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European Journal of General Medicine
Medical Investigations Society
ISSN: 1304-3897
Vol. 6, Num. 4, 2009, pp. 223-228

European Journal of General Medicine, Vol. 6, No. 4, October-December, 2009, pp. 223-228

Article

Prevalence of temporomandibular disorders in pregnancy

Özlem Solak1 , Nurten Turhan-Haktanır2 , Gülengül Köken3 , Hasan Toktas1 , Özkan Güler4 , Vural Kavuncu1 , Yavuz Demir2

1 Afyon Kocatepe University, Department of Physical Medicine and Rehabilitation, Turkey
2 Afyon Kocatepe University, Department of Plastic, Reconstructive and Aesthetic Surgery, Turkey
3 Afyon Kocatepe University, Department of Obstetric and Gynecology, Turkey
4 Afyon Kocatepe University, Department of Psychiatry, Turkey

Correspondence Address: Özlem Solak, Afyon Kocatepe Üniversitesi Tıp Fakültesi Fiziksel Tip ve Rehabilitasyon AD Afyonkarahisar, TÜRKİYE
ozlemsolak@hotmail.com

Code Number: gm09047

Abstract

Aim : To determine if the prevalence of systemic joint hypermobil­ity and temporomandibular disorders (TMD) is higher during preg­nancy or not and also to confirm a correlation between systemic joint hypermobility and TMD. Methods : 70 pregnant and 40 age-matched non pregnant women were enrolled in the study. 30% of the pregnant women were in the first trimester of gestation, 34.3% of them were in the second,and 35.7% of them were in the third trimester. All of the sub­jects completed a self-administered questionnaire, and underwent a standardized clinical examination using the Research Diagnostic Criteria for TMD (RDC/TMD). Hypermobility was determined ac­cording to the criteria of Beighton et al. Results : 7.1% of the pregnant women and 7.5% of the non-preg­nant women received an RDC/TMD Axis I diagnosis (p> 0.05). 31.4% of the pregnant women and 40% of the non-pregnant women had systemic joint hypermobility (p> 0.05). Among all subjects who received a RDC/TMD Axis I diagnosis, 35.3% had systemic joint hypermobility and among all subjects who did not meet criteria to receive a RDC/TMD Axis I diagnosis, 25% had systemic joint hypermobility (p> 0.05). Conclusion : The prevalence of TMD and systemic joint hypermo­bility were not high among pregnant women compared to age matched non-pregnant women. And we were not able to confirm a correlation between systemic joint hypermobility and TMD.

Keywords: Temporomandibular disorders; prevalence; pregnancy; pain; hypermobility

Introduction

Temporomandibular disorder (TMD) is a collective term that embraces a number of clinical conditions that involve the masticatory musculature or temporo-mandibular joints (TMJ) and associated structures. These clinical conditions are characterized by pain in the preauricular area, TMJ, or muscles of mastica-tion, limitation or deviation in the mandibular range of motion, and TMJ sounds (clicking, popping, and crepitus) during mandibular function [1] .

The higher prevalence of temporomandibular disor-der pain among women has been extensively hypoth-esized and documented in numerous epidemiological studies [2] . Several theories involving both biological and psychological factors have been proposed to ex-plain this gender difference [3] . It was suggested that post-menopausal women, those receiving hormone re-placement therapy (HRT) were found to be at higher risk for TMD than those not receiving HRT [4] .

Pregnancy produces dramatic changes in levels of estrogens and progesterone. Both estrogen and pro-gesterone levels rise throughout pregnancy. Estrogens are known to increase joint laxity [5] , at least during pregnancy, and laxity of the temporomandibular joint is thought to play a role in the development of some of these disorders [6] . Another possibility is that es-trogens enhance a number of specific inflammatory responses in the temporomandibular joint [7] .

Another possible hormonal factor may be relaxin. Relaxin levels increase 2- to 3-fold during pregnancy [8] . Increased systemic joint laxity in pregnant wom-en has been linked to elevated levels of relaxin [9] .

As the levels of relaxin and estrogen increases throughout pregnancy, laxity of the temporomandibu-lar joint may increase and there may be a tendency to TMD. We aimed to determine if the prevalence of TMD and systemic joint hypermobility is higher dur-ing pregnancy or not . And we purposed to confirm a correlation between systemic joint hypermobility and TMD.

Material and Method

70 pregnant (mean ages 26.9±5.2) and 40 (mean ages 28.15±7.1) non pregnant women were enrolled in the study. A known psychiatric disease, a trauma to tem-poromandibular joint or face, Rheumatoid arthritis and seronegative sondyloarthropathy were excluded from the study. 30% (n= 21) of the pregnant women were in the first trimester of gestation, 34.3% (n= 24) of them were in the second, and 35.7% (n= 25) of them were in the third trimester.

