CRANIO®

The Journal of Craniomandibular & Sleep Practice

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Temporomandibular disorders and quality of life

among 12-year-old schoolchildren

Marina de Faria da Silva , Silvia A. S. Vedovello , Mario Vedovello Filho ,

Giovana C. Venezian , Heloísa C. Valdrighi & Viviane V. Degan

To cite this article: Marina de Faria da Silva , Silvia A. S. Vedovello , Mario Vedovello Filho ,
Giovana C. Venezian , Heloísa C. Valdrighi & Viviane V. Degan (2016): Temporomandibular
disorders and quality of life among 12-year-old schoolchildren, CRANIO®, DOI:
10.1080/08869634.2016.1248590

To link to this article: http://dx.doi.org/10.1080/08869634.2016.1248590

Published online: 31 Oct 2016.

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CRANIO®: The Journal of Craniomandibular & Sleep Practice, 2016
http://dx.doi.org/10.1080/08869634.2016.1248590

ORTHODONTICS

Temporomandibular disorders and quality of life among 12-year-old

schoolchildren
Marina de Faria da Silva MSb, Silvia A. S. Vedovello PhDa  , Mario Vedovello Filho PhDa, Giovana C. Venezian PhDa,
Heloísa C. Valdrighi PhDa and Viviane V. Degan PhDa
a
Department of Orthodontics, Araras Dental School, Uniararas, Araras, Brazil; bAraras Dental School, Uniararas, Araras, Brazil

ABSTRACT KEYWORDS
Objectives: The aim of this study was to investigate the association between symptoms of Quality of life;
temporomandibular disorders (TMD), quality of life, and malocclusion. temporomandibular
Methods: A cross-sectional observational design study was utilized among 248 schoolchildren aged disorder; malocclusion
12  years old. Symptoms of TMD were assessed using the Orofacial Pain and Temporomandibular
Disorders Triage Questionnaire, and subjects were further evaluated as oral-health-related quality
of life (CPQ11-14), tooth clenching/grinding and malocclusion (Dental Aesthetic Index). Chi-square for
independence, Odds Ratio and Mann–Whitney test were used (p = 0.05) statistically.
Results: Statistically, association was detected between TMD symptoms with pain and worse quality
of life (p < 0.0138), and pain with quality of life and clenching/grinding (p = 0.0120 and 0.0007).
Discussion: The symptoms of TMD are associated with pain and teeth clenching, causing a negative
impact on schoolchildren’s quality of life; thus, a study of the TMD impact on quality of life is justified.

Introduction interpersonal relationships that result in the combination

The term temporomandibular disorders (TMD), accord-
ing to the American Dental Association (ADA), refers to
a group of disorders characterized by pain in the tempo-
romandibular joint (TMJ), periauricular area or in the
masticatory muscles, in addition to joint sounds during
mandibular function, and deviations or restriction of
movements.[1]
TMD is a multifactorial disease comprising a number
of clinical problems.[1,2] Parafunctional habits, such as
bruxism, have also been associated with increasing risk
for the development of TMD.[3] Studies on TMD in chil-
dren have pointed out the importance of early detection
and intervention with the purpose of reducing possible
harm, and have reinforced the importance of recogniz-
ing children with a predisposition to dysfunction of the
stomatognathic system.[4]
In view of the psychosocial implications of TMD, indi-
viduals’ perception of the impact of TMD on their quality
of life becomes relevant, especially when considering the
need to evaluate care of oral health. Pain is always a sub-
jective perception that may involve relevant interference
in the activities of school, leisure, sleeping, eating, and in
of different factors; and its intensity rarely corresponds to
the severity of clinical damage alone. Individuals perceive
the importance of pain for their quality of life in a variety
of ways in the physical, social and psychological domains,
with the capacity of eating and the occurrence of pain and
discomfort usually being considered the most relevant posi-
tive and negative aspects, respectively, for quality of life.[5,6]
In this context, the aim of this study was to investi-
gate the association between TMD, quality of life, and
malocclusion.
Materials and methods
Sample
The current study was a transversal observational study
carried out with a representative sample of schoolchildren
aged 12 years, registered in public schools of the city of
Araras (São Paulo, Brazil).
The minimum sample calculated was 240 individuals,
considering the level of sample loss of 20%, significance
of 5%, test power of 80%, and minimum detectable odds
ratio of 1.5. Excluded from the sample were children who

CONTACT  Silvia A. S. Vedovello  silviavedovello@gmail.com

© 2016 Informa UK Limited, trading as Taylor & Francis Group
2    S. A. S. Vedovello et al.

