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Anxiety and malocclusion are associated with Temporomandibular disorders

in adolescents diagnosed by RDC/TMD. A cross sectional study

Article in Journal of Oral Rehabilitation · July 2018

DOI: 10.1111/joor.12684

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Received: 24 April 2018 | Revised: 15 June 2018
DOI: 10.1111/joor.12684
ORIGINAL ARTICLE
Anxiety and malocclusion are associated with
temporomandibular disorders in adolescents diagnosed by
RDC/TMD. A cross-­sectional study
Fernanda Mara de Paiva Bertoli1 | Carolina Dea Bruzamolin1 |
Graciely Osternack de Almeida Kranz1 | Estela Maris Losso1 |
Joao Armando Brancher1 | Juliana Feltrin de Souza2
1
Dentistry Departament, Universidade
Positivo, Curitiba, Brazil
2
Department of Stomatology, Universidade
Federal do Paraná, Curitiba, Brazil
Correspondence: Juliana Feltrin de Souza,
Department of Stomatology, Universidade
Federal do Paraná, Av. Prefeito Lothário
Meissner 632, 80060-240 Curitiba, Brazil
(julianafeltrin@hotmail.com).
J Oral Rehabil. 2018;1–9.
| Accepted: 30 June 2018
Summary
Background: Temporomandibular Disorders (TMD) is a multifactorial condition,
which could be associated to occlusal and psychological factors, such as anxiety.
Objective: Investigate if anxiety and malocclusion are associated with the prevalence
of TMD in adolescents.
Methods: To ensure a population-­based representative sample, 934 adolescents
aged 10 to 14 years old from Curitiba-­PR, Brazil were randomly selected and exam-
ined according to Research Diagnostic Criteria for Temporomandibular Disorders
(RDC/TMD) and malocclusion by a single-­calibrated examiner (Kappa > 0.80).
Anxiety was assessed according to trait anxiety (STAI-­T ), categorised as high, moder-
ate and low levels. For occlusal exam, it was considered: Angel’s molar relationship,
anterior and posterior crossbite, excessive overjet, open and deep bite. The associa-
tions were analysed by the crude and adjusted prevalence ration (RPa) of TMJ, calcu-
lated by a Poisson multivariate regression with robust variance (α = 0.05).
Results: The prevalence of at least one type of malocclusion was found in 52.3%.
Anxiety was found in high level (12.2%), moderate (70.4%) and low (17.5%). Presence
of high anxiety was significantly associated with the prevalence of TMD symptoms
(RPa = 4.06, P < 0.001), as well as the prevalence of myofascial pain (RPa = 24.78;
P < 0.001) and prevalence of disc displacement with reduction (RPa = 11.08,
P < 0.001). Adolescents Class II had higher prevalence of myofascial pain (Class II
RPa = 1.73; P < 0.015) than adolescents Class I. Adolescents Class III presented
higher prevalence of myofascial pain (PRa 2.53; P = 0.004) than adolescents Class I.
Conclusion: Anxiety is strongly associated with TMD in adolescents. Presence of
Class II or III is associated with higher prevalence of myofascial pain in adolescent-
sPLESAE check and approve the edit made in the article title.
KEYWORDS
adolescent, anxiety, malocclusion, temporomandibular joint disorders
wileyonlinelibrary.com/journal/joor
© 2018 John Wiley & Sons Ltd | 1
2 |
1 | BAC KG RO U N D
The temporomandibular disorders (TMD) is a term related with
dysfunctions-­affected masticatory muscles, temporomandibular
joint (TMJ) and associated structures, characterised by joint and/
or muscular pain, joint noises and limited or irregular mandibular
function. It can affect quality of life considerably.1 The American
Academy of Pediatric Dentistry (AAPD) recognises that disorders
of the temporomandibular joint (TMJ), masticatory muscles, and
associated structures occasionally occur during childhood and ad-
olescence, 2 but with less intensity than in adult populations. The
signs and symptoms in this population are usually mild to moder-
ate, furthermore the prevalence of signs and symptoms related to
temporomandibular disorders can be explained by the develop-
ment stage of craniofacial growing, that has a lot of morphological
changes. 3
The aetiology of TMD has been considered to be one of the most
4
controversial issues in clinical dentistry. The most acceptable the-
ory regarding TMD aetiology is based on the biopsychosocial model
with a biological disorder that may have psychological antecedents,
such as anxiety and this situation exists in a social framework in
adults.5
It is well known that psychosocial problems in children and ad-
