E. Zdanavičienė et al.

REVIEWS REVIEWS
SCIENTIFIC ARTICLES
Stomatologija, Baltic Dental and Maxillofacial Journal, 20: 3-9, 2018

Quality of life in patients with temporomandibular

disorders. A systematic review
Dovile Bitiniene*, Roberta Zamaliauskiene*, Ricardas Kubilius*, Marijus Leketas*, Tadas Gailius*,
Karina Smirnovaite*

SUMMARY

Objective. The purpose of this study was to systematically review the literature concerning
the quality of life of patients with temporomandibular joint disorder.
Material and methods. Systematic review was performed with the information contained in
international databases: PubMed and Google Scholar. Keywords and their combinations were
used to find relevant articles and publications concerning the subject.
Results. A total of 320 publications were initially retrieved. After further examination 12
articles were selected due to their relevance to inclusion criteria and were included in the sys-
tematic review. The selected 12 articles published between year 2006 and 2016.
Conclusion. In this systematic review it was found that there is a direct correlation be-
tween temporomandibular disorders and lower quality of life. Out of questionnaires used for
identification of patient satisfaction SF-36 and OHIP-14 were most popular in these studies.
Statistical analysis of studies mentioned lead us to believe that psychological and physical ail-
ments caused by TMD result in lower quality of life in patients.

Key words: quality of life, temporomandibular joint disorders, temporomandibular dys-

function.

INTRODUCTION

Temporomandibular disorder (TMD) is a gen- to limited range of movement (3, 4). Our selected
eral term given for an illness involving a series of studies show that the main cause of non-dental
clinical signs and symptoms concerning masticatory pain in the orofacial region are musculoskeletal
muscles, temporomandibular joints (TMJ) and as- conditions related to cervical regions, as well as
sociated structures (1). masticatory musculature, while longitudinal studies
Most common TMD signs and symptoms are have shown that the progression of pain severity is
chronic pain, jaw muscle soreness, limited range of uncommon (6).
jaw movement and temporomandibular joint noises Temporomandibular disorders can have a wide
(2). Majority of pain reported by patients is located variety of causes, among which, most common are:
in masticatory muscles and/or pre-auricular region, parafunctional habits, occlusal disharmony, stress,
this can be easily exacerbated by chewing or other anxiety, trauma and microtrauma, mandibular in-
jaw activity (1). Other symptoms include, but are not stability, postural imbalance and abnormal physi-
limited to joint noises, jaw movement asymmetry, ological conditions (7). Several factors including
commonly described as clicking, popping, grating, sleep disorders as well as physical, emotional, and
or crepitus (3-5), painless masticatory muscles hy- occlusal stress may inhibit the adaptive capacity of
pertrophy, muscle fatigue (1), also a wide variety of the stomatognathic system and make the occurrence
symptoms including headache, bruxism, tenderness of the disorder more likely (8).
upon palpation and difficulty opening the mouth due Clinical studies agree that chronic medical
conditions have strong negative effects on patients
*
Faculty of Odontology, Medical Academy, Lithuanian Univer- quality of life (9, 10).
sity of Health Sciences, Kaunas Lithuania
Main objective of this review was to fi nd a
Address correspondence to Dovile Bitiniene, Faculty of Odontol- relation between temporomandibular disorder and
ogy, Medical Academy, Lithuanian University of Health Sciences,
A. Lukšos-Daumanto g. 6, Kaunas, Lithuania. a decrease in patients quality of life.
E-mail address: dovilez92@gmail.com Goals of our systematic review:

Stomatologija, Baltic Dental and Maxillofacial Journal, 2018, Vol. 20, No. 1 3
D. Bitiniene et al. REVIEWS

Review clinical trials of pa-

tients with TMD on international
databases to find out about their
quality of life.
Find out what methods
should be used to determine
quality of life of patients with
temporomandibular disorder.
Determine why TMD is
causing patients to have a lower
quality of life.