Question 1 Do you have difficulty, pain, or both when opening your mouth, for instance, when
(Q1) yawning?
Question 2 Does your jaw "get stuck", "locked" or "go out"?
(Q2)
Question 3 Do you have difficulty, pain, or both when chewing, talking, or using your jaws?
(Q3)
Question 4 Are you aware of noises in the jaw joints?
(Q4)
Question 5 Do your jaws regularly feel stiff, tight, or tired?
(Q5)
Question 6 Do you have pain in or near the ears, temples or cheeks?
(Q6)
Question 7 Do you have frequent headaches, neck aches, or toothaches?
(Q7)
Question 8 Have you had a recent injury in your head, neck or jaws?
(Q8)
Question 9 Have you been aware of any recent changes in your bite?
(Q9)
Question 10 Have you been previously treated for unexplained facial pain or a jaw joint problem?
(Q10)

Figure 1. Orofacial pain and temporomandibular disorders triage questionnaire proposed by the American Academy of Orofacial Pain.

had previously undergone, or were at present undergoing
orthodontic treatment; physical or intellectual limitations
that would prevent the exam from being performed; or
those whose parents did not authorize their participation,
so that a final sample of 248 schoolchildren was obtained,
of whom 112 were boys and 136 girls.
Collection of data
The parents or guardians of the children were informed
of the research proposals and gave their written consent
to participate.
Data was collected through application of question-
naires with the schoolchildren. Symptoms of TMD were
assessed through Orofacial Pain and Temporomandibular
Disorders Triage Questionnaire, recommended by the
American Academy of Orofacial Pain (Figure 1). This
questionnaire has been validated for use in Brazil, with
children from 12 to 14 years of age.[7] This instrument
is composed of seven questions with dichotomized
responses (yes/no) that were read and explained to the
volunteers in a simple manner.[8,9] To this questionnaire,
a question was added about the occurrence of diurnal and/
or nocturnal teeth clenching and/or grinding.
Quality of life was evaluated by the Oral Health-related
Quality of Life in Children (COHRQoL) questionnaire,
by means of Child Perceptions Questionnaire (CPQ11-14)
for the age-ranges of 11–14 years. The questionnaire con-
tains 37 items, divided into four domains: oral symptoms;
functional limitations; emotional well-being, and social
well-being. The response option score values varied from
zero to four points (0 = never; 1 = once or twice; 2 = some-
times; 3  =  several times, and 4  =  every day or almost
every day). The total score of the scale is the sum of these
scores. A high score indicated more negative impacts on
OHRQoL.[10–13] The data obtained by the CPQ11-14 were
dichotomized into better and worse quality of life, with
the responses “never and once or twice” being awarded
score 0, signifying absence of impact. To the responses
“sometimes, several times, every day or almost every day”,
score 1 was attributed, indicating presence of impact.
The clinical variables (malocclusion and joint sounds)
were obtained with the children seated, head aligned in
relation to the body, eyes fixed on a certain point, and
under natural light.[14,15]
The Dental Aesthetic Index (DAI) is a numerical index
that evaluates the occlusal characteristic selected accord-
ing to the potential of causing psychosocial incapacity. It
includes 10 parameters of dentofacial anomalies related
to clinical and aesthetic aspects: number of visibly absent
teeth; anterior crowding; anterior spacing; midline dias-
tema; maxillary anterior misalignment; maxillary ante-
rior horizontal overlap; mandibular anterior horizontal
overlap; open bite; anteroposterior molar relationship,
and posterior crossbite. Four classes of malocclusion were
established, with the priorities and recommendations for
orthodontic treatment being attributed to each Grade:
Grade 1 (DAI ≤ 25): normal or minor malocclusion/no
treatment necessary; Grade 2 (DAI 26–30): malocclusion/
definitive treatment is elective; Grade 3 (DAI 31–35):
severe malocclusion /treatment is highly desirable; and
Grade 4 (≥36 DAI): weakening malocclusion requiring
mandatory treatment. The schoolchildren were diagnosed
with absence of malocclusion (DAI ≤ 25) or present mal-
occlusion (DAI > 25).
The presence of joint sounds during mouth opening
was identified by means of bilateral manual palpation of
the TMJ during the mouth opening movement. Three rep-
etitions of the movement were made. The presence of joint
sounds was found in at least one of the repetitions.[16]
 CRANIO®: The Journal of Craniomandibular & Sleep Practice   3

