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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 4  |  Page : 414-420

Evaluation of dentition status and temporomandibular joint disorders in patients with chronic neck and/or back pain – A cross-sectional study

Department of Oral Medicine and Radiology, Vasantdada Patil Dental College and Hospital, Sangli, Maharashtra, India

Date of Submission27-May-2021
Date of Acceptance24-Nov-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Pradnya Chandanshive
Plot No. 146, Survey No. 41/B, New Mukindwadi, Aurangabad - 431 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_146_21

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Background: The stomatognathic system (SS) is a functional unit of the body formed by the orofacial structures, together with peripheral sensory and motor neuronal connections to perform different functions like mastication, speech, and deglutition. Stomatognathic system consists of skeletal components (maxilla and mandible), dental both maxillary and mandibular arches, soft tissue (salivary glands, their nervous and vascular supplies), and temporomandibular system, that is, temporomandibular joints (TMJ; which connects the mandible to the base of the skull), muscles of mastication and their ligaments and nerves (III, IV, V, XI) which regulates and co-ordinates all its structures. The stomatognathic system also plays an important role in postural control. In balance of imbalance stomatognathic system components such as occlusion may cause temporomandibular joint disorder (TMD), TMDs may affect neck and back muscles. Aims and Objectives: To evaluate the dentition status and TMDs in patients with chronic neck and/or back pain and to correlate dentition status and TMDs in both neck and back pain patients. Material and Methods: A cross-sectional study was carried out on 300 patients. Patients were selected according to inclusion and exclusion criteria. Findings were noted in specialized case history proforma. Results: Out of 300 patients, 116 (38.67%) were males and 184 (61.33) were females. The mean age of patients referred for the study was 38.09 years. The most common dental finding in both chronic neck and/or back pain patients was flat curve of Wilson's (90%) whereas the least finding found was Grade III tooth mobility (0.04 ± 0.31 teeth). In TMDs most common finding was deviation of jaw (79.3% in neck and 100% in back pain) whereas the least finding found was deflection of jaw (50% in neck and 48.2% in back pain). Statistical analysis: The result was found highly significant (p-value <0.05). Conclusion: There was an association between disturbed dentition status, temporomandibular joint disorders, chronic neck and back pain.

Keywords: Dentition status, neck and back pain, temporomandibular disorders

How to cite this article:
Chandanshive P, Kshar A, Byakodi R, Paranjpe A, Awale S, Shete MK. Evaluation of dentition status and temporomandibular joint disorders in patients with chronic neck and/or back pain – A cross-sectional study. J Indian Acad Oral Med Radiol 2021;33:414-20

How to cite this URL:
Chandanshive P, Kshar A, Byakodi R, Paranjpe A, Awale S, Shete MK. Evaluation of dentition status and temporomandibular joint disorders in patients with chronic neck and/or back pain – A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2023 Jan 28];33:414-20. Available from: http://www.jiaomr.in/text.asp?2021/33/4/414/333862

   Introduction Top

The stomatognathic system (SS) is a functional unit of the body which plays an important role in postural control.[1] Postural adjustments are the result of a complex system of mechanisms (feed-back and feed-forward) that are controlled by multisensory inputs integrated in the central nervous system and play a critical role in orthostatic and dynamic postural control, influencing the ability to perform daily living activities.

Evidence continues to accumulate those untreated diseases of SS, in particular like temporomandibular disorders (TMDs) and dental malocclusion, both leads to changes in their head and shoulder positions.[1] TMJ is a load-bearing joint and bruxism loads the joint excessively.[2] Recent studies emphasize the potential role of dental occlusion and of trigeminal afferents in maintaining postural control. For example, a change in the mandibular position, can lead to changes in the proprioceptive and periodontal afferents, which affect the center of foot pressure (COP) position and gait stability.[1]

Furthermore, patients with cervical spine disorders (generally by dysfunction of muscular origin like cervical lordosis and cervical spondylosis)[2] show higher frequencies of malocclusion than control patients; these include Angle Class II malocclusions, lateral cross-bites, lower midline deviations, and facial asymmetries. When the occlusal relationship is lost either unilaterally or bilaterally, the body posture may take on an unusual position, causing neck or shoulder pain.

In particular, the TMJ makes muscular and ligamentary connections to the cervical region, forming a functional complex called the “craniocervico-mandibular system”. The extensive afferent and efferent innervations of the stomatognathic system are reflected in the extensive representation of the oro-facial district in the motor and sensory areas of the cerebral cortex.[1]

The primary aim of this study was to evaluate the dentition status and TMDs in patients with chronic neck and/or back pain, thereby providing awareness of the fact that a postural disorder is an alteration with both medical and dental field, to promote an interdisciplinary approach in treating patients with postural disorder with specialists such as Otolaryngologist, Neurologist, Orthopedic Surgeon, Cardiologist and Psychiatrist.

