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The Journal of Craniomandibular & Sleep Practice

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Evaluation of temporomandibular disorder

symptoms and oral health-related quality of life
in adolescent orthodontic patients with different
dental malocclusions

Ahmet Karaman DDS, MSc & S. Kutalmış Buyuk

To cite this article: Ahmet Karaman DDS, MSc & S. Kutalmış Buyuk (2019): Evaluation
of temporomandibular disorder symptoms and oral health-related quality of life in
adolescent orthodontic patients with different dental malocclusions, CRANIO®, DOI:
10.1080/08869634.2019.1694756

To link to this article: https://doi.org/10.1080/08869634.2019.1694756

Published online: 25 Nov 2019.

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CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2019.1694756

ORTHODONTICS

Evaluation of temporomandibular disorder symptoms and oral health-related

quality of life in adolescent orthodontic patients with different dental
malocclusions
Ahmet Karaman DDS, MSca and S. Kutalmış Buyuk DDS, PhDb
a
Department of Orthodontics, Faculty of Dentistry, Istanbul Aydın University, Istanbul, Turkey; bDepartment of Orthodontics, Faculty of
Dentistry, Ordu University, Ordu, Turkey

ABSTRACT KEYWORDS
Objective: To estimate the prevalence of temporomandibular disorders in adolescent orthodon- Temporomandibular
tic patients with different dental malocclusions and to assess the relationship between oral disorders; oral health impact
health-related quality of life. profile; Fonseca’s
questionnaire; quality of life
Methods: This study was carried out on 648 randomly selected individuals 14–19 years of age.
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), Fonseca Questionnaire, and Oral
Health Impact Profile-14 (OHIP-14) forms were used.
Results: TheGCPS,TMDPain,Fonseca,OHIP-14, PHQ-9, GAD-7,OBC,andPHQ-15 mean scores of female
participants were statistically significantly higher than males (p < 0.05).There was a significant
difference among the malocclusion groups in terms of their mean scores in GCPS, Fonseca, and
OHIP-14 (p < 0.05).The age values and JFLS, TMD Pain, Fonseca, OHIP-14, PHQ-9, GAD-7, and PHQ-
15 were statistically significant correlations in the positive direction.
Conclusion: The DC/TMD form allows both a physical assessment of Axis I and II that examines
psychosocial status and pain-related disorders and a more comprehensive assessment. The mean
OHIP-14 and Fonseca questionnaire scores of Class III groups were found to be significantly higher.

Introduction accurate results, Axis II, which allows evaluation of

psychosocial status and pain-related disorders is
Temporomandibular joint disorders constitute a problem
based on a biopsychosocial pain model. The
that consists of a set of clinical symptoms involving the
Diagnostic Criteria for Temporomandibular
temporomandibular joint, teeth, nerves, chewing mus-
Disorders (DC/TMD) contains significant additions,
cles, connective tissue, or a combination of these. While
omissions, and changes as a result of research on the
its prevalence is higher among women and individuals
original RDC/TMD. As a result of contributions of
aged 20–45 years, it may affect individuals of all ages.
research findings, professional clinic, and research
Several studies have shown that about 60-70% of the
groups and experts, the changes emerged with the
general population has a sign or symptom of temporo-
principle of new, evidence-based Diagnostic Criteria
mandibular disorder (TMD) at one point in their lives,
for temporomandibular Disorders (DC/TMD) [2].
although only 5% need treatment for TMDs [1].
The questionnaire proposed by Da Fonseca et al. [4] is
Temporomandibular disorders are musculoskeletal
used to categorize the severity of temporomandibular dis-
system diseases that are the second most frequently
orders in a sample. This questionnaire is highly effective in
encountered as a result of pain and injury. Pain-
obtaining epidemiological data. Fonseca’s questionnaire
related temporomandibular disorders may affect the
provides the opportunity of a multi-dimensional assess-
individual’s daily activities, psychosocial functionality,
ment by allowing observation of the presence of tempor-
and quality of life [2]. The Research Diagnostic Criteria
omandibular joint, head, and back pains in the presence of
for Temporomandibular Disorders (RDC/TMD) are
chewing, parafunctional habits, movement restrictions,
used as the most prevalent diagnosis protocol in
joint sounds, malocclusion, and emotional stress [5].
researching temporomandibular disorders [3]. While
Due to pain caused by restriction of the regular func-
the RDC/TMD allows physical assessment with Axis
tions of the chewing system and originating in the
I that covers reliable diagnostic criteria that provide

