Int. J. Med. Sci.

2012, 9 539

Ivyspring
International Publisher
International Journal of Medical Sciences
2012; 9(7):539-544. doi: 10.7150/ijms.4474
Research Paper

Gender Difference in Prevalence of Signs and Symptoms of Temporoman-

dibular Joint Disorders: A Retrospective Study on 243 Consecutive Patients
Bora Bagis1, Elif Aydogan Ayaz2, Sedanur Turgut2, Rukiye Durkan3, Mutlu Özcan4
1. İzmir Katip Celebi University, Faculty of Dentistry, Department of Prosthodontics, İzmir, Turkey;
2. Karadeniz Technical University, Faculty of Dentistry, Department of Prosthodontics, Trabzon, Turkey;
3. Kocatepe University, Faculty of Dentistry, Department of Prosthodontics, Afyon, Turkey;
4. University of Zürich, Center for Dental and Oral Medicine, Clinic for Fixed and Removable Prosthodontics and Dental
Materials Science, Zürich, Switzerland.

 Corresponding author: Assoc. Prof. Bora Bagis, Adress: İzmir Katip Celebi Universitesi Dis Hekimligi Fakultesi, Aydınlık Evler Mahal-
lesi, Cemil Meriç Caddesi, 6780 Sokak. No:48, 35640-Çiğli/İzmir/Turkey. E-mail: bbagis@yahoo.com Tel: +90-532-6804656.

© Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/
licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited.

Received: 2012.04.16; Accepted: 2012.08.191; Published: 2012.08.30

Abstract
Background: This study evaluated the prevalence of the signs and symptoms of temporo-
mandibular joint disorder (TMD) among patients with TMD symptoms. Methods: Between
September 2011 and December 2011, 243 consecutive patients (171 females, 72 males, mean
age 41 years) who were referred to the Department of Prosthodontics, Faculty of Dentistry,
Karadeniz Technical University, Trabzon were examined physically and completed a ques-
tionnaire regarding age, gender, social status, general health, antidepressant drug usage, dental
status, limited mouth opening, temporomandibular joint (TMJ) sounds, and parafunctions
(bruxism, clenching). The data were analyzed using the chi-square test and binary logistic
regression model (alpha = 0.05). Results: With a frequency of 92%, pain in the temporal
muscle was the most common symptom, followed by pain during mouth opening (89%) in
both genders. TMJ pain at rest, pain in the masseter muscle, clicking, grinding, and an-
ti-depressant use were significantly more frequent in females than males. Age (p=0.006; odds
ratio 0.954; 95% CI 0.922–0.987) and missing teeth (p=0.003; odds ratio 3.753; 95% CI
1.589–8.863) had significant effects on the prevalence of TMD. Conclusion: Females had
TMD signs and symptoms more frequently than males in the study population. The most
common problem in both genders was pain.
Key words: temporomandibular joint dysfunction, orofacial pain, epidemiology, oral parafunc-
tions, dental health.

INTRODUCTION
It is generally accepted that the etiology of tem- symptoms of TMD are pain, limited mouth opening,
poromandibular joint disorders (TMD) is multifacto- joint sounds, mandibular deviation, and chewing
rial, and is related to a number of dental and medical disability. These symptoms may exist alone or in
conditions, such as occlusion, posture, parafunctional combination [2].
habits, restorative procedures, orthodontic treatment, Pain is the most important symptom of TMD for
emotional stress, trauma, anatomy of the disc, path- both patients and clinicians, as it is often the main
ophysiology of the muscles, genetic and psychosocial reason why patients seek for medical help [3]. Most
factors, age, and gender [1,2]. Typical signs and patients suffer from pain during mandibular move-

