performed to determine the dif­
ference, the mean scores of the fifth-year students from
Fonseca TMD, OHIP-14, and OBC were significantly
higher than those of the first, second, third, and fourth- between the male and female students (p > 0.05). Of
year students (p < 0.05) (Table 2). the female students, 42.2% had no TMD, while 49.8%
A statistically significant difference regarding the dis­ had mild, 5.6% had moderate, and 2.4% had severe
tribution of TMD scores was present between the class TMD. Regarding the male students, 53.4% had no
years (p < 0.05). As a result of the pairwise comparisons TMD, 40.4% had mild, 3.1% had moderate, and 3.1%
performed to determine the difference, the severity of had severe TMD (Table 5).
the fifth-year students’ Fonseca score was significantly A positive and statistically significant relationship
higher than those of the first (0%), second (0%), third was present between the Fonseca TMD scores and
(0%), and fourth-year (5.9%) students (p < 0.05). No mean OHIP-14 scores (p < 0.05). Moreover, a positive
statistically significant difference regarding the distribu­ and statistically significant relationship was found
tion of the Fonseca scores was present between the other between the total mean Fonseca TMD scores and OBC
years (p> 0.05) (Table 3). (p < 0.05). Another positive and statistically significant
The mean Fonseca score of the female students was relationship was present between the total mean scores
significantly higher than those of the male students from OHIP-14 and OBC (p < 0.05) (Table 6).
(p < 0.05). No significant difference regarding OHIP- There was a statistically significant difference regard­
14 or oral habit scores was present between the male and ing the OHIP-14 score between the Fonseca TMD
female students (p > 0.05) (Table 4). scores (p < 0.05). The mean OHIP-14 scores of those
No statistically significant difference regarding the whose Fonseca score was high were significantly higher
distribution of the Fonseca TMD scores was present (p < 0.05). A statistically significant difference regarding
4 A. KARAMAN AND Z. SAPAN

Table 4. Comparison of Fonseca, OHIP-14, and OBC values Discussion

between genders.
Gender This study assessed the impact of the oral habits of 480
Females Males dental students on their TMDs regarding their joints
(Min-Max)-(mean ± SD (Min-Max)-(mean ± SD and quality of life based on oral health. It is a fact that
(median)) (median)) p psychological factors have an impact on the etiology of
Fonseca (0–85)-(23.29 ± 17 (20)) (0–85)-(20.39 ± 17.54 0.014* TMDs. Accordingly, anxiety and stress-related symp­
(15))
OHIP-14 (0–34)-(5.83 ± 7.14 (3)) (0–37)-(4.64 ± 6.52 (2)) 0.055 toms that arose as TMD patients were severely exposed
OBC total (0–49)-(14.61 ± 12.4 (0–49)-(13.16 ± 10.66 0.341 to stressful living conditions were reported [15,16].
score (13)) (12))
Psychosocial factors, such as anxiety, stress, and depres­
p*: p-value from Mann–Whitney U test; SD: standard deviation; OBC: Oral
Behaviors Checklist; OHIP-14: Oral Health Impact Profile-14; (p < 0.05). sion have a role in the pathogenesis of TMDs [17]. High
stress levels affect the circulation within the local mus­
cles, causing continuous tooth-on-tooth interlocking.
Table 5. Distribution of Fonseca classification between genders. Additionally, they may change the ionic balance within
Gender the cell membranes. Consequently, lactic and pyruvic
Females Males acids can accumulate, and pain receptors may be stimu­
Fonseca classification n (%) n (%) p lated [18].
