Abdullah Awdah AlQarni et al, 2019;3(3):307–310.

International Journal of Medicine in Developing Countries

https://doi.org/10.24911/IJMDC.51-1544475165

REVIEW ARTICLE

Association of temporomandibular joint

disorder symptoms with anxiety and
depression
Abdullah Awdah AlQarni1, Mohammad Alharbi2, Ibrahim Ayiz Almutairi3,
Moayad Ahmed Alomaym4, Ibrahim Fahad Alkurdi5*, Nasser Faiz Alkhaldi6,
Nafea Awadh Alharbi7

ABSTRACT
Background: Temporomandibular joint and muscle disorders (TMD) are a group of conditions that cause pain
and dysfunction in the jaw joint and muscles that control jaw movement. This study was done to declare the
association of temporomandibular joint disorder symptoms with anxiety and depression.
Methodology: An online survey was done which consisted of many questions for indicating the presence or
absence of TMD and its association with anxiety and depression. During August and September, this survey was
sent on email to many dental students of different dental classes asking them to participate in the survey. The
answers of the students were counted and underwent for analysis.
Results: Most of the students did not suffer from either TMD nor anxiety and depression. It was obvious that
students who suffered from TMD were also suffering from anxiety or depression. The risk of TMD occurrence
was directly proportional to the psychological status of the individuals; especially anxiety and depression.
Conclusion: Anxiety and depression are considered serious factors for TMD incidence and severity. Few stud-
ies have focused on the association of TMD symptoms with anxiety and depression, but still there is need to
increase studies about the association of TMD symptoms with anxiety and depression.
Keywords: TMD, anxiety, depression, TMJ.

Introduction

Temporomandibular joint and muscle disorders,
commonly called TMD, are a group of conditions that
cause pain and dysfunction in the jaw joint and muscles
that control jaw movement [1]. It affects many people
with variable ages, especially from 20 to 45 years [2,3].
The cause of TMD is not known, but there are many
factors that can increase the occurrence of TMD [4];
clenching and bruxism, whenever the patient is awake
or asleep, usually associated with fatigue and stress
and usually triggered with occlusal irregularities [5],
TMJ arthritis, or stress and anxiety that might force
the individual to clench his teeth or tighten his facial
muscles [6].
Several studies have concluded that many individuals
(60%–70%) have TMD disorder with varying degrees
and only a few of them (5%) need treatment [7,8].
The signs and symptoms of TMD [9,10] reported are;
severe pain that may be temporary or lasting for many
years, masticatory muscles spasm and fatigue, difficulty
in mouth opening, clicking and crepitus sound in TMJ
in either opening or closing the mouth, myofascial pain,
stuck jaws in open or closed position, radiating pain to the
shoulder area, tinnitus in ears, a toothache and headache,
and swelling occurring around the jaw.
Many types of research about TMD have shown that
parafunctional habits which are the main cause of TMD
are aggravated by emotional stress and disorders [11,12].
Also, myofascial pain and chronic muscular fatigue may
Correspondence to: Ibrahim Fahad Alkurdi
*Ministry of Health, Hofuf, Al-Ahsa Region, Saudi Arabia.
Email: dr.ialkurdi@gmail.com
Full list of author information is available at the end of
the article.
Received: 12 December 2018 | Accepted: 31 December 2018