CONTACT Ahmet Karaman ahmeet.ka@hotmail.com Department of Orthodontics, Faculty of Dentistry, Istanbul Aydın University, Istanbul 34295,
Turkey
© 2019 Taylor & Francis Group, LLC
2 A. KARAMAN AND S. K. BUYUK
stomatognathic muscles, temporomandibular joints, or
the temple region, temporomandibular disorders may
affect daily life negatively because of their significant
influence on quality of life [6]. Temporomandibular
joint disorders may negatively affect quality of life, and
especially quality of life that is related to oral health,
which is a multi-dimensional concept that covers the
subjective assessment of the perceived physical, psycho-
logical, and social aspects of oral health [7].
The Oral Health Impact Profile (OHIP) was devel-
oped with the purpose of making a comprehensive mea-
surement of a person’s existing dysfunctions, disorders,
or limitations based on the oral conditions stated by the
individual. OHIP is the most prevalently used question-
naire on quality of life associated with oral health.
A short version of OHIP, OHIP-14, was developed
with the same validity and reliability as OHIP, with 14
items, including 2 items for each of the 7 dimensions in
it (functional limitation, physical pain, psychological
discomfort, physical disability, psychological disability,
social disability, and handicap) [8].
The purpose of this study is to estimate the pre-
valence of temporomandibular disorders in adolescent
orthodontic patients with different malocclusions and
investigate the relationship of it with quality of life
related to oral health.
Materials and methods
Six hundred-forty-eight randomly selected indivi-
duals, 14–19 years old, who visited the Orthodontics
Department at the Faculty of Dentistry at Ordu
University for treatment were included in the study.
This study received approval from the clinical
research ethics board of Ordu University with the meet-
ing date of 18/01/2018 and meeting number of 2018/03.
In the power analysis for this study that was carried
out with the G*power 3.1 software (alpha error prob-
ability = 0.05), the sufficient sample size was calculated
as 95. The patients and their parents were informed
about the study, and required approval was obtained.
Information was provided about the contents of the
questionnaire forms distributed to the patients:
● Diagnostic Criteria for Temporomandibular
Disorders (DC/TMD): Assessment Instruments:
Axis I: TMD Questionnaire, Diagnostic Criteria for
Temporomandibular Disorders Symptom
Questionnaire, Demographic Information;
Axis II: Graded Chronic Pain Scale Version 2.0
(GCPS), Jaw Functional Limitation Scale-8 (JFLS-8),
Patient Health Questionnaire-9 (PHQ-9), GAD-7,
Patient Health Questionnaire-15 (PHQ-15), Oral
Behaviors Checklist (OBC);
● Fonseca Anamnestic Questionnaire (FAQ),
● Oral Health Impact Profile-14 (OHIP-14),
and the objective and method of the study.
The inclusion criteria were the following:
● Age 14–19 years,
● Having no disorders that would prevent commu-
nication with the patient,
● Having no history of any orthodontic treatment
or orthognathic surgery,
● Having no mental retardation,
● Having the literacy skills sufficient to respond to
the questionnaires.
The exclusion criteria were the following:
● Class II and Class III subdivision malocclusions.
● No loss of any permanent teeth (except for 3rd
molars).
The individuals who were included in the study were
divided into three groups. The study was carried out on
a total of 648 individuals, including 257 with Class
I (179 females, 78 males; mean age: 16.93 ± 1.39 years),
269 with Class II (177 females, 92 males; mean age: 16.98
± 1.34 years), and 122 with Class III (73 females, 49 males;
mean age: 17.28 ± 1.21 years) malocclusions (Table 1).
Diagnostic criteria for temporomandibular
disorders: Assessment instruments
The Turkish version of the Diagnostic Criteria for
Temporomandibular Disorders: Assessment Instruments
(DC/TMD) was utilized [9].
The DC/TMD consists of two parts: Axis I and Axis II.
For the present study, while the TMD Pain Questionnaire
and DC/TMD Symptom Questionnaire were taken from
Axis I as they are, the Demographic Information part was
revised to obtain data on the participants’ sex, age, and
monthly income levels. From Axis II, the Graded Chronic
Pain Scale Version 2.0 (GCPS), Jaw Functional Limitation
Scale-8 (JFLS-8), Patient Health Questionnaire-9 (PHQ-9),
General Anxiety Disorder-7 (GAD-7), Patient Health
Questionnaire-15 (PHQ-15), and Oral Behaviors
Checklist (OBC) were utilized.
● PHQ-9 (Depression Scale): For 9 questions, the
total PHQ-9 score varies from 0 to 27.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3

Table 1. Comparison of demographic characteristics between groups.