M AT E R I A L AND
METHODS

A systematic review was

conducted which relied on infor-
mation contained in international
databases: National Library of
Medicine – Medline/PubMed
and Google Scholar.The review
was conducted in accordance
with PRISMA Statement guide-
lines. The articles used for this
review were found and selected
on 6th of February, 2016. The
search was conducted with the
goal to find clinical trials con-
cerning the relationship between
quality of life and temporoman-
dibular disorders. The keywords
and their combinations used
in our search were: Quality of
life, Temporomandibular joint
disorders, Temporomandibular Fig. Search strategy flow chart
dysfunction. A total of two inde-
pendent investigators performed the aforementioned eliminated. The next step of screening involved titles
searches and study selection. The appropriateness of and abstract reviewing. At this stage, the following
the studies was evaluated by reading and reviewing exclusion criteria were used: duplicates, clinical
the articles. The following selection criteria were trials with children, articles not in English, not full
applied: full text articles, only clinical trials, arti- text articles. This eliminated most of the articles
cles in English, adult patients, selected publications retrieved from PubMed due to their titles and con-
contains information for the tasks specified criteria. tents, leaving 26 articles (7 articles from Google
Systematic literature reviews and publications Scholar database and 19 articles from PubMed
considering quality of life as a treatment outcome database). Out of 26 remaining studies, 12 were
(related to intervention) are not included in this in full accordance with provided inclusion criteria
systematic review. and were included in the systematic review, the 14
A total of 320 publications were initially re- that were excluded were either not clinical trials or
trieved. Out of total 320 articles, 41 were found by were related to quality of life after treatment. Due to
using Google Scholar and 279 by using PubMed previous removal of articles older than 10 years our
search. Firstly, after initial retrieval, all articles selected publications were published from 2006 to
that were older than 10 years were removed, leav- 2016. A total of 12 clinical trials are presented and
ing 243 that were suitably up to date. Secondly, discussed in the review. Search strategy is illustrated
article duplicates and incomplete publications were on the flow-chart (Figure).

4 Stomatologija, Baltic Dental and Maxillofacial Journal, 2018, Vol. 20, No. 1
REVIEWS D. Bitiniene et al.

RESULTS mandibular disorders do not affect the quality of life

(13, 14). Another three studies found that patients
Relation between quality of life and with this particular pathology have lower quality of
temporomandibular disorders life than their control group (4, 15, 16). Finally five
The 12 clinical trials that were included in this studies concluded that more severe cases of TMD
review, assessed the quality of life of patients with disorder, cause lower quality of life (1-3, 7, 17).
temporomandibular disorders. Three of the selected One of the studies selected pointed out that patients
studies have found that there is a direct relation be- with arthralgia, osteoarthritis or osteoarthrosis have
tween temporomandibular disorders and a degrada- lower quality of life than patients with myofascial
tion of patients quality of life (2, 11, 12), however pain or disc displacement (3). A brief summary of
two of the reviewed studies concluded that temporo- selected study descriptive characteristics can be
found below (Table).
Table. Summary of the study descriptive characteristics of included studies

