Perspectives on signs and symptoms

indicative of temporomandibular
disorders among adults

Negin Yekkalam

Department of Clinical Oral Physiology

Umeå 2021
This work is protected by the Swedish Copyright Legislation (Act 1960:729)
Dissertation for PhD
ISBN:978-91-7855-555-0 (PDF)
ISSN:0345-7532
Umeå University Odontological dissertation series nr 145
Electronic version available at: http://umu.diva-portal.org/
Printed by: CityPrint i Norr AB
Umeå, Sweden, 2021
Dedicated to

Professor Anders Wänman

who made my dream come true.

The only source of knowledge is experience.

Albert Einstein
Table of Contents

Abstract iii
Abbreviations v
Original papers vi
Preface vii
Introduction 1
Public health & Epidemiology 1
Pain 2
Jaw system and its function 4
Temporomandibular disorders (TMD) 4
Terminology in this thesis 5
TMD pain aspect 6
TMD dysfunction aspect 6
Epidemiology of TMD 7
Etiology of TMD 8
Biomechanics 8
Dental occlusion 8
Parafunctions 9
Traumatic injuries 9
Genetic factors 10
Comorbidity 10
Psychosocial factors 11
Pathophysiology 12
Treatment need attributed to TMD 12
Methods to identify individuals with TMD 13
Helkimo indices 14
American Academy of Orofacial Pain (AAOP) 14
Research Diagnostic Criteria for TMD (RDC/TMD) 15
Diagnostic Criteria for TMD (DC/TMD) 15
Screening questions for the recognition of TMD 15
Rationale for the thesis 17
Objective 18
Specific aims 18
Study populations and Methods 20
Study population and sample 21
Papers I-IV 21
Questionnaire 22
Clinical examination 23
Paper V 26
Clinical examination 26
Statistical analysis 28
Paper I (Prevalence) 28
Paper II (Associations) 28
Paper III (Treatment need) 29
Paper IV (Pain to palpation) 29

i
Paper V (Widespread pain and TMD pain) 30
Results 31
Paper I 31
Prevalence of symptoms indicative of TMD 31
Prevalence of signs indicative of TMD 34
Paper II 36
Comorbidity 36
35- and 50-year olds sample 36
65- and 75-year olds sample 37
Paper III 38
Treatment need 38
Paper VI 39
Pain to palpation 39
Paper V 40
Widespread pain and TMD pain 40
Discussion 42
Main findings 42
Signs and symptoms indicative of TMD 43
Gender patterns 43
Age patterns 44
Residence patterns 46
Comorbidity patterns 46
Treatment need patterns 48
Methodological considerations 51
Papers I-IV 51
Questionnaire 51
Clinical examination 52
Paper V 53
Clinical examination 53
Ethical considerations 53
Clinical implications and future directions 55
Summary of main findings 56
Conclusions 57
Acknowledgment 58
Amendments 61
References 62
Papers I-V

ii
Abstract

Background. The aim of this thesis was to delve deeper into the different
aspects of temporomandibular disorders (TMD) as a public health problem
among adults. The studies evaluated signs and symptoms indicative of TMD in
terms of prevalence, associated factors, treatment need estimate, possible factors
underpinning treatment need owing to TMD, as well as possible influences of
pain conditions on TMD symptoms and diagnosis in adult populations.

Study populations and Methods. The thesis is comprised of five papers.

The first four papers (I-IV) included individuals 35, 50, 65 and, 75 years old living
in Västerbotten County, Sweden. The study sample was stratified based on the
area of residence – coast (mainly urban area) and inland (mainly rural area).
Scrutiny constituted a questionnaire and a clinical examination. Of 1200
individuals contacted (300 in each age group), 987 (82%) returned a filled-out
questionnaire and 779 (65%) participated in the clinical examination.
Distribution of signs and symptoms indicative of TMD in the different age groups,
associations between different factors and TMD signs, symptoms and treatment
need owing to TMD, as well as association between different patterns of pain to
palpation and pain in the jaw-face-head region were analyzed. Paper V assessed
the association between widespread pain and TMD pain in 300 individuals of
which 110 diagnosed as TMD pain according to DC/TMD (arthralgia, myalgia and
myofascial pain with referral). Logistic regression analysis was applied in the
papers II-V and the results were presented as odds ratios (OR) with 95%
confidence interval (95% CI).

Results. The prevalence of symptoms indicative of TMD and frequent

headaches was high in the adult population. The age and gender patterns were,
for the most part, similar for the frequent symptoms in terms of prevalence. In
general, lower prevalence of frequent headaches and symptoms indicative of
TMD were observed among the elderly compared to the younger age groups.
Clinical signs indicative of TMD were more commonly registered among women.
In the analysis of putative factors related to presence of signs and symptoms, self-
perceived impaired general health status was the most consistent finding in the
different age groups. The estimated treatment need owing to TMD was 15% for
the total sample. The presence of TMD signs, symptoms, smoking, living on the
coast, and being a woman emerged as important factors in the clinical decision-
making process of treatment need due to TMD. A significant dose-response like
pattern was observed between frequent pain in the jaw-face-head region and the
patterns of pain elicited to palpation. Individuals with widespread pain compared
to those without widespread pain significantly more often had a TMD diagnosis
of myofascial pain with referral and myalgia according to the DC/TMD.

iii
Conclusions. The age and gender differences on signs and symptoms
indicative of TMD among adults are likely related to factors included in the
biopsychosocial model. The associations between comorbidities and TMD may
influence demand for treatment among the affected. Thus, TMD treatment
should be included in the medical health care payment systems. A significant
proportion of the adult population has a need of treatment related to TMD.
Generalized hyperalgesia and widespread pain conditions are related to pain in
the jaw-face-head region and should be acknowledged in clinical evaluations,
diagnostic decisions, treatment planning as well as in research settings.

Keywords: epidemiology, temporomandibular disorders, headache, gender,

treatment need, clinical decision-making, widespread pain

iv
Abbreviations
ACR American College of Rheumatology
CE Clinical examination
CI Confidence interval
COPCs Chronic overlapping pain conditions
DC/TMD Diagnostic Criteria for Temporomandibular disorders
ICOP International classification of Pain
OHRQoL Oral health-related quality of life
OFP Orofacial pain
OR Odds Ratio
Q Questionnaire
SD Standard deviation
TMD Temporomandibular disorders
TMJ Temporomandibular joint
TTH Tension-type headaches
RDC/TMD Research Diagnostic Criteria for Temporomandibular Disorders
WSP Widespread pain
WPI Widespread pain index
3Q/TM Three screening questions (Q1, Q2 and Q3) on jaw pain and
dysfunction

v
Original papers

I. Yekkalam N, Wänman A. Prevalence of signs and symptoms

indicative of temporomandibular disorders and headaches in 35-
, 50-, 65- and 75-year olds living in Västerbotten, Sweden. Acta
Odontol Scand 2014; 72(6): 458-65.

II. Yekkalam N, Wänman A. Associations between craniomandibular

disorders, socio-demographic factors, and self-perceived general
and oral health in an adult population. Acta Odontol Scand 2014;
72(8): 1054-65.