© IJMDC. https://www.ijmdc.com 307

 Temporomandibular joint disorder and depression

occur due to psychological disorders [13]. Many types Results

of research about TMD have shown that parafunctional
habits which are the main cause of TMD are aggravated Answers of 600 students were included. The students
by emotional stress and disorders [14,15]. were of different educational classes and showed variety
in their answers. The answers about having TMD or not
Materials and Methods were recorded Table 1 and the percentage of each answer
was calculated separately. The results of having anxiety
An online survey prepared by the researcher during or depression were recorded in Table 2 and the percentage
August and September 2018 consisting of different of each answer was calculated. The association between
questions for investigating the correlation between TMD TMD and anxiety or depression for the students was
symptoms with anxiety and depression. Focus was laid on noted in Table 3 and the percentage was calculated. The
exploring the clinical condition of the participants about results of the binary logistic regression analysis of TMD
TMJ and their psychological state, especially if anxiety risk was recorded in Table 4, while the results of binary
and depression was present. Then, an email containing logistic regression analysis of anxiety/depression risk
the survey was sent to different dental students from were recorded in Table 5.
different levels of education. The students were informed
of all objectives of the survey by ensuring the privacy It was clear that the number of females who participated
of the results and their ability for withdrawal from the in the survey was the double of the number of males.
study at any time. They were asked to participate in the Most of the students (75%) did not have TMD with
survey by answering the questions from their point of percentage (50%) for females and (25%) for males. Only
view. The survey questions consist of three parts; socio- (25%) of the students had suffered from TMD with the
demographic questions, which included questions about percentage (16.7%) for females and (8.3%) for males.
the student’s age, sex, and their year of study. Also, they
were asked to answer with (yes) or (no) if they had ever
been TMD patients, also if they were currently under
treatment for TMD disease. The Fonseca Anamnestic
Questionnaire: Table 1. Students answers for a question if they had TMD
symptoms.
It is a modified version of the Helkimo Anamnestic
Index that identifies TMD signs and symptoms and Variables No TMD TMD p-value
(450; 75%) (150; 25%)
measures the severity of TMD symptoms. The Fonseca
Anamnestic Questionnaire has a 95% correlation Sex 0.001
Male 200 (33.3%) 150 (25%) 50 (8.3%)
with the Helkimo Anamnestic Index (r = 0.6169,
Female 400 300 (50%) 100 (16.7%)
p < 0.05) and 95% reliability in application. This type of (66.7%)
questionnaire is considered a rapid, easy, and inexpensive
Year of study 0.08
way of collecting information. The questionnaire 1st 100 (16.7%) 74 (12.3%) 26 (4.4%)
consisted of 10 questions about the presence of pain 2nd 73 (12.2%) 50 (8.3%) 23 (3.8%)
in TMJ, limitations in jaw movement, the presence of 3rd 77 (12.8%) 57 (9.5%) 20 (3.4%)
malocclusion and psychological disorders, pain during 4th 150 (25%) 129 (21.5%) 21 (3.5%)
chewing, and pain in head and neck. Answering with 5th 200 (33.3%) 140 (23.3%) 60 (10%)
(no) was scored with 0 while answering with (yes) was
scored with 10. These scores provided an index for the Table 2. Students answers for having anxiety or depression.
participants who did not have TMD (0–15), mild TMD Variables No anxiety or Anxiety or p-value
(20–45), moderate TMD (50–65), and severe TMD depression depression
(70–100). The Hospital Anxiety and Depression (HAD) N = 420 (70%) N = 180 (30%)
scale: it was used to measure the degree of depression Sex 0.01
and anxiety in nonpsychiatric environment. It is a Male (200) 120 (20%) 80 (13.3%)
sensitive and specific scale for assessing depression and Female (400) 300 (50%) 100 (16.7%)
anxiety symptoms. It consists of two scales; HADS-D, Year of study 0.003
which is a scale consisting of 7 items to measure the 1st (100) 82 (13.7%) 18 (3%)
intensity and degree of depression. HADS-A, which is a 2nd (73) 61 (10.1%) 12 (2%)
3rd (77) 57 (9.5%) 20 (3.3%)
scale consisting of 7 items to measure the intensity and
4th (150) 120 (20%) 30 (5%)
degree of anxiety. 5th (200) 100 (16.7%) 100 (16.7%)
Each item was scored from 0 to 3 according to the
response, and maximally reached 21 points for each Table 3. Association between TMD and anxiety/depression.
scale. The absence of anxiety or depression was scored
Anxiety or No TMD TMD p-value
with points ranging from (0–7), possible anxiety or depression (450) (150)
depression was scored with points ranging from (8–10),
Absent (420) 390 (65%) 30 (5%) 0.001
and presence of anxiety or depression was scored 11 or
higher. Present (180) 60 (10%) 120 (20%)

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 Temporomandibular joint disorder and depression