A single trained examiner performed all the clinical Table 1. Malocclusion, pain and quality of life of children with and
exams, and a second examiner applied the questionnaires. without TMD symptoms (n = 248).
Both examiners received an equal κ value of 0.97. TMD symptoms
In the statistical analysis, bivariate association of the Variables With n (%) Without n (%) p*
variables malocclusion, pain, and quality of life was made Quality of life 0.0138
with TMD symptoms and pain by means of the Chi-  Better 60 (30) 140 (70)
 Worse 6 (13) 42 (88)
square test for independence. Logistic regression models Malocclusion 0.4284
were also developed according to the odds ratio calcu-  No 20 (30) 56 (70)
 Yes 46 (25) 136 (75)
lation for the variable joint sounds, clenching/grinding Pain <0.001
and quality of life with pain. The Mann–Whitney test was  No 66 (36) 119 (64)
 Yes 182(73) 63 (100)
used to verify statistically significant variables between the Joint sounds
evaluations of facial and mandibular asymmetry in chil-  No 48 (23) 157 (77) 0.1259
dren with and without TMD. All the tests of hypotheses  Yes 28 (65) 15 (35)

developed considered a significance of 5%. *Chi-squared (χ2) for independence.

Ethical aspects Table 2. Percentage of each question, per gender.

The Research Ethics Committee of the University approved Gender
the study. The participation by the schoolchildren was TMD symptoms Male Female p*
voluntary. The parents or guardians signed the Free and Q1 10 (50) 10 (50) 0.6502
Q2 11 (55) 9 (45) 0.3565
Informed Consent form (Termo de Consentimento Livre e Q3 19 (49) 20 (51) 0.6268
Esclarecido – TCLE), and the schoolchildren signed a Free Q4 43 (45) 52 (55) 0.9797
Q5 19 (40) 29 (60) 0.3872
and Informed Consent form (Termo de Assentimento Q6 25 (40) 37 (60) 0.3767
Livre e Esclarecido – TALE), confirming awareness and Q7 49 (43) 65 (57) 0.5248
acceptance of participation in the survey. Q8 9 (45) 11 (55) 0.1259
Q9 7 (47) 8 (53) 0.2815
Q10 11 (55) 9 (45) 0.1571

Results *Chi-squared (χ2) for independence.

