|Year : 2022 | Volume
| Issue : 3 | Page : 281-285
Prevalence of temporomandibular disorders and their correlation with gender, anxiety, and depression in dental students − A cross-sectional study
S Lokesh Kumar1, Zameera Naik2, Arun Panwar2, M Sridhar2, Anjana Bagewadi2
1 Department of Oral Medicine, Radiology, and Special Care Dentistry, Saveetha Dental College and Hospitals (SIMATS), 162, Poonamalle High Road, Chennai, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, KAHER'S KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka, India
|Date of Submission||01-Mar-2022|
|Date of Decision||17-Aug-2022|
|Date of Acceptance||18-Aug-2022|
|Date of Web Publication||26-Sep-2022|
S Lokesh Kumar
Senior Lecturer, Department of Oral Medicine, Radiology, and Special Care Dentistry (SIMATS), Chennai - 600 077, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: The role of anxiety and depression in causing temporomandibular disorders (TMDs) has been well established in the past; however, there are no studies on dental students that evaluate both the TMD and psychological factors. Aim: To determine the prevalence of TMD among dental students and its correlation with gender, anxiety, and depression. Materials and Methods: The study included 384 dental students (both undergraduates and postgraduates). The prevalence and severity of TMD were assessed with an anamnestic questionnaire. The severity of anxiety and depression was evaluated by Hospital Anxiety and Depression Scale after eliciting a detailed case history to include/exclude the participants. Statistical tests, including Shapiro-Wilk's, Chi-square, and Spearman's rank correlation coefficient, were done to check the normality distribution, association, and correlation, respectively. Results: The results revealed that 52.9% of the students had some degree of TMD. There was no statistically significant difference in the TMD severity between different gender (P = 0.373). About 51% of the students had anxiety, and 24% had depression. There was a statistically significantly high level of anxiety in females than in males (P = 0.046); however, not for depression (P = 0.312). There was a significant positive correlation between TMD severity and anxiety (P < 0.001) but not depression (P = 0.10). Conclusions: A high TMD prevalence was observed in dental students. There was a significant positive correlation between TMD severity with anxiety but not gender and depression. Psychological counseling and appropriate management are the need of the hour to prevent further complications.
Keywords: Anxiety, dental students, depression, gender, mental health, prevalence, temporomandibular disorders
|How to cite this article:|
Kumar S L, Naik Z, Panwar A, Sridhar M, Bagewadi A. Prevalence of temporomandibular disorders and their correlation with gender, anxiety, and depression in dental students − A cross-sectional study. J Indian Acad Oral Med Radiol 2022;34:281-5
|How to cite this URL:|
Kumar S L, Naik Z, Panwar A, Sridhar M, Bagewadi A. Prevalence of temporomandibular disorders and their correlation with gender, anxiety, and depression in dental students − A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:281-5. Available from: http://www.jiaomr.in/text.asp?2022/34/3/281/356970
| Introduction|| |
The temporomandibular joint (TMJ) is an area of interest for over a century; however, despite a considerable number of studies in this area, it is still a mystery. “Temporomandibular disorder (TMD) is a collective terminology that defines a subgroup of painful orofacial disorders involving the TMJ, craniofacial muscle fatigue, especially of the masticatory muscles, movement limitation of the jaws, muscle tenderness, and presence of articular clicking sound.” The etiology of such disorders is multifactorial, often attributed to occlusal interferences, emotional stress, malocclusion, masticatory muscle dysfunctions, intrinsic and extrinsic changes of the TMJ structure, parafunctional habits, and a combination of these factors., The role of psychological factors in the development of TMD has been highlighted, and is thought to predispose the patient to chronicity. The prevalence rate has been broadly reported to be from 26% to 50%, depicting the differences in population, criteria, and data collection method. TMDs are 1.5 to 2 times more prevalent in females than males, and 80% of the patients treated for the same are females. The gender difference is most evident in the 20−40 age group and least in children, adolescents, and the elderly.