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ments, at rest, or on palpation of the muscles. Pain tic approaches that might help to establish prevention
results from the changes in muscle activity that limit and control programs [3]. Therefore, this study eval-
the movements of the mandible and protect it from uated the prevalence of the signs and symptoms in
further damage, while trying to promote healing [4]. TMD patients and investigated whether gender in-
TMD can also occur as a consequence of pain of fluences its prevalence.
non-dental origin in the orofacial region, including
the head, face, and related structures [4]. TMD is a METHODS
possible cause of headaches, as a positive correlation
Subjects
was found between TMD and the prevalence of
headaches [4]. Fortunately, the treatment of sympto- Data were collected from 243 consecutive pa-
matic TMD significantly decreases headache com- tients (171 females, 72 males; mean age 41 (range
plaints [5,6]. Although limited mouth opening is 14–59) years) seeking treatment for TMD at Karadeniz
generally a result of painful mandibular movement, it Technical University, Faculty of Dentistry, Depart-
may or may not be accompanied by pain. In general, ment of Prosthodontics, Trabzon. Patients who joined
mouth opening of less than 30 mm is considered lim- the study gave informed consent. The Ethics Com-
ited [7]. mittee in Human Research of Karadeniz Technical
Temporomandibular joint (TMJ) sounds, such as University approved the research protocol (Number:
clicking or crepitation, are one of the most common 2011.91.21.2).
symptoms, followed by headache [8]. Since sound is Patients with fibromyalgia, trigeminal neuralgia,
not always considered as a problem, but rather as a burning mouth syndrome, atypical facial pain, mi-
risk factor, TMJ clicking may be a normal variant ra- graine, atypical odontalgia, and cervical and neuro-
ther than a disorder [9]. Changes in condyle mor- pathic pain and those with a history of TMD treat-
phology, disk displacement, and mechanical disk de- ment were excluded from the study.
rangements may cause TMJ clicking without pain or Patients were initially questioned using a ques-
significant dysfunction. Epidemiological studies have tionnaire based on the Research Diagnostic Criteria
shown an increased prevalence of TMJ sounds among for TMD (RDC/TMD) [11] including the following
patients between 15 and 25 years old [10]. items: age, gender, social status, general health (dia-
Studies have identified changes in occlusion, betes mellitus, osteoporosis, arthritis, etc.), antide-
such as angle malocclusion, crossbite, open bite, oc- pressant use, dental status (missing/filled teeth,
clusal interference, excessive overjet, and overbite, fixed/removable prosthetic restorations), occlusion
crowding, midline discrepancies, and missing teeth, type, limited mouth opening, TMJ sounds, and para-
as predisposing, triggering, or perpetuating factors functions (bruxism, clenching).
for TMD [11]. The lateral bite forces between the Clinical examination
retruded and intercuspal contact positions, as well as
unilateral crossbite, are possible local risk factors for A history was taken and the patients were ex-
developing TMD [10]. Parafunctional habits such as amined clinically, including the muscles and TMJ. The
bruxism, tooth clenching, gum chewing, biting for- physical examination followed the order of the ques-
eign objects, and prolonged nail biting might increase tionnaire items; i.e., inspection, palpation, and an in-
the risk of developing TMD [10,11]. Parafunctional traoral examination. The masticatory, subhyoid, su-
activities are usually harmless, until the forces exerted prahyoid, and head and neck muscle were examined.
exceed the structural tolerance [7]. Bruxism and Tense areas and localized pain were identified. The
clenching reportedly lead to joint space reduction, masseter was palpated at its attachments to the zy-
followed by disc compression, and resulting pain in gomatic arch and angle of the mandible. The tem-
the masticatory muscles [9]. In addition, psychological poralis, in both the temporal fossa and intraorally
factors have been closely linked to TMD and may be a along the ascending ramus of the mandible, and the
component of the clinical presentation. Increased lev- medial pterygoid were examined bimanually, by
els of somatization; i.e., depression or anxiety, affect placing one finger externally at the medial aspect of
TMD sufferers negatively compared to people with- the angle of the mandible and the other intraorally in
out TMD [12]. the lingual vestibule in the retromolar region. While
Epidemiology is a discipline that evaluates the the lateral pterygoid muscle was palpated behind the
frequency and distribution of conditions related to tuber maxilla in a medial direction, the digastric
disease or health in a population. Epidemiological muscle was palpated at the mid-point between the
studies of TMD are important for amassing angle of the mandible and the jaw. Mouth opening
knowledge of symptomatic complexes and therapeu- was measured between the central incisors using a