Class I Malocclusion Class II Malocclusion Class III Malocclusion
n = 257 n = 269 n = 122 p
Age Mean ± SD 16.93 ± 1.39 Mean ± SD 16.98 ± 1.34 Mean ± SD 17.28 ± 1.21 0.053*
Gender Male 78 30.35% 92 34.20% 49 40.16% 0.166+
Female 179 69.65% 177 65.80% 73 59.84%
Degree of Study Middle School 3 9 3.50% 8 2.97% 1 0.82% 0.055+
HighSchool Preparation 39 15.18% 24 8.92% 6 4.92%
High School 1 47 18.29% 56 20.82% 19 15.57%
High School 2 62 24.12% 63 23.42% 36 29.51%
High School 3 47 18.29% 73 27.14% 25 20.49%
Graduated 53 20.62% 45 16.73% 35 28.69%
Income (Monthly) < 1000 TL 42 16.34% 46 17.10% 19 15.57% 0.506+
1001-1999 TL 76 29.57% 86 31.97% 43 35.25%
2000-2999 TL 59 22.96% 59 21.93% 27 22.13%
3000-3999 Tl 38 14.79% 43 15.99% 21 17.21%
4000-4999 TL 16 6.23% 21 7.81% 8 6.56%
> 5000 TL 26 10.12% 14 5.20% 4 3.28%
p*: p-value from One-Way Analysis of Variance (ANOVA);p+: p-value from Chi-Square Test; SD: Standard deviation; TL: Turkish Lira; n: number of subjects.

● GAD-7 (Anxiety Scale): For 7 questions, the total Statistical analysis

GAD-7 score varies from 0 to 21.
● PHQ-15 (Physical Symptom Scale): For 15 ques-
tions, the total PHQ-15 score varies from 0
to30 [10].
The participants were asked to fill out the Oral
Behaviors Checklist (OBC), which is a 21-item ques-
tionnaire that assesses the frequency of respondents’
parafunctional behaviors. Each response to OBC is
assessed with a 5-point Likert-type scale. The total
score of a person may vary from 0 to 84 [11].
Fonseca anamnestic questionnaire (FAQ)
For the current study, the Turkish version of the
Fonseca Anamnestic Questionnaire was utilized and
implemented [12]. The participants were asked to
respond to 10 questions without any time limitation.
They were also asked to pick only one option per ques-
tion, with 10 for “yes,” 5 for “sometimes,” and 0 for
“no.”After adding the scores together, respondents were
categorized as, No TMD (0–15), Mild TMD (20–40),
Moderate TMD (45–65), or Severe TMD (70–100) [13].
Oral health impact profile-14 (OHIP-14)
Responses to OHIP-14, which is a short version of
OHIP, are scored with a 5-point Likert-type scale,
with 0 for “no,” 1 for “rarely,” 2 for “sometimes,” 3
for “often,” and 4 for “always.” In OHIP-15, the total
score varies from 0 as the minimum to 56 as the
maximum. It is interpreted that, as the total score of
OHIP-14 increases, quality of life related to oral health
decreases, and the severity of the problem increases [8].
In the current study, the statistical analyses were car-
ried out by using the NCSS (Number Cruncher
Statistical System, 2007, Kaysville, UT, USA) statistical
package software. While analyzing the data, in addition
to descriptive statistics (mean, standard deviation),
one-way analysis of variance (ANOVA) was used for
intergroup comparisons of the normally distributed
variables, t-test was used to make pairwise compari-
sons, Kruskal-Wallis test was used for comparison
among the variables that were not normally distribu-
ted, Dunn’s Multiple Comparisons test was utilized for
sub-group comparisons, Mann–Whitney U test was
employed for pairwise comparisons, Chi-Squared test
was carried out for comparisons of qualitative data, and
Pearson’s correlation test was conducted to determine
the relationships among variables.
P < 0.05 was accepted to be statistically significant.
Results
Among the Class I, Class II, and Class III malocclusion
groups, no significant difference was observed in terms of
age, sex, class, and monthly income distribution (p > 0.05)
(Table 1).
Nor was there any significant difference among the
Class I, Class II, and Class III malocclusion groups in
terms of pain, open jaw locking, and closed jaw locking
(p > 0.05) (Table 2).
A statistically significant difference was found
among the malocclusion groups in terms of the dis-
tributions of temporomandibular joint (TMJ) sounds
(p < 0.05). Headache and TMJ sounds were found to be
higher in the Class III malocclusion group than those
4 A. KARAMAN AND S. K. BUYUK

Table 2. Comparison of TMD Symptom Questionnaire values among the groups.

