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ORIGINAL ARTICLE

Prevalence of temporomandibular disorders and its association

with parafunctional habits among senior‑secondary school
children of Lucknow, India
Kriti Agarwal, Sabyasachi Saha, Pooja Sinha
Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh,
India

Address for correspondence:

Dr. Kriti Agarwal, Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Utrathia,
Raebareily Road, Lucknow, Uttar Pradesh, India. E‑mail: dragarwalkriti@gmail.com

ABSTRACT:
Introduction: Temporomandibular disorders (TMD) are defined as heterogeneous group of psychological disorders, commonly
characterized by orofacial pain, chewing dysfunction, or both. Aim: To determine the prevalence of TMD and to describe the
association between parafunctional habits and signs and symptoms of TMD among 15–17‑year‑old school children in Lucknow.
Materials and Methods: This study followed a cross‑sectional design, with a sample of 407 school children aged 15–17‑year‑old.
A single, trained, calibrated investigator interviewed the participants according to Fonseca’s Anamnestic Questionnaire‑1994,
which provided information on the prevalence of TMD, followed by the clinical examination of temporomandibular joint (TMJ)
according to WHO (1997). Chi‑square test and Univariate and Multivariate Logistic Regression analysis were used. Results: The
prevalence of TMD was (22.4%). There was no statistically significant association was found between age, (P = 0.81) gender
(P = 0.09) and TMD. Nail‑biting (88.3%) was the most common habit, followed by clenching/grinding (68.4%) and mouth breathing
(53.4%). However, habits and TMJ symptoms were found statistically significant P < 0.01 or P < 0.001 associated to TMD. Further,
adjusted (age and gender) logistic regression analysis revealed that digit‑sucking, mouth breathing, nail biting, and clenching
has made a significant contribution to prediction (P < 0.001). Conclusion: The habits especially digit‑sucking, mouth breathing,
nail biting, and clenching had statistically significantly associated with TMD.
Key words:
Adolescent health, orofacial pain, parafunction

INTRODUCTION in adolescence, there is a direct need for accurate

Temporomandibular disorders (TMD) are considered as
the common cause of orofacial pain of nondental origin.[1]
Thus, it is an enigmatic issue for dental professional all
around the globe as it affects the deleterious effects on
the stomatognathic system.[2] The common symptoms
of TMD are muscle and/or joint pain on palpation,
impaired mandibular function, and joint noises. As
temporomandibular joint (TMJ) remodeling occurs
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assessment of dental conditions, the joint itself and the
neuromuscular apparatus in this period.[3]
Adolescents need to be informed about the negative effects
of parafunctional habits. The early diagnosis of signs and
symptoms of TMD can help to improve the course of
treatment and quality of life of adolescents. Thus, the
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How to cite this article: Agarwal K, Saha S, Sinha P. Prevalence of

DOI: temporomandibular disorders and its association with parafunctional habits
10.4103/2319-5932.183809 among senior-secondary school children of Lucknow, India. J Indian Assoc
Public Health Dent 2016;14:139-43.