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ruler. TMJ sounds were evaluated with a stereoscope In both genders, pain in the temporal muscle
and recorded as no sound, clicks, or crepitation. was the most common symptom, with a frequency of
One examiner examined all of the subjects and a 92%, followed by pain during mouth opening (89%).
second reviewer controlled whether all of the ques- TMJ pain at rest and pain in the masseter muscle were
tions were understood and answered in full. significantly more frequent in the females than males
(Table 1). Among TMJ sounds and parafunctions,
Statistical analysis clicking (p=0.044) and grinding (p=0.013) were signif-
The data were analyzed using the statistical icantly more frequent in females than in males (Table
package SPSS for Windows, version 15.0 (SPSS, Chi- 2).
cago, IL). The chi-square test was used to compare the Antidepressant use was reported by 16% of the
distribution of variables in TMD patients according to patients and females reported significantly more use
gender and binary logistic regression model tests than males (p=0.021). Limited mouth opening was
were used to identify dominant factors. P-values less observed in 89% of the patients, but it was not signif-
than 0.05 were considered statistically significant for icantly different between the genders (p=0.219). Hy-
all statistical tests. The confidence level was set at peractivity in the temporal muscle was less frequent
95%. (8%; p>0.05; Table 3).
No significant difference was found between the
RESULTS dental status groups according to gender (p>0.05; Ta-
The study population had more females (n=171, ble 4).
mean age 35 years) than males (n=72n 30%; mean age Age (p=0.006; odds ratio 0.954; 95% CI
41 years). Class I malocclusion (55% females, 20% 0.922–0.987) and missing teeth (p=0.003; odds ratio
males) was most common, followed by Classes II 3.753; 95% CI 1.589–8.863) had significant effects on
(11% females, 6% males) and III (4% females, 3% the prevalence of TMD (Table 5).
males).

Table 1. Incidence of TMD symptoms and differences between genders. *Significant at p<0.05.
Symptom Female Male Significance Incidence (%)
Pain during opening mouth 120 55 p=0.352 72
Pain during mastication 112 50 p=0.655 66
Headache 149 63 p=0.1 87
Earache 147 65 p=0.407 87
TMJ pain at rest 129 44 p=0.018* 71
Pain in masseter muscle 113 34 p=0.009* 39
Pain in temporal muscle 158 67 p=0.858 92

Table 2. Incidence of TMJ sounds, parafunctions, and differences between genders. *Significant at p<0.05.
Symptom Female Male Significance Incidence (%)
Clicking 74 21 p=0.044* 39
Crepitation 8 8 p=0.087 6
Clenching 96 37 p=0.573 54
Grinding 40 7 p=0.013* 19

Table 3. Incidence of other TMD symptoms, antidepressant use, and differences between genders. *Significant at p<0.05.
Symptom Female Male Significance Incidence (%)
Hyperactivity in temporal muscle 12 8 p=0.311 8
Limited mouth opening 150 67 p=0.219 89
Antidepressant drug use 21 18 p=0.021* 16

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Table 4. Dental status and differences between genders. *Significant at p<0.05.

Dental status Female Male Significance Incidence (%)
Missing teeth 95 37 p=0.575 54
Unerupted teeth 37 14 p=0.863 20
Teeth with fillings 83 18 p=0.713 37
Fixed partial denture 34 17 p=0.605 20
Removable partial denture 13 5 p=0.858 7
Complete denture 5 5 p=0.150 4

Table 5. The effects of variables on TMD according to binary logistic regression model tests. *Significant at p<0.05.
Variables B S.E. Wald df Significance Exp (B) 95% CI.
Lower Upper
Age -,047 ,017 7.554 1 ,006* ,954 ,922 ,987
Wisdom tooth -19.553 14373.941 ,000 1 ,999 ,000 ,000 .
Missing tooth 1.322 ,438 9.096 1 ,003* 3.753 1.589 8.863
Filling -21.223 4814.836 ,000 1 ,996 ,000 ,000 .
Fixed partial denture 2.233 16747.565 ,000 1 1.000 9.332 ,000 .
Removable partial denture -22.068 14094.323 ,000 1 ,999 ,000 ,000 .
Complete denture 20.982 14094.323 ,000 1 ,999 1295147073.969 ,000 .
Drug use 38.155 9851.574 ,000 1 ,997 37206949702489390.000 ,000 .
Constant 2.693 1.167 5.323 1 ,021 14.776

