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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 62-66

To assess the prevalence of signs and symptoms of temporomandibular disorders in Vidarbha population by Fonseca's questionnaire


1 Department of Oral Medicine and Radiology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of Conservative Dentistry Sharad Pawar Dental College, DMIMS, Wardha, Maharashtra, India
3 Department of Oral Medicine and Radiology, Sharad Pawar Dental College, DMIMS, Wardha, Maharashtra, India

Date of Web Publication26-Jul-2017

Correspondence Address:
Rakhi Manoj Chandak
Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Hingna Road, Wanadongri, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_7_17

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  Abstract 

Aim: The aim of this epidemiological study was to assess the prevalence of signs and symptoms of TMDs in Vidarbha population by Fonseca's questionnaire.
Materials and Methods: A group of 200 patients were randomly selected from the outpatients attending Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital. Each patient was provided with a questionnaire and points were given accordingly for each question. The sum of points was used to classify participants into TMD free, mild TMD, moderate TMD, and severe TMD.
Results: Among all the participants examined sixty participants had no TMD (30%), 110 participants had mild TMD (55%); 28 patients had moderate TMD (14%) and two participants had severe TMD (1%). The reliability of Fonseca's questionnaire was found to be 0.603.
Conclusion: The Fonseca questionnaire can be used as effective tool in the prevalence of signs and symptoms of TMDs. Public health services should adopt the questionnaire for screening as it will be obtained in a relatively short period and at low cost covering a wide population.

Keywords: Craniocervicofacial, Fonseca's questionnaire, temporomandibular disorders


How to cite this article:
Chandak RM, Pandhripande RM, Sonule SS, Chandak MG, Rawlani SS. To assess the prevalence of signs and symptoms of temporomandibular disorders in Vidarbha population by Fonseca's questionnaire. J Oral Res Rev 2017;9:62-6

How to cite this URL:
Chandak RM, Pandhripande RM, Sonule SS, Chandak MG, Rawlani SS. To assess the prevalence of signs and symptoms of temporomandibular disorders in Vidarbha population by Fonseca's questionnaire. J Oral Res Rev [serial online] 2017 [cited 2017 Oct 18];9:62-6. Available from: http://www.jorr.org/text.asp?2017/9/2/62/211639


  Introduction Top


Temporomandibular disorders (TMDs) are a collective term embracing all the problems involving painful orofacial disorders, complaints of pain with temporomandibular joint (TMJ) region and fatigue of the craniocervicofacial muscles, especially masticatory muscles, limitation of mandible movement, and presence of articular clicking.[1]

TMDs have multifactorial causes such as emotional stress, occlusal interferences, malpositioning or loss of teeth, postural changes, dysfunctions of the masticatory musculature and adjacent structures, extrinsic and intrinsic changes on TMJ structure, and/or a combination of such factors. Certain nonpatient prevalence studies have reported that approximately 50%–75% of participants exhibit one or more signs of TMD and 33% have at least one symptom.[1]

TMD is usually associated with tenderness in the jaw muscles and joints and deviation or deflection of the mandible, locking of the joint, and joint sounds such as clicking or popping noise during opening or closing the mouth.[2] Pain is usually experienced in the masseter muscle, preauricular area, and/or anterior temporalis muscle regions.[3] The pain may be dull, poorly localized, and unilateral rather than bilateral.[2] There may also be episodes of sharp pain, and when the pain worsens, the primary pain quality may become a throbbing sensation. Patients with TMD tend to report that their pain is intensified by events such as stress, clenching, and eating, while it is relieved by relaxing, applying heat to the painful area, and taking over-the-counter analgesics.[3]

Several instruments for TMD diagnosis have been proposed, but there is no appropriate diagnostic criterion. The anamnestic index (AI) presented by Campos JA, et al. is one of the available instruments in Portuguese language for characterization of TMD symptoms, and it was developed to classify patients according to severity of those symptoms.[4]

Hence, the purpose of this epidemiological study was to assess the prevalence of signs and symptoms of TMDs in Vidarbha population by Fonseca's questionnaire.


  Materials and Methods Top


Sample size calculation

The sample size of the study was calculated using OpenEpi calculator and based on prevalence values of similar studies.[4] Therefore, study group consisted of 200 patients which were randomly selected from the outpatients attending Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India. All the patients included in the study were explained in detail about the study pattern and approval from the Ethical Committee was obtained. Patients were given proper instructions about the goals of the research and experimental procedures and signed an informed consent form was taken from each patient participating in the study.

Patient selection

Patients experiencing pain in the TMJ and/or masticatory muscles for 1 week or longer and between age of 18 and 27 years were included in the study. Patients with TMD with only clicking and no pain, pain from bone or joint disease associated with systemic disease such as rheumatoid arthritis, patients with regular use of medications such as analgesics, antianxiety drugs, antidepressants, and other psychotropics, and patients with the presence of molar defects and/or use of a removable partial denture were excluded from the study.