139 © 2016 Journal of Indian Association of Public Health Dentistry | Published by Wolters Kluwer - Medknow
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Agarwal, et al.: Association of parafunctional habits and TMD
aim of this study to assess the prevalence of TMD and to
describe the association between parafunctional habits
and signs and symptoms of TMD among 15–17‑year‑old
school children in Lucknow.
MATERIALS AND METHODS
A descriptive cross‑sectional survey was designed among
15–17‑year‑old school going children of Lucknow from
March 2014 to August 2014. Ethical clearance was
obtained from the Institutional Ethical Committee.
Approval was obtained from the principals of the
concerning schools. Written consent was obtained from
the parents for the participation of their children during
parents‑teachers meeting.
A pilot study was conducted on 50 school going children.
The sample size was estimated using n Master software
(version 2, CMC, Vellore, Tamil Nadu, India). Anticipating
a 15% prevalence of TMD was obtained during the pilot
study in the study population, an absolute precision of
5% and a 95% confidence interval, a sample size of 205
is found to be sufficient. As the study population was
selected using multi‑stage cluster sampling technique;
hence, this sample size was multiplied by 2 (i.e., design
effect). Thus, the minimum sample size required was 205
which was rounded off to 410.
The estimated sample was selected by multistage cluster
random sampling technique. In the first stage, Lucknow
city was divided geographically into five areas, that is,
East, West, North, South, and Central. List of all the wards
from the five geographic areas was obtained from census
enumeration areas data. A list of schools located within the
Lucknow municipality was obtained from District School
Officer. Approximately, 22 wards came under each of
these geographic areas. In the second stage, one ward was
randomly selected from each of these geographic areas. In
the third stage, two schools from each of the 5 wards were
randomly selected. This was followed by a school survey
in which all the students aged 15–17 years meeting the
following inclusion and exclusion criteria.
Inclusion criteria
• School children who were present on the day of
examination
• Parents of children who gave consent.
Exclusion criteria
• Children with special health care needs like physically
handicapped children
• Students undergoing orthodontic treatment
• Students with a history of trauma or dental pain.
Three students were absent on the day of the examination,
hence final sample size was attained 407.
Journal of Indian Association of Public Health Dentistry
Vol. 14, Issue 2, | April-June 2016
Method of data collection
The single investigator was trained and calibrated in the
department before the commencement of the survey,
and the kappa coefficient was estimated to be 0.86. The
study proforma had two parts: The first part consisted
of the demographic characteristics of subjects included
the name, age, gender, address, and name of the school.
The second part consisted of The Fonseca Anamnestic
Questionnaire (FAQ) (1994)[4] to assess the severity of
the TMD symptoms and clinical examination of TMJ as
per WHO 1997.[5] FAQ (1994) consists of 10 questions,
whose answer options are no, sometimes, and yes. The
questionnaire included questions on the presence of
TMJ pain, head and neck pain, pain while chewing,
questions on parafunctional habits, limitation of joint
movement, the perception of malocclusion, and emotional
stress. Each answer has a value; answer “NO” = 0,
“SOMETIMES” = 5, and “YES” = 10. The sum of the values
obtained provides an index that classifies individuals in
the absence of TMD (0–15), mild TMD (20–45), moderate
TMD (50–65), and severe TMD (70–100). Participants’
history and clinical examination was used to determine
parafunctional habits like attrition on mandibular
incisors, etc., Each parafunction was reported as either
present or absent.
The children were interviewed and examined by single,
trained calibrated examiner as per American Dental
Association Type III criteria[6] using mouth mirrors while
seated on chair under natural light.
Statistical analysis
Data were entered into Microsoft Excel and analyzed
using Statistical Package for the Social Sciences (SPSS)
version 21.0 (SPSS, Inc., Chicago, IL, USA). Results
were subjected to statistical analysis using descriptive
statistics, were made to all variables in the study.
Chi‑square Test was applied to evaluate the association
between the occurrence of TMD and gender, age group,
and parafunctional habits. The influence of the variables
use in this study with the presence of TMD was assessed
using Univariate and Multivariate‑Logistic regression
analysis. For all the tests, the level of significance was
set up at P < 0.05.
RESULTS
Out of 407 students, who were interviewed and examined,
158 were 15‑year‑old (38.8%), 173 were 16‑year‑old
(42.5%) and 76 were 17‑year‑old (18.7%). Among children
further, 190 were female children (46.7%) and 217 were
male children (53.3%) [Table 1]. The overall prevalence
of TMD (mild and moderate) was found to be 21.4%. A
total of 19.2% had mild TMD and 2.2% had moderate
TMD, none of the children had severe TMD and majority
of school children (78.6%) did not have TMD [Table 2].
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Agarwal, et al.: Association of parafunctional habits and TMD
Table 1: Distribution of participants by age groups
and gender
Variables Number of
participants (407)
Age groups  (years)
15 158
16 173
17 76
Gender
Male 217
Female 190
Table 2: Distribution of children according to different
grades of temporomandibular disorders according to
the Fonseca’s Anamnestic Questionnaire
Grades of TMD Fonseca questionnaire Number of
total score range children
No dysfunction 0-15 320
Mild TMD 20-45 78
Moderate TMD 50-65 9 2.2
Severe TMD 70-100 0 0
TMD – Temporomandibular disorders
There was statistically significant association was found
between sign and symptoms of TMD (P < 0.001). The
most common symptom was frequent headache which
was most prevalent in both with TMD (86.2%) and
without TMD (12.2%), morning facial pain was common
in cases of TMD (86.2%) but was less common in cases
not having TMD (3.4%), among cases of TMD pain in
ear or about the ear was the most common item (89.7%)
[Table 3]. The most common habit was nail biting
(88.3%), clenching (68.4%), mouth breathing (53.4%),
thumb/digit sucking (21.4%), lip biting (19.4%), and
tongue thrusting (1.3%), respectively [Table 4]. In
the present study, we used a clinical examination
of TMJ as per WHO (1997). Table 5 depicts TMJ
examination as per the WHO (1997) evaluation. Among
all participants, majority of children did not have any
sign or symptoms. There were 22.6% symptomatic
children. The most common sign was clicking 22.4%,
followed by tenderness 2.5% and reduced jaw mobility
2.2%, respectively.
A univariate and multivariate logistic regression
analysis was depicted in Table 6 for the presence of
TMD by different variables conducted to predict the
occurrence of TMD among adolescents using age,
gender, thumb/digit sucking, mouth breathing, nail
biting, lip biting, and clenching as predictors. Tongue
thrusting was not included in the model as there was
only one case found among the study population. The
Wald criterion demonstrated that thumb sucking,
mouth breathing, nail biting, and clenching has made
a significant contribution to prediction (P < 0.001). Age,
141
gender, and lip‑biting were not appeared as significant
predictors.
Percentage of
participants DISCUSSION
38.82
This survey identified the prevalence of TMD was 22.4%
42.51
among 15–17‑year‑old school children of Lucknow. A
18.67
similar observation was reported by Feteih[7] also revealed
TMD prevalence of 21.3% in 385 adolescents aged
53.32
between 12 and 16 years. Some studies[8,9] have shown
46.68 a higher prevalence than in the present study, such as
Gazit et al.[10] which evaluated 369 Israeli students in the
age group of 10–18 years (56.4%).
Study done by Motta et al.,[1] and Thilander et al.,[11]
showed the prevalence was 20% and 25% among
adolescents, Morinushi et al.,[12] showed the prevalence
Percentage
was 31% among aged between 12 and 14 years and 39.6%
among 15–17 years and Magnusson et al.,[13] assessed
78.6
through Helmiko index concluded that 34% adolescents
19.2
showed mild symptoms of TMD.[1,11‑13] The diversity of
TMD prevalence among different studies have been
attributed to the differences in the age group studied,
the sample size and its composition, the numbers of
examiners as well as diagnostic criteria used between
different studies.
In the present study regarding severity, most students
exhibited mild TMD (19.2%) as there is repitition, (2.2%)
had moderate TMD and (0%) had severe TMD. Almost
similar findings were also reported in a longitudinal
study done by Magnusson et al.,[13] which evaluated 119
children at intervals of 4 years and found that in most
cases, the signs were mild; however, moderate TMD was
noted in 11% of the 11‑year‑old children and 17% of the
15‑year‑old children.
For all the items of FAQ, the most common symptom
observed was frequent headaches (28%), followed by
morning facial pain (21.1%), pain in ear or about the ear
(20.4%), respectively. Clenching or grinding teeth (15.7%)
and using only one side of mouth while chewing (11.5%)
were the other less commonly reported symptoms.
In the present study, we used a clinical examination of
TMJ as per WHO (1997). Among all participants majority
of children did not have any sign or symptoms. There
were 22.6% symptomatic children. The most common
sign was clicking 22.4%, followed by tenderness 2.5%
and reduced jaw mobility 2.2%, respectively.
The most common parafunction reported was nail biting
(23.3%), clenching/grinding (15.0%), mouth breathing
(14.5%), thumb/digit sucking (5.7%), lip biting (4.7%),
and tongue thrusting (1.3%). These data are similar to
the study done by Motta et al.[1] in 244 adolescents in
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Agarwal, et al.: Association of parafunctional habits and TMD