Table 4. Results of binary logistic regression analysis of Discussion

TMD risk.
Variables Odds ratio Odds ratio It is obvious from the results of this research that TMD
crude adjusted** was less prevalent among the dental students who
(95% CI); p (95% CI); p participated in the survey (25%). Many studies have found
Sex (male*) that TMD is highly prevalent among the dental students
Female 1.8 (1.5–2.8); 1.8 (1.5–2.8); with percentage higher than the present study’s results.
p = 0.001 p = 0.001 Previous study among 308 dental students of Nigerian
Anxiety or depression 2.4 (1.8–3); 2.6 (1.9–3.3); university had found that TMD was highly prevalent
(none*) p = 0.001 p = 0.001 among the dental students with percentage of 42.4% [16].
Presence Another study in Brazil among 218 dental students had
*Class reference; **adjusted for sex and absence/presence of found that TMD was highly prevalent among the students
anxiety or depression. with percentage of 53.2% [17]. The present study findings
were consistent with many studies that have found that
Table 5. Results of binary logistic regression analysis of females were affected with TMD more than males with
anxiety/depression risk. OR [1.8 (1.5–2.8); p = 0.001], for many reasons such as
Variables Odds ratio Odds ratio the physiological, hormonal, and muscular differences
crude adjusted** between males and females that allow high muscular
(95% CI); p (95% CI); p laxation and TMJ excessive movement in females and so
Sex (male*) - more TMD occurrence. Stress and anxiety may force the
Female 1.2 (0.9–1.7); individual for parafunctional habits like clenching and
p = 0.1
bruxism which may lead to TMD problems with painful
Year of study 2.2 (1.5–3); 2.2 (1.5–3); jaw movement. The present study has found that 30% of
p = 0.01 p = 0.01 the students had anxiety and depression while females were
*Class reference; **adjusted for sex and absence/presence of considered more affected with anxiety and depression than
anxiety or depression. males with OR [1.2 (0.9–1.7); p = 0.1). Other studies have
found higher prevalence of anxiety and depression among
the students like two studies in Pakistan, the first was done
Students of 5th year were most involved in the survey among 252 students at Ziauddin Medical University, which
with the percentage (33.3%), the 4th year students ranked found that anxiety and depression was highly prevalent
second in participation with the percentage (25%) while among the students (60%) [14], and the second study was
the 1st year students ranked third in participation with the done in Multan among medical students that had found
percentage (16.7%). 43.9% of the students who participated in the survey had
anxiety and depression [15]. This study has found a strong
The results have shown that most females (300 female) correlation between TMD and anxiety/depression that is
did not suffer from anxiety or depression while only 100 consistent with the results of many studies [12,16].
female had anxiety or depression. Also, the number of Conclusion
males who had anxiety or depression was (80 males) less
than the number of males who did not suffer from anxiety A strong correlation was identified between
or depression (120 male). temporomandibular joint disorders and anxiety/
It is clear from the results that there is a strong association depression which may increase the occurrence and
between TMD symptoms and anxiety/depression. There severity of TMD. There is a scarcity in studies that were
were 150 students suffering from TMD, 120 of them had conducted on the association of temporomandibular
anxiety or depression while only 30 students of them did joint disorder symptoms with anxiety and depression. It
not have anxiety or depression. On the other hand, there is recommended to establish more studies which focus
were 450 students who did not suffer from TMD, 390 on understanding the association of temporomandibular
students from them did not have anxiety or depression joint disorder symptoms with anxiety and depression.
while only 60 students of them had anxiety or depression.
List of Abbreviations
As compared with males, females had an OR of 1.8 (95% TMD Temporomandibular joint and muscle disorders
CI: 1.5–2.8; p = 0.001) for TMD. Students with anxiety
or depression had an Odds ratio crude of 2.4 (95% Funding
CI: 1.8–3; p = 0.001) for TMD and had an Odds ratio None.
adjusted of 2.6 (95% CI:1.9–3.3; p = 0.001 as compared
Declaration of conflicting interests
with students without these symptoms.
The authors declare that there is no conflict of interest
As compared with male, female had an Odds ratio crude regarding the publication of this article.
of 1.2 (95% CI: 0.9–1.7; p = 0.01). Students had an OR of
2.2 (95% CI: 1.5–3; p = 0.01) for anxiety or depression, Consent for publication
as compared with students enrolled in other classes. Informed consent was obtained from all participants.