A total of 248 children took part in the study, of which

55% were girls and 45% boys, with no significant differ- Table 3.  Logistic regression model for presence of pain versus
ence between the groups (p-value = 0.1275). For analy- joint sounds, tooth clenching/grinding and impact on quality of
sis of the independent variables with TMD symptoms, life.
the Chi-square test for independence was used. No sta- Unadjusted PR**
tistically significant association between malocclusion Variables [95% CI***] p*
and TMD symptoms was observed (p = 0.4284). For the Joint sounds 0.1259
 No 0.655 (0.303–1.413)
variables pain and quality of life, significant association  Yes 1
was detected, with p-value equal to <0.001 and 0.0138, Tooth clenching/grinding 0.0007*
respectively (Table 1).  No 0.334 (0.177–0.632)
 Yes 1
The frequency of questionnaire questions per gender Quality of life 0.0120*
was verified, followed by the p-value of the Chi-square test  Better 0.430 (0.221–0.840)
 Worse 1
for independence; no association was found between the
questions and the variable gender (Table 2). *Chi-squared (χ2) for independence.
**OR adjusted: variables adjusted.
Association of the presence of joint sounds, tooth ***CI 95%: Confidence interval 95%.
clenching/grinding and quality of life versus pain was sta-
tistically evaluated. The Chi-square test for independence
was used, and afterwards a logistic regression model was Discussion
developed, and the odds ratio was calculated. A statisti- In the present study, the prevalence of TMD in school-
cally significant association was detected between quality children was found to be considerably higher, with 73%
of life and pain (p = 0.0120) and tooth clenching/grinding reporting one or more TMD symptoms. The literature
and pain (p = 0.0007). For the variable joint sounds, no relates similar values, of around 66–78%. This variability
association was observed (p = 0.1259). From the logistics, in the prevalence of TMD may result from the different
it was possible to observe an odds ratio of 0.43 for the methodologies and data analysis.[17–19] In addition,
category “better”, indicating that a better quality of life no difference between genders was observed, in agree-
reduced the chances of presenting pain (Table 3). ment with previous studies.[20,21] According to some
4    S. A. S. Vedovello et al.
authors, children at this age do not yet suffer any influ-
ence of reproductive hormones that are associated with
increased risk for pain due to TMD. According to Habib
et al. [22] and McNeill et al. [23], this also explains the
tendency of TMD to affect women from 20 to 40 years of
age more frequently.
Although the prevalence of malocclusion was high, no
association with the presence of TMD was observed, a
fact that has also been proved by other studies.[24,25] A
probable hypothesis for this would be that younger indi-
viduals have greater capacity of adaptation of the masti-
catory system and orofacial muscles, thereby minimizing
the symptoms of TMD.[1,26,27]
The presence of joint sounds was proved by clinical
exam in 17% of the sample, but no association with pain
was found. Other studies have reported similar prevalence.
[28,29] The presence of joint sounds is considered one of
the most common symptoms of TMD.[20] Joint sounds
may be caused by articular disc displacement, structural
changes in the articular surface, and hypermobility of the
condyle-disc complex, in addition to degenerative pro-
cesses that cause crepitation. Nevertheless, in children,
joint sounds may also result from changes in the contour
of the TMJ with age, and may be a normal finding.[19]
When the habit of clenching or grinding the teeth is
frequent, it may result in tooth wear, TMD symptoms,
headache, toothache and periodontal problems.[30] The
results of this study showed a high frequency of these signs
when compared to the literature findings.[29,31,32]
In the present study, the prevalence of pain was
observed in 25% of the sample. In the literature, similar
[6,33] or higher prevalence [32] of pain was observed.
Pain is considered a public health problem and is one of
the main reasons leading people to seek health care.[6,19]