TMD Symptom Questionnaire Class I Malocclusion n = 257 Class II Malocclusion n = 269 Class III Malocclusion n = 122 p+
Pain
TMD No 207 80.54% 218 81.04% 87 71.31% 0.067
Question 1
Yes 50 19.46% 51 18.96% 35 28.69%
Mean duration (in months) Mean duration Mean duration
(in months) (in months)
TMD Mean ± SD Mean ± SD Mean ± SD 0.909*
Question 2 15.88 ± 16.63 16.41 ± 15.07 17.51 ± 20.03
Class I Class II Class III p+
Malocclusion Malocclusion Malocclusion
n = 257 n = 269 n =122
TMD No pain 15 27.78% 18 30.51% 8 21.62% 0.645
Question 3
Pain 37 68.52% 39 66.10% 29 78.38%
comes and goes
Pain is always present 2 3.70% 2 3.39% 0 0.00%
TMD Question 4.A No 20 50.00% 23 54.76% 14 48.28% 0.846
Yes 20 50.00% 19 45.24% 15 51.72%
TMD Question 4.B No 30 75.00% 25 59.52% 19 65.52% 0.328
Yes 10 25.00% 17 40.48% 10 34.48%
TMD Question 4.C No 19 47.50% 18 42.86% 17 58.62% 0.419
Yes 21 52.50% 24 57.14% 12 41.38%
TMD Question 4.D No 35 87.50% 32 76.19% 21 72.41% 0.256
Yes 5 12.50% 10 23.81% 8 27.59%
Headache
TMD Question 5 No 204 79.38% 205 76.21% 80 65.57% 0.013
Yes 53 20.62% 64 23.79% 42 34.43%
Mean duration Mean duration Mean duration
(in months) (in months) (in months)
TMD Mean ± SD Mean ± SD Mean ± SD 0.749*
Question 6 18.36 ±19.6 16.57 ±15.92 15.52 ± 20.83
Class I Class II Class III p+
Malocclusion Malocclusion Malocclusion
n = 257 n = 269 n =122
TMD Question 7.A No 41 75.93% 46 70.77% 30 71.43% 0.803
Yes 13 24.07% 19 29.23% 12 28.57%
TMD Question 7.B No 43 79.63% 60 92.31% 32 76.19% 0.055
Yes 11 20.37% 5 7.69% 10 23.81%
TMD Question 7.C No 36 66.67% 39 60.00% 27 64.29% 0.746
Yes 18 33.33% 26 40.00% 15 35.71%
TMD Question 7.D No 47 87.04% 57 87.69% 33 78.57% 0.384
Yes 7 12.96% 8 12.31% 9 21.43%
Jaw Joint Noises
TMD No 209 81.32% 200 74.35% 78 63.93% 0.001
Question 8 Yes 48 18.68% 69 25.65% 44 36.07%
Region Right 19 43.18% 25 37.31% 14 32.56% 0.867
Left 11 25.00% 21 31.34% 14 32.56%
Bilateral 14 31.82% 21 31.34% 15 34.88%
Closed Locking
of Jaw
TMD No 246 95.72% 255 94.80% 114 93.44% 0.638
Question 9 Yes 11 4.28% 14 5.20% 8 6.56%
TMD No 6 54.55% 10 66.67% 7 77.78% 0.551
Question 10 Yes 5 45.45% 5 33.33% 2 22.22%
TMD No 8 72.73% 12 85.71% 8 88.89% 0.584
Question 11 Yes 3 27.27% 2 14.29% 1 11.11%
TMD No 4 100.00% 2 50.00% 2 66.67% 0.273
Question12 Yes 0 0.00% 2 50.00% 1 33.33%
Open Locking of Jaw
TMD No 256 99.61% 268 99.63% 119 97.54% 0.061
Question 13 Yes 1 0.39% 1 0.37% 3 2.46%
TMD No 3 75.00% 2 100.00% 1 25.00% 0.153
Question14 Yes 1 25.00% 0 0.00% 3 75.00%
p*:p-value from One-Way Analysis of Variance (ANOVA); p+: p-value from + Chi-Square Test. p‡: p-value from ‡Kruskal Wallis Test; SD: Standard deviation;
Temporomandibular Disorders (TMD); Pain (TMD Question 1-2-3-4.A-4.B-4.C-4.D); Headache (TMD Question 5–67.A-7.B-7.C-7.D); Jaw Joint Noises (TMD
Question 8); Closed Locking of Jaw (TMD Question 9–10,11-12); Open Locking of Jaw (TMD Question 13–14).

in the Class I and Class II groups. There was no However, it was found in regional distribution that,
statistically significant difference among the groups in while the highest joint sound was on the right side in
terms of their regions of TMJ sounds (p > 0.05). the Class I and Class II malocclusion groups, it was
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5

mostly distributed bilaterally in the Class III malocclu- Table 4. Comparison of GCPS, Fonseca, OHIP-14 values
sion group (Table 2). between groups according to Dunn’s Multiple Comparison test.
No statistically significant difference was found among Dunn’s Multiple Comparison Test GCPS Fonseca OHIP-14
Class I Malocclusion/Class II Malocclusion 0.029 0.827 0.504
the malocclusion groups in terms of their mean scores in Class I Malocclusion/Class III Malocclusion 0.290 0.007 0.045
JFLS, TMD Pain Scale, PHQ-9, GAD-7, PHQ-15, OBC Class II Malocclusion/Class III Malocclusion 0.004 0.008 0.018
total and OBC activities during sleep and OBC activities Graded Chronic Pain Scale Version (GCPS); Fonseca Questionnaire; Oral
while awake (p > 0.05) (Table 3). Health Impact Profile-14 (OHIP-14).