Research Quality of life Number of patients, Number of patients Results

assessment gender (average age) in the control group,
method gender (average age)
Moreno, B. G. D. SF-36 27 female (30.1±5.8) 18 female (23.4±2.3) Patients‘ with TMD quality of
et al. 2009 (15) life is lower than control group.
Tjakkes, G. H. SF-36 HADS 95 patients, – The more severe TMD is, the
E. et al. 2010 90 female and 5 male lower quality of life
(3) (40.3±13.1)
Kim, T. Y. et al. EQ-5D 17, 198 patients (≥19) – Patients‘ with TMD quality of
2015 (4) life is lower due to sociode-
mographic and general health
problems
Roberto, D. et SF-36 146 patients, – Patients‘ with TMD quality
al. 2009 (16) 30 male and 116 female of life is lower in all aspects
(35, 2 ±14, 38) related to pain and depression.
Pereira, T. C. et OHIP-14 33 female (25.61) – The more severe TMD is, the
al. 2010 (17) QVV lower quality of life
Gui, M. S. et al. SF-36 37 female with localized 40 female Temporomandibular disorders
2014 (13) pain (24.92±5.0) and 39 (50.93±12.34) do not affect the quality of life.
female with widespread Patients‘ with TMD quality of
pain (53.21±9.34) life in all aspects was the same
as in control group.
Rovida, T. A. S. WHO 39 patients, 2 male and – Temporomandibular disorders
et al. 2015 (14) 37 female (38, 7) do not affect the quality of life,
there is no relation between
temporomandibular disorders
and quality of life
Lemos, G. A. et OHIP-14 135 patients, 58 male – The more severe TMD is, the
al. 2015 (1) and 77 female (18-25) lower quality of life
Resende, C. M. WHO 60 patients, 53 female – There is a relation between
B. M. d. et al. and 7 male (36, 48) temporomandibular disorders
2013 (11) and quality of life
Oliveira, L. K. SF-36 119 female 41 female The more severe TMD is, the
d. et al. 2015 (7) lower quality of life
Blanco-Agu- OHIP-14 407 patients, 365 female – There is a relation between
ilera, A. Et al. (42.15 ± 14.63) and 42 temporomandibular disorders
2014 (12) male (41.48 ± 17.28) and quality of life
Miettinen, O. OHIP-14 149 patients, 79 TMD – There is a relation between
2012 (2) patients including 18 temporomandibular disorders
male and 61 female and quality of life. The more
(43.5±13.1), 70 not TMD severe TMD is, the lower qual-
patients including 23 male ity of life
and 47 female (25.3±6.5)

Stomatologija, Baltic Dental and Maxillofacial Journal, 2018, Vol. 20, No. 1 5
D. Bitiniene et al. REVIEWS

chological disability, social disability and handicap.

