Journal of Oral Rehabilitation, 1992, Volume 19, pages 353-359
Signs and symptoms of temporomandibular joint dysfunction in a Saudi Arabian population R . G . J A G G E R and C . W O O D * Department of Prosthetic Dentistry, Dental School, University of Wales College of Medicine, Cardiff and * Dental Department, Riyadh Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia
Summary
The signs and symptoms of temporomandibular joint dysfunction present in 219 Saudi Arabians attending a dental clinic for routine dental treatment are described. Joint sounds (36%) and muscle tenderness to palpation (34%) were common findings. Of the subjects examined, 31% reported suffering from frequent headaches. The study demonstrated a high incidence of signs and symptoms of temporomandibular joint dysfunction. Findings were similar to those of a previous study of an investigation in a bedouin community in Western Egypt (Abdel-Hakim, 1983). Introduction
Temporomandibular joint (TMJ) dysfunction is a term that is applied to a range of disorders that affect the TMJ and muscles of mastication. Such disorders produce a variety of signs and symptoms that include muscle pain, joint pain, joint sounds and pain on opening of the mouth. The dental literature contains reports of the incidence of such symptoms of TMJ dysfunction in many different parts of the world and a review of these has been presented by Carlsson (1984). He concluded that despite the great range of values recorded in the different studies it is evident that both signs and symptoms of mandibular dysfunction are common in non-patient populations. The only report of the incidence of such symptoms in the Arab world is by AbdelHakim (1983) who investigated a bedouin population in an isolated community in Western Egypt. He found a high prevalence that included an incidence of clicking TMJ sounds in 19% and tenderness to palpation of one or more masticatory muscles in 39% of the population studied. The present study was carried out to investigate the prevalence of symptoms of TMJ dysfunction in a Saudi Arabian population. Al Kharf
Al Kharj is an oasis town situated approximately 80 kilometres south of the Saudi Arabian capital of Riyadh with a population of approximately 20000, (Fig. 1). It is a predominantly agricultural area although in recent years light industry has been developed. The A! Kharj Hospital was established in 1980 as part of the Riyadh Al Kharj Correspondence: Robert G. Jagger, Department of Prosthetic Dentistry, Dental School, University of Wales College of Medicine, Cardiff, South Wales, U.K.
353
354
R. G. Jagger and C. Wood
Fig. 1. 7he Arabian Peninsula.
hospital programme lor military personnel and their dependents. The hospital has an eligible population of 50000. Materials and methods All patients attending the daytime dental clinic of the Al Kharj hospital were included in the study. Patients below the age of 16 years were excluded, as were non-Saudi Arabian nationals. Patients were investigated both by questionnaire to assess subjective disorders, and by clinical examination to determine objective symptoms, in a method similar to that described by Hansson & Nilner (1975). Clinical history Ouestionnaires were read to the patient by an interpreter from a standard form as shown below and any uncertainties were explained to the patients. Answers were recorded on the standard form. 1. Do you find it difficult to open your mouth wide? 2. Do you feel pain on opening your mouth wide?
TMJ in a Saudi Arabian population
355
3. Do you hear any clicking or noise from the joint when you open your mouth wide? 4. Do you have headaches more than twice a week? 5. Do you ever have pain in your ears or in front of your ears? Clinical examination Maximum interincisal opening of the mouth was measured by means of a metal ruler. No account was taken of the patient's overbite. The lateral aspects of the joints were gently palpated in order to detect crepitus or uncoordinated movement of the head of the mandibular condyle during opening and closing of the mouth. The presence of a click was recorded if the sound was heard or if a sudden uncoordinated movement of the mandibular condyle occurred during opening or closing of the mouth. The joints were then firmly palpated laterally and posteriorly and the patient was asked whether this palpation caused pain. Left and right temporalis, masseter and lateral pterygoid muscles were palpated according to standard procedures (Hansson & Nilner, 1975) and the patient was again asked whether palpation caused pain. Any specific muscle causing pain was noted. Results
A total of 219 patients, (100 male and 119 female) were included in the investigation. The age distribution is given in Table 1. Clinical history The findings of the clinical history are given in Table 2. Clinical examination Mean maximum interincisal opening was 49 mm SD ± 14 mm. Only nine patients were
Table 1. Age distribution (219 patients)
60
40
20
59
4
0
10
mean 35 years ±14
20
30
37 40
20
37 50
Age Male KX) Female 119
60
3 70
80
356
R.G. Jagger and C. Wood
Table 2. Clinical history (219 patients)
n Difficult to open mouth wide Pain on wide opening Hear clicking or noise Headaches more than twice per week Pain in front of ears
Yes (%)
n
No (%)
(95) (92) (85)
151
(69) (81)
12 17 33
(15)
207 202 186
68 41
(31) (19)
178
(5) (8)