There was a significant difference among the malocclu-

sion groups in terms of their mean scores in the Graded Table 5. Investigation of the Pearson correlation test between
Chronic Pain Scale (p < 0.05) (Table 3). The GCPS scores the ages and the values of GCPS, JFLS, TMD pain screener,
of the Class II group were significantly lower than those of Fonseca, OHIP-14, PHQ-9, GAD-7, OBC, and PHQ-15.
the Class I and Class III groups (p > 0.05) (Table 4). Age
There was a significant difference among the Class I, GCPS r 0.069
p 0.081
Class II, and Class III malocclusion groups in terms of their JFLS r 0.097
mean scores in the FAQ (p < 0.05) (Table 3). The mean p 0.013
TMD Pain Screener r 0.100
FAQ score of the Class III group was significantly higher p 0.011
than those of the Class I and Class II groups (p < 0.05) Fonseca r 0.153
p 0.0001
(Table 4). OHIP-14 r 0.108
There was a significant difference among the mean p 0.006
OHIP-14 scores of the Class I, Class II, and Class III PHQ-9 r 0.198
p 0.0001
malocclusion groups (p < 0.05) (Table 3). The mean GAD-7 r 0.203
OHIP-14 score of the Class III group was significantly p 0.0001
OBC sleep activities r 0.024
higher than those of the Class I and Class II groups p 0.54
(p < 0.05) (Table 4). OBC awake activities r 0.006
p 0.887
No significant correlation was observed between age OBC total score r 0.009
values and the variables of GCPS, OBC activities dur- p 0.810
PHQ −15 r 0.196
ing sleep, OBC activities while awake and OBC total p 0.0001
scores (p > 0.05). Statistically significant relationships Correlation coefficient (r); Statistically significant (p < 0.05); Temporomandibular
were found between age values and the variables of Disorders (TMD); Graded Chronic Pain Scale Version (GCPS); Jaw Functional
JFLS, TMD Pain, Fonseca, OHIP-14, PHQ-9, GAD-7, Limitation Scale (JFLS); Patient Health Questionnaire-9 (PHQ-9); Generalized
Anxiety Disorder-7 (GAD-7); Patient Health Questionnaire-15 (PHQ-15); Oral
and PHQ-15 (p < 0.05) (Table 5). Behaviors Checklist (OBC); Fonseca Questionnaire; Oral Health Impact Profile-
The GCPS, TMD Pain, Fonseca, OHIP-14, PHQ-9, 14 (OHIP-14).
GAD-7, OBC activities during sleep, OBC activities
while awake, OBC total, and PHQ-15 mean scores of statistically significant difference between the male and
the female participants were significantly higher than female participants in terms of their JFLS scores
those of the male participants (p < 0.05). There was no (Table 6).

Table 3. Comparison of GCPS, JFLS, TMD pain screener, Fonseca, OHIP-14, PHQ-9, GAD-7, PHQ-15, and OBC values among
the groups.
Class I Malocclusion Class II Malocclusion Class III Malocclusion p‡
GCPS Mean ± SD 4.61 ± 14.54 Mean ± SD 1.88 ± 6.67 Mean ± SD 5.05 ± 11.66 0.009
JFLS 1.86 ± 3.97 1.88 ± 4.04 2.92 ± 4.86 0.151
TMD Pain Screener 0.95 ± 1.3 0.96 ± 1.27 1.35 ± 1.73 0.236
Fonseca 21.48 ± 16.13 21.43 ± 15.07 27.38 ± 19.43 0.013
OHIP-14 8 ± 7.96 7.96 ± 8.4 9.57 ± 8.92 0.048
PHQ-9 5.13 ± 5.5 4.17 ± 4.68 5.57 ± 6.06 0.057
GAD-7 3.25 ± 4.17 2.73 ± 4.12 3.56 ± 4.76 0.125
OBC sleep activities 0.68 ± 0.98 0.79 ± 1.05 0.79 ± 1 0.268
OBC awake activities 14.13 ± 9.82 13.8 ± 9.65 13.97 ± 11.33 0.850
OBC total score 15.49 ± 10.82 15.38 ± 10.7 15.55 ± 12.55 0.948
PHQ-15 4.32 ± 4.35 3.77 ± 3.97 4.07 ± 4 0.448
p‡: p-value from ‡Kruskal Wallis Test; SD: Standard deviation; TMD: Temporomandibular Disorders; GCPS: Graded Chronic Pain Scale Version; JFLS:
Jaw Functional Limitation Scale; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7; PHQ-15: Patient Health
Questionnaire-15; OBC: Oral Behaviors Checklist; Fonseca Questionnaire; OHIP-14: Oral Health Impact Profile-14.
6 A. KARAMAN AND S. K. BUYUK