Methods for assessment of quality of life These segments are based on conceptual model of
The following questionnaires were used to oral health (2).
assess mental and physical wellbeing of patients QVV – V-RQOL protocol (17) – it is a voice-
with TMD disorder: SF-36 (3, 7, 13, 15, 16), HADS related quality of life protocol. The purpose of this
(3), EQ-5D (4), OHIP-14 (1, 2, 12, 17), QVV (17), protocol is to understand how a speech impediment
WHO (11, 14). can affect person’s daily activities. It displays a list
SF-36 – Short Form 36 Medical Outcomes of possible voice-related issues, to which the indi-
Study questionnaire (used in studies (3, 7, 13, viduals has to respond on a 5-point scale, depending
15, 16)). This self-administrated, general purpose on how their voice was affected during the last two
questionnaire is composed of 36 questions related weeks (1 – excellent, 2 – very good, 3 – good, 4 –
to patients health (16). It is not targeted towards reasonable and 5 – bad). Out of 10 questions in this
any specific age group, disease or treatment group. protocol, 6 of them are for the physical and func-
The patient has to rate their wellbeing in 8 scales: tional domain and 4 are meant to evaluate patients‘
physical function (10 items), role-physical (4 items), socio-emotional domain. The full score ranges from
bodily pain (2 items), general health status (5 items), 0 (zero) to 100. The higher the value, the lower the
vitality (4 items), social function (2 items), role- quality of life is (17).
emotional (3 items), mental health (5 items) and 1 WHO – The WHOQOL-BREF – The World
question comparing evaluation between the current Health Organization Quality of Life questionnaire
health and their wellbeing the previous year, on a (11, 14) - the questionnaire consists of 2 general
scale from 0 to 100 (higher score meaning better questions about the participant’s perception of their
quality of life) (15). Poor average score in any of the quality of life and their health and other 24 ques-
8 scales can be taken as an indication of problems tions relating to 4 domains: physical, psychological,
or compromised quality of life (16). social relationships and environment. The patient
HADS – the Hospital Anxiety and Depression has to choose out of three available answers, each
Schedule (3) – this questionnaire is used to evaluate one rated with a score, depending on the question.
anxiety and depression. It consists of 14 questions, After all questions have been answered, the result
of which odd numbers are used to screen for anxi- is summed and converted into scale of 0 to 100. The
ety (HADS-A) and even numbers for the screening default scale rating system for severity of the disor-
of depression (HADS-D). The patient rates himself der is as follows: without TMD (0 to 15 points), mild
on a scale of 0 to 3 on each of the questions. A total TMD (20 to 45 points), moderate TMD (50 to 65)
score of up to 7 out of 21 in any subscale, indicate and severe TMD (70-100 points). The scores show
a normal quality of life, while 8 and higher may a profile of the quality of life of the participants.
indicate an onset of anxiety or depression (3). Higher scores directly correlate to lower quality of
EQ-5D - EuroQol-5 Dimension (4) – composed life and general patient health (14).
of 5 segments regarding current health state: mobil-
ity (M), self care (SC), usual activities (UA), pain/ Reasons which determine lower quality of life
discomfort (PD), and anxiety/depression (AD). The The most common symptoms observed in
EQ-5D evaluation questionnaire is only used to as- patients with temporomandibular disorders were:
sess quality of life. Patient functionality is rated in chronic pain (3, 4, 7, 12, 15-17); loss of energy (3,
3 grades (1 no problem; 2 some/moderate problem; 7, 15, 16); activity restriction (inability) of physical
and 3 extreme problem) (4). ailments and emotional disorders (3, 4, 7, 15-17);
OHIP-14 – OHIP-short form questionnaire (1, emotional state (3, 7, 15-17); general health prob-
2, 12, 17) - questionnaire consists of 14 questions lems (3, 7, 15, 16); anxiety/depression (2-4, 7, 15-
aimed at measuring of patients‘ perception of the 17); taste changes (12, 18), discomfort when eating
impact their oral conditions have on their quality (12); voice changes (17), absence from work due to
of life. The patient has to rate their wellbeing on a chronic pain (19).
5-point scale (never – 0, almost never – 1, some- The reviewed studies show that 78.13% of
times – 2, almost always – 3 and always – 4). Final patients reported feeling tired or having a sore jaw
score is obtained by summing obtained values of upon waking in the morning. This leads to a con-
all 14 questions (17). OHIP-14 consists of 7 seg- clusion that poor quality of sleep in TMD patients
ments detailing patients‘ oral health impact on their is important problem because physical and mental
quality of life: functional limitation, physical pain, health is related to effective sleep which contributes
psychological discomfort, physical disability, psy- to a good quality of life (19). Some studies noted that