III. Yekkalam N, Wänman A. Factors associated with clinical

decision-making in relation to treatment need for
temporomandibular disorders. Acta Odontol Scand 2016; 74 (2):
134-141.

IV. Yekkalam N, Wänman A. Association between signs of

hyperalgesia and reported frequent pain in jaw-face and head.
Acta Odontol Scand 2020; Sep 12: 1-6.

V. Lövgren A, Visscher CM, Lobbezzo F, Yekkalam N, Vallin S,

Wänman A, Häggman-Henrikson B. The association between
myofascial orofacial pain with and without referral and
widespread pain. Submitted.

Papers are reprinted with kind permission from the publishers.

vi
Preface
This thesis is one of the major fruits of my journey to Sweden.

I began my career in the field of Temporomandibular disorders (TMD) in 2007

at my former teacher’s clinic, Dr. Majid Nouhi, in Tehran. He was a graduate of
Karolinska institute (KI) in 1986, and his passion was to develop in Iran the
Scandinavian approach in the field of TMD. He generously shared his knowledge
and skills with me both in the clinic and in the research setting. I learned to
examine the patients based on the criteria in the Clinical Dysfunction Index
(Helkimo index), and to manage them according to the most common treatment
in Sweden. He inspired me to choose TMD as my future career and recommended
a move to Sweden to develop my knowledge.

In 2010, my journey to Sweden started despite my parents’ desire. I began a

research career within epidemiology in the Department of Public Health, Umeå
university and defended a Master’s degree in 2012 in a project related to WHO in
global ageing and adult health. Meanwhile, I was continually looking for a project
to combine both of my interests – epidemiology and TMD. In December 2012, I
met Dr. Albert Crenshaw who encouraged me to contact Dr. Per Stål to enquire
about the possibility to get in contact with Professor Anders Wänman. Finally, in
Spring 2013 I met the professor in his office at the department of Odontology. I
was really impressed by his humble and friendly attitude in addition to his
epidemiological knowledge. He had a project within TMD with a big data set
covering different factors in social determinants of health among adults in the
Västerbotten County in 2002. We discussed the future plan regarding publication
of four papers in order to achieve a holistic picture of TMD in different aspects.
The project was the first study in the County with four age groups: 35-, 50-, 65-
and 75-year-olds.

Parallel to this project, I accomplished the Swedish language and started a

complementary education at KI in 2014-2015 in order to be able to work in the
clinic. In 2016-2018, I took part in a clinical research project at KI within
experimental pain under supervision of Professor Malin Ernberg. This project
developed my knowledge considerably regarding pain concepts and gender
differences in pain perception, which in turn facilitated and deepened my
understanding of the core concepts in papers 4 and 5 of my PhD thesis.

On June 21, 2018, I was accepted as a PhD student. This was one of the best days
of my life; the joy and happiness were not comparable even to the day when I
became a mother for the first time. After accomplishing the mandatory services
as a general practitioner and as a meritorious dentist within TMD, I was accepted

vii
in 2020 as a resident dentist in the field of Clinical Oral Physiology at Umeå
University.

I hope a combination of skills in the research and clinic provides me the

possibility for the best care of the patients.

Another advantage of my 10-year journey was to experience that:

Attitude is a little thing that makes a BIG difference.

(Winston Churchill)

Negin Yekkalam Balfe DDS, MPH, MSc in Odontology

Umeå, May 2021

viii
Introduction
Public health & Epidemiology

The Centers for Disease Control and Prevention define Public health as ¨the
science of protecting and improving the health of population¨ (1). One of the basic
sciences of public health is epidemiology. It is defined as ¨a philosophy and
methodology to study the distribution (frequency, pattern) and determinants
(causes, risk factors) of health-related states and events in specified populations
(local, global) ¨. Epidemiology generates information required by public health
professionals to develop, implement, and evaluate effective intervention
programs to control health problems (2).

One of the common epidemiological methods to measure health and disease

frequency is calculation of incidence and prevalence. Incidence refers to the rate
of occurrence of new cases arising in a given period in a specified population,
while prevalence is the frequency of existing cases in a defined population at a
given point in time. Prevalence is often measured for chronic diseases with long
duration with unknown dates of onset. Diseases with high prevalence may reflect
high incidence or prolonged survival without cure or both (2).

One of the essential concepts in epidemiology is causation. A cause of the

disease/event is ¨an event, condition or characteristic that preceded the disease
event and without which the disease event either would not have occurred at all
or would not have occurred until some later time¨. Necessary cause is a condition
without which the effect cannot occur , and a sufficient cause is a condition with
which the effect must occur (3). According to such definition four different types
of causal relations can be discussed – necessary and sufficient, necessary but not
sufficient, sufficient but not necessary, and neither necessary nor sufficient (4).
Even if a cause that is neither necessary nor sufficient is blocked, a substantial
amount of disease may be prevented. Based on the multicausality concept, most
identified causes are neither necessary nor sufficient to produce disease (5).

In 1965, Sir Austin Bradford Hill proposed nine aspects of association for
evaluating if the observed association between a risk factor and disease was likely
to be a causal relationship. These aspects are often referred to as the Bradford
Hill Criteria and include the following: strength of association, consistency,
specificity, temporality, biological gradient, plausibility, coherence, experiment,
and analogy (6). These valid and useful criteria have been broadly applied as a
checklist for assessing causation. However, they should be seen as a list of
possible considerations to generate thoughtful discourse among researchers from
various scientific fields (5).

1
Epidemiological studies are divided into experimental and non-experimental
studies (observational). All types of designs have their own limitations. One of the
most common observational study that does not consider the causality
phenomena is a Cross-sectional study. This type of study estimates the
prevalence of occurrence of events and makes it possible to compare multiple
variables in different population groups at a single point of time. Moreover, it is
used to prove or disprove assumptions, as well as generating outcomes to create
new theories and studies (7). Longitudinal study is other type of observational
studies. The data are repeatedly collected from the same sample over prolonged
periods of time in order to assess the relationship between risk factors and the
development of disease, as well as changes over time on the group level or
individual level. High cost and attrition bias are the most common disadvantages
of this type of study (8).

Pain

Pain is a global health problem among adults worldwide (9). The International
Association for the study of Pain defines pain as ¨an unpleasant sensory and
emotional experience associated with, or resembling that associated with actual
or potential tissue damage¨(10). The definition is expanded by the addition of six
key notes and the etymology of the word pain for further valuable context:

• Pain is always a personal experience that is influenced to varying degrees

by biological, psychological, and social factors.
• Pain and nociception are different phenomena. Pain cannot be inferred
solely from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person's report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects
on function and social and psychological well-being.
• Verbal description is only one of several behaviors to express pain;
inability to communicate does not negate the possibility that a human or
a nonhuman animal experiences pain.

Pain is a multivalent, dynamic, and ambiguous phenomenon with disparities

across population groups globally. Pain with high prevalence and consequences
such as morbidity, mortality, disability, and disrupted social relationships poses
significant demands on the health care system. In order to manage pain both in
the preventive and treatment aspects, there should be a shift in policy from the
micro-level focus, such as provision of health care services, to a macro-level
approach to address the structural determinants of health. On the other hand,

2
pain should be regarded as a public health priority instead of a medical problem.
Consequently, a more comprehensive understanding of pain as well as the
appropriate public health responses to this problem will be provided globally (11).