olescents are more frequent than in the past, 5 and also that they
are an association of mental disorders and physical diseases in ad-
olescents with mental-­p hysical comorbidity. 6 In adolescents, there
is a positive correlation between increased age and the presence
of signs and symptoms of TMD, so the emotional aspects seem
to be significant factors in the presence of those disorders. 5,7
Furthermore, there is a high prevalence of malocclusion in chil-
dren and adolescents, which is considered a public health problem
in the world and the third priority in oral care. Occlusal abnormal-
ities may be associated with TMD, headache, facial growth and
muscles function alterations. 8
Regarding to the multifactorial aetiology of TMD, the identifi-
cation of signs and symptoms of TMD in adolescents as well as the
factors associated to it can improve the ability to detect earlier the
TMD in this age. Once, it is fundamental to prevent or minimise TMD
pain and to reduce its impact on adolescent’s quality of life.9 Thus,
the aim of this cross-­sectional study was to investigate if anxiety and
malocclusion are associated with the prevalence of diagnosed TMD
in adolescents.
2 | M E TH O DS
This study received the approval from the Research Ethics
Committee of Universidade Positivo (Process no. 879.404). This
cross-­sectional study included adolescents aged 10-­14 years old at-
tending public and private schools in the city of Curitiba, Paraná,
Brazil. The city has approximately 1.893.997 inhabitants and has a
Human Development Index of 0.823. The schools are geographically
distributed in 9 sanitary districts. The participants received written
de PAIVA BERTOLI et al.
information about the study, and signed consent was obtained from
a parent for all participants. The study followed the Declaration of
Helsinki guidelines.
2.1 | Study population
The sample size calculation considered 5% accuracy, a confidence
interval (CI) of 95%, a previous prevalence of TMD in adolescents
of approximately 25.5%,10 considering the effect of stratified sam-
pling (1.5), a representative sample should be 800 adolescents. For
a stratified representative probabilistic population-­based sample,
a random sampling procedure was applied to select a proportional
sample by sanitary district and teaching systems using the website
(http://www.randomizer.org). A total of 19 schools, 2 per sanitary
district, were randomly selected according described by Bertoli
et al.11
The exclusion criteria were individuals with pain of odon-
togenic origin, orthodontic appliances, occlusal splints, dental
prostheses, severe facial or dental anomalies, teeth with exten-
sive coronary destruction, systemic disorders with cognitive
or behavioural problems, speech disorders; those using medi-
cations such as antidepressants, muscle relaxants and non-­
steroidal anti-­inflammatory drugs; or adolescents who declined
to participate.
2.2 | Data collection
Previously, a pilot study was performed at a private school in
Curitiba, which was not considered as part of the study sample.
The questionnaire was pre-­tested, it was considered adequate for
the study population and no alterations were made. One examiner
(F.M.P.B.) with more than 10 years of practice calibrated for the clini-
cal RDC/TMD criteria, examined twice a sample of 30 adolescents
aged 10-­14 years old with an interval of 15 days.
The intra-­examiner coefficient of concordance kappa for TMD
according to the RDC/TMD was > 0.80. In addition, questions about
general health and for adolescent girls about menarche were applied.
The clinical examination was performed from September 2014
to July 2016. First, an explanation about TMD and about the aims
of the research was made to school principal. Later, the adolescents
were invited to participate in the study and were given a letter to
hand over to their parents or legal guardian. The letter contained
a general presentation of the research aims and a term of free and
informed consent, authorising the adolescent’s participation in the
study.
2.3 | TMD screening
For TMD screening, the presence of self-­reported symptoms of TMD
was determined using a valid Portuguese version of the self-­reported
questionnaire by the American Academy of Orofacial Pain (AAOP).
This questionnaire was previously validated by Franco et al., show-
ing good reliability and validity for screening for TMD in Brazilian
de PAIVA BERTOLI et al. | 3