Absence 121 (42.2) 103 (53.4) 0.070 Bevilaqua-Grossi et al. [7] administered the Fonseca
Mild 143 (49.8) 78 (40.4)
Moderate 16 (5.6) 6 (3.1)
questionnaire to 109 Brazilian university students and
Severe 7 (2.4) 6 (3.1) found mild and moderate TMD among 78% of them.
p-value from Chi-square test. (p < 0.05). Nomura et al. [6] used Fonseca’s questionnaire in their
study conducted with 218 dentistry students. Among
their participants, 35.78% had mild TMD, while
Table 6. Comparison of Fonseca, OHIP-14, and OBC total mean 11.93% had moderate TMD, and 5.5% had severe
scores. TMD. Modi et al. [19] conducted a study with 310
Fonseca OHIP-14 students who were studying medicine and dentistry
OHIP-14 r 0.543 1.000 and aged between 18 and 25 years and found that
p 0.000*
OBC total score r 0.493 0.431
34.83% of the students had mild TMD, 8.38% had mod­
p 0.000* 0.000* erate TMD, and 1.96% had severe TMD. Ayalı and
p*: p-value from Spearman’s rho correlation analysis; OBC: Oral Behaviors Ramoglu [20] conducted a study on 409 dentistry stu­
Checklist; OHIP-14: Oral Health Impact Profile-14; (p < 0.05).
dents and found that 38.6% had mild TMD, 13.4% had
moderate TMD, and 4.4% had severe TMD. Habib et al.
[21] administered the Fonseca questionnaire to 400
people in their study and found that 36.1% of them
Table 7. Comparison of OHIP-14 and OBC scores between
Fonseca levels. had mild TMD, 9.6% had moderate TMD, and 1.1%
OHIP-14 OBC had severe TMD. Garcia et al. [22] used the Fonseca
Fonseca (Min-Max)-(mean ± SD (Min-Max)-(mean ± SD questionnaire on 200 university students in their study
classification (median)) (median)) and reported TMD in 122 students (61%). Among the
Absence (0–15)-(2.33 ± 3.5 (0)) (0–35)-(8.81 ± 8.41 (8)) 480 students in this study, 46.7% did not have TMD,
Mild (0–28)-(6.09 ± 6.13 (4)) (0–49)-(16.72 ± 11.44
(15)) while 46% had mild TMD, 4.6% had moderate TMD,
Moderate (4–37)-(18.32 ± 7.95 (18)) (12–49)-(30.45 ± 11.53 and 2.7% had severe TMD. Regarding the distribution
(29.5))
Severe (13–34)-(22.92 ± 7.57 (13–46)-(30.31 ± 11.63 of class years, the mean Fonseca TMD scores of the
(23)) (30)) fifth-year students were significantly higher than those
p 0.000* 0.000*
of the other class years.
p*: p-value from Kruskal–Wallis test; SD: standard deviation; OBC: Oral
Behaviors Checklist. OHIP-14: Oral Health Impact Profile-14; (p < 0.05).
Basafa and Shahabee [23] found, in their study con­
ducted with 425 students, that the prevalence of TMD
among women was more frequent than among men.
The study conducted by Ahuja et al. [24] with 450
students studying at faculties of dentistry indicated
the OBC was present between the Fonseca TMD scores that women suffer from joint disorders more than
(p < 0.05). The mean OBC scores of those whose men. Tozoglu et al. [25] conducted a study on 170
Fonseca TMD score was high were significantly higher patients and revealed that most of the patients who
(p < 0.05) (Table 7). visited a clinic due to TMD-related complaints were
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
female (77.1%). Minghelli et al. [18] found, in their
study conducted with Portuguese children aged between
5 and 19 years, that the prevalence of TMD was higher
among females. Karaman and Buyuk [26] found that
women’s mean Fonseca TMD scores were significantly
higher than those of men. Nomura et al. [6] and
Bonjardim et al. [27] reported that women had
a higher temporomandibular disorder prevalence than
men, which was in agreement with previous studies in
the relevant literature. The studies by Hongxing et al.
[28], Karibe et al. [29], and Kim et al. [30] found that
symptoms of masticatory disorders were more frequent
among women in comparison to men. Wieckiewicz
et al. [31] and Kim et al. [30] stated that this frequency
arose from biological differences, including hormonal
and psychosocial factors. Poveda et al. [4] and Nomura
et al. [6] noted that this higher TMD prevalence among
women could be related to women’s physiological char­
acteristics, hormonal variations, and structures in con­
nective tissues and muscles. A study by Landi et al. [32]
indicated that the serum value of 17-beta-estradiol
among TMD patients was higher than that of patients
who did not suffer from TMD. This study indicated that
the TMD prevalence among the women (57.8%) was
significantly higher than the prevalence among the men
(46.6%), which agreed with the findings of previous
studies in the relevant literature.