Pain can be either acute or chronic. Acute pain is the sensory and emotional
experience during the normal healing phase following an injury. It is also termed
as transient and protective since it has biological significance to protect the
injured tissue (12). In contrast, chronic pain is defined as pain that lasts or recurs
for a longer duration than 3 months (13), and should be considered as a health
condition in its own and not just as a symptom (14).

In population-based surveys, the prevalence of chronic pain has been estimated

to affect 20-35% in the adult population with the back, joints, head and neck as
the most common sites (15). One in 10 adults are diagnosed with chronic pain
each year. Of those living with chronic pain, the median time of exposure is 7
years (9). Chronic pain is a common health problem in Sweden. The mean total
cost (direct and societal cost) per patient with chronic pain per year was estimated
at 6400 EUR in 2012 (16). Taken together, chronic pain as a major public health
concern is more complex compared to acute pain and requires special treatment
and care.

Pain is also categorized spatially into local, regional and widespread pain
conditions. Widespread pain (WSP) is characterized by pain in multiple body
regions (17). The term chronic widespread pain has been widely used in the
research field. It may be relevant to use such a term since the majority of WSP in
the population (>90%) are chronic (18, 19). It has been suggested that
hyperalgesic priming via long-lasting changes in nociceptor function may be
responsible for the widespread patterns of chronic pain, e.g. in the patients with
Chronic Overlapping Pain Conditions (COPCs) (20).

The definition for WSP varies which results in different prevalence estimates. The
American College of Rheumatology (ACR) defines WSP (using a mannequin) as
a pain that is in two contralateral quadrants and in the axial skeleton that is
present for at least three months (21). A WSP condition has also been defined as
pain at seven or more sites in the pain-site drawings (WSP index). The validity of
this index has been reported in several studies (22, 23). According to the ACR
definition, the prevalence of the chronic WSP in population-based-studies has
been estimated in the range of 10% to 15% (17). In a prospective cohort study,
WSP emerged as a risk factor for both onset and persistence of pain in the
orofacial region such as myalgia and arthralgia (24). WSP also affected the
outcome of diagnostic tests for myalgia diagnosis (25). The associations between
subtypes of myalgia and widespread pain need to be explored in order to

3
understand further possible pathophysiological mechanisms underpinning
temporomandibular pain.

Jaw system and its function

The jaw system comprises soft tissues (muscles, ligaments, salivary glands,
connective tissue, fat), mandible, maxilla, temporomandibular joint (TMJ)
including the disc, vascular supply, and several cranial nerves of which the
trigeminal nerve is involved in the major sensori-motor functions (26). The jaw
and upper part of the spine are functionally integrated, thus, jaw opening and
closing movements engage head and neck extension-flexion (27). These
structures in the jaw system are together aligned to provide the ability to speak,
smell, taste, touch, chew, swallow and convey a range of emotions through facial
expressions. According to the World Dental Federation, Oral health is the ability
to execute these vital functions with confidence and without pain, discomfort and
disease of the craniofacial complex (28). Thus, the jaw system’s function is
essential for survival, and dysfunction of this system may affect the quality of life.

Temporomandibular disorders (TMD)

TMD describes a number of painful and non-painful disorders affecting the jaw
muscles, the TMJ, and associated structures (29). It is characterized by a triad of
clinical features involving muscle and/or joint pain, noises in the TMJ (clicking
and crepitus), and impairment in the mandibular movements (30). TMD is
considered as the most common cause of nondental orofacial pain (31), and as
the second most commonly occurring musculoskeletal condition (32).

Historically, various terms have been used to describe pain and dysfunction of
the TMJ. In 1934, Dr. James Costen suggested that a group of signs and
symptoms of jaw and ear disturbances were attributed to loss of mandibular
posterior teeth and lower jaw overclosure. The concept was coined as Costen’s
syndrome (33). Since then, several terms such as TMJ dysfunction syndrome,
occlusomandibular disturbances, myoarthropathy of the TMJ, and myofascial
and pain dysfunction syndrome have been used to describe pain and dysfunction
in the jaw system. In 1980, Craniomandibular disorders (CMD) was a common
term used to embrace pain and dysfunction in the jaw–face–head region (34).
The term temporomandibular disorders (TMD) has been the most commonly
used expression in the literature since the 1990s and is included in the Research
Diagnostic Criteria for Temporomandibular disorders (RDC/TMD) (29). This
term was later used officially by the Diagnostic Criteria for Temporomandibular
Disorders (DC/TMD) to unify the terminology worldwide in both the research
standard for the disorder’s diagnostic criteria and taxonomy (35). Another
common term is ¨orofacial pain¨(OFP) that consists of both facial and oral pain.

4
Facial pain includes pain with the origin below the orbitomeatal line, above the
neck and anterior to the ears; whereas, oral pain indicates pain within the mouth
(36). Recently, the International classification of Pain (ICOP) has classified OFP
conditions in different types and subtypes; however, the term TMD is maintained
to align with DC/TMD (37).

Terminology in this thesis

In this thesis the terminology used to enclose pain and dysfunction in the jaw,
oral, face, head and body regions, vary to some extent although some may be
considered synonymous. Some of the terms are related to citations of authors and
organizations. Below some of the terms used:

• Craniofacial pain or region: used in definition based on The World Dental

Federation.
• Craniomandibular: used in paper II to include the jaw-face-head region.
Reported pain in jaw and face was merged with reported headaches. In the
questionnaire, the question related to headaches did not restrict location to
the temples. Thus, the term craniomandibular pain was used.
• Myofascial orofacial pain: used in paper V and adhered to recent
terminology advocated in the International Classification of Orofacial Pain.
• Jaw muscles: used at the department in Umeå to include muscles involved in
jaw functions.
• Masticatory muscles: used for muscles involved in mastication in the
literature and is synonym with jaw muscles.
• Temporomandibular disorders (TMD): used an umbrella term to embrace
pain and dysfunction in the temporomandibular region.
• Mandibular dysfunction: used previously to embrace pain and dysfunction
in the temporomandibular region.
• TMD pain: used to emphasize on the pain-related or painful TMD.
• Jaw dysfunction and TMD dysfunction: used to emphasize on the
dysfunction part, i.e. impaired jaw opening, locking and TMJ sounds.
• Jaw/face pain: location of reported pain in the questionnaire used in papers
I-IV.
• Orofacial pain (OFP): used as pain in the mouth and face.
• Widespread pain (WSP) and chronic WSP: used as synonyms. Based on the
number of pain sites on a mannequin.
• Generalized pain: used in paper IV for signs of widespread hyperalgesia (i.e.
palpebral reflex or withdrawal to palpation on all of the following sites: neck/
shoulders, underarm, thumb and calf muscles).
• Bodily pain: defined as pain in the body used as in the literature.

5
According to the National Institute of Health consensus conference, TMD is
divided into two main aspects – pain and dysfunction. However, individuals may
present with both aspects (38).

TMD pain aspect

The most common subtypes of TMD include pain-related disorders involving the
jaw muscles (myalgia), the TMJ (arthralgia), and headache attributed with TMD
(35). Recently, the National institute of Dental and Craniofacial Research
estimated that 5 to 12% of the population experience pain and disability because
of TMD. Around half to two-thirds of those seek treatment. Among these,
approximately 15% are estimated to develop chronic TMD (32).