adolescents.10 It is composed of 10 dichotomous questions about TA B L E 1 Characteristics of the population (Curitiba, Paraná,
TMD symptoms. This questionnaire was used to screen patients Brazil, 2016)
who were examined. Then, all participants included in the inclusion Characteristics n (%)
criteria (934) answered this questionnaire but, just the adolescents
Age N = 934
that have at least one positive answer were examined (n = 345).
10 260 (27.8)
11 321 (34.3)
2.4 | Clinical examination 12 207 (22.1)

The clinical examination was carried out in schools. The adolescents 13 87 (9.3)
and the researcher remained seated in chairs in front of a window in 14 59 (6.3)
order to obtain the maximum natural lighting. Mean age (SD) 11.32 (1.15)
The clinical examination was composed by intra-­oral examina- Gender N = 934
tion of malocclusion, and TMD examination. The TMD examination Female 518 (55.4)
was performed according to the protocol of the Portuguese version Male 416 (44.5)
of the RDC/TMD Axis I. The participants were diagnosed accord-
Anxiety level N = 921
ing to RDC/TMD in 3 groups: Group I, Muscle Diagnosis (myofas-
Low Anxiety 161 (17.48)
cial pain and myofascial pain with limited opening); Group II, Disc
Moderate Anxiety 648 (70.36)
displacements (with and without reduction); Group III (Arthralgia,
High Anxiety 112 (12.16)
Osteoarthrosis and Osteoarthritis), as described by Bertoli et al.11
Mean IDATE (SD) 38.97 (8.78)
The criteria for occlusion exam12 were based on Anteroposterior
molar relationship were established by Angel’s classification: Class I, Malocclusion N = 934

Class II, Class III on both sides. These classifications were mutually Yes 489 (52.3)

exclusive. The cases with the molars in one side being in Class I and No 445 (47.6)
on the other side in Class II or Class III relationship were excluded Angle’s Classification N = 934
because of the difficulties of classification. Anterior Crossbite was Class I 773 (82.7)
noted when 2 or more maxillary anterior teeth were located lingual Class II 1 division 109 (11.7)
to the mandibular anterior teeth. Posterior Crossbite was deter- Class I 2 division 25 (2.6)
mined when 2 or more maxillary posterior teeth were located lin- Class III 23 (2.4)
gual to the mandibular posterior teeth.13 Open Bite was recorded
Occlusal Factors N = 931
if the vertical overbite was negative. Deep Bite: was determined if
Anterior Open Bite 35 (3.7)
the anterior upper teeth covered more than half the length of the
Anterior Crossbite 21 (2.2)
crowns of the lower anterior teeth. Excessive Overjet was recorded
Posterior Crossbite 54 (5.8)
when the measured distance between the labial surface of the upper
Excessive Overjet 170 (18.2)
incisor and the labial surface of the lower incisor was greater than
4 mm. 13 Deep Bite 208 (22.2)
Crowding 98 (10.5)

2.5 | Anxiety evaluation

The anxiety was assessed according to the State-­Trait Anxiety
Inventory (STAI),14 the trait anxiety part (STAI-­T ), which evaluates
personality are composed by 20 questions. The 4 response catego-
ries for trait anxiety questions are 1 (almost never), 2 (sometimes),
3 (frequently) and 4 (almost always). The scores for each scale var-
ied from 20 to 80 with distinct counts, in which higher scores indi-
cated higher anxiety. The scales were validated by Gorenstein and
15
Andrade, presenting moderate sensitivity for children and adoles-
cents.16 Individuals were classified as low anxiety, with scores <33;
moderate anxiety with scores between 34 and 49; and as high anxi-
ety with scores >50. The classifications for trait anxiety are relatively
stable, whereas the classifications for state anxiety can vary rapidly
as a function of anxiogenic stimuli.14 The total score for each part
was calculated by summing the score for all 20 items and was used to
categorise participants as having mild anxiety (20-­30 points), moder-
ate anxiety (31-­49 points) or severe anxiety (≥50 points).
2.6 | Data analysis
Data were analysed using SPSS 20.0 (SPSS, Chicago, IL, USA) and
STATA software (Stata Corporation, college station, Texas, US). The
dependent variables were TMD, which were categorised in presence
and absence of TMD symptoms by the AAOP questionnaire, as well
as, the signs of TMD according to the examination were categorised
in myofascial pain and myofascial pain with limited opening, Disc dis-
placements (with and without reduction), Arthralgia, Osteoarthrosis
and Osteoarthritis according to the RDC-­TMD criteria. The independ-
ent variables were anxiety and malocclusion.
4 | de PAIVA BERTOLI et al.