unable to open more than 40 mm whilst 29 could open more than 60 mm but only 2 more than 70mm. Of the patients studied, 8% said that they felt pain on maximum opening of the mouth. Table 3 shows the joint sounds that were recorded. Table 4 shows the frequency of tenderness to palpation of the tempormandibular joints and muscles of mastication. Discussion The aim of this investigation was to determine the signs and symptoms of TMJ dysfunction in a population that had not been described previously. The design of the investigation was similar to the earlier studies of Hansson & Nllner (1975) who examined 1069 workers in a ship-building yard in southern Sweden and of Abdel-Hakim (1983) who examined 215 males from an oasis eommunity in the western desert of Egypt. These studies ean be used as useful comparisons. The method was a combination of subjective assessment of symptoms by questionnaire and objective findings by examination. Although Abdel-Hakim included only male subjects in his investigation of a bedouin Arab community the results of the present questionnaire are strikingly similar and differ in several ways from the results of Hansson and Nilner (Table 5). All groups had a similar incidence of reported difficulty to open the mouth widely, whilst the Swedish group was slightly more aware of joint sounds than the Arab populations. When compared to the Swedish subjects both Arab groups reported a higher incidence of pain on opening of the mouth, pain in front of the ears and a considerably higher incidence of reported recurrent headaches. The Ineidence of recurrent headache is very high in both Arab groups and this deserves further investigation. It is said that more than 85% of recurrent headaches are either of the muscle contraction/tension or migraine variety (Blau, 1989). Migraine headaches do not, however, generally occur more than twice per week. Because the questionnaires in the studies specified frequency of more than twice per week this would perhaps indicate a very high incidence of muscle contraction/tension headaches in the Arab populations. A comparison of the clinical findings of Swedish and Arab studies is given in Table 6. Here, considerable differences are apparent. All groups had strikingly similar results for tenderness to palpation of muscles of mastication. The Egyptian group were adjudged to have a very high incidence of tenderness to palpation of the TMJ. It is possible that this is due to a difference in examination technique. The Swedish
TMJ in a Satidi Arabian poptdation
357
Table 3. Joint sounds (219 patients)
Patients with joint sounds Crepitus alone
78 23 20 3
36
Clicks alone Unilateral-open -close -reciprocal Bilatcral-opcn -close -reciprocal
45 9 9
21 4 4 7 2 0 3
Clicks and crepitus Unilateral-open -close -reciprocal Bilateral-open -close -reciprocal
10 4 3 1 0 1
Bilateral
10 9
1
17 4 0 6
5 2 1 1 0 1 1
Table 4. Tenderness to palpatation of TM.I and muscles of mastication (21M patients) n
%
Tenderness TMJ Unilateral Bilateral
24 9
11 4
Total
33
15
Tenderness of at least one muscle of mastication Unilateral Bilateral
42 32
19 15
Total
74
34
Table 5. Comparison of subjective findings
Diftieulty opening mouth Pain on opening mouth Joint sounds Headaches more than twice per week Pain in front of ears
Jagger & Wood
Abdcl-Hakim (1983)
Hanson & Nilner (1975)
5 8 15
8 10 19
6 3 23
31 19
29 24
18 7
358
R- G. Jagger and C. Wood
Table 6. Comparison of objective findings
Jagger & Wood
Abdel-Hakim (1983)
Hanson & Nilner (1975)
Tenderness of TMJ Unilateral Bilateral
11
Total
15
30
11
34
39
37
8 4
4
Tenderness of museles Total Joint sounds Crepitus Clicking Clieking and crepitus Total
10 21
21 41
5
3
36
37
65
group had a very high incidence of joint sounds when compared to the Arab populations. Wabeke et al. (1989) have reviewed the literature on TMJ elicking and consider that 30% is an approximate mean for joint sounds in most non-patient populations. The figure of 36% for the present study is In agreement with this and with the findings of Abdel-Hakim. However, some studies, including that of Hansson and Nilner, vary widely from this mean. Methods and criteria for adjudging joint sounds differ in various studies and this will affect the results. The present study did not include the use of a stethoscope and this means that comparison between the results of the studies are unreliable. The incidence of 33% of joint sounds is similar to the Egyptian study and is in the range of the mean described by Wabeke et al. (1989). Another Swedish study of a non-patient population has also described an incidence of joint sounds of approximately 30% (Agerberg & Carlsson, 1975). The nature of joint sounds has not previously been classified in the manner of the present study for such a large population, and the results are thus of some intererst. Reciprocal clicking is believed to be a sign of anterior disk displacement although the exact relationship has not yet been determined. This study has demonstrated a very high incidence of reciprocal clicking. Conclusion The study has demonstrated a high incidence of signs and symptoms of TMJ dysfunction in an Arab population. The results of subjective and objective findings agreed closely with those of a previous study of a bedouin community in Western Egypt. References (1983) Stomatognathic dysfunction in the western desert of Egypt: An epidemiological survey. Journal of Oral Rehabilitation, 10, 461. AGERBKRCI, G . & CARt-SSON, G.E. (1975) Symptoms of funetional disturbance of the masticatory
ABDKL-HAKIM, A . M .