According to a systematic review study, the myofascial pain was the most
common diagnosis in TMD patient populations (45.3%) (39). The pain is
normally experienced locally in the muscles as a feeling of fatigue, and a dull
steady pain overlaying the muscles in the jaw, head and neck (40). Muscle pain
diagnosis in the DC/TMD is based on: history of pain in the orofacial area within
the last 30 days, and pain modification by chewing, biting, or jaw movement, and
familiar pain elicited on provocation tests, such as palpation of masticatory
muscles or jaw movements during clinical examination. Standardized palpation
force and duration are 1 kg for 2 seconds, respectively, to establish provocation of
pain on palpation, and 1 kg for 5 seconds, respectively, to establish pain referrals
or spreading (35).

Arthralgia refers to pain localized to the TMJ that occurs at rest or during jaw
movement or palpation based on the DC/TMD (35). A systematic review reported
a 2.6% prevalence among community samples and 30.1% in patient-based
samples for a group of joint disorders (arthralgia, osteoarthritis, or
osteoarthrosis) based on the RDC/TMD (39).

TMD dysfunction aspect

TMD dysfunction manifests with impaired chewing capacity, impaired

mandibular movement, and TMJ sounds during movements (26). The reasons
behind such dysfunction may be attributed to elicited pain during functions, disk
displacement, impaired neck function or a combination of these. Clicking in the
joint is a common phenomenon found in about 18-35% of the population with a
higher prevalence among women compared to men (41, 42). However, the
absence of a click does not necessarily indicate a healthy TMJ (26).

6
Disk displacement without reduction can manifest with an impaired jaw function
and deflection of the mandible on jaw opening (39). If disc displacement without
reduction affects translation of the mandible, deflection of the mandible can be
observed. If the condyle articulates on retrodiscal tissues that have nerve endings,
stimulation of such an area may result in pain in the TMJ (26).

There are a number of studies within the pain aspects of TMD, whereas the
research in terms of TMD dysfunction is limited. Therefore, research in this
perspective is needed.

Epidemiology of TMD

TMD is one of the public health concerns. Patients with TMD regardless of pain
or dysfunction can have limitations in social function and emotional well-being
(43). Furthermore, a systematic review demonstrated that Oral health-related
quality of life (OHRQoL) was negatively affected among TMD patients (44).

Interest in epidemiology of TMD began in Scandinavia and Northern Europe in

the 1970s. In the 1980s, a review of 18 epidemiologic studies revealed the
prevalence of reported symptoms in the range of 16% to 59% and for clinical signs
33% to 86% (45). Another epidemiological study reported the prevalence of TMD
between 3 and 15% in the Western population and being twice as common in
women as in men (46). The variation in prevalence may relate to different
wordings of the questions used to capture the prevalence of TMD symptoms in
different time frames. Different homogeneity in the diagnostic criteria among
different studies may be another reason for such variation. Taken together, the
true TMD prevalence at the population level has been a matter of debate (39);
therefore, more investigation is warranted.

According to population-based studies, gender and age seem to influence the

prevalence of TMD signs and symptoms (47, 48). Higher susceptibility to TMD
among women compared to men, has been reported both in clinical settings and
in experimental studies (49). Nevertheless, the annual incidence for the first
onset of TMD pain in the adult population is estimated at approximately 4%
among both men and women (50, 51). The gender difference in duration of TMD
may clarify why women seek health care more often than men do. Still, the
reasons behind the more frequent and severe TMD signs and symptoms among
women compared to men remain unknown (45).

Previous studies reported a higher prevalence of TMD among women in the

childbearing age group (20-40 years) (42). However, recent large studies in
Europe and the United states showed that the prevalence of TMD peaks past

7
childbearing ages (45-64 years of age), and gradually decreases afterwards (52).
Nevertheless, there are a few studies on TMD after 65 years of age. Therefore, the
association between TMD signs and symptoms and different age groups require
further investigation.

Etiology of TMD

One of the aims of epidemiology is to assess the risk for disease. There is still
concern regarding the lack of scientific evidence to support the etiology of TMD
since no single factor has been identified as a sufficient or necessary etiological
factor. Thus, an etiology-qualified diagnosis (e.g. stress-related myalgia vs.
injury-related myalgia) may develop in the future (53). The understanding of
etiology has shifted in concept from mainly biomechanical models and local
factors to a multidimensional model and the outcome of multiple risk
determinants (38). The biopsychosocial model was introduced in the field of
medicine in 1977 as a framework in which all the levels of a patient’s health and
disease could be conceptualized (54). This model considers the biological factors
that may have psychological backgrounds as well as behavioral consequences
(54).

Biomechanics

Biomechanics is a study of the structure, function and motion of the mechanical

aspects of biological systems (55). It can be assessed in both function and
parafunction.

Dental occlusion

The interaction between TMD and dental occlusion is one of the controversial
topics in dentistry. It is hard to distinguish if some occlusal features are
consequences of the TMD or the cause/initiating factors of the TMD. In a large
epidemiological cross-sectional survey in Germany, the evidence of relationship
was weak in the presented associations between some occlusion-related variables
and TMD signs or symptoms (56). In the TMD patients’ sample, there was no
significant association between various malocclusion and the presence of any
pain-related TMD (56). Furthermore, the severity of a deep overbite and presence
of a posterior crossbite (unilateral/bilateral) were not risk factors for pain
associated with TMD and disc displacement (57). In a study using RDC/TMD, the
loss of five or more posterior teeth was not associated with TMD (58). In a
systematic literature review, there was no disease-specific association for dental
occlusion in the pathophysiology of TMD (59).

8
Conversely, a longitudinal study among university students found that unstable
occlusion at baseline increased the likelihood of TMD signs and symptoms and
headaches during the 2-year follow-up period (51). Furthermore, a review of 52
selected randomized control trials in 2018 reported that the role of occlusion in
the etiology of TMD has not been adequately evaluated (60). The authors argued
that the occlusal interferences could affect TMD and influence the natural jaw
muscle functions. Nevertheless, an ability of the jaw system to adapt to the
biomechanical changes, either by structural changes or in functional demands,
should be considered in the management of TMD patients (61).

Parafunctions
Parafunctions are habits aside from normal functional activity. Bruxism, as a
common parafunction, is defined as an abnormal repetitive movement disorder
characterized by jaw clenching and tooth gnashing or grinding (62). It has a
multifactorial etiology that includes biologic, psychologic, and exogenous factors
(59). Bruxism can occur during wakefulness (awake bruxism) with an estimated
prevalence of 20% among the adult population. It is mainly associated with stress
and anxiety (63). The role of the limbic system has also been suggested in the
awake bruxism pathophysiology (64). Sleep bruxism, as an awareness of tooth
grinding during sleep is reported by approximately 8% of the population (63).
Sleep bruxism is a behavior classified as a ¨sleep-related movement
disorder¨(63).