The associations between TMD and independent variables were
analysed using Multivariate Poisson regression model with robust vari-
ance were constructed to investigate the association between TMJ
symptoms, myofascial pain and disc displacement with reduction and
independent variables, which permits estimating the prevalence ratios
(PR) and respective 95% confidence interval (CI). The adjusted prev-
alence ratios (PRa) were calculated considering independent variables
with P < 0.20. Significance level of 0.05 was adopted.
3 | R E S U LT S
A total of 4.055 adolescents were invited to participate in the pre-
sent study. Nine hundred and thirty-­four adolescents returned the
written consent, met the inclusion criteria, agreed to participate, and
were present when the evaluations were performed. The sample was
composed by 55.4% (n = 518) girls. Table 1 presents the age, gender,
anxiety and occlusal characteristics of the study population.11
3.1 | TMD symptoms results
The association between TMD symptoms and the independent vari-
ables are shown in Table 2. The TMD symptoms were significantly
associated with anxiety (P < 0.001). Adolescents with high anxiety
level had TMD symptoms prevalence of 4.06 times (RPa = 4.06; 95%
CI, 2.82-­5.85, P < 0.001), while adolescents with moderate anxiety
level had the TMD symptoms prevalence of 1.94 times (RPa = 1.94;
95% CI, 1.36-­2.79), independently of the gender (Table 2).
Considering the association of TMD symptoms and malocclu-
sions, there is no significant association between TMD symptoms
and anteroposterior molar relationship or other malocclusions
(Table 2).

TA B L E 2 Association between prevalence of TMD symptoms and independent variables (Curitiba, Parana, Brazil, 2017)

TMD [n (%)]

Total
Characteristics Yes No n PRc (95% CI) P value PRa (95% CI) P value

Age (y)
10 86 (33.08) 174 (66.92) 260 1.00
11 112 (34.89) 209 (65.11) 321 1.05 (0.83-­1.32) 0.647
12 69 (33.33) 138 (66.67) 207 1.00 (0.77-­1.30) 0.953
13 38 (43.68) 49 (56.32) 87 1.32 (0.98-­1.77) 0.065
14 21 (35.59) 38 (64.41) 59 1.07 (0.73-­1.58) 0.709
Gender
Male 120 (28.85) 296 (71.15) 416 1.00 0.001 1.00 0.026
Female 206 (39.77) 312 (65.10) 518 1.37 (1.14 -­1.65) 1.23 (1.02-­1.48)
Malocclusion
Malocclusiona 179 (36.61) 310 (63.39) 489 1.10 (0.92-­1.32) 0.254
Anterior Open Bite 13 (37.14) 22 (62.86) 35 1.06 (0.68-­1.65) 0.777
Anterior Crossbite 6 (28.6) 15 (71.4) 21 0.81 (0.41-­1.61) 0.557
Posterior Crossbite 18 (33.3) 36 (66.7) 54 0.95 (0.64-­1.40) 0.805
Excessive Overjet 77 (45.29) 93 (54.71) 170 1.39 (1.14-­1.69) 0.001 1.17 (0.96-­1.42) 0.118
Deep Bite 80 (38.46) 128 (61.54) 208 1.13 (0.93-­1.39) 0.205
Crowding 29 (34.84) 69 (70.41) 98 0.83 (0.60-­1.14) 0.267
Angle’s Classification
Class I 258 (33.51) 514 (66.49) 773 1.00
Class II 55 (41.04) 79 (58.96) 134 1.22 (0.97-­1.53) 0.078
Class III 10 (43.48) 13 (56.52) 23 1.29 (0.80-­2.09) 0.284
Anxiety level
Low Anxiety 27 (16.77) (81.99) 161 1.00 1.00
Moderate Anxiety 214 (33.02) 418 (64.51) 648 1.96 (1.37-­ 2.82) <0.001 1.94 (1.36-­2.79) <0.001
High Anxiety 80 (71.43) 31 (27.68) 112 4.25 (2.96-­6.12) <0.001 4.06 (2.82-­5.85) <0.001