TMJ in a Saudi Arabian population
359
system. A comparison of frequencies in a population sample and in a group of patients. Acta Odontologica Scandinavica, 33, 183. BLAU, J . N . (1989) Are common migraine and tension headache clinically distinguishable? In: Migraine and Other Headaches (eds M.D. Ferrari & X. Lataste) p.131, Parthenon Publishing Group, Carnforth. CARLSSON, G . E . (1984) Epidemiology studies of signs and symptoms of temporomandibular joint pain — dysfunction. A literature review. Australian Prosthodontic Society Bulletin, 14. 7. HANSSON. T . & NILNER, M . (1975) A study of the occurrence of symptoms of diseases of the temporomandibular joint, masticatory muscles and related structures. Joumal of Oral Rehabilitation, 2, 313. WABEKE, K.B., HANSSON. T.L., HOOGSTRATEN, J. & VAN DER KUY, P. (1989) Temporomandibular joint clicking: A literature overview. Journal of Craniomandibular Disorder Facial Oral Fain, 3. 163. WATI, D . M . (1980) Temporomandibular joint sounds. Journal of Dentistry. 8, 121.
Signs and symptoms of temporomandibular joint dysfunction in a Saudi Arabian population R . G . J A G G E R and C . W O O D * Department of Prosthetic Dentistry, Dental School, University of Wales College of Medicine, Cardiff and * Dental Department, Riyadh Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia
Summary
The signs and symptoms of temporomandibular joint dysfunction present in 219 Saudi Arabians attending a dental clinic for routine dental treatment are described. Joint sounds (36%) and muscle tenderness to palpation (34%) were common findings. Of the subjects examined, 31% reported suffering from frequent headaches. The study demonstrated a high incidence of signs and symptoms of temporomandibular joint dysfunction. Findings were similar to those of a previous study of an investigation in a bedouin community in Western Egypt (Abdel-Hakim, 1983). Introduction
Temporomandibular joint (TMJ) dysfunction is a term that is applied to a range of disorders that affect the TMJ and muscles of mastication. Such disorders produce a variety of signs and symptoms that include muscle pain, joint pain, joint sounds and pain on opening of the mouth. The dental literature contains reports of the incidence of such symptoms of TMJ dysfunction in many different parts of the world and a review of these has been presented by Carlsson (1984). He concluded that despite the great range of values recorded in the different studies it is evident that both signs and symptoms of mandibular dysfunction are common in non-patient populations. The only report of the incidence of such symptoms in the Arab world is by AbdelHakim (1983) who investigated a bedouin population in an isolated community in Western Egypt. He found a high prevalence that included an incidence of clicking TMJ sounds in 19% and tenderness to palpation of one or more masticatory muscles in 39% of the population studied. The present study was carried out to investigate the prevalence of symptoms of TMJ dysfunction in a Saudi Arabian population. Al Kharf
Al Kharj is an oasis town situated approximately 80 kilometres south of the Saudi Arabian capital of Riyadh with a population of approximately 20000, (Fig. 1). It is a predominantly agricultural area although in recent years light industry has been developed. The A! Kharj Hospital was established in 1980 as part of the Riyadh Al Kharj Correspondence: Robert G. Jagger, Department of Prosthetic Dentistry, Dental School, University of Wales College of Medicine, Cardiff, South Wales, U.K.