The study protocol was approved by our Institutional Research Ethics Committee. All of the subjects gave written informed consent, completed a self-adminis-tered questionnaire, and underwent a standardized clinical examination using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) [1] . The patients diagnosis are grouped as follows: Group I

Group Ia: Myofascial pain

Group Ib: Myofascial pain with limited opening No Group I diagnosis

Group II-Left joint

Group IIa: Left disc displacement (DD) with reduction

Group IIb: Left DD without reduction with limited opening

Group IIc: Left DD without reduction without limited opening.

No Left Group II diagnosis

Group II- Right joint

Group IIa: Right DD with reduction

Group IIb: Right DD without reduction with limited opening

Group IIc: Right DD without reduction without limited opening.

No Right Group II diagnosis

Group III- Left joint

Group IIIa. Left arthralgia

Group IIIb: Left osteoarthritis

Group IIIc: Left osteoarthrosis No Left

Group III diagnosis

Group III- Right joint

Group IIIa: Right arthralgia

Group IIIb: Right osteoarthritis

Group IIIc: Right osteoarthrosis No Right

Group III diagnosis

Pain severity was assessed using the Graded Chronic Pain Scale (GCPS) [10] . The GCPS, was developed to provide a brief and simple method of grading the severity of chronic or recurrent pain. It has good validity and reliability, as assessed in samples of patients with headache and with TMD pain. All sub-jects were asked to rate their average, worst and current pain intensity on 0 to 10 scales; the mean of these three ratings is the characteristic pain in-tensity score. They were also asked to rate on 0 to 10 scales the degree to which the pain interferes with daily activities, work/housework activities and recreational/ social activities. The mean of these three ratings is the pain-related disability score. In addition, GCPS was used to classify the subjects into one of five categories:

0= no pain;

I= low pain intensity and low pain-related disability;

II= high pain intensity and low pain-related disability;

III= moderate pain-related disability;

IV= severe pain-related disability.

The RDC/TMD Axis II was used to measure depression and somatization [1] . Non-specific physical symp-toms (NPS) with pain items included and excluded are assessed in somatization scale. Depression and somatization scales are validated as a screening tool (not diagnostic); normed for RDC/TMD using population-based data and patients are classified as normal, moderate or severe symptom level [11] . The clinical utility of the RDC/TMD Axis II was demon-strated [11] .

Clinical TMD findings were assessed using the stan-dardized RDC/TMD clinical examination and Axis I diagnosis were generated according to RDC/TMD criteria. An extra oral muscle palpation pain sever-ity score was calculated by summing the subject's ratings of pain on palpation of 16 muscle sites (bilateral palpation of the posterior, middle, and anterior temporalis; superior, middle and inferior masseter; posterior mandibular region; and sub-mandibular region). Ratings for each site can range from 0 (no pain) to 3 (severe pain), so the severity score can range from 0 to 48. Measures of pain-free unassisted mandibular opening and maximum assisted mandibular opening (in millimeters) were also collected.

Hypermobility was determined according to the cri-teria of Beighton et al [12] . Patients were given a score of 0-9, one point being allocated for the ability to perform each of the tests: (a) passive dorsiflexion of the little finger beyond 90°; (b) passive apposition of the thumb to the flexor aspects of the forearm; (c) hyperextension of the elbow beyond 10°; (d) hyperextension of the knee beyond 10°; and (e) for-ward flexion of the trunk, with the knees straight,so the palms of the hands rested easily on the floor.Patients were considered hypermobile if they scored 4 or more out of 9.

Statistical Analysis

Differences between the pregnant and non-pregnant groups were assessed using t- tests for continuous variables and X2 tests for dichotomous variables.

Result

There was not statistically difference between preg-nant and non-pregnant women according to age (p< 0.05) 7.1% (n= 5) of the pregnant women and 7.5% (n= 3) of the non pregnant women received an RDC/ TMD Axis I diagnosis (p> 0.05). These RDC/TMD diag-noses were distributed as follows [Table - 1]. Among pregnant women, one in the first trimester had right osteoarthrosis (Group IIIc), one in the second trimes-ter had right and left arthralgia (Group IIIa), one in the second trimester had right arthralgia (Group IIIa), one in the second trimester had myofascial pain with limited opening (Group Ib) and the last one in the third trimester had right disc displacement (RDD) with reduction (Group IIa). Among control group, two had myofascial pain with limited opening (Group Ib) and one had RDD with reduction (Group IIa).