The relationship between bruxism and TMD pain is not conclusive. The lack of
longitudinal studies as well as the fluctuating natures of sleep bruxism,
psychological stress and TMD pain are suggested as possible reasons. Recently, a
dose-response gradient association between bruxism and TMD pain was rejected
(65). Furthermore, anterior tooth wear as an indicator for long-term bruxing
behavior and as a contributing factor to TMD pain was proposed as an
unacceptable concept (66).

On the other hand, a recent systematic review proposed that an association

between bruxism and TMD pain and dysfunction could be considered (67). In a
population-based study, self-reported bruxism was associated with TMD pain
related signs and symptoms (68). In a prospective cohort study, self-reported
bruxism was a strong predictor of chronic TMD (69).

Traumatic injuries

Those with a history of physical trauma present more severe subjective, objective,
and psychological dysfunction compared to those without a trauma history (70).
One of the most common injuries is Whiplash injuries related to car accidents
(71). The trauma can result in pain in the neck and head as well as in the jaw-face

9
region (72).The impairment of jaw-neck sensory-motor function is reported
shortly after a whiplash trauma (73). In a prospective study, discomfort with daily
jaw function was also reported (74). It has been proposed that Whiplash injuries
increase the prevalence and incidence of TMD pain (75).

Genetic factors

Genetic predisposition is believed to effect persistent pain conditions probably by

modulating nociceptive sensitivity, psychological well-being, inflammation, and
autonomic response (76, 77). Studies show that only a few genes have been
associated with TMD such as polymorphism of Catecholamine-O-
methyltransferase (COMT) (77) and the serotonergic system (78). The level of
enzymatic activity of COMT was inversely correlated with pain sensitivity and the
risk of developing TMD (79). A recent large candidate gene association study
observed associations between several genetic risk factors for clinical,
psychological, and sensory phenotypes with TMD; however, no genetic markers
predicted the onset of TMD (80). Advanced genetic technologies have been
recommended to assess the genetics of myofascial TMD in the future (81).

Comorbidity

TMD is one of the co-prevalent or co-existing chronic pain conditions included in

the COPCs. Fibromyalgia, back pain, irritable bowel syndrome (IBS), and primary
headaches are some other conditions included in the COPCs (82).
Neuroinflammation has been suggested as a contributor to the pathophysiology
of such conditions and associated widespread pain (83, 84).

The presence of pain in other parts of the body has been proposed as a factor
associated with OFP. Neck and shoulder pain, back pain, stomach pain, hip pain
and knee pain are examples (85-87). In a general adult population, the prevalence
of neck pain increased with increasing severity of TMD symptoms (88). A mutual
relationship between pain in the trigeminal and spinal regions (89) may be due
to central and peripheral sensitization mechanisms. These mechanisms will be
discussed in the section on pathophysiology.

Headache disorders are sixth on the list of the causes of years lived with disability
among other causes worldwide (90). Headaches are associated with impaired
quality of life (91) and an increased use of health care and medication (92). TMD
symptoms are more common in individuals with migraine, episodic tension-type
headaches (TTH), and chronic daily headaches compared to those without
headache (93). Reflecting on the overlap and probably shared pathophysiological

10
mechanism between myofascial TMD and TTH, differential diagnoses between
TMD and headache disorders are required for a successful treatment (94).

There are also associations between symptoms of TMD with impaired general
health status (95, 96). Sami women with more severe signs and symptoms of
TMD significantly more often reported an impaired general state of health
compared to controls without TMD (97).

The associations between TMD symptoms and inflammatory (98), hypermobility

disorders (99) and fibromyalgia (100) have also been reported. Fibromyalgia is a
chronic and widespread musculoskeletal pain in the four quadrants of the body
that has been present 3 months or longer (22). An overlap of similar types of
complaints has been reported among patients with fibromyalgia and those with
TMD (100-102).

In summary, such comorbidities emphasize the importance of an accurate

differential diagnosis between a local TMD pain condition and a TMD pain
condition related to the generalized pain condition. More research in this field is
warranted since the results affect both diagnosis and prognosis of TMD.

Psychosocial factors

Psychosocial factors such as anxiety, depressed mood, fear-avoidance beliefs,

catastrophic thoughts (exaggeration of the perceived threat of pain), passive
coping strategies, and social isolation are generally associated with the risk for
the development of chronic pain (103). In a prospective cohort study, measures
of somatization were among the strongest psychosocial predictors for TMD onset
(104). Stress is also reported as an important factor in TMD etiology, progression
and treatment (105). About 50% of the patients with persistent pain had
significant symptoms of depression (106). Catastrophic thoughts have been
related to anxious and depressed moods (107). Both depression and
catastrophizing are proposed as factors complicating the management of TMD
(108). Hence, psychosocial factors should be screened with proper instruments
to identify different degrees of health burdens (109). Further, psychosocial
factors should be considered as potential targets in the treatment plan of TMD
(107).

It has been pointed out that the majority of TMD studies have not addressed
psychosocial factors (110). Moreover, the association between TMD and
socioeconomic factors (i.e. social supports, occupation, education and financial
resources) have not been adequately investigated (96, 111, 112). Taken together,
such shortcomings may indicate that the biopsychosocial concept has not been

11
understood in its proper value, which in turn affects the understanding of TMD.
This makes research in the etiology of TMD both complicated and essential.

Pathophysiology

Pathophysiology of TMD may involve peripheral and central sensitizations

among other mechanisms (113). Peripheral nerves and ganglia are affected in
peripheral sensitization, whereas the spinal cord, brainstem and brain are
involved in central sensitization. During trauma or inflammatory injury, muscle
tenderness and hyperalgesia (increased pain sensation from noxious stimuli) are
mainly displayed by peripheral sensitization of nociceptors (114). This is
characterized by increased spontaneous activity, decreased response threshold to
noxious stimuli, increased responsiveness to the same noxious stimuli, and
increased receptive size. An increased activity of peripheral nociceptors can lead
to development of central sensitization (central hyperexcitability) (115).

Central sensitization is an increased response to pain stimulation mediated by

amplification of signaling to the central nervous system. This amplification in
pain processing may be due to an imbalance between facilitatory and inhibitory
mechanisms (116). Among TMD patients with myalgia, the central
hyperexcitability in the trigeminal system may account for hyperalgesia in the
masticatory muscles (117). Furthermore, greater sensitivity to noxious stimuli
applied outside the area of clinical pain indicates generalized hyperexcitability in
the second order or higher nociceptive neurons in the central nervous system
among these patients (118). Pain can also be induced in trigeminal area from
other cervical areas due to peripheral and central mechanisms (113). In an
experimental pain model, the induced pain outside the jaw region influenced the
motor function of the jaw system (119).

Treatment need attributed to TMD

Epidemiology has been applied to evaluate the treatment need for TMD.
Variation in prevalence of TMD as well as factors involved in decision-making
may affect estimates for treatment need owing to TMD in the population. In a
systematic review with a meta-analysis, the estimated treatment need for TMD
was in the range of 1.5-30% (120). In a population-based longitudinal study, the
prevalence of a more significant treatment need owing to TMD was estimated at
4.5% among men and 13.5% among women (121). In Sweden, a large discrepancy
has been observed between estimated treatment need for TMD and related
traceable treatments performed in the dental health care (122). The reason
behind such undertreatment is still a gap in the knowledge.