PRc, Crude Prevalence ratio; PRa, Adjusted Prevalence ratio; CI, confidence interval;
a
It was computed at least one type of malocclusion.
de PAIVA BERTOLI et al. | 5

3.2 | Myofascial pain results
Regarding myofascial pain, it presented a strong and positive sig-
nificant association with anxiety and anteroposterior molar rela-
tionship. Adolescents with high anxiety level presented myofascial
pain prevalence of 24.78 times (RPa = 24.78; 95% CI, 5.98-­102.57,
P < 0.001), independent of the other characteristics (Table 3). When
the occlusal factors were considerate, adolescents Class II presented
myofascial pain prevalence of 1.73 times (RPa = 1.73; 95% CI 1.12-­
2.70; P = 0.015). Adolescents Class III presented myofascial pain
prevalence of 2.53 times (RPa = 2.53; 95% CI 1.34-­4.71; P = 0.004)
than adolescents Class I (Table 3).
(RP = 11.08; 95% CI, 3.70-­37.99; P < 0.001). Adolescents with mod-
erate anxiety levels presented disc displacement with reduction
prevalence of 3.35 times (RP = 3.35; 95% CI, 1.05-­10.67; P = 0.035).
Considering the relation between disc displacement with reduction
and malocclusions, there is no significant association between them
(Table 4).
Myofascial pain with limited opening and arthralgia were ob-
served in few cases, no relation with the independent variables was
observed.
4 | D I S CU S S I O N

Considering the multifactorial exposures involved on the individu-

3.3 | Disc displacement with reduction results
Disc displacement with reduction presented also a significant as-
sociation with anxiety. Adolescents with high anxiety levels pre-
sented disc displacement with reduction prevalence of 11.08 times
als with TMD, the present study aimed to investigate the role of
malocclusion and anxiety on TMD in adolescents. Malocclusion was
collected as a local factor, anxiety as an emotional/psychological
factor, and individual independent characteristics such as age and

TA B L E 3 Association between myofascial pain and independent variables (Curitiba, Paraná, Brazil, 2017)

Myofascial [n (%)]

Total
Characteristics Yes No n PRc (95% CI) P value PRa (95% CI) P value

Age (y)
10 24 (9.23) 236 (90.77) 260 1.00 -­
11 31 (9.66) 290 (90.34) 321 1.04 (0.62-­1.73) 0.861
12 17 (8.21) 190 (91.79) 207 0.88 (0.49-­1.61) 0.700
13 13 (14.94) 74 (85.06) 87 1.61 (0.86-­3.03) 0.134
14 11 (18.64) 48 (81.36) 59 2.01 (1.04-­3.89) 0.036
Gender
Male 30 (7.21) 386 (92.79) 416 1.00 0.007 1.00 0.078
Female 66 (12.74) 452 (87.26) 518 1.76 (1.17-­2.66) 1.45 (0.95-­2.20)
Anxiety level
Low Anxiety 2 (1.24) 159 (98.76) 161 1.00 1.00
Moderate Anxiety 54 (8.33) 594 (91.67) 648 6.70 (1.60-­27.24) 0.008 6.66 (1.63-27.23) 0.008
High Anxiety 38 (33.93) 74 (66.07) 112 27.3 (6.72-­110.98) <0.001 24.78 (5.98-102.57) <0.001
Malocclusion
Malocclusiona 55 (11.25) 434 (88.75) 489 1.22 (0.83-­ 1.79) 0.308
Anterior Open Bite 13 (37.14) 22 (62.86) 35 0.55 (0.14-­2.14) 0.390
Anterior Crossbite 2 (9.52) 19 (90.48) 21 0.93 (0.24-­3.53) 0.917
Posterior Crossbite 2 (3.70) 52 (96.30) 54 0.34 (0.08-­1.38) 0.134
Excessive Overjet 29 (17.06) 141 (82.94) 170 1.96 (1.31-­2.94) 0.001 1.40 (0.91-­2.15) 0.115
Deep Bite 23 (10.22) 185 (88.94) 208 1.10 (0.71-­1.72) 0.648
Crowding 8 (8.16) 90 (91.84) 98 0.78 (0.39-­1.56) 0.484
Angle’s Classification
Class I 69 (8.93) 704 (91.07) 773 1.00
Class II 20 (14.93) 114 (85.07) 134 1.67 (1.05-­2.65) 0.010 1.73 (1.12-­2.70) 0.015
Class III 6 (26.09) 17 (73.91) 23 2.92 (1.41-­6.02) 0.001 2.53 (1.34-­4.71) 0.004