nal, and constitutional factors, no conclusions have

DISCUSSION been drawn [11,15]. In our study, females were found
A number of factors have been studied in rela- to have a higher risk of TMD (2.3:1) than males, yet
tion to TMD, such as dental status, number of teeth, the results were not significant. Manfredini et al. made
parafunctions, clicking and locking of the jaws, and a similar observations in a study of 433 patients in
history of trauma [2]. It has been difficult to charac- whom the risk ratio was 2.6:1 (276 females, 73.2%; 101
terize TMD owing to the large number of symptoms males, 26.8%) [17].
and signs, and the variation in the number and types Patients with TMD generally suffer from differ-
manifested in any one patient. A systematic review of ent kinds of pain. Our study also demonstrated a
clinical studies reported that age, gender, and psy- strong relationship between TMD and orofacial pain.
chological factors were associated with TMD. Several TMD-related orofacial pain is generally seen as a
retrospective clinical studies have investigated the chronic, regional pain in the form of headaches or
relationship between the risk factors and TMD. Mi- earaches. Our questionnaire indentified pain localized
chelotti et al. examined the effect of oral parafunctions during opening mouth, mastication, or at rest, head-
on TMD in 557 patients and concluded that diurnal ache, and earache, and pain in temporal or masseter
parafunctional activities, especially daytime tooth muscle. The patients mostly reported pain in the
clenching/grinding, were risk factors for subgroups temporal region (92%), followed by headache (87%).
of TMD and myofascial pain [13]. In a study of 87 Cooper et al. examined the presence of symptoms and
patients with psychological distress, Lee et al. found signs of TMD in 4528 patients and reported that 96.1%
jaw disability [14]. In another study, malocclusion and of the patients complained of TMJ pain, followed by
orthodontic treatment were not associated with TMD headache (79.3%) [2]. Although our study population
[15], while Hagag et al. found that occlusion and was smaller than that of Cooper et al. [2], similar
prosthodontic treatment influenced TMD [16]. trends were observed.
This study studied the gender effect on the The incidence of TMD pain in females has been
prevalence of signs and symptoms of TMD primarily. studied widely [3]. While Velly et al. reported that
Generally, epidemiological studies have documented females had approximately three times the risk of
a greater frequency and severity of TMD in females myofascial pain than males in a series 83 patients [18],
than in males [11,17]. Although these differences have Karibe et al. investigated 71 patients and found that
been explained by behavioral, psychosocial, hormo-

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chewing significantly increased the pain in patients avoid TMD symptoms. Nevertheless, the prevalence
with a history of chronic masticator muscle pain, but of TMD sounds and parafunctions tended to increase
also in females with no such history [19]. Moreover, with the stress level, especially in females [28].
the increased pain persisted significantly longer in Studies have identified dental status, malocclu-
females. According to our results, pain in the joint sions, and missing teeth as factors predisposing to
region in the resting position and in the masseter TMD [29,30], although the role of occlusion-related
muscle was significantly greater in females than in factors is controversial and they are weakly associated
males. This might be related to biological, anatomical, with TMD [10]. Regression analysis indicated a sig-
or hormonal factors acting alone or in combination in nificant influence of missing teeth on the incidence of
females. TMD. These results need to be verified in a larger
Temporomandibular joint sounds, in the form of population, while considering the number of missing
clicks and crepitus, are other signs and symptoms of teeth.
TMD [8,20]. In our series, joint sounds were infre- With its multi-factorial etiology, risk factors for
quent symptoms: 39% of the patients had clicking and TMD include age, gender, social status, and race.
6% crepitus. In a similar study of 40 patients, clicking Although epidemiological studies generally concur,
was observed in 40% and crepitus in 15% [21]. Alt- there are some contradictory results. One reason for
hough we found no significant difference between the this could be non-standardized examination proce-
genders regarding these signs, Troeltzsch et al. re- dures [10]. Despite numerous studies, the mechanism
ported a significant difference in TMJ clicking in fe- of TMD is not fully understood. Each clinician who is
males compared to males in a series of 1031 patients confronted with a patient complaining of symptoms
[22]. In our study, a significant difference was found TMD needs to address the entire problem to maxim-
between genders in terms of clicking sounds, which ize the potential for a successful outcome. In our se-
were nearly four times more frequent in females than ries, females were more likely to suffer from TMD. In
in males. addition, age-related factors and missing teeth should
Painful jaw movements frequently lead to a re- be considered when evaluating TMD patients.
duction in mouth opening, which causes problems Healthcare systems might make use of this infor-
while chewing and social difficulty for the patients. mation when implementing policy.
Clinically, limited mouth opening poses problems for
dental treatments. In general, the mouth opening is CONCLUSIONS
greater in males than in females [23,24]. This differ- Females had TMD signs and symptoms more
ence may be the result of the significant difference in frequently than males in our study population. The
mandibular length between males and females [21]. most common problem in both genders was pain.
Our results also indicated that the patients with lim- Headache, earache, pain in the temporal muscle, and
ited mouth opening were mostly females (61%) com- limited mouth opening were the most frequent
pared with males (28%), which might affect dental symptoms, being reported in more than 80% of the
treatments. TMD patients. Age and missing teeth had a significant
Parafunctional habits such as bruxism, clench- effect on the prevalence of TMD.
ing, and grinding are considered among the im-
portant etiological causes of TMD [18,25]. In patients COMPETING INTERESTS
with bruxism, the habit of pressing or grinding the The authors have declared that no competing
teeth changes the lubrication mechanism of the artic- interest exists.
ular structures due to the overload on the articular
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