12
A patient’s values and preferences together with clinician expertise should be
considered in the decision-making process; this is referred to as ¨shared decision-
making¨ concept (123). However, the decision-making process is troublesome
when there is multidisciplinary approach in TMD diagnosis and treatment that
may involve both dental and non-dental professions (124). Studies show that
there is no consensus among caregivers from different disciplines in terms of
diagnosis and treatment of TMD (125, 126). This may lead to disparities in TMD
treatment as well as unsatisfactory service to the patient population (127). In
Sweden, undertreatment of TMD was found among general dental practitioner
despite the presence of well-implemented screening tools for diagnosis of TMD
(128-130).

It seems that the clinical decision-making process among those affected by TMD
is partly related to care givers’ attitude and organization of health care. Evaluating
the effect of other factors related to the health seeker’s side (i.e. sociodemographic
factors, behavioral factors, general and oral health status) on this process is
therefore required for a better understanding of the estimation of treatment need
for TMD.

Methods to identify individuals with TMD

Diagnostic methods are applied to identify whether a subject has or does not have
a particular condition. A method must fulfill a sufficient level of reliability and
validity to help clinicians diagnose and consequently properly treat patients.
Reliability is consistency and repeatability of outcomes as measured by the
clinical test. Validity refers to accuracy of the test in measuring what it is
purporting to measure (131, 132).

In the public health paradigm, screening programs are one of the most common
tools to control epidemics and target treatment for chronic diseases. Screening is
the application of a test to all individuals in a defined population either to identify
cases or for surveillance purposes. Identification of a previously unknown or
unrecognized condition in apparently healthy or asymptomatic individuals
(cases) results in triggering interventions that will benefit the cases. Screening
tests are judged in terms of sensitivity (proportion of actual cases found by the
test to be positive), specificity (proportion of non-cases found to be negative),
positive predictive value (proportion of positive test results that are actual cases)
and negative predictive value (proportion of negative test results that are not
actually diseased). False negatives and false positives are counted as screening
tests failures (2).

13
In this section, TMD diagnostic and screening tests are presented.

Helkimo indices

Dr. Martti Helkimo is considered a pioneer in developing an index to measure the

severity of mandibular dysfunction on both the individual and general population
levels. The indices were introduced in 1974 and were based on the characteristic
signs and symptoms of TMD (133).

The Helkimo indices are comprised of anamnestic and clinical dysfunction

components. The anamnestic index (Ai) classifies symptoms into three grades –
(Ai0) denotes the absence of subjective symptoms of dysfunctions of the jaw
system, (Ai1) denotes mild symptoms (TMJ sounds or feeling of tiredness/fatigue
of the jaws), and (Ai2) denotes severe symptoms of dysfunction (pain in the face
or jaws, pain on jaw movements, difficulties in opening the jaw wide, locking or
luxation of the jaw).

The signs construct the clinical dysfunction index (Di). The Di is based on the
sum of the scores of five clinical signs – jaw function, jaw movement capacity,
TMJ pain to palpation, muscle pain to palpation, and pain on jaw movements.
The severity of the clinical signs is used to classify four dysfunction groups –
(Di0)=0 point = normal function, (Di1)=1 - 4 points = mild dysfunction, (Di2)=5
- 9 points = moderate dysfunction, and (Di3)=10 - 25 points =severe dysfunction
(133).

The validity of the Ai has been questioned regarding the mild (Ai1) and severe
(Ai2) symptoms with different symptoms frequency and intensity levels (134).
The Di has been both questioned (135) and recently advocated as a valid and
reliable instrument to identify those with TMD (136). In summary, the Helkimo
indices have been used since 1974 worldwide due to the valuable elements (137-
140).

American Academy of Orofacial Pain (AAOP)

The AAOP diagnostic criteria for TMD-related masticatory disorders was

introduced in 1990 and was one of the most used internationally classification
system (141). The AAOP criteria was based on the international headache
society’s classification of OFP disorders. Its focus was mainly on the biomedical
factors as opposed to the biopsychosocial.Therefore, a separate axis was
recommended by the AAOP for defining psychosocial factors and diagnosing
mental disorders (142).

14
Research Diagnostic Criteria for TMD (RDC/TMD)

The RDC/TMD was introduced in 1992 to standardize examination for

diagnostics of TMD. It has been widely used for diagnosis, evaluation and
classification of TMD. It has a dual-axis classification system based on a bio-
behavioral model of pain. Axis I has physical components (signs and symptoms)
and axis II comprises psychological and disability factors (29). Although axis I
was shown to be both reliable and valid, axis II is reliable but the validity is below
the suggested target sensitivity of > 0.7 and specificity of > 0.95 (143, 144).
Therefore, the revision of these algorithms was considered to improve the validity
and clinical utility of the RCD/TMD in both clinical and research settings.

Diagnostic Criteria for TMD (DC/TMD)

The DC/TMD was launched in 2014 to provide criteria for the most common
TMD diagnoses. Familiar pain is a criterion for establishment of a TMD pain
related diagnosis. The DC/TMD includes two axes (35). Axis I as a physical
diagnosis is a screening tool that detects any pain related TMD within the last 30
days. A strong inter-examiner reliability has been reported for pain related TMD
with a kappa of >0.85. The axis II protocol is both a screening tool and a self-
assessment instrument to assess psychosocial status. It screens pain intensity,
disability related to pain, psychological factors, limitation in jaw function,
parafunctional behaviors, and a pain drawing at the pain site. An effort is under
process to create Axis III to consider genetics, epigenetics, and neuroscience for
specifying standardized diagnostic categories pathognomonic of chronic TMD
pain (53).

Although the DC/TMD is a valid instrument for TMD diagnostics, effective

screening methods for TMD are important to identify those who would benefit
from the systematic examination.

Screening questions for the recognition of TMD

TMD with other conditions, included in the COPCs, share common features such
as persistent pain that requires treatment, and becomes devastating in
approximately 10% of patients (53). With early intervention the chronicity of
TMD may be prevented, which can result in a cost-effective management (145). A
valid and reliable TMD screener is useful to identify those who need to be referred
to specialized TMD/OFP clinics for further diagnosis and treatment readily and
cost-effectively. Previous studies showed that identifying TMD with existing
screeners had methodological or logistic limitations. Screening instruments in
distinguishing between patients with TMD pain from odontogenic pain showed

15
lack of diagnostic accuracy and low specificity for both instruments (146). A self-
reported instrument in screening patients only for pain-related TMD showed
high sensitivity and specificity in relation to the RDC/TMD (147).

In 2000, two questions capturing self-reported TMD pain were introduced in the
County of Östergötland, Sweden.

The questions were:

(Q1) Do you have pain in your temples, face, temporomandibular joint (TMJ),
or jaws once a week or more?

(Q2) Do you have pain when you open your mouth wide or chew once a week or
more?

These two questions were validated in adolescence in relation to the RDC/TMD.

The results showed decidedly good reliability and high validity in the adolescent
population (148). Still, dysfunctional aspects of TMD have not been included in
any of the mentioned screeners. Therefore, a third question – (Q3) Does your jaw
lock or become stuck once a week or more?, was introduced to identify the intra-
articular TMD that may lead to functional disturbances of the TMJ.