Table 6. Comparison of GCPS, JFLS, TMD pain screener, headaches in the Class III malocclusion group was found
Fonseca, OHIP-14, PHQ-9, GAD-7, OBC, and PHQ-15 values to be higher than those in the Class I and Class II groups.
between genders. Lei et al. [14] reported significantly higher levels of TMJ
Males Females
(n = 219) (n = 429) p* sounds among women. In this study, the incidence of TMJ
Mean ± SD Mean ± SD sounds was found to be higher among Class III individuals.
GCPS 1.79 ± 5.72 4.46 ± 13.29 0.019 Additionally, there was a significant difference among the
JFLS 1.62 ± 3.28 2.3 ± 4.57 0.205
TMD Pain Screener 0.86 ± 1.25 1.11 ± 1.45 0.044 groups. In addition to this, while TMJ sounds were mostly
Fonseca 18.24 ± 14.38 24.78 ± 17.11 0.0001 on the right side in Class I and Class II malocclusions, they
OHIP-14 6.66 ± 6.75 9.11 ± 8.95 0.002
PHQ-9 3.62 ± 4.53 5.43 ± 5.58 0.0001
were distributed mostly bilaterally in Class III individuals.
GAD-7 2.35 ± 3.65 3.47 ± 4.51 0.0001 Nomura et al. [16] and Kim et al. [17] reported that
OBC sleep activities 0.59 ± 0.86 0.83 ± 1.08 0.019 TMJ disorder prevalence is higher among women.
OBC awake activities 11.13 ± 9.28 15.41 ± 10.11 0.0001
OBC total score 12.32 ± 10.18 17.06 ± 11.21 0.0001 Minghelli et al. [13] studied a Portuguese population
PHQ-15 2.93 ± 3.34 4.62 ± 4.38 0.0001 with the age group of 5–19 years and showed that the
p*: p-value from Mann–Whitney-U test; SD: Standard deviation; females had higher incidence rates of temporomandibular
Temporomandibular Disorders (TMD), Graded Chronic Pain Scale
Version (GCPS), Jaw Functional Limitation Scale (JFLS), Patient Health disorders than the males, and there was a significant rela-
Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), tionship between sex and temporomandibular disorder.
Patient Health Questionnaire-15 (PHQ- 15), Oral Behaviors Checklist
(OBC), Fonseca Questionnaire, Oral Health Impact Profile-14 (OHIP-14). Kim et al. [17] stated that the reason for this prevalence
is based on biological differences, possibly including hor-
monal and psychosocial factors. Poveda et al. [1] and
There was no significant relationship between the Nomura et al. [16] suggested that the high TMD preva-
male participants’ malocclusion classifications and their lence in women may be associated with their physiologi-
Fonseca TMD group distributions (p > 0.05), while there cal characteristics, especially hormonal variations and the
was a significant relationship between the female parti- structures in the connective tissue and muscles. They
cipants’ malocclusion classifications and their Fonseca reported that these tissues relaxed more due to the level
TMD group distributions (p < 0.05) (Table 7). of estrogen, and as a result of this, they cannot support
functional pressure and, in turn, lead to temporomandib-
ular disorders. LeResche et al. [18] reported that tempor-
Discussion
omandibular disorders and the severity of pain changed
The authors conducted a comprehensive questionnaire during the menstruation cycle. In the present study, the
study with 648 adolescent patients (257 Class I, 269 authors found the mean TMD Pain score of the women
Class II, and 122 Class III malocclusion). Lei et al. [14] to be significantly higher than that of the men.
reported high rates of symptoms of temporomandibular Lei et al. [14] found the frequency of temporoman-
disorder among Chinese adolescent individuals in their dibular disorder, depression, anxiety, and stress symp-
study. They stated that the most frequently reported toms among individuals at the ages of 16–18 to be
temporomandibular disorder symptom was orofacial significantly higher than those at the ages of 12–15.
pain, which was followed by TMJ sounds and headaches. In this study, a significant relationship was found
Severe temporomandibular disorders associated between the age values and the TMD Pain values.
with pain in the head and face are seen in 1-2% of Studies have determined that facial pain and TMD
children, 5% of adolescents, and 5-12% of adults [15]. prevalence in malocclusion and dentofacial deformities
In this study, although the incidence of orofacial pain were higher than those in patients with normal occlu-
was higher among Class III individuals, the difference sion [19]. Temporomandibular disorders are associated
among the Class I, Class II, and Class III malocclusion with types of malocclusion, such as unilateral crossbite,
groups was not statistically significant. The incidence of anterior open bite, and excessive overjet. Moreover,