Table 3: Association between Fonseca Anamnestic Questionnaire and temporomandibular disorders according to
Fonseca criteria
Items of FAQ Total Without TMD With TMD Statistical significance
(n=320) n (%) (n=87) n (%)
χ2 P
Difficulty in mouth opening 19 1  (0.3) 18 (20.6) 63.82 <0.001*
Difficulty in movement of jaws to side 12 0 (0) 12 (13.8) 45.48 <0.001*
Muscular pain or fatigue during mastication 19 2 (0.6) 17  (19.5) 54.99 <0.001*
Frequent headaches 114 39  (12.2) 75  (86.2) 185.86 <0.001*
Neck pain or stiff neck 4 0 (0) 4 (4.6) 14.86 <0.001*
Pain in ear or about the ear 83 5  (1.6) 78  (89.7) 326.98 <0.001*
Noise in your jaw joint while chewing or opening mouth 6 1  (0.3) 5  (5.8) 13.91 <0.001*
Clenching or grinding teeth 64 1  (0.3) 63  (72.4) 268.3 <0.001*
Using only one side of your mouth while chewing 47 3 (0.9) 44 (50.6) 165.0 <0.001*
Morning facial pain 86 11  (3.4) 75  (86.2) 281.19 <0.001*
*P<0.05 was considered statistically significant. TMD – Temporomandibular disorders, FAQ – Fonseca Anamnestic Questionnaire