Due to the high prevalence and variations in the symptoms, the diagnosis of TMD is frequently based on the signs and symptoms. Some features may be prevalent even in an unaffected population. Questionnaires have been designed for widely applicable simpler assessment procedures and standardizing the research samples by recording the main symptoms of TMD and the degree of severity. A simple self-administered questionnaire will be useful for easy and faster application at a lower cost. It also has the advantage of providing a severity index with less investigator influence on the subjects and their answers. The level of severity of the TMD is referred to as “TMD degree.”
Despite the high prevalence of TMD and its association with psychological factors, there are no studies that evaluate TMD as well as psychological factors among the Indian dental student population. Hence, this study aimed to determine the prevalence of TMD in Indian dental students and its association/correlation with gender, anxiety, and depression.
| Materials and Methods|| |
Design, setting, and sample size
This study was conducted among the undergraduate and postgraduate students of a private dental college in North Karnataka who were aged between 18 and 28 years, of either gender, after obtaining written informed consent. Ethical clearance was obtained from the Institutional Research and Ethics Committee with the reference number 09/01/2020/1349. The study was conducted in accordance to the “ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1964 and later versions.” The sample size (N) was estimated to be 512 with 15% attrition using the formula N = (Z1–α/2)2 (pq)/d2, where z = 1.96, α = 5%, d = 10, p = 0.53, q = 0.47).
A universal sample of 518 dental students was included after eliciting a detailed case history for the presence of any excluding factor. Dental students undergoing orthodontic treatment or any treatment for TMD and those with systemic, neurological, or musculoskeletal disorders and missing teeth were excluded from this study. The printed questionnaires in the English language were distributed to the included students, and enough time was given to fill the same without any time limit. Finally, 448 students were included based on the inclusion and exclusion criteria, out of which 384 students successfully submitted the filled questionnaires with a response rate of 85.7% (Attrition <15%).
Evaluation of TMD
The presence and severity of the TMD was assessed using a self-administered anamnestic questionnaire that had 10 closed-ended questions related to the common symptoms of TMD. This questionnaire was designed by Fonseca et al. in 1994 by modifying Helkimo's anamnestic index. It checks for the presence of symptoms related to TMD like pain in the TMJ, head, and back while mastication; limitation of movements; clicking; perception of malocclusion; etc. The students were asked to answer the multiple-choice questions with the options of “Yes and severe,” “Yes, Sometimes,” and “No” and were also limited to giving one response per question.
The scores were given based on the criteria laid down by Conti et al., which were as follows: A score of '0' for no symptoms (No), '1' for occasional symptoms (Sometimes), '2' for the presence of dysfunction (Yes), and '3' for severe/bilateral symptoms (Yes and severe). A score of '3' could be given only to questions 4, 6, and 7. The sum of the scores of all the 10 questions was calculated, and the inference was as follows: 0-3 = TMD-free; 4-8 = Mild TMD; 9-14 = Moderate TMD, and 15-23 = Severe TMD, which indicate the “TMD degree.”
Evaluation of psychological factors (anxiety and depression)
The Hospital Anxiety and Depression Scale (HADS) was used for self-rating anxiety and depression levels by the dental students. Zigmond and Snaith were the first to use this scale in their study. HADS is a 14-item closed-ended questionnaire in which 7 items relate to anxiety (HADSa) and 7 items related to depression (HADSd). The most salient feature of HADS is that it eliminates the somatic symptoms of anxiety and depression. The sum of the scores of anxiety-related items (HADSa) and depression-related items (HADSd), which indicate mental disorders, were calculated. They were inferred as follows: 0-7 = Normal; 8-10 = Mild; 11-14 = Moderate, and 15-21 = Severe.