Table 7. Gender distribution of Class I, Class II, and Class III malocclusions according to severity of TMD.
0-15 Fonseca 20-40 Fonseca 45-65 Fonseca 70-100 Fonseca
Absence of TMD Mild TMD Moderate TMD Severe TMD p*
Males Class I 45 36.59% 29 36.25% 4 26.67% 0 0.00% 0.615
Class II 53 43.09% 32 40.00% 7 46.67% 0 0.00%
Class III 25 20.33% 19 23.75% 4 26.67% 1 100.00%
Females Class I 74 45.96% 79 39.11% 24 41.38% 2 25.00% 0.026
Class II 69 42.86% 88 43.56% 17 29.31% 3 37.50%
Class III 18 11.18% 35 17.33% 17 29.31% 3 37.50%
*p-value from Chi-Square Test. TMD: Temporomandibular disorder.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
deep bite and Angle Class II/III occlusal factors are also
argued to be risk factors for TMD [20]. In the current
study, although the TMD Pain scores of individuals
with Class III malocclusion were higher than those of
the individuals with Class I and Class II malocclusions,
the difference among the groups in terms of this vari-
able was not statistically significant.
One of the possible reasons for the different degrees
of prevalence of temporomandibular disorders in dif-
ferent populations is the diversity of the criteria that
are questioned and the clinical examination protocols
that are used [21]. The RDC/TMD is a clinical exam-
ination protocol for TMD that is internationally
accepted [6]. In later years, some limitations were
found in the RDC/TMD protocol, and by revising
these, a clinical examination protocol known as the
Diagnostic Criteria for Temporomandibular Disorders
(DC/TMD) was recently developed [2].
As a result of assessment of the differences of the
DC/TMD in terms of its inquisitional reliability among
educated and qualified research groups, because its
inquisitional reliability was found to be high, it was
concluded to be an adequate tool to diagnose tempor-
omandibular disorders [22].
High stress levels may lead to development of bruxism
by affecting the circulation in local muscles. They also
change the ionic balance in cell membranes, and as
a result of this, they lead to stimulation of pain receptors
by causing accumulation of lactic and pyruvic acids. This is
why psychosocial factors, such as anxiety, stress, and
depression may be effective in the pathogenesis of
TMDs [13].
Winocur et al. [23] found somatization values to be
significantly associated with sex, and in both cases,
women showed higher values in comparison to men.
No significant relationship was found between depression
values and sex. Komiyama et al. [24] could not find
a significant relationship between somatization scores
and age groups. Nevertheless, they found the somatiza-
tion scores among women to be significantly higher than
those among men. Likewise, in this study, the mean
PHQ-9, GAD-7 and PHQ-15 somatization scores of the
women were significantly higher than those of the men.
Minghelli et al. [13] found that the sex and age
group of individuals were significantly associated with
anxiety and depression. They reported that anxiety and
depression increased with increased age. Moreover,
they found the anxiety and depression levels of
women to be higher than those of men.
Lei et al. [14] found the prevalence of depression,
anxiety, and stress among individuals at the ages of
16–18 to be significantly higher than those at the ages
of 12–15. Gatz and Hurwicz [25] determined that
7
patients with severe physical symptoms/depression
levels and severe disability were older than those who
had normal and moderate scores. As a result of this,
the epidemiology of depression becomes higher in
populations of older ages in comparison to younger
populations. In the current study, a positive and sig-
nificant relationship was found between the age values
and the PHQ-9, GAD-7, and PHQ-15 scores.
While some studies found positive relationships
between parafunctional habits and temporomandibular
disorders, some others could not [26]. Michelotti et al.
[27] reported that there is a relationship between tempor-
omandibular disorders and parafunctional habits. Van der
Meulen et al. [28] could not find any difference between
men and women in terms of their mean OBC scores or
ages. Antoun et al. [11] could not find a significant differ-
ence in the OBC scores of hyperdivergent and normodi-
vergent groups. Neither group displayed significant
differences in terms of their OBC scores in cases of sleep
or being awake. In this study, the malocclusion groups did
not significantly differ based on their OBC activities during
sleep, OBC activities while awake, and total scale mean
scores. Furthermore, the OBC total, OBC activities during
sleep, and OBC activities while awake scores of the women
were significantly higher than those of the men.
As the Fonseca anamnestic questionnaire provides
similar results to those in studies conducted with the
RDC/TMD, it may also help clinicians in their epidemio-
logical studies on temporomandibular disorders [5,16].
Pedroni et al. [29] conducted a study with 50
Brazilian university students by using Fonseca’s ques-
tionnaire and determined that 68% of the participants
had at least one TMD sign or symptom. They also found
that the signs and symptoms were mild in 42%, moder-
ate in 20%, and severe in 6% of participants.
Nomura et al. [16] in their study that used Fonseca’s
questionnaire and included 218 dentistry students, deter-
mined temporomandibular disorders with mild levels in
35.78%, moderate levels in 11.93%, and severe levels in
5.5% of the participants. Chandak et al. [30]conducted
a study with 200 participants at the ages of 18-27 years in
the population of Vidharbian in India and reported no