309
 Temporomandibular joint disorder and depression
Ethical approval
The research was conducted under the supervision of the
Ministry of Health, Hofuf, Al-Ahsa Region.
Author details
Abdullah Awdah AlQarni1, Mohammad Alharbi2, Ibrahim
Ayiz Almutairi3, Moayad Ahmed Alomaym4, Ibrahim Fahad
Alkurdi5, Nasser Faiz Alkhaldi6, Nafea Awadh Alharbi7
1. Ministry of Health, Sabt Alalaya, Asir Region, Saudi Arabia
2. Ministry of Health, Altiraq, Alqassim Region, Saudi Arabia
3. Ministry of Health, Albadai, Alqassim Region, Saudi Arabia
4. King Fahad Specialist Hospital, Ministry of Health, Buraydah,
Saudi Arabia
5. Ministry of Health, Hofuf, Al-Ahsa Region, Saudi Arabia
6. Ministry of Health, Aljouf Region, Saudi Arabia
7. East Riyadh Specialized Dental Center, Riyadh, Saudi Arabia
References
1. Poveda-Roda R, Bagán JV, Díaz Fernández JM, Bazán SH,
Soriano YJ. Review of temporomandibular joint pathology.
Part I: classification, epidemiology and risk factors. Med
Oral Patol Oral Cir Bucal. 2007;12(4):E292–8.
2. Poveda-Roda R, Bagán JV, Sanchis JM, Carbonell E.
Temporomandibular disorders. A case-control study. Med
Oral Patol Oral Cir Bucal. 2012;17(5):e794–800. https://
doi.org/10.4317/medoral.18040
3. Liao CH, Chang CS, Chang SN, Lane HY, Lyu SY, Morisky DE,
et al. The risk of temporomandibular disorder in patients
with depression: a population-based cohort study.
Community Dent Oral Epidemiol. 2011;39(6):525–31.
https://doi.org/10.1111/j.1600-0528.2011.00621.x
4. Conti PC, Pinto-Fiamengui LM, Cunha CO, Conti AC.
Orofacial pain and temporomandibular disorders: the
impact on oral health and quality of life. Braz Oral Res.
2012;26(spe1 Suppl 1):120–3. https://doi.org/10.1590/
S1806-83242012000700018
5. Suma S, Veerendra Kumar B. Temporomandibular
disorders and functional somatic syndromes: deliberations
for the dentist. Indian J Dent Res. 2012;23(4):529–36.
6. Lajnert V, Francisković T, Grzic R, Kovacević Pavicić D,
Bakarbić D, Buković D, et al. Depression, somatization
and anxiety in female patients with temporomandibular
disorders (TMD). Coll Antropol. 2010;34:1415–9.
7. Miettinen O, Lahti S, Sipilä K. Psychosocial aspects of
temporomandibular disorders and oral health-related
310
quality of life. Acta Odontol Scand. 2012;70(4):331–6.
https://doi.org/10.3109/00016357.2011.654241
8. Anderson GC, Gonzalez YM, Ohrbach R, Truelove EL,
Sommers E, Look JO, et al. Research diagnostic criteria for
temporomandibular disorders: future directions. J Orofac
Pain. 2010;24(1):79–88.
9. Slade GD, Diatchenko L, Bhalang K, Sigurdsson A, Fillingim
RB, Belfer I, et al. Influence of psychological factors on risk
of temporomandibular disorders. J Dent Res. 2007;86(11):
1120–5. https://doi.org/10.1177/154405910708601119
10. Kindler S, Samietz S, Houshmand M, Grabe HJ, Bernhardt O,
Biffar R, et al. Depressive and anxiety symptoms as risk factors
for temporomandibular joint pain: a prospective cohort
study in the general population. J Pain. 2012;13(12):1188–97.
https://doi.org/10.1016/j.jpain.2012.09.004
11. Celić R, Braut V, Petricević N. Influence of depression
and somatization on acute and chronic orofacial pain
in patients with single or multiple TMD diagnoses. Coll
Antropol. 2011;35(3):709–13.
12. de Oliveira AS, Dias EM, Contato RG, Berzin F. Prevalence
study of signs and symptoms of temporomandibular disorder
in Brazilian college students. Braz Oral Res. 2006;20(1):3–7.
https://doi.org/10.1590/S1806-83242006000100002
13. Steenks MH, de Wijer A. Validity of the Research
Diagnostic Criteria for Temporomandibular Disorders
Axis I in clinical and research settings. J Orofac Pain.
2009;23(1):9–16.
14. Inam SN, Saqib A, Alam E. Prevalence of anxiety and
depression among medical students of private university.
J Pak Med Assoc. 2003;53(2):44–7.
15. Jadoon NA, Yaqoob R, Raza A, Shehzad MA, Zeshan SC.
Anxiety and depression among medical students: a cross-
sectional study. J Pak Med Assoc. 2010;60(8):699–702.
16. Otuyemi OD, Owotade FJ, Ugboko VI, Ndukwe KC, Olusile OA.
Prevalence of signs and symptoms of temporomandibular
disorders in young Nigerian adults. J Orthod. 2000;27(1):
61–5. https://doi.org/10.1093/ortho/27.1.61
17. Nomura K, Vitti M, Oliveira AS, Chaves TC, Semprini M,
Siéssere S, et al. Use of the Fonseca’s questionnaire to
assess the prevalence and severity of temporomandibular
disorders in Brazilian dental undergraduates. Braz Dent
J. 2007;18(2):163–7. https://doi.org/10.1590/S0103-
64402007000200015