6 Stomatologija, Baltic Dental and Maxillofacial Journal, 2018, Vol. 20, No. 1
REVIEWS D. Bitiniene et al.

difficulty falling asleep, waking up at dawn and rest- a lower quality of life in women when compared to
less or disturbed sleep affected TMD patients (7, 19). men with TMD (12, 27).
90.62% of the patients complained about squeaks Out of 12 clinical trials reviewed, 10 (1-4, 7,
or involuntary clenching of the teeth during sleep. 11, 12, 15-17) have found a direct relation between
Poor quality of sleep caused by stress and chronic worse temporomandibular disorder cases and lower
pain leads to impediment in daily, social and family quality of life and general patient health and only 2
activities, which may result in worse psychological (13, 14) did not. This leads to a conclusion that tem-
status. This both inhibits their ability to work and poromandibular disorder is directly correlated with
minimizes desire to enjoy their free time (19). worse quality of life. Most commonly used methods
of assessment were questionnaires SF-36(used in 5
DISCUSSION of the clinical trials) and OHIP-14 (used in 4 of the
clinical trials).
Last few years have seen increasing growth of In summary, it can be reliably concluded that
interest in oral-health related quality of life. Oral ail- TMD negatively impacts patients quality of life, this
ments can have consequences that affect various as- is supported by 83.33% of the reviewed clinical tri-
pects of patients‘ mental and physical wellbeing and als. Two trials that did not agree with this conclusion
impair their quality of life (20). The most common (13, 14), had particularly small sample size com-
TMD symptom, chronic pain, often leads to various pared to other clinical trials, this might have been the
forms of psychological distress like anxiety, stress cause of their different findings. A limitation of this
or depression, social impairment, reduced working systematic review could have been caused by large
capacity, social costs, physical disability, reduced female predominance in clinical trials which may
economical income which is caused by extensive have hampered the generalizability of the results.
need of medical services(21). In worst cases this Only one systematic review about TMD patiens
can lead to unbearable pain or total incapacitation quality of life was found in international data-
(22). Therefore, it is accepted that quality of life is bases. So the results of this systematic review were
negatively affected by chronic pain (3). Excluding compared to a review about temporomandibular
physical abnormalities of jaw muscles or teeth and disorders and oral health related quality of life,
joints, emotional stress may also lead most patients performed by Dahlström, L. and Carlsson, G. E.
to require psychological assistance (22). A large in 2010. Clinical trials included in their systematic
percentage of patients with TMD have reported to review were performed between years 1989 and
have difficulty falling or staying asleep (15). Sleep 2009. None of the clinical trials used in 2010 sys-
disruption due to pain is most commonly accented tematic review were used this review. The systematic
and can lead to sleep apnea and insomnia (19). review performed by Dahlström, L. and Carlsson,
Furthermore, pain and stress associated with TMD G. E. showed that a substantial part of patients
represent a negative influence on systemic health with TMD had their quality of life impacted by the
and quality of life, which compromise daily social disorder. Only about less than 5% of TMD patients
activities at school or work, social functions, affec- experienced no significant impact to their quality of
tive and cognitive equilibrium, sleep and physical life. In the clinical trials used by this review, most
activities (11). common assessment method used was OHIP-14
Although TMD has been mostly observed in questionnaire, it was used in 7 out of 12 reviewed
adults, epidemiological studies have reported signs studies. However the review found that gender
and symptoms of temporomandibular disorders in differences were insignificant and statistically ir-
adolescents as well as children (23). The literature relevant in relation to TMD and lower quality of
review conducted did not cater to either gender, but life (20). To summarize, both systematic reviews
it should be noted that the number of female clini- found direct correlation between lower quality of
cal trials was higher. To add to that epidemiological life and temporomandibular disorder and even after
studies clearly state that TMD symptoms are more 6 years TMD remains a big problem due to its large
commonly observed in women than men (24, 25). influence on patients’ quality of life.
This may have been caused by more female patients However, in the future, further studies for
with TMD, compared to male, looking for treatment assessing other factors that impact quality of life
for their pain problems (26). In reviewing gender (other diseases, social, demographic, psychologi-
differences in relation to quality of life, male pa- cal factors) are needed to establish and validate the
tients appeared to be more affected by TMD than relationship between low quality of life and tempo-
female (4). On the other hand, some studies show romandibular disorders.

Stomatologija, Baltic Dental and Maxillofacial Journal, 2018, Vol. 20, No. 1 7
D. Bitiniene et al. REVIEWS

CONCLUSIONS were: SF-36 and OHIP-14. All questionnaires are

equally good in evaluating this topic, but SF-36
This systematic review shows, that there is a and OHIP-14 are short form questionnaires, which
direct correlation between worse cases or temporo- are therefore very comfortable to use in everyday
madibular disorder and lower quality of life. Most practice. It can be concluded that psychological and
commonly used methods for quality of life assess- physical ailments discussed lead to lower quality of
ment of patients with temporomandibular disorder life in patients with temporomandibular disorders.

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Received: 28 01 2018
Accepted for publishing: 27 03 2018

Stomatologija, Baltic Dental and Maxillofacial Journal, 2018, Vol. 20, No. 1 9