31.4% (n= 22) of the pregnant women and 40% (n= 16) of the non-pregnant women had systemic joint hypermobility (p> 0.05).

Among all subjects who received a RDC/TMD Axis I diagnosis, 35.3% had systemic joint hypermobility and among all subjects who did not meet criteria to receive a RDC/TMD Axis I diagnosis, 25% had systemic joint hypermobility (p> 0.05).

85.7% of pregnant women had a Graded Chronic Pain score of 0, and 8.6% had grade 1 pain, 5.7% had grade 2 pain. 45% of non-pregnant women had grade 0 pain, 37.5% had grade 1 pain and 17.5% had grade 2 pain. Non-pregnant women had more pain and this was statistically significant (p< 0.05).

Levels of depression, NPS pain items included and NPS pain items excluded were not different between pregnant and non-pregnant women [Table - 2].

Among all subjects who received a RDC/TMD Axis I diagnosis (n= 8), 50% had severe depressive symptoms and among all subjects who did not meet criteria to receive a RDC/TMD Axis I diagnosis (n= 102), 29.4% had severe depressive symptoms (p= 0.427).

NPS pain items included and NPS pain items excluded were also not different between the subjects who received a RDC/TMD Axis I diagnosis and who did not (p> 0.05).

Discussion

We found the prevalence of TMD and systemic joint hypermobility not different between the pregnant and non-pregnant women. Furthermore, we observed no correlation between the presence of systemic joint hypermobility and TMD.

Population-based studies show the prevalence of TMD to be approximately 2 to 5 times higher in women than in men in community samples [13] . During preg-nancy, the ligaments of the pubic symphysis and sac-roiliac joints loosen, possibly because of the hormone relaxin [9] and estrogen [5] . This increased joint laxity extends to peripheral joints [14] and temporo-mandibular joint [15] .

A hypermobile TMJ may be more prone to dysfunc-tion. Westling [6] has postulated that TMD are associ-ated with joint laxity. There is a controversy in the literature over correlating relaxin and other hormonal changes during pregnancy with joint hypermobility. Some authors suggest that female reproductive hor-mones represent a risk factor for the development of TMD [16] , whereas other authors find no correla-tion between relaxin and other female hormones and TMD [17] . LeResche et al [15] found that the in-creased joint laxity in TMJ occurring over the course of pregnancy was accompanied by decreased rather than increased musculoskeletal orofacial pain levels in a prospective study. In the present study, we ob-served that non-pregnant women had higher levels of Graded Chronic Pain than pregnant women (p< 0.05). Findings from studies of experimental pain suggest that the high levels of estrogen and progesterone characteristic of the pregnancy have antinociceptive properties [18] .

In a cross-sectional study among Cape Coloured pregnant women, the incidence of systemic joint hypermobility was found surprisingly low [19] . On contrary, Charlton et al [20] found that high se-rum estrodiol levels during the third trimester of pregnancy correlated with increased laxity of ante-rior cruciate ligament by measuring anterior tibial translation. And Silviera et al [21] observed a high incidence of systemic hypermobility which was not correlated with mandibular hypermobility and TMD in pregnancy. In the present study, the prevalence of systemic joint hypermobility was found to be not different between the pregnant and non-pregnant women. Furthermore, there was not any difference in the prevalence of RDC/TMD Axis I diagnosis be-tween pregnant and non-pregnant women in the present study (p>0.05). And also no correlation was found between the presence of TMD and systemic joint hypermobility.

An association with increased psychological dimension changes, particularly depression scores, in TMD pa-tients was reported [22] . Interestingly, other studies found increases in depression scores that were not in the psycho-pathological range [23] . In concordant with this finding, in the present study the levels of depressive symptoms, NPS pain items included and NPS pain items excluded were not different between the subjects who received a RDC/TMD Axis I diagnosis and who did not.

The limitation of our study was that our sample size was small.

To summarize, the prevalence of TMD and systemic joint hypermobility were not high among pregnant women compared to age matched non-pregnant wom-en . And we were not able to confirm a correla-tion between systemic joint hypermobility and TMD. Further large sampled and prospective studies are needed to confirm these results.