Moreover, association was observed between the pres-
ence of TMD symptoms, pain, and quality of life, sug-
gesting that the presence of pain negatively influences the
quality of life. A previous study, although conducted with
adults, reported association between quality and pain,[34]
and considered it a limiting factor on daily activities that
could be associated with a worse quality of life. These data
were also shown in another study,[35] which found that
pain as a symptom of TMD has a negative impact on the
patient’s quality of life, confirming the results presented.
Therefore, the importance of early diagnosis may be
considered, in order to detect factors that may interfere
in the growth and adequate development of the stomato-
gnathic system, in addition to the adoption of preventive
and self-care measures, with the goal of reducing possible
harm.[6,20] No associations were found between TMD
symptoms and presence of malocclusion, joint sounds,
asymmetry of mandibular movements, and of the face.
There was association between the symptoms of TMD
and pain, and with the habit of clenching/grinding the
teeth that have a negative effect on the quality of life of
these children.
Conclusion
The symptoms of TMD are associated with pain and teeth
clenching, causing a negative impact on schoolchildren’s
quality of life.
Contributors
Silva MF made data collection; Silva MF, Valdrighi HC,
Venezian GC and Degan VV participated in the develop-
ment of research, data analysis and writing of the Article;
Vedovello Filho M and Vedovello SAS reviewed Article;
and, Venezian GC developed the statistical analysis.
Acknowledgement
PIBIC-CNPq 136015/2014-0.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Silvia A. S. Vedovello   http://orcid.org/0000-0002-7203-2867
References
  [1] Lei J, Fu J, Yap AU, et al. Temporomandibular disorders
symptoms in Asian adolescents and their association
with sleep quality and psychological distress. Cranio.
2016;28:1–8.
 [2]  Loddi PP, Miranda ALR, Vieira MM, et al. Factors
predisposing 6 to 11-year old children in the first stage of
orthodontic treatment to temporomandibular disorders.
Dental Press J Orthod. 2010;15:87–93.
  [3] Weijenberg RA, Lobbezoo F. Chew the pain away: oral
habits to cope with pain and stress and to stimulate
cognition. Biomed Res Int. 2015;2015:149–431.
  [4] Merighi LBM, Silva MMA, Ferreira AT, et al. Occurrence
of temporomandibular disorder (TMD) and its
relationship with harmful oral habits in children from
Monte Negro. Rev CEFAC. 2007;9:497–503.
  [5] Oliveira LK, Almeida GA, Lelis ÉR, et al.
Temporomandibular disorder and anxiety, quality of
sleep, and quality of life in nursing professionals. Braz
Oral Res. 2015;29:1–7.
  [6] Karibe H, Goddard G, Kawakami T, et al. Comparison of
subjective symptoms among three diagnostic subgroups
of adolescents with temporomandibular disorders. Int J
Paediatr Dent. 2010;20:458–465.
 [7]  Franco-Micheloni AL, Fernandes G, Gonçalves DA,
et al. Temporomandibular disorders among Brazilian
 CRANIO®: The Journal of Craniomandibular & Sleep Practice   5
adolescents: reliability and validity of a screening
questionnaire. J Appl Oral Sci. 2014;22:314–322.
  [8] Manfredi APS, Da Silva AA, Vendite LL. The sensibility
appreciating of the questionnaire for selection of orofacial
pain and temporomandibular disorders recommended
by the American Academy of Orofacial Pain. Rev Bras
Otorrinolaringol. 2001;67:763–768.
  [9] American Academy of Orofacial Pain. General
assessment of the orofacial pain patient. In: De Leeuw
E, Klasser GD, editors. Orofacial pain – guidelines for
assessment, diagnosis and management. 5th ed. Chicago,
IL: Quintessence; 2013. p. 25–46.
[10] Jokovic A, Locker D, Stephens M, et al. Validity and
reliability of a questionnaire for measuring child oral-
health-related quality of life. J Dent Res. 2002;81:459–463.
[11]  Feu D, Quintão CCA, Miguel JAM. Quality of life
instruments and their role in orthodontics. Dental Press
J Orthod. 2010;15:61–70. Available from: http://www.
scielo.br/pdf/dpjo/v15n6/en_v15n6a08.pdf
[12] Sardenberg F, Martins MT, Bendo CB, et al. Malocclusion
and oral health-related quality of life in Brazilian school
children. Angle Orthod. 2013;83:83–89.