Computerized data entry was done using Microsoft® Excel 2019 and was subjected to statistical analysis using “IBM Corp. Released 2012. IBM SPSS® Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.” The percentages of the dental students with different grades of TMD severity, anxiety, and depression in both genders were calculated. Shapiro-Wilk's test was done to test the normality, and the data distribution was skewed. The association and correlation between the TMD degree, gender, anxiety, and depression were evaluated by the Chi-square test and Spearman's rank correlation coefficient test, respectively, by setting the significance level as P ≤ 0.05.
| Results|| |
Overall, 47.1% of the subjects were TMD-free, 45.6% had mild TMD, 7% had moderate TMD, and 0.3% had severe TMD. In females, 46.9% were TMD-free, 46.2% had mild TMD, 6.9% had moderate TMD, and none had severe TMD. In males, 47.9% were TMD-free, 43.8% had mild TMD, 7.3% had moderate TMD, and 1% had severe TMD [Figure 1]. The results of the HADS for anxiety and depression assessment revealed 54.5% females and 40.6% males with some degree of anxiety and 24.4% females and 24% males with some degree of depression [Table 1]. The difference between the genders was statistically significant, with a P value of 0.046 for depression.
|Figure 1: Gender-wise percentage (%) of various TMD degree. TMD − Temporomandibular disorder|
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|Table 1: Number and percentage of students with various TMD degree, level of anxiety, and level of depression|
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Overall, 49% of the subjects were anxiety-free, 27% had mild anxiety, 19% had moderate anxiety, and 5% had severe anxiety; 76% were depression-free, 18% had mild depression, 5.7% had moderate depression, and 0.3% had severe depression. In females, 45.5% were anxiety-free, 26.7% had mild anxiety, 22.2% had moderate anxiety, and 5.6% had severe anxiety; 75.7% were depression-free, 18.1% had mild depression, 6.3% had moderate depression, and none of them had severe depression. In males, 59.4% were anxiety-free, 26% had mild anxiety, 11.5% had moderate anxiety, and 3.1% had severe anxiety; 76% were depression-free, 18.8% had mild depression, 4.2% had moderate depression, and only 1% had severe depression [Figure 2] and [Figure 3]. Chi-square test presented a highly significant association of TMD with anxiety (P < 0.001) but not with gender (P = 0.303) and depression (P = 0.101) [Table 2]. In Spearman's rank correlation coefficient test to determine the correlation between TMD degree and gender and anxiety/depression, the correlation coefficient values from 0.71 to 1.0, from 0.31 to 0.70, and 0.0 to 0.30 were considered as high, medium, and low correlations, respectively. There was a significant positive correlation between TMD degree and anxiety (r = +0.261, P < 0.001). However, there was a weak correlation of TMD degree with gender (r = +0.026, P = 0.606) and depression (r = +0.096, P = 0.06), which was insignificant.
|Figure 2: Gender-wise percentage (%) of anxiety (HADSa). HADSa − Hospital anxiety and depression scale-anxiety|
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|Figure 3: Gender-wise percentage (%) of depression (HADSd). HADSd − Hospital anxiety and depression scale-depression|
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|Table 2: Association between TMD degree and level of anxiety and level of depression|
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| Discussion|| |
In the present study, we evaluated the prevalence of TMD in dental students and its association/correlation with gender and psychological factors (anxiety and depression). Fonseca determined a 95% reliability of the anamnestic questionnaire and a good correlation with the TMJ disorders (r = 0.62, P < 0.05). It was used by Fonseca et al., Conti et al., Nomura et al., Modi et al., Chandak et al., and Bonjardim et al., previously. It demonstrated high diagnostic efficiency and the advantages of multi-dimensional characteristics, easy administration, and low cost. The anamnestic questionnaire provided a considerable amount of information in a short period and was useful and sensitive for finding the degree of TMD in the study population. The point prevalence (determined by a clinical evaluation) can be less than the period prevalence which has been determined by using this questionnaire. In the present study, only the period prevalence was taken into consideration. Several studies validate the use of this anamnestic questionnaire for epidemiological studies. In the current study, it is evident that 52.9% of the students had some degree of TMD. Similar results were found by Shiau and Chang (41%), Conti et al. (42%), Bonjardim et al. (50%), and Modi et al. (45.16%). However, Grosfeld et al. (72%), Schiffman (75%), Pedroni et al., (68%), and Chandak et al. (69%), depicted a higher number of subjects with TMD. The ethical, racial, and social background could be attributed to this difference in prevalence. Mild TMD (45.6%) was the most prevalent TMD found among the Indian dental students which was consistent with the studies by Dekon et al., Pedroni et al., Oliveira et al., Nomura et al., Bonjardim et al., Modi et al., and Chandak et al., who also got similar results. Nassif et al., found that the TMD prevalence was higher in the younger participants but with less severity as only 7.3% of the subjects had moderate and severe TMD, which is in line with the findings of Bonjardim et al., (9.18%) and Modi et al., (10.34%). Fonseca advocated that the subjects with moderate to severe TMD should be referred to a TMJ specialist; Hence, 7.3% of the dental students with moderate to severe TMD in our study had to undergo further clinical evaluation and treatment for TMD. Though TMD prevalence among females (53.9%) is 1% higher than that among males (52.9%), the difference was statistically insignificant (P = 0.373), which was in agreement with the findings of Oliveira et al., Bonjardim et al., and Modi et al. However, Conti et al., Pedroni et al., Nomura et al., Ryalat et al., Vojdani et al., and Chandak et al. found a higher prevalence of TMD in females than in males and attributed this difference to the fluctuation in the levels of female sex hormones, especially estrogen, which is crucial for the regular functioning of the brain. Females have high baseline plasma corticosterone levels and increased hypothalamic-pituitary axis markers both when at rest and under stress than males. The HADS scale used to evaluate the psychological factors in this study has well-established psychometric properties and has been well tested. A mild level of anxiety (27%) and depression (18%) were the most prevalent. There was a statistically significant difference in the anxiety levels (HADSa) between females (54.5%) and males (40.6%) but no statistically significant difference in the depression levels (HADSd) between females (24.4%) and males (24%). The correlation between the TMD degree and anxiety levels (HADSa) was statistically significant but not between TMD degree and depression levels (HADSd) which are in agreement with the studies by Bonjardim et al., and Bonjardim et al., who declared that anxiety has a vital role in TMD, being a predisposing or aggravating factor. Wahlund et al., confirmed this possibility, indicating that anxiety is linked to the increased pain cases in clinics.
TMDs are often related to physical and psychological factors, including sleep disturbances, fatigue, anxiety, and depression., Hence, considering the association of stress with the psychological disturbances of anxiety and depression, we can conclude that there is a positive relationship between stress and TMD degree in the present study.
This is a cross-sectional study involving a limited sample size of 384 dental students from a single institution. The assessment of TMD was done using an anamnestic questionnaire rather than the clinical examination or imaging.
This finding being a cross-sectional observation, should be further evaluated with a longitudinal study involving a larger sample size of dental students from multiple institutions.
| Conclusion|| |
In conclusion, this study depicted a higher TMD prevalence among the Indian dental student population, with a majority of mild severity. There was no significant difference in the TMD prevalence between males and females. There was a statistically significant increase in anxiety levels among females than males, and there was a positive correlation between TMD symptoms and anxiety. There was no significant correlation with depression. These outcomes advocate the evaluation of psychological factors among young adults with a confirmed diagnosis of TMD and appropriate management, if deemed necessary. Also, the inclusion of psychological counseling sessions and recreational activities in their curriculum/routine is recommended to increase the productivity and efficiency of the dental students to be successful professionals in the future.
Declaration of patient consent
The authors certify that they have obtained all appropriate participant consent forms. In the form, the participant (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants 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.
The authors would like to acknowledge the support of Dr. Sivakumar M and Dr. Ram Surath Kumar K in statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]