Methodology

A cross-sectional study based on the questionnaire proposed by Fonseca was used to classify TMD severity in the study population. It was composed of ten questions, which include checking for the presence of pain in TMJ, head, and back, while chewing, parafunctional habits, movement limitations, joint clicking, perception of malocclusion, and sensation of emotional stress. The questions included in the Fonseca's questionnaire are given in [Table 1].
Table 1: Fonseca's Questionnaire

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The volunteers were informed that the ten questions should be answered with “yes” (10 points), “no” (0 points), and “sometimes” (5 points) and that only one answer should be marked for each question. The sum of points was used to classify participants into four categories: TMD free (0–15), mild TMD (20–40), moderate TMD (45–60), and severe TMD (70–100).

Statistical analysis

The reliability of each question of Fonseca's questionnaire was calculated using Cronbach's alpha coefficient. This measure can be viewed as an extension of Kuder–Richardson formula 20 (kr-20) The internal consistency of Cronbach's alpha coefficient may range from 0.5 to 0.9 while if the value of alpha is <0.5, the internal consistency of the particular question may be considered as unacceptable.[5] Kappa statistics were used to calculate the observer rating, in which a kappa of 1 indicates perfect agreement while a kappa of 0 indicates agreement equivalent to the chance.[6]


  Results Top


A total of 200 participants among the vidharbian population were included in the study of age >18 years. Among all the participants examined, sixty participants had no TMD (30%), 110 participants had mild TMD (55%), 28 patients had moderate TMD (14%), and 2 participants had severe TMD (1%). The prevalence of signs and symptoms of TMD among vidharbian population is demonstrated in [Figure 1].
Figure 1: Prevalence of temporomandibular disorder among vidharbian population

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The reliability of questionnaire (Questions 1–10) proposed by Da Fonseca evaluated using Cronbach's alpha coefficient was found to be 0.562, this consistency was lowered than desired. The reliability of each question is shown in [Table 2]. The mean and standard deviation of individual questions is given in [Table 3]. Among all the questions, the reliability of question number 1, 2, 3, 4, and 10 was found to be the lowest and the reliability of question number 5, 6, 7, 8, and 9 was found to be highest. Hence, to check the reliability of question number 1, 2, 3, 4, and 10, question number 5, 6, 7, 8, and 9 were deleted from the questionnaire and the internal consistency was again evaluated using Cronbach's alpha coefficient. After deleting these (question number 5, 6, 7, 8, and 9) items, the internal consistency of question no. 1, 2, 3, 4, and 10 was found to be 0.603 [Table 4].
Table 2: Reliability of each question included in Fonseca questionnaire

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Table 3: Mean and standard deviation

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Table 4: Reliability after item deletion

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Hence, the present study revealed that all the questions of Fonseca's questionnaire are reliable, but the reliability of question number 5, 6, 7, 8, and 9 was found to be more significant as compared to question number 1, 2, 3, 4, and 10.


  Discussion Top


TMDs include a number of clinical conditions involving TMJ, masticatory muscle, or both.[7],[8],[9],[10],[11],[12] TMDs are a matter of interest from the past many decades as it has various etiological factors and treatment modalities.[8] Various etiologic factors include occlusal disharmony, masticatory muscle fatigue, oral habits (bruxism), emotional stress, and malfunction of structures adjacent to TMJ.[7],[8],[9],[10],[11]

Early diagnosis and treatment of TMD is very important because it is a progressive disease which gets worse with the passage of time. If treated in early stage, the prognosis of this disease is good, at later stages, it becomes irreversible because of damage to TMJ. Presence of inflammatory mediators, tissue necrosis factor, and presence of pain mediators multiply with the passage of time. Thus, the Fonseca's questionnaire may be helpful in early diagnosis of TMD cases.[8]

This study evaluated the prevalence and severity of and symptoms of TMDs using Fonseca's questionnaire. Helkimo in 1974 developed AI and clinical indexes from clinical observations. Based on Helkimo's (1974) indexes, Fonseca (1992) developed his anamnestic questionnaire that classifies TMD signs and symptoms as light, moderate, or severe or non-TMD. The author obtained a reliability of 95% and a good correlation with Helkimo's index (r = 0.6169, P < 0.05).

In this study, 30% patients were classified as no TMD, whereas 69% were classified as having mild-to-moderate TMD. This was found in relation to Pedroni et al. who reported 62% frequency of mild-to-moderate TMD among college students.[9] Similarly, a study conducted by Debora et al. among young Brazilian college students found 78% of patients having mild to moderate TMD.[10] On the other hand, Debora BG et al. who evaluated Brazilian college students observed that most of the students (58.71%) were classified as TMD free and total of 40% were classified as having mild-to-moderate TMD.[10]

Thus, the establishment of TMD severity symptoms in epidemiologic studies can play an important role in the determination of TMD patients in research samples or can differentiate volunteers classified with TMD with real treatment needs. This could suggest that the greater the severity of symptoms, the greater the chance of selecting patients with real treatment needs.