Since May 2010, the three questions together (Q1, Q2, Q3) have been applied to
identify patients with potential TMD to indicate the demand for treatment. The
questions have been included in the digital health declaration in the dental record
system of the Swedish version of the Dental Practice Management System, T4
(Eastman Kodak Company, New York, NY, USA) in the Public Dental Health
Services in Västerbotten, Sweden. Each question is answered by ¨yes¨or ¨no¨.
Substantial validity for the frequent pain (Q1 & Q2) and fair to moderate validity
for the frequent impairment of jaw function (Q3) in relation to DC/TMD were
reported in an adult population (149). In summary, the 3Q/TMD can be
considered as a feasible screener for further diagnostics and even tracing possible
treatment needs among adult populations.

16
Rationale for this thesis

The Swedish National Board of Health and Welfare inquired about population-
based studies on oral health in regard to specific indicator ages. In Västerbotten,
Northern Sweden, surveys of oral health based on 35-, 50-, and 65-year old
individuals were done in 1990; in 2002, 75-year olds were added.

The rationale of this thesis was to use data from the survey in 2002 to delve
deeper into the different aspects of TMD as a public health problem. This was
done by estimating distribution of signs and symptoms indicative of TMD in
relation to gender and age, identifying possible risk or comorbid factors
associated with TMD, and estimating the treatment need in the adult population.

17
 Objective

The overall aim of this thesis was to study signs and symptoms indicative of TMD
in terms of prevalence, associated factors, treatment need estimate, and possible
factors underpinning clinical decision-making in terms of treatment need owing
to TMD. The possible influence of pain conditions on TMD symptoms and TMD
diagnosis based on DC/TMD in the adult population was also analyzed.

Specific aims

I. To analyze and compare prevalence of signs and symptoms indicative of

TMD and headaches in 35-, 50-,65-, and 75-year old men and women living
in Västerbotten County.

Hypothesis
• Clinical signs and symptoms indicative of TMD and headaches would be
more commonly registered and reported among women than men.
• The 35- and 50-years old groups would have a higher prevalence of
reported TMD symptoms and headaches compared to the older age groups.
• Clinically registered TMD signs would show an increasing prevalence with
age.

II. To analyze the relationships between the domains craniomandibular pain

and jaw dysfunction, respectively, and socio-demographic factors and self-
perceived general and oral health in a middle-aged and an elderly
population.

Hypothesis
• Socio-demographic factors and general and oral health would be
associated with signs and symptoms of pain in the craniomandibular
region and /or jaw dysfunction in a middle-aged and an elderly population.

III. To analyze the prevalence of estimated treatment need owing to TMD in

an adult population, and to analyze which factors posed significant
influence on dentists’ estimated treatment need.

Hypothesis
• Socio-demographic characteristics, general and oral health factors and
behavioral factors would influence decisions regarding treatment need.
• The presence of signs and symptoms of TMD would influence decisions
regarding treatment need.

18
IV. To analyze the relationship between different patterns of pain to palpation
and reported frequent pain in jaw-face and head.

Hypothesis
• Patterns of pain to palpation are associated with the presence of jaw-face
pain and headaches.

V. To estimate the weighted prevalence of widespread pain in the sample, and

to evaluate the association between myofascial orofacial pain with and
without referral, respectively, and widespread pain.

Hypothesis
• Myofascial orofacial pain with referral would be associated with
widespread pain after adjusting for the effect of age and gender.

19
 Study populations and Methods
A short overview of the included papers, with aims, study populations, included
variables, and statistical analyses are presented in table 1.

Table 1. Overview of the five papers.

Paper I Paper II Paper III Paper IV Paper V
Prevalence Associations Treatment need Pain to palpation Widespread pain
and TMD pain
Aim To analyze and To analyze the To analyze the To analyze the To estimate the
compare prevalence of relationships between prevalence of relationship between weighted prevalence of
signs and symptoms the domains estimated treatment different patterns of widespread pain in the
indicative of TMD and craniomandibular need owing to TMD in pain to palpation and sample and, to
headaches in 35-, 50-, pain and jaw an adult population, reported frequent pain evaluate the
65-, and 75-year old dysfunction, and to analyze which in the jaw-face and association between
men and women living respectively, and factors posed head. myofascial orofacial
in Västerbotten socio-demographic significant influence pain with and without
County. factors and self- on dentists’ estimated referral, respectively,
perceived general and treatment need. and widespread pain.
oral health in a
middle-aged and an
elderly population.
Design Cross-sectional
Subjects 35-, 50-, 65-, 75-yrs 35+50 yrs 35-, 50-, 65-, 75-yrs 35-, 50-, 65-, 75-yrs 20-69 yrs
Q n=491 CE n=397
Q (♂495 & ♀472) 65+75 yrs Q & CE n= 779 Q & CE n= 779 Q & CE n= 300
Q n=496 CE n=370 (♂409 & ♀370) (♂409 & ♀370) (♂98 & ♀ 202)
CE (♂399 & ♀368)
Variables Headaches Dependent Dependent Dependent Dependent
TMD Symptoms variables variables variables variables
Jaw/face pain TMD symptoms Estimated treatment TMD Pain Widespread pain
Jaw tiredness Pain & Dysfunction need owing to TMD: Headaches ≥7 pain sites
TMJ sounds TMD signs (i) No need
TMJ locking Pain & Dysfunction (ii) Treatment needs
Difficulties to open Independent Independent Independent
the jaw wide variables variables variables Independent
TMD signs Socio-demographic TMD symptoms Pain to palpation variables
Jaw muscle pain to factors Pain & Dysfunction patterns: Myalgia
palpation Self-rated general & No pain Myofascial pain with
TMJ pain to palpation oral health status TMD signs Local pain referral
TMJ sounds Dental status Pain & Dysfunction Regional pain Gender
Pain on jaw Occlusal supporting & Generalized pain Age
movement zones Independent variables
Impaired jaw opening Chewing capacity in Paper II.
Statistical Prevalence Logistic regression Prevalence Logistic regression Prevalence
analysis Chi2 test analysis Logistic regression analysis Logistic regression
Odds ratio (OR) analysis Odds ratio (OR) analysis
Fisher´s exact test Chi2 test Odds ratio (OR) Chi2 test Mann-Whitney -U test
Chi2 test Chi2 test
* The study sample is the same in paper I-IV.
** Q stands for Questionnaire and CE stands for Clinical examination.
*** Q & CE in papers III & VI is comprised of Q & CE and No Q and CE in table 2.

20
Study population and sample

Papers I-IV

The first four papers in the thesis were based on a randomly drawn sample from
11324 individuals aged 35, 50, 65 and, 75 years living in the Västerbotten County,
Sweden in September 2002. The study sample was stratified based on area of
residence – coast (mainly urban area) and inland (mainly rural area). Each
stratum constituted 600 individuals with 150 in each age group. In total, 1200
individuals (300 in each age group), who were randomly drawn from the
population were included in the study sample. The sample size was calculated
based on a previous study in 1990 (150), with an estimated drop out of 25% of the
sample.