353
354
R. G. Jagger and C. Wood
Fig. 1. 7he Arabian Peninsula.
hospital programme lor military personnel and their dependents. The hospital has an eligible population of 50000. Materials and methods All patients attending the daytime dental clinic of the Al Kharj hospital were included in the study. Patients below the age of 16 years were excluded, as were non-Saudi Arabian nationals. Patients were investigated both by questionnaire to assess subjective disorders, and by clinical examination to determine objective symptoms, in a method similar to that described by Hansson & Nilner (1975). Clinical history Ouestionnaires were read to the patient by an interpreter from a standard form as shown below and any uncertainties were explained to the patients. Answers were recorded on the standard form. 1. Do you find it difficult to open your mouth wide? 2. Do you feel pain on opening your mouth wide?
TMJ in a Saudi Arabian population
355
3. Do you hear any clicking or noise from the joint when you open your mouth wide? 4. Do you have headaches more than twice a week? 5. Do you ever have pain in your ears or in front of your ears? Clinical examination Maximum interincisal opening of the mouth was measured by means of a metal ruler. No account was taken of the patient's overbite. The lateral aspects of the joints were gently palpated in order to detect crepitus or uncoordinated movement of the head of the mandibular condyle during opening and closing of the mouth. The presence of a click was recorded if the sound was heard or if a sudden uncoordinated movement of the mandibular condyle occurred during opening or closing of the mouth. The joints were then firmly palpated laterally and posteriorly and the patient was asked whether this palpation caused pain. Left and right temporalis, masseter and lateral pterygoid muscles were palpated according to standard procedures (Hansson & Nilner, 1975) and the patient was again asked whether palpation caused pain. Any specific muscle causing pain was noted. Results
A total of 219 patients, (100 male and 119 female) were included in the investigation. The age distribution is given in Table 1. Clinical history The findings of the clinical history are given in Table 2. Clinical examination Mean maximum interincisal opening was 49 mm SD ± 14 mm. Only nine patients were
Table 1. Age distribution (219 patients)
60
40
20
59
4
0
10
mean 35 years ±14
20
30
37 40
20
37 50
Age Male KX) Female 119
60
3 70
80
356
R.G. Jagger and C. Wood
Table 2. Clinical history (219 patients)
n Difficult to open mouth wide Pain on wide opening Hear clicking or noise Headaches more than twice per week Pain in front of ears
Yes (%)
n
No (%)
(95) (92) (85)
151
(69) (81)
12 17 33
(15)
207 202 186
68 41
(31) (19)
178
(5) (8)
unable to open more than 40 mm whilst 29 could open more than 60 mm but only 2 more than 70mm. Of the patients studied, 8% said that they felt pain on maximum opening of the mouth. Table 3 shows the joint sounds that were recorded. Table 4 shows the frequency of tenderness to palpation of the tempormandibular joints and muscles of mastication. Discussion The aim of this investigation was to determine the signs and symptoms of TMJ dysfunction in a population that had not been described previously. The design of the investigation was similar to the earlier studies of Hansson & Nllner (1975) who examined 1069 workers in a ship-building yard in southern Sweden and of Abdel-Hakim (1983) who examined 215 males from an oasis eommunity in the western desert of Egypt. These studies ean be used as useful comparisons. The method was a combination of subjective assessment of symptoms by questionnaire and objective findings by examination. Although Abdel-Hakim included only male subjects in his investigation of a bedouin Arab community the results of the present questionnaire are strikingly similar and differ in several ways from the results of Hansson and Nilner (Table 5). All groups had a similar incidence of reported difficulty to open the mouth widely, whilst the Swedish group was slightly more aware of joint sounds than the Arab populations. When compared to the Swedish subjects both Arab groups reported a higher incidence of pain on opening of the mouth, pain in front of the ears and a considerably higher incidence of reported recurrent headaches. The Ineidence of recurrent headache is very high in both Arab groups and this deserves further investigation. It is said that more than 85% of recurrent headaches are either of the muscle contraction/tension or migraine variety (Blau, 1989). Migraine headaches do not, however, generally occur more than twice per week. Because the questionnaires in the studies specified frequency of more than twice per week this would perhaps indicate a very high incidence of muscle contraction/tension headaches in the Arab populations. A comparison of the clinical findings of Swedish and Arab studies is given in Table 6. Here, considerable differences are apparent. All groups had strikingly similar results for tenderness to palpation of muscles of mastication. The Egyptian group were adjudged to have a very high incidence of tenderness to palpation of the TMJ. It is possible that this is due to a difference in examination technique. The Swedish