This study reveals that only 32 patients (16%) consider themselves tensed, nine patients (4.5%) clench or grind their teeth, 171 patients (85%) have frequent headaches, and 116 patients (58%) have pain in the neck or stiff neck. This was found in contrast to study conducted by Nomura et al. among Brazilian students and found 76.72% considered themselves tensed, 65.52% reported TMJ clicking, and 61.21% neck pain.[1]

In this study of total 200 participants, 91 patients were females and 109 were male patients, of which 70.32% females were affected by TMD which was greater than males (69.72%). Different studies show that females have more prevalence of TMD as compared to males because of mental stress. A study conducted by Pedroni et al. using anamnestic questionnaire found that around 68% participants were having TMD, of which 84% were females.[9] Similarly, in a study conducted on Brazilian students, researchers have reported nine times greater prevalence of TMD in females as compared to males.

The Fonseca's questionnaire follows the characteristics of a multidimensional evaluation, containing an AI and the volunteers classified accordingly as having mild TMD, moderate TMD, severe TMD, or non-TMD. The Fonseca's questionnaire thus allows collecting a large quantity of information in a relatively short period, and at low cost, it is easy to understand and has almost no influence from the examiner. Using a simplified questionnaire, we were able to recognize unnoticed symptoms that could lead to a wear or a greater disorder of the stomatognathic system. Public health and screening services should adopt the questionnaire, as the AI may be obtained by technical personnel, in a relatively short period and at low cost, and it has wide population coverage. With proper diagnosis and treatment, this could manage orofacial pain in a large contingent of people.

Fonseca's questionnaire (Fonseca's AI [FAI]) can also serve as a preliminary TMD screening tool. After the affected population is identified, a more thorough investigation can be conducted, which would include a complete clinical examination and use of diagnostic instruments to confirm the diagnosis. The FAI is a useful TMD screening tool that has important implications for the early diagnosis of TMD and the prevention of future complications from it.


  Conclusion Top


Thus, it can be concluded that the Fonseca questionnaire can be used as an effective tool in the prevalence of signs and symptoms of TMDs. However, pain in nape or stiff neck, earaches or pain in craniomandibular joints, TMJ clicking, and articulation have a better ability to distinguish TMD patients from non-TMD patients. The question regarding side to side movement, pain while chewing, frequent headaches, and nervousness proved to be poor predictors of TMJ severity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nomura K, Vitti M, Oliveira AS, Chaves TC, Semprini M, Siéssere S, et al. Use of the Fonseca's questionnaire to assess the prevalence and severity of temporomandibular disorders in Brazilian dental undergraduates. Braz Dent J 2007;18:163-7.  Back to cited text no. 1
    
2.
Preeti D. Possible etiological factors and clinical features of TMD. J Adv Clin Res Insights 2016;3:91-3.  Back to cited text no. 2
    
3.
Wright EF, North SL. Management and treatment of temporomandibular disorders: A clinical perspective. J Man Manip Ther 2009;17:247-54.  Back to cited text no. 3
    
4.
Campos JADB, Gonçalves DAG, Camparis CM, Speciali JG. Reliability of questionnaire for diagnosing the severity of temporomandibular disorder. Rev Bras Fisioter 2009;13:38-43.  Back to cited text no. 4
    
5.
Gliem JA, Gliem RR. Calculating, Interpretating and Reporting Cronbach's Alpha Reliability Co-Efficient for Likert-Type Scales. Midwest Research to Practice Conference in Adult, Continuing, and Community Education; 2003. p. 82-8.  Back to cited text no. 5
    
6.
Viera AJ, Garrett JM. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37:360-3.  Back to cited text no. 6
    
7.
Okeson JP. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Chicago: Quintessence; 1996.  Back to cited text no. 7
    
8.
Arsalan W, Farrukh IM, Abdul R, Syed AH, Tazmeen K, Anum I, et al. Prevalence and severity of temporomandibular disorders in undergraduate medical students using Fonseca's questionnaire. Pak Oral Dent J 2014;34:38-41.  Back to cited text no. 8
    
9.
Pedroni CR, De Oliveira AS, Guaratini MI. Prevalence study of signs and symptoms of temporomandibular disorders in university students. J Oral Rehabil 2003;30:283-9.  Back to cited text no. 9
    
10.
Debora BG Thaís CC, Anamaria SO, Vanessa MP. Anamestic index severity and signs and symptoms of TMD. J Craniomandib Pract 2006;24:112-8.  Back to cited text no. 10
    
11.
Akira N, et al. Evaluation of therapeutic effects using the limitation of daily functions questionnaire in patients with temporomandibular disorders. Oral Health Dent Manag 2014;13:982-6.  Back to cited text no. 11
    
12.
Nilsson IM, List T, Drangsholt M. The reliability and validity of self-reported temporomandibular disorder pain in adolescents. J Orofac Pain 2006;20:138-44.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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