PRc, Crude Prevalence ratio; PRa, Adjusted Prevalence ratio; CI, confidence interval.
a
It was computed at least one type of malocclusion.
6 | de PAIVA BERTOLI et al.

TA B L E 4 Association between disc displacement with reduction and independent variables (Curitiba, Paraná, Brazil, 2017)

Disc Displacement with Reduction [n (%)]

Total
Characteristics Yes No n PRc (95% CI) P value PRa (95% CI) P value

Age (y)
10 17 (6.54) 243 (93.46) 260 1.00 -
11 29 (9.03) 292 (90.97) 321 1.38 (0.77-­2.45) 0.271
12 15 (7.25) 192 (92.75) 207 1.10 (0.56-­2.16) 0.764
13 9 (10.34) 78 (89.66) 87 1.58 (0.73-­3.42) 0.244
14 5 (8.47) 54 (91.53) 59 1.29 (0.49-­3.37) 0.595
Gender
Male 21 (5.05) 395 (94.95) 416 1.00 0.004 1.00 0.040
Female 54 (10.42) 464 (89.58) 518 2.06 (1.26-­3.36) 1.68 (1.02-­2.77)
Anxiety level
Low anxiety 3 (1.86) 158 (98.14) 161 1.00 1.00
Moderate anxiety 42 (6.48) 606 (93.52) 648 3.47 (1.09-­11.08) 0.035 3.35 (1.05-­10.67) 0.035
High anxiety 28 (25.00) 84 (75.00) 112 13.41 (4.17-­43.08) <0.001 11.08 (3.70-­37.99) <0.001
Malocclusion
Malocclusiona 42 (8.59) 447 (91.41) 489 1.15 (0.74-­1.79) 0.511
Anterior Open Bite 4 (11.43) 31 (88.57) 35 1.46 (0.08-­4.07) 0.596
Anterior Crossbite 1 (4.76) 20 (95.24) 21 0.59 (0.12-­2.31) 0.812
Posterior Crossbite 3 (5.56) 51 (94.44) 54 0.68 (0.22-­2.10) 0.511
Excessive Overjet 21 (12.35) 149 (87.65) 170 1.77 (1.09-­2.85) 0.019 1.40 (0.86 -­2.26) 0.168
Deep Bite 22 (10.58) 186 (89.42) 208 1.46 (0.91-­2.35) 0.112
Crowding 8 (8.16) 90 (91.84) 98 1.02 (0.50-­2.07) 0.936
Angle’s Classification
Class I 58 (7.50) 715 (92.50) 773 1.00
Class II 13 (9.70) 121 (90.30) 134 1.29 (0.72-­2.29) 0.380
Class III 2 (8.70) 21 (91.30) 23 1.15 (0.30-­4.46) 0.830

PRc, Crude Prevalence ratio; PRa, Adjusted Prevalence ratio; CI, confidence interval.
a
It was computed at least one type of malocclusion.