TMD in 30% of the participants, while 55% had mild, 14%
had moderate, and 1% had severe TMD levels. Minghelli
et al. [13] carried out a study on a Portuguese population at
the ages of 5–19 years and found the rate of the cases who
showed TMD symptoms as 25.2%, while they reported the
severity of TMD in these as mild in 22.4%, moderate in
2.5%, and severe in 0.3% of the cases. In their study that
included a total of 409 dentistry students, Ayalı and
Ramoglu [12] reported the severity of TMDs among the
participants to be mild in 38.6%, moderate in 13.4%, and
severe in 4.4% of the students.
8 A. KARAMAN AND S. K. BUYUK
Pedroni et al. [29] and Nomura et al. [16] reported
that women have a higher prevalence of TMD. Ayalı
and Ramoglu [12] also found the prevalence of TMD
in women to be higher than men and stated that this
difference was statistically significant. Furthermore,
they concluded that, in addition to factors such as
ethnic origin and sample size, sex distribution may
also be associated with the changes in TMD prevalence.
In this study, the Fonseca’s questionnaire mean score
of the women was significantly higher than that of men.
According to Poveda et al. [1] and Nomura et al. [16],
this high TMD prevalence in women may be associated
with their physiological characteristics, especially hor-
monal variations and the structures in their connective
tissues and muscles. They reported that these tissues
relaxed more due to the level of estrogen, and as
a result of this, they cannot support functional pressure
and, in turn, lead to temporomandibular disorders.
There was no significant relationship between the
male participants’ malocclusion classifications and their
Fonseca TMD group distributions, while there was
a significant relationship between the female participants’
malocclusion classifications and their Fonseca TMD
group distributions. The malocclusion groups differed
based on their mean scores in the FAQ. The mean
Fonseca questionnaire score of the Class III group was
significantly higher than those of the other groups.
Fonseca’s questionnaire contributes to clinical
examination of the stomatognathic system in daily
practice. Additionally, this questionnaire may also
be used as a preliminary TMD screening instru-
ment. This questionnaire is a useful temporoman-
dibular disorder screening instrument in terms of
early diagnosis of temporomandibular disorders and
prevention of complications caused by these disor-
ders [30].
Malocclusions and dentofacial deformities are highly
prevalent in society; they may affect physical, social,
and psychological functionality. The concept of quality
of life related to oral health shows the effects of oral
health or disorders on the person’s daily functioning,
health, or general quality of life [31].
As a result of their statistical analysis, Chen et al. [31]
found that more severe malocclusion had a stronger effect
on the quality of life of individuals. de Oliveira and
Sheiham [32] reported that malocclusion had a negative
effect on oral health-related quality of life in patients with
TMD. In the current study, a statistically significant dif-
ference was observed among the different malocclusion
groups in terms of their mean OHIP-14 scores. The main
OHIP-14 score of the Class III group was found to be
significantly higher than those of the Class I and Class II
groups.
In their study, de Oliveira and Sheiham [32] found
a significant relationship between sex and OHIP-14
scores among adolescents. Additionally, the OHIP-14
values among female individuals were higher than those
among males. They also found a significant relationship
between age and OHIP-14 scores in adolescents.
Likewise, in the current study, the female participants
had significantly higher OHIP-14 scores than the male
participants. Moreover, there was a positive and signifi-
cant correlation between age values and OHIP-14 scores.
Conclusion
The DC/TMD form allows both a physical assessment
of Axis I and Axis II that examine psychosocial status
and pain-related disorders and a more comprehensive
assessment. Therefore, the authors believe that it
should be utilized for comprehensive evaluation of
individuals with different malocclusions.
In the current study, the results of the Class III mal-
occlusion group in the Fonseca questionnaire were signif-
icantly higher than those of the other groups. Additionally,
the Fonseca questionnaire, since it is lower-cost and easily
applicable in a shorter time on patients with different
malocclusions in comparison to the RDC/TMD or DC/
TMD questionnaire forms, may be implemented as an
alternative in clinical settings for diagnosis and classifica-
tion of temporomandibular disorders.
The results of this study showed that there is
a strong relationship between malocclusion and oral
health-related quality of life. The OHIP-14 results of
the Class III group were significantly higher than those
of the other malocclusion groups. As the severity of
malocclusion increased, the participants’ mean OHIP-
14 scores increased, while their oral health-related
quality of life decreased.
Acknowledgments
This study was conducted as a master thesis in Ordu
University Faculty of Dentistry. Also, this study was pre-
sented as an oral presentation in 95th European
Orthodontic Society Congress in France.
Disclosure statement
The authors have stated explicitly that there are no conflicts
of interest in connection with this article.
Funding
No funding agency provided a significant amount of money
in support of this research.

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