   Material and Methods Top

The convenience samplings were obtained from the Department of Oral Medicine and Radiology of a Dental College and Orthopedic OPD, after the approval of the Institutional Ethical Review Board (reference no. 672/17-18, Date- 12/10/2017) & superintendent of civil hospital, clearance was taken for cross-sectional study to conduct on 300 patients. and followed the principles of Helsinki declaration, proposed in 1964 and modified in 2000.

Sample size derivation: Formula of calculating sample size (descriptive/cross sectional/survey study) was n = Z12 x {P (1-P)}/d2

Assuming all the factors, sample size comes around 254 rounded to 300 subjects in this study. Each patient was selected according to inclusion and exclusion criteria.


  1. Patients with neck and/or back pain.
  2. Patient age between 18 to 70 years (both Male and Female)
  3. Patients with TMDs (as per RDC/TMD criteria).


  1. History of spine surgery.
  2. Congenital anomalies.
  3. Neoplasm involving spine and TMJ.
  4. Osteomyelitis of TMJ.
  5. Osteoarthritis.
  6. Rheumatoid arthritis.
  7. Spondylitis of spine.
  8. Neuropathy.
  9. Non-Compliant Subjects.

A written consent was obtained from all patients before evaluation. Case history proforma was made. In dentition status findings such as mouth opening, protrusive/laterotrusive movement, Angle's molar and canine relationship, midline shift, missing teeth, teeth mobility, overjet/overbite, enamel cracks, attrition/abfraction, partially erupted third molars, Supra/infra- erupted teeth, tooth rotation, deep bite/open bite/cross bite, bruxism, fremitus test, Incisal/canine guidance and curve of Spee/Wilson's were seen. Visual analogue scale (VAS) was used to classify (VAS score 0 = no pain, VAS score 1-3 = mild pain, VAS score 4-6 = moderate pain, VAS score 7-10 = severe pain) chronic pain of neck (platysma, sternocleidomastoid and splenius Capitis,) and back superficial or extrinsic muscles (trapezius, letissimus dorsi, levator scapulae, rhomboid major and rhomboid minor). Diagnosis was documented based on RDC/TMD criteria (group I).

The statistical analysis was performed using statistical package for the social sciences (SPSS) version 16 for Windows (SPSS, Chicago, IL). Descriptive quantitative data was expressed in proportions (percentages). Various statistical tests (P < 0.05) Chi-square test, unpaired t test, and one-way analysis of variance F (ANOVA F) test were performed to find out various results based on the aim and objective of the study.

   Results Top

Out of total 300 patients mild neck pain (n = 29) was 9.66%, moderate neck pain (n = 199) was 66.34% and severe neck pain (n = 72) was 24% [Table 1] whereas no back pain (n = 4) was 1.3%, mild back pain (n = 147) was 49.2%, moderate back pain (n = 139) was 46.5% and severe back pain (n = 10) was 3% [Table 2].
Table 1: Neck pain categories based on cumulative severity in each neck muscle

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Table 2: Back pain categories based on cumulative severity in each back muscle

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The mean and standard deviation (SD) of the patient's age were 38.09 ± 12.43 (ranges 18-70) years old [Table 3], in which 61.33% of them were females and 38.67% were males [Table 4]. The most common dental finding in neck pain was flat curve of Wilson's followed by bruxism whereas the least dental finding was infra-eruption of teeth, grade I and grade II tooth mobility [Table 5] and [Table 6]. The most common dental finding in back pain was flat curve of Wilson's followed by bruxism whereas the least dental finding was grade I, grade II tooth mobility and infra-eruption of teeth [Table 7] and [Table 8].
Table 3: Age distribution in each gender

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Table 4: Gender distribution

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Table 5: Most prevalence of dentition status in neck pain patients

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Table 6: Mean±SD of various dental finding in neck pain patients

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Table 7: Prevalence of dentition status in back pain patients

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Table 8: Mean±SD of various dental finding in back pain patients

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   Discussion Top

TMDs are defined by the American Academy of Orofacial pain as a number of clinical problems involving the masticatory musculature, TMJs and their associated structures.[2] According to the National Institute of Dental and Craniofacial Research,[3] the prevalence of TMDs ranging from 5% to 12% with higher involvement of younger persons and twice the prevalence in women than men. TMDs leads to muscle weakness, muscle fatigue, TMDs associated pain is the 3rd most prevalent chronic pain condition worldwide after tension headaches and back pain.[4] TMD has multifactorial, etiologic musculoskeletal pain condition and are related to number of dental and medical condition.[5]

Most influential factors that affect head and neck position:

In understanding the relationship between the head, neck, shoulder, and TMJ one must know the neuronal connections between them. Neurons of the three divisions of the trigeminal nerve (CN V) and cranial nerve VII, IX, and X all interact within the sub-nucleus caudalis of the spinal nucleus of V within the brainstem. Also, interacting within this system are the C1, C2, and C3 [Figure 1]. The phenomenon of concurrent pain, suggests neurophysiological and structural convergence of cervical sensory and muscle afferent inputs into trigeminal subnucleus caudalis, nociceptive and non- nociceptive neurons sensory-motor system/craniocervical-mandibular system,[6] Owning to the increased pain sensitivity of the cervical muscles in TMDs patients develops silent functional disorders of the cervical spine patients with internal derangement of the TMJ before these patients develop the neck complaints which are typical of craniocervical dysfunction, decreased pain threshold of the masticatory muscles in patients with chronic neck pain.[7]
Figure 1: Most influential factors that affect head and neck position

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Our study is apparently the largest study evaluating dentition status and TMDs on 300 patients. Large sample sizes justify the need to review findings on dentition status and TMDs, as some rare findings can be visualized when a large sample size is used. Minimum aged individual in the study is 18 years & maximum aged individual is 70 years old. Mean age for total patient is 38.09 years with SD age of 12.43 years. Mean age for total male patients is 38.84 years with SD age of 11.56 years. The fourth decades of life, mention physiological difference of female gender due to regular hormonal variation, muscular structure, and estrogen receptor. In addition, in our study females were more sensitive to pain (P = 0.027) than males. Males (In our study 38.67%) may be at lower risk than females due to the protective effect of testosterone in combination with relatively low estrogen levels.[8]

In the present study the main symptoms of TMDs like range of mandibular movements (ROM) like mouth opening, painful jaw movements frequently lead to the changes in muscles of mastication activity that reduces motor symptoms such as mouth opening, protrusive and laterotrusive movements as well as the shift of the dental midline to protect it from further damage, while trying to promote healing in limited range of motion that affects chewing, social difficulty for the patients and might affect dental treatments.[9] In this study TMJ status showed deflection (P = 0.025 in neck pain (50%) and P = 0.042 in back pain (48.2%)), deviation (p value 0.016 in neck (79.3%) and P value 0.025 in back pain (66%)). In our study functionally the midline shift can be because of the presence of occlusal interferences leading to deflection of mandible. Jain et al.,[10] in 2015, found 77% midline deviation in routine clinical examination. Around 21% of patients showed upper dental midline shift, whereas 43% patients showed lower dental midline. Any shift in the midline can disturb the seating of condyle in the glenoid fossa or apply unequal functional forces.

In our study, the majority of patients show Angles Class I molar relationship (84.7%). Naïf A Bindayel et al.,[11] mention occurrence of molar relationship among males and females within the studied sample of patients with TMDs had a class I molar relationship (70.9%), followed by class II (21.1%) and class III molar relationship (8%).

Amira A. Aboalnaga, et al.,[12] mention prevalence for the left and right sides, Class I canine relation constituted 56.7% and 52.0% of the total sample, Class II 35.3% and 38.0%, and Class III 6.0% and 5.3%, respectively. The right side canine relation was statistically significant among the groups. Class I canine relation was most prevalent in Group 1 (M) (80.6%) and least prevalent in Group 4 (D) (20%). Class II canine relation was most prevalent in Group 4 (D) (80%) and least in Group 1 (M). The prevalence of Angles Class I canine (71%) relation in the presents study falls near this range.

In our study, facial asymmetry in neck (P = 0.023) and back pain (P = 0.037) subjects was 66.0%. In the study conducted by T. Nakamura et al.,[13] the healthy subject group also complained of neck or shoulder stiffness or pain, but the incidence was far lower than that in the patient group. In this study enamel cracks shows statistical significant result (P = 0.025) in neck pain subject.

The mean missing teeth in neck pain is 2.37 ± 4.56 whereas in back pain is 1.86 ± 3.84. This missing teeth is in congruence with study done by M. Q. Wang et al.,[14] where they indicate that individuals having fewer missing posterior teeth in more quadrants, have a higher prevalence of TMD, especially young women due to tightly locked occlusion.

Claudia L. Cruz et al.,[15] had done meta-analysis to found that static occlusal factors (overjet, overbite, open-bite, and cross-bite) had no significant association with TMD. In both neck and back pain patients results were consistent with our study for these occlusal factors.

Egle Mickeviciute et al.,[16] gave scientific literature to confirm the increased mechanical tooth surface wear leads to pathological tooth wear (PTW) and subsequently it progresses and cause TMDs. This hypothesis is in consistent with our study that showed attrition of 10 or more teeth in neck pain (P = 0.025) and 9 or more teeth in back pain patients. Enamel cracks in neck pain shows significant difference (P = 0.025).