gender, considering an integral approach to identify the TMD. The
alterations in TMJ usually begin in young ages, thus it is important
to identify earlier the temporomandibular disorders as well as which
factors and characteristics are influenced on the TMD, to develop
a preventive care programme of TMD in children and adolescents.
Different from adulthood population, children and adolescents have
particularities such as the continual growth process of these struc-
tures, thus alterations in maxilomandibular relation or oral behaviour
(in consequence of anxiety) could result in a functional alteration or
pathological process at this age or adulthood.3 Our hypothesis was
confirmed in this study: adolescents with high level of anxiety pre-
sented higher prevalence of TMD (TMD symptoms or myofascial
pain or disc displacement with reduction). Moreover, adolescents
Class II and Class III presented higher prevalence of myofascial pain.
The main finding of this study was the strong positive significant
association between anxiety and TMD. In this study, anxiety was
statistically significant associated with TMD, considering the TMD
symptoms, myofascial pain and disc displacement with reduction.
Thus, anxiety was the unique characteristic that maintains associ-
ated with all types of TMD, independent of other characteristics. In
adulthood, patients with myofascial pain have reported more severe
symptoms of depression and anxiety, compared to those reported
by normal, pain-­free individuals.17 Which is in agreement with other
studies.7,18,19 In children, similar results were found by Pizolato
et al.,7 in a case-­control study. The authors found that the children
with anxiety presented the chance of 18.06 to have TMD.
There were a few studies considering TMD and anxiety in chil-
dren and adolescents.7,20 Children, in general, can be assumed to
develop anxiety more than depression, which usually appears more
frequently in adolescence.7 In this study, the prevalence of anxiety
was high, around 70% of the sample presented moderate anxiety
and around 12% presented high anxiety. The levels of anxiety were
assessed according to the State-­Trait Anxiety Inventory (STAI),14
the trait anxiety part (STAI-­T ), which detects the personality are
de PAIVA BERTOLI et al.
composed. This tool has been usually used in the literature, present-
ing high accuracy in measuring anxiety. 21 In a case-­control study,
Pizolato et al.7 observed that 57.5% of children aged 8 to 12 years
old presented anxiety. In a Japanese cross-­section study, Karibe
et al. 20 evaluated the relation between TMD symptoms by RDC cri-
teria and anxiety by STAI in Japanese adolescents aged 11-­15 years
old. The authors found a significant higher mean of anxiety in the
group with TMD symptoms (STAI mean of 38.9) than control group
(STAI mean of 35.0). This mean of anxiety is similar to our results.
A possible explanation for the relation between TMD pain and
anxiety might be due to the fact that anxiety exacerbates the mas-
ticatory muscle tension by clenching and grinding.5,20 This was also
observed by Bertoli et al (2007), who found a significant difference
in the signs and symptoms of TMD according to emotional status.
The authors described higher TMD symptoms in children with tense
status compared to calm status. 22 Karibe et al20 found a significant
association between head-­forward posture, diurnal clenching and
nocturnal tooth grinding with TMD in adolescents.
Studies have used RDC/TMD in children and adolescents, show-
10
ing good reliability. These diagnostic criteria have been used as
gold standard for both children and adults, improving clinical TMD
exam accuracy and reproducibility. However, the recently published
23
Diagnostic Criteria for TMD (DC/TMD), are not yet validated for
children5 neither for Portuguese language. Moreover, the conven-
tional RDC/TMD criteria is the most acceptable and well-­known
10
standard for diagnosing TMD in researches. Considering that the
prevalence of diagnosis of at least one TMD type was 22% and that
signs and symptoms can increase with age, clinicians and pediatric
dentists should be prepared to diagnose early TMD signs for man-
agement of this condition.
Another important finding of this study was the association be-
tween malocclusions and TMD. Adolescents class II and Class III also
associated with higher prevalence of myofascial pain. The relation
between Angle molar relationship and TMD is controversial on the
literature. Thilander (2002)24 evaluated 4724 children and adoles-
cents (5-­17 years old) and Bilgiç (2017)25 examined 923 children (7-­
12 years old) found a significant association between Class III and
26
TMD. Other authors found no evidence of this relationship. We