TMJ in a Satidi Arabian poptdation
357
Table 3. Joint sounds (219 patients)
Patients with joint sounds Crepitus alone
78 23 20 3
36
Clicks alone Unilateral-open -close -reciprocal Bilatcral-opcn -close -reciprocal
45 9 9
21 4 4 7 2 0 3
Clicks and crepitus Unilateral-open -close -reciprocal Bilateral-open -close -reciprocal
10 4 3 1 0 1
Bilateral
10 9
1
17 4 0 6
5 2 1 1 0 1 1
Table 4. Tenderness to palpatation of TM.I and muscles of mastication (21M patients) n
%
Tenderness TMJ Unilateral Bilateral
24 9
11 4
Total
33
15
Tenderness of at least one muscle of mastication Unilateral Bilateral
42 32
19 15
Total
74
34
Table 5. Comparison of subjective findings
Diftieulty opening mouth Pain on opening mouth Joint sounds Headaches more than twice per week Pain in front of ears
Jagger & Wood
Abdcl-Hakim (1983)
Hanson & Nilner (1975)
5 8 15
8 10 19
6 3 23
31 19
29 24
18 7
358
R- G. Jagger and C. Wood
Table 6. Comparison of objective findings
Jagger & Wood
Abdel-Hakim (1983)
Hanson & Nilner (1975)
Tenderness of TMJ Unilateral Bilateral
11
Total
15
30
11
34
39
37
8 4
4
Tenderness of museles Total Joint sounds Crepitus Clicking Clieking and crepitus Total
10 21
21 41
5
3
36
37
65
group had a very high incidence of joint sounds when compared to the Arab populations. Wabeke et al. (1989) have reviewed the literature on TMJ elicking and consider that 30% is an approximate mean for joint sounds in most non-patient populations. The figure of 36% for the present study is In agreement with this and with the findings of Abdel-Hakim. However, some studies, including that of Hansson and Nilner, vary widely from this mean. Methods and criteria for adjudging joint sounds differ in various studies and this will affect the results. The present study did not include the use of a stethoscope and this means that comparison between the results of the studies are unreliable. The incidence of 33% of joint sounds is similar to the Egyptian study and is in the range of the mean described by Wabeke et al. (1989). Another Swedish study of a non-patient population has also described an incidence of joint sounds of approximately 30% (Agerberg & Carlsson, 1975). The nature of joint sounds has not previously been classified in the manner of the present study for such a large population, and the results are thus of some intererst. Reciprocal clicking is believed to be a sign of anterior disk displacement although the exact relationship has not yet been determined. This study has demonstrated a very high incidence of reciprocal clicking. Conclusion The study has demonstrated a high incidence of signs and symptoms of TMJ dysfunction in an Arab population. The results of subjective and objective findings agreed closely with those of a previous study of a bedouin community in Western Egypt. References (1983) Stomatognathic dysfunction in the western desert of Egypt: An epidemiological survey. Journal of Oral Rehabilitation, 10, 461. AGERBKRCI, G . & CARt-SSON, G.E. (1975) Symptoms of funetional disturbance of the masticatory
ABDKL-HAKIM, A . M .
TMJ in a Saudi Arabian population
359
system. A comparison of frequencies in a population sample and in a group of patients. Acta Odontologica Scandinavica, 33, 183. BLAU, J . N . (1989) Are common migraine and tension headache clinically distinguishable? In: Migraine and Other Headaches (eds M.D. Ferrari & X. Lataste) p.131, Parthenon Publishing Group, Carnforth. CARLSSON, G . E . (1984) Epidemiology studies of signs and symptoms of temporomandibular joint pain — dysfunction. A literature review. Australian Prosthodontic Society Bulletin, 14. 7. HANSSON. T . & NILNER, M . (1975) A study of the occurrence of symptoms of diseases of the temporomandibular joint, masticatory muscles and related structures. Joumal of Oral Rehabilitation, 2, 313. WABEKE, K.B., HANSSON. T.L., HOOGSTRATEN, J. & VAN DER KUY, P. (1989) Temporomandibular joint clicking: A literature overview. Journal of Craniomandibular Disorder Facial Oral Fain, 3. 163. WATI, D . M . (1980) Temporomandibular joint sounds. Journal of Dentistry. 8, 121.