References

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2.Azak AN. Temporomandibular disorders in relation to female reproductive hormones: A literature review. J Prosthet Dent 2004; 91: 491-3.  Back to cited text no. 2    
3.Dao TTT, LeResche l. Gender differences in pain. J Orofac Pain 2000; 14: 169-84.  Back to cited text no. 3    
4.LeResche L, Saunders K, yon Korff MR, Barlow W, Dworkin SE Use of exogenous hormones and risk of tem­poromandibular disorder pain. Pain 1997; 69: 153-60.  Back to cited text no. 4    
5.Calguneri M, Bird HA, Wright V. Changes in joint lax­ity occurring during pregnancy. Ann Rheum Dis 1982;41: 126-8.  Back to cited text no. 5    
6.Westling L. Temporomandibular joint dysfunction and systemic joint laxity. Swed Dent J Suppl 1992; 81: 1-79.  Back to cited text no. 6    
7.Hoskin CL, Milam SB, Cameron IL. Pathogenesis of degenerative joint disease in the human temporoman­dibular joint. Crit Rev Oral Biol Med 1995; 6: 248-77.  Back to cited text no. 7    
8.Glock JL, Nakajima ST, Stewart DR, Badger GJ, Brumsted JR. The relationship of corpus luteum volume to relax­in, estradiol, progesterone, 17-hydroxyprogesterone and human chorionic gonadotropin levels in early normal pregnancy. Early Pregnancy 1995; 1: 206-11.  Back to cited text no. 8    
9.Mushayandebvu TI, Goldsmith LT, yon Hagen 5, Santoro N, Thurston D, Weiss G. Elevated maternal serum re­laxin concentrations throughout pregnancy in singleton gestations after superovulation. Obstet Gynecol 1998; 92: 17-20.  Back to cited text no. 9    
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11.Dworkin SF, Sherman J, Mancl L, Ohrbach R, LeResche L,Truelove E. Reliability, validity, and clinical utility of the research diagnostic criteria for Temporomandibular Disorders Axis 11 Scales: depression, non-specific physi­cal symptoms, and graded chronic pain. J Orofac Pain 2002; 16: 207-20.  Back to cited text no. 11    
12.Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis 1973; 32: 413-18.  Back to cited text no. 12    
13.LeResche L. Epidemiology of temporomandibular dis­orders: Implications for the investigation of etiologic factors. Crit Rev Oral Biol Med 1997; 8: 291-305.  Back to cited text no. 13    
14.Schauberger CW, Rooney BL, Goldsmith L, Shenton D, Silva PD, Schaper A. Peripheral joint laxity increases in pregnancy but does not correlate with relaxin levels. Am J Obstet Gynecol 1996; 174: 667-71.  Back to cited text no. 14    
15.LeResche L, Sherman JJ, Huggins K, et al. Musculoskeletal orofacial pain and other signs and symptoms of tem­poromandibular disorders during pregnancy: A prospec­tive study. J Orofac Pain 2005; 19: 193-201.  Back to cited text no. 15    
16.LeResche L, Saunders K, Von Korff MR, Barlow W,Dworkin SF. Use of exogenous hormones and risk of tem­poromandibular disorder pain. Pain 1997; 69: 153-60.  Back to cited text no. 16    
17.Pokorny MJ, Smith TD, Calus SA, Dennison EA. Self­ reported oral contraceptive use and peripheral joint laxity. J Orthop Sports Phys Ther 2000; 30: 683-92.  Back to cited text no. 17    
18.Dawson-Basoa ME, Gintzler AR. Estrogen and proges­terone activate spinal kappa-opiate receptor analgesic mechanisms. Pain 1996; 64: 169-77.  Back to cited text no. 18    
19.Van Dongen PW, De Boer M, Lemmens WA, Theron GB. Hypermobility and peripartum pelvic pain syndrome in pregnant South African women. Eur J Obstet Gnecol Reprod Biol 1999; 84: 77-82.  Back to cited text no. 19    
20.Charlton WP, Coslett-Charlton LM, Ciccotti MG. Correlation of estradiol in pregnancy and anterior cru­ciate ligament laxity. Clin Orthop Relat Res 2001; 387: 165-70.  Back to cited text no. 20    
21.Silveira EB, Rocabado M, Russo AK, Cogo JC, Osorio RA. Incidence of systemic joint hypermobility and temporomandibular joint hypermobility in pregnancy. Crania 2005; 23: 138-43.  Back to cited text no. 21    
22.Vimpari SS, Knuuttila ML, Sakki TK, Kivela SL. Depressive symptoms associated with symptoms of the temporomandibular joint pain and dysfunction syn­drome. Psychosomatic Med 1995; 57: 439-44.  Back to cited text no. 22    
23.Wright J, Deary IJ, Geissler PR. Depression, hassles and somatic symptoms in mandibular dysfunction syndrome patients. J Dent 1991; 19: 352-6.  Back to cited text no. 23    

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