Table 4: Association between parafunctional habits and temporomandibular disorders among children
Parafunctional habit Total n (%) Without TMD With TMD Statistical significance
(n=320) n (%) (n=87) n (%)
χ2 P
Thumb sucking 23  (21.4) 6  (1.9) 17  (19.5) 40.035 <0.001*
Mouth breathing 10 (3.1) 49 (56.3) 156.17 <0.001*
Tongue thrusting 1  (1.3) 0 (0.0) 1  (1.3) 7.393 0.417
Nail biting 95  (88.3) 25  (7.8) 70 (80.5) 201.8 <0.001*
Lip biting 19  (19.4) 3 (0.9) 16  (18.4) 46.82 <0.001*
Clenching 61  (68.4) 2 (0.6) 59  (67.8) 242.37 <0.001*
*P<0.05 was considered statistically significant. TMD – Temporomandibular disorders

as triggering point for the appearance of TMD due to its

Table 5: Temporomandibular joint examination as per
World Health Organization (1997) evaluation
Evaluation criteria Number of children
Presence of symptoms 92
Presence of signs
Clicking 91
Tenderness 10
Reduced jaw mobility 9 2.2
the age group of 10–20 years from the city of Sao Roque,
Brazil.
This survey highlighted no statistically significant
association was found between age (P = 0.81), gender
(P = 0.09) and signs and symptoms of TMD. which was
in accordance with the study done by Motta et al.[1] they
also found that signs and symptoms of TMD were not
associated with age and gender.
A statistically significant association was found between
parafunctional habits and TMD. The results were in
accordance to study done by Winocur et al.,[14] Troeltzsch
et al.[15] and Motghare et al.[16] These parafunctional habits
should be considered as risk factor for TMD as they act
effect on the stomatognathic system.
Percentage
The present study was a cross‑sectional survey. Since
22.6 TMD is a fluctuating disorder, hence further longitudinal
study relating stress and occlusal interferences are
22.4
needed for better associations. The questionnaire
2.5
employed here can be useful to determining the complex
diagnosis of TMD to send affected adolescents for further
clinical diagnosis and preventive treatment.
CONCLUSION
The results of this study revealed that there was an
association between signs and symptoms of TMD and
parafunction habits. These data highlighted the need
to carry out screening to send affected adolescents for
further treatment. This can help to prevent problems that
predispose individuals to TMJ pain as this could manage
orofacial pain in a large contingent of people.
Acknowledgment
All the participants’ and their parents’ and school
authorities and faculty mem`bers of our department.

Journal of Indian Association of Public Health Dentistry 142

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Agarwal, et al.: Association of parafunctional habits and TMD

Table 6: Logistic regression analysis for presence of temporomandibular disorders with different variables
Univariate analysis Multivariate analysis
Unadjusted OR (95% CI^) P Adjusted OR* (95% CI^) P
Age group (years)
15 1$ 1$
16 1.36  (0.80-2.29) 0.25 0.87  (0.17-4.39) 0.81
17 0.85  (0.41-1.72) 0.64 0.01 (0.00-0.20) 0.06
Gender
Females 1$ 1$
Males 0.978  (0.61-1.56) 0.926 3.93  (0.86-17.98) 0.09
Thumb/digit sucking
Absent 1$ 1$
Present 12.71  (4.83-33.39) <0.001 48.94 (7.01-341.32) <0.001
Mouth breathing
Absent 1$ 1$
Present 39.97  (18.71-85.39) <0.001 97.69  (16.4-594.9) <0.001
Nail biting
Absent 1$ 1$
Present 48.59  (24.89-94.86) <0.001 13.47  (3.11-58.19) <0.001
Lipbiting
Absent 1$ 1$
Present 23.81  (6.75-83.92) <0.001 6.44 (0.71-58.38) 0.09
Clenching
Absent 1$ 1$
Present 335.03  (17.71-1444.38) <0.001 1927  (318.25-11673.72) <0.001
*Adjusted for all other factors listed in the table, $Reference category, ^95% CI. CI – Confidence interval, OR – Odds ratio

Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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