Oral health-related quality of life reflects the
impact of oral health or disorders on one’s daily
routines, health, or general quality of life [33].
TMDs may adversely affect the quality of life based
on oral health, which is a multidimensional process
containing the subjective assessment of perceived
physical, psychological, and social aspects of oral
health [34]. Most relevant studies have used the
Oral Health Impact Profile-14 (OHIP-14). OHIP-14
helps reveal the impacts of malocclusion and impacts
that are related to other oral disorders [35]. Steele
et al. [36] found, in their study conducted with 7065
people aged over 16 years, that the OHIP-14 score
was higher in women in comparison to men. Ingle
et al. [37] also reported that the OHIP-14 score was
higher among women. The study conducted by de
Oliveira and Sheiham [38], using the OHIP-14,
revealed a significant relationship between increase
in age and OHIP-14. Acharya and Sangam [39]
found a difference regarding oral health-related qual­
ity of life between students of dentistry at different
years of study. The total OHIP-14 score differed
from the first (mean score: 13.4) to the fourth years
(mean score: 10.7). However, no significant differ­
ence regarding the total OHIP-14 score was found
between different stages of academic education.
5
Gonzales-Sullcahuamán et al. [40] found no statisti­
cally significant relationship between OHIP-14
and year of academic education. Additionally, no
difference was found between the sexes. Karaman
and Buyuk [26] found that women’s mean OHIP-14
scores were significantly higher than those of men.
This study showed that the OHIP-14 scores of the
fifth-year students were significantly higher than
those of the students in other years.
Moreover, the mean OHIP-14 scores of those whose
TMD score was high were found to be significantly
higher. However, no significant relationship was found
between the sexes and mean OHIP-14 scores.
The studies conducted by Chen et al. [34],
Michelotti et al. [41], Rossetti et al. [42], and
Perrotta et al. [43] to explain the relationships
between parafunctional habits and TMD reported
that there was a relationship between these two.
The study by Van der Meulen et al. [44] found no
significant difference regarding the OBC total score
values and age factor between male and female par­
ticipants. Karaman and Buyuk [26] observed no sig­
nificant correlation between age values and mean
OBC scores.
Antoun et al. [11] found no significant difference
regarding the total OBC score between hyperdiver­
gent and normodivergent groups. Chow and Cioffi
[45] reported that women’s OBC scores were higher
than those of male participants. Winocur et al. [46]
and Michelotti et al. [41] found that oral habits were
directly related to sex and displayed by women more
than men. Karaman and Buyuk [26] stated that the
mean OBC scores were higher among women than
men. Paduano et al. [47] found no relationship
between age or sex and oral parafunctions. The
mean oral habit scores of the fifth-year students
were significantly higher than those of the
first, second, third, and fourth-year students in this
study. However, no statistically significant difference
regarding the mean oral habit scores was present
between the male and female participants.
Moreover, a positive and statistically significant rela­
tionship was present between the total mean scores
from the Fonseca TMD and OBC.
Conclusion
This study found that the TMD prevalence was higher
among the senior students of the Faculty of Dentistry.
Additionally, the TMD prevalence was higher among
the female students in comparison to the male students.
TMDs, quality of life, and oral habits were found to be
related to each other. Necessary measures should be
6 A. KARAMAN AND Z. SAPAN
taken in the dentistry educational system to raise stu­
dents’ quality of life, improve joint disorders, and elim­
inate current oral habits.
Announcement
The authors waited for students to fill in questionnaires dur­
ing internships, exam times and preclinics.The authors wish
to thank the student participants for good cooperation.
Disclosure statement
The authors have stated explicitly that there are no conflicts of
interest in connection with this article.
Funding
This study did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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