[13] Leme MS, Souza Barbosa T, Gavião MB. Relationship
among oral habits, orofacial function and oral health-
related quality of life in children. Braz Oral Res.
2013;27:272–278.
[14]  Nascimento GKBO, Lima LM, Freitas MCR, et al.
Preference side masticatory and facial symmetry in total
laryngectomy: clinical and electromyography study. Rev
CEFAC. 2013;15:1525–1532.
[15] Lopes RG, Godoy CHL, Motta LJ, et al. Evaluation of
the association between temporomandibular disorder
and vertical dimension of occlusion in children and
adolescents aged seven to 12 years. Rev CEFAC.
2014;16:892–898.
[16] Karibe H, Goddard G, McNeill C, et al. Comparison
of patients with orofacial pain of different diagnostic
categories. Cranio. 2011;29:138–143.
[17]  Emodi-Perlman A, Eli I, Friedman-Rubin P, et al.
Bruxism, oral parafunctions, anamnestic and clinical
findings of temporomandibular disorders in children. J
Oral Rehabil. 2012;39:126–135.
[18] Motta LJ, Guedes CC, De Santis TO, et al. Association
between parafunctional habits and signs and symptoms
of temporomandibular disorders among adolescents.
Oral Health Prev Dent. 2013;11:3–7.
[19] Negoro T, Briggs J, Plesh O, et al. Bruxing patterns in
children compared to intercuspal clenching and chewing
as assessed with dental models, electromyography, and
incisor jaw tracing: preliminary study. ASDC J Dent
Child. 1998;65:449–458.
[20]  Bonjardim LR, Gavião MBD, Pereira LJ, et al. Signs
and symptoms of temporomandibular disorders in
adolescents. Braz Oral Res. 2005;19:93–98.
[21] Pizolato RA, Freitas-Fernandes FS, Gavião MB. Anxiety/
depression and orofacial myofascial disorders as factors
associated with TMD in children. Braz Oral Res.
2013;27:156–162.
[22] Habib SR, Al Rifaiy MQ, Awan KH, et al. Prevalence
and severity of temporomandibular disorders among
university students in Riyadh. Saudi Dent J. 2015;27:125–
130.
[23] McNeill C, Falace D, Attanasio R. Continuing education
for TMD and orofacial pain: a philosophical overview. J
Craniomandib Disord. 1992;6:135–136.
[24] Biasotto-Gonzalez DA, Silva DS, Costa JM, et al.
Comparative analysis between two cervical angles with
occlusion in children with and without TMD. Rev.
CEFAC. 2012;14:1146–1152.
[25] Špalj S, Šlaj M, Athanasiou AE, et al. Temporomandibular
disorders and orthodontic treatment need in
orthodontically untreated children and adolescents. Coll
Antropol. 2015;39:151–158.
[26] Serra-Negra JM, Paiva SM, Abreu MH, et al. Relationship
between tasks performed, personality traits, and sleep
bruxism in Brazilian school children – a population-based
cross-sectional study. PLoS One. 2013–2014;8:e80075.
[27] Cattoni DM, Fernandes FDM. Anthropometric orofacial
measurements and proportions in mouth breathing
children. Pró-Fono. 2004;16:7–18.
[28] Farsi NM. Symptoms and signs of temporomandibular
disorders and oral parafunctions among Saudi children. J
Oral Rehabil. 2003;30:1200–1208.
[29] Santos ECA, Bertoz FA, Pignatta LMB, et al. Clinical
evaluation of signs and symptoms of children’s
temporomandibular dysfunction. Rev Dent Press
Ortodon Ortop Facial. 2006;11:29–34.
[30] Kataoka K, Ekuni D, Mizutani S, et al. Association
between self-reported bruxism and malocclusion in
university students: a cross-sectional study. J Epidemiol.
2015;25:423–430.
[31] Serra-Negra JM, Ramos-Jorge ML, Flores-Mendoza CE,
et al. Influence of psychosocial factors on the development
of sleep bruxism among children. Int J Paediatr Dent.
2009;19:309–317.
[32] Karibe H, Shimazu K, Okamoto A, et al. Prevalence
and association of self-reported anxiety, pain, and oral
parafunctional habits with temporomandibular disorders
in Japanese children and adolescents: a cross-sectional
survey. BMC Oral Health. 2015;15:1–7.
[33] McNeill C, Mohl ND, Rugh JD, et al. Temporomandibular
disorders: diagnosis, management, education, and
research. J Am Dent Assoc. 1990;120:253–263.
[34] Cacchiotti DA, Plesh O, Bianchi P, et al. Signs
and symptoms in samples with and without
temporomandibular disorders. J Craniomandib Disord.
1991;5:167–172.
[35] Franco AL, Fernandes G, Gonçalves DA, et al. Headache
associated with temporomandibular disorders among
young Brazilian adolescents. Clin J Pain. 2014;30:340–
345.