Hussein Haleem Jasim et al.,[17] 2019, conducted a prospective study, where they concluded that impacted third molars were not considered to be an effective factor in the occurrence or development of TMJ clicking or sound. This result is in contrast with our study mean partial erupted teeth in neck pain (P = 0.606) where and back pain (P = 0.018) is effective.

Naser Azmi Rushdi Khayat et al.,[18] concluded that the posterior crossbite in the adolescent population may be related to TMDs, while in our study posterior crossbite was seen in 1% in neck pain and 0.7% in back pain subjects. The prevalence of anterior deep-bite seen was 69% in neck pain and 70% in back pain. Anterior cross bite in back pain shows statistical significant result (P < 0.001).

Adriano F. Lima et al.,[19] mentioned occlusal interference can cause the alteration of muscular tonus, which can lead to pain in muscles of mastication, head and neck muscles. In our study prevalence of posterior interferences on anterior guidance on left side was 51.7% in neck pain and in back pain 39.5% on right side. Canine guidance on left working side shows statistical signicant result (P = 0.027 in neck pain and back pain).

Ephraim Winocur et al.,[20] suggested TMDs are often associated with pain and/or parafunctional activities such as bruxism due to the various substances related to the dopaminergic, serotonergic and adrenergic systems ameliorate or exacerbate bruxism in humans and animals. This association of bruxism habit was in congruence with our study prevalence of 91.5% subjects in neck pain and 90.5% in back pain (P = 0.027).

Mohd Toseef Khan et al.,[21] mentioned positive fremitus test is the sign of pathological occlusion and subsequently TMDs. This positive fremitus test was in consistent with our study as 82.4% seen in neck pain and 81.6% in back pain.

Georgios et al.,[22] concluded that a flatter curve of Spee could possibly be a predisposing factor for the development of TMDs while deeper occlusal curvatures i. e. Curve of Spee and Wilson's are not associated with temporomandibular pain or pain of muscular origin.

The presence of referred pain in TMDs due to triple neuron reflex within cranial nervous system, is the reason why patients suffering from TMDs usually feel pain in different regions such as in the ear, forehead, temples, back of the head, cervical spine and shoulder girdle, as well as in the thoracic, lumbar and sacral spine or legs. Patients are directed from one doctor to another until, eventually, they visit their dentist, whereas the cause of their persistent pain is found to lies precisely in the masticatory motor system.[23]

Neck pain is defined by the International Association for the Study of Pain (IASP) – Based on anatomical location as a pain perceived anywhere in the posterior region of the cervical spine from the superior nuchal line to the first thoracic spinous process.[24] The prevalence of neck pain in the general population has been reported to range between 30% and 50%; with average prevalence for chronic neck pain is 11.5%. Whereas incidence is 30% to 43% in men and females respectively. The significant disability develops in 5% of neck pain population.[25]

Although neck pain was predominantly considered and treated in clinical practice as a neuro-musculoskeletal problem due to the close anatomical connection of the cervical region with the thoracic spine in parallel with their musculoskeletal and neural connection have led some researchers to believe that neck pain may lead to associated changes in thoracic spine and rib cage and consequential changes in pulmonary function.[26]

Back pain (BP) is multi-factorial in both etiology and management as it is radiating from various structures of the spine. In 2012 Global Burden of disease study reported that the low back pain and neck pain was one of the five top ranked causes for year lived with disability.[27] The term chronic back pain is generally used to describe pain that lasts more than three or six months, or beyond the point of tissue healing.[28] Mid-back pain (MBP) is defined as pain experienced in the body region between the 1st to 12th thoracic vertebrae and the corresponding posterior aspect of the trunk and it can occasionally cause radiating pain into the anterior chest wall. Low back pain (LBP) is discomfort, muscle tension or stiffness localized to the area around the lumbar spine.[29] Manchikanti et al.,[30] estimated the prevalence of spinal pain in the general population as 66%, out of this 44% of patients reported pain in the cervical region, 15% in the thoracic region and 56% in the lumbar region. 70% of all adults experience back or neck pain at some point in their lives, resulting in more than 15 million outpatient physician visits for back pain alone in a given year.

Limitation of study

  1. Being a cross-sectional study we could not find temporality of association between neck and back pain with orofacial aberration or other abnormalities.
  2. We advocate future research studies adopt longitudinal study with larger samples to confirm the findings and to correlation between dentition status, temporomandibular joint and neck and back pain over long period of time by full coverage occlusal splint therapy with specific interval follow up.

   Conclusion Top

This is the first study of evaluation of dentition status and TMDs in patients with chronic neck and/or back pain. During the study, we found there is association between disturbed dentition status, TMDs, chronic neck and back pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patients consent forms. In the form the patient(s) has/have given his/her their consent for his/her/their clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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