observed a strong positive association between Class III malocclu-
sion and TMD. Class III malocclusion can be an important role in the
deviation of the temporomandibular joint components and also on
25
the masticatory muscle tenderness.
Although excessive loading may stress the masticatory mus-
cles, 25 in this study the association between excessive overjet and
TMD was not significant in the multiple regression analysis. In a bi-
variate analysis, TMD symptoms have a statistically significant rela-
tionship with excessive overjet as well as myofascial pain and disc
displacement with reduction. It could be explained because exces-
sive overjet could be related with Class II malocclusion. To Demir
et al, 26 that evaluated the association of occlusal factors with masti-
catory muscle tenderness in 10 to 19 years old, excessive overjet in-
creased masseter and lateral pterygoid muscle tenderness. 26 Other
studies confirm the relation between TMD and anterior open bite, 27
| 7
posterior crossbite, 27,28 crowding of teeth13; maxillary overjet.12
However, our results showed that Angle’s molar relationship and
anxiety influenced on TMD symptoms and myofascial pain.
Regarding to the occlusal abnormalities, from total of 935 ado-
lescents who were examined, the prevalence of malocclusion was
52.3%. It is more than those observed in the last oral health survey
carried out by the Ministry of Health (SB Brazil). In 2010, there was
an occurrence of malocclusions were 38.8% at the age of 12 years
old. Our results are near to the related by Jordão who found a
prevalence of 40.1%, when examined 2.075 Brazilian people aged
12 years old. 29 Higher prevalence were found in other studies, such
as in a systematic review in Iran population (54.6%)30 and in a cross-­
sectional study that included 2366 Indian students aged 10-­12 years
old (83.3%).31
Considering the Angle criteria, the present study verified prev-
alence which were similar to those observed by Demir (2015) in
Turkish Caucasian adolescents, Class I (76%), Class II.1 (15.6%), Class
II.2 (4.7%) and Class III (3%).26 In this study, the most prevalent was
deep bite (22.2%), which corroborates with by Pizolato7 in the sam-
ple at mixed and permanent dentition.
These malocclusions should be treated orthodontically in ado-
lescents and eliminate the occlusion problem, 27 but the question of,
if the orthodontic treatment will prevent or reduce the development
of TMD is still open in literature. 24 However, it is not possible to pre-
dict the risk of temporomandibular dysfunction based on the pres-
ence or absence of malocclusion. These patients should be followed
longitudinally to develop recommendations for adequate treatment
planning in the future. It seems logical to assume that some maloc-
clusions should be treated early to take advantage of the craniofa-
cial growth and thereby achieve the greatest possible adaptation in
function. 25
Analysing the strong influence of anxiety on the TMD, a limita-
tion of the present study has not evaluated the daily activities re-
garding the parafunctional habits, such as head-­forward posture,
diurnal clenching and nocturnal tooth grinding. Other limitation of
the present study could be related to the external validity of the
data, once the study had strict exclusion criteria as well as criteria
for occlusal exam, such as severe facial abnormalities were not eval-
uated in this study. Future studies should be considering a longitu-
dinal study design to confirm these factors as the predictor factors
to TMD, as well as the role of parafunction habits on this relation.
Therefore, the pediatric dentistry should take in account
these factors in a preventive TMD approach, considering treat-
ment for psychological disorders in a multidisciplinary approach.
Consequently, an interdisciplinary approach from both dental clini-
cians and psychologists is a prerequisite for a successful therapy in
patients suffering from TMD.32
5 | CO N C LU S I O N
It can be concluded that TMD in Brazilian adolescents was multi-
factorial condition, in which anxiety is strongly associated with
8 |
TMD diagnosis. Some malocclusions showed association with TMD,
mainly the presence of Class II and Class III were associated with
higher prevalence of myofascial pain in adolescents.
AC K N OW L E D G M E N T S
The study was approved by the Research Ethics Committee of
Universidade Positivo (Process no. 879.404). The study did not re-
ceive any founding source.
D I S C LO S U R E
The authors have stated explicitly that there are no conflicts of inter-
est in connection with this article.
ORCID
Juliana Feltrin Souza http://orcid.org/0000-0001-9969-3721
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