The scrutiny included both a questionnaire and a clinical examination. Of the

1200 individuals, 987 (response rate 82%) returned a filled-out questionnaire
and 779 (response rate 65%) participated in the clinical examination. Complete
data (both from questionnaire and clinical examination) were obtained as
follows: 768 individuals (64%), 219 (18%) only answered the questionnaire, 11
(1%) only participated in the clinical examination. Totally 202 individuals (17%)
did not participate in the study (Table 2).

Table 2. Description of the study population and reasons for not participating.
Age group 35 yrs 50yrs 65 yrs 75 yrs Total
Population 3464 3375 2460 2025 11 324
Sample 300 300 300 300 1200
Q& CE 207 190 195 176 768 (64%)
Q& no CE 38 56 61 64 219 (18%)
No Q& CE 7 4 11 (1%)
Total number of 252 246 260 240 998 (83%)
participants
Reasons for not
participating
Just visited a 14 12 18 15 59
dentist
Do not want to 9 15 13 28 65
come
Afraid 7 3 10
Miscellaneous 10 12 5 12 39
Deceased 2 5 7
Non-resident 1 1
Not reached 8 12 1 21
Total number 48 54 40 60 202 (17%)
of non-
participants

21
Questionnaire

The questionnaire was constructed to obtain a comprehensive picture of oral

health in a large sample size to be representative of the population in the
Västerbotten County. It was designed based on the interest of policy makers and
experience from other similar studies in Sweden. The questionnaire included 65
questions dealing with socio-demographic characteristics, self-perceived general
health and oral health, tobacco use, medication, symptoms indicative of TMD and
headaches (Table 3).

Table 3. Operational definition of independent variables from the questionnaire.

Variable Definition Scale

Age Adult population 35+50 (Middle-aged)
35, 50, 65, 75 yrs 65+75 (Elderly)
Gender Self-defined gender Men
Women
Region Residence area of the Inland
respondent Coast
Education Highest level of education Elementary
of the respondent High school
University
Living condition Household structure With other
Alone
Employment status Employment status of Working
respondent Not working
Economic status Income per months before ≥15000 SEK
tax < 15000 SEK
Financial resources Able to obtain Yes
14000 SEK within a week No
General health status Self-perceived general Good
health during the last year Moderate
Bad
General arthritis History of general No
arthritis Yes
Medication Regular use of prescribed No
medicine Yes
Tobacco use Currently smoking No
Yes
Currently using snuff No
Yes
Oral health status Self-perceived oral health Good
during the last year Moderate
Bad
Oral hygiene Brushing the teeth ≥ daily
prosthesis and implants < daily
Proximal cleaning using ≥ weekly
dental floss, toothpick or < weekly
interdental brush
Regular dental health care Regular dental visit <2 years between
examinations
>2 years between
examinations
Chewing capacity of hard Able to chew hard bread No problem
food or apples With caution

22
The six questions in the questionnaire related to symptoms indicative of TMD
asked for the presence of the following symptoms during the last 3 months: TMJ
sounds, jaw/face pain, jaw tiredness, difficulties in opening jaw wide, TMJ
locking, and headaches. The symptom occurrence was reported on frequency
scale: No, Yes, occasionally, once or twice every week, several times a week,
daily. The reported occurrence once a week or more often was defined as
¨frequent symptoms¨. The answers in the analysis were dichotomized to the
frequent symptoms and those remaining.

Clinical examination

The clinical examinations were performed by four dentists, each assisted by a

chair-side assistant, at public dental clinics close to the living address of the
randomly selected participants. Two dentists were men and two were women
(mean age=48.3, SD=3.1) and their individual clinical experience was
approximately 25 years. The examiners were trained and their examination
techniques were calibrated for all of the clinical variables before the study started.
The calibration was done in relation to a golden standard. Two calibrations on
voluntary subjects were needed before the accepted level was achieved for inter-
examiner reliability (Kappa value 0.64-0.84). The obtained percentage
agreement for the clinical variables was ranged 85-93%.

The examinations included registration of dental status, occlusal supporting

zones (Eichner index) (151), periodontal pocket depth, soft tissue examination,
function of temporomandibular joint, maximal jaw opening capacity, presence of
pain to palpation and treatment needs (Table 4).

Examination of jaw function

• TMJ sounds was registered during opening and closing movements by

bilateral palpation. The sounds were registered without the aid of a
stethoscope. The sounds were classified as dull clicking, sharp clicking, or
crepitations.
• TMJ locking was registered if no sliding movements of one or both condyles
could be felt and the jaw opening was less than 25 mm, or if the mandible
deviated 5 mm or more when opening the jaws wide.
• TMJ pain was registered during palpation laterally and posteriorly (via the
auditory meatus) when it elicited a palpebral reflex.
• TMJ pain during movements was registered if free movements (opening
wide, laterotrusion and protrusion) of the jaw elicited TMJ pain.
• Maximal mandibular opening capacity was measured to the nearest
millimeter with the aid of a ruler during unassisted maximal jaw opening as

23
 the distance between upper and lower incisors and with the vertical overbite
added in.

Examination of muscles and tendons

The registration of pain to palpation of specified muscle sites was done when the
palpation with firm pressure during two seconds elicited a palpebral reflex in the
eyes, or a protection reflex.

The following muscle and tendon attachment sites were palpated:

Extra oral sites

Temporal muscles: with the index, middle and ring fingers over the temple to
palpate the anterior and posterior parts extra orally.

Medial pterygoid muscles: the subjects were asked to tilt the head slightly
towards the palpated site. The inner surface of the mandible angle was palpated
with the index finger.

Deep masseter muscles: with the index finger in the area located between the
back side of the ramus and the back border of the superficial masseter 2 cm lower
than the tragus.

Intra oral sites

The origin of the masseter muscles was palpated bi-digitally with the index finger
from inside and the thumb from outside the mouth and palpation was done along
the zygomatic arch.

The tendon of the temporal muscles: the inside of the coronoid process was
palpated intra orally with the index finger.

Lateral pterygoid area: subjects were asked to move the jaw towards one side to
palpate behind the buccal area of the third molar region with tip of the little finger
in a medial direction behind the maxillary tuberosity.

Body sites
The center part of the sternocleidomastoid muscles, the trapezius muscles, the
underside muscles of the forearm, thumb muscles, and calf muscles were
palpated bi-digitally.

24
 Table.4. Operational definition of different variables from clinical examination
apart from muscles and tendons examination.
TMJ sound No sound during opening and closing movements No
Presence of clicking and crepitation on the movements Yes
TMJ locking No TMJ locking No
Lack of sliding movements of one/both condyles & the jaw Yes
opening < 25 mm
Lack of sliding movements of one/both condyles & deviation of
the mandible ≥5 mm with opening the jaw wide
TMJ pain No pain No
Pain to palpation laterally or posteriorly or both Yes
TMJ pain during 0= no pain No
movements 1= pain at one movement Yes
2= pain at two or more movements
Maximum jaw ≥ 40 mm Normal
opening < 40 mm Impaired
Occlusal A1: Antagonist contacts in all supporting zones with no dental In paper II
supporting zones limiting gaps defined as
in premolar and A2: Antagonist contacts in all supporting zones with dental (35+50 yrs)
molar regions gap/s in one jaw A1 vs. Other
(Eichner index) A3: Antagonist contacts in all supporting zones with dental
gaps in two jaws (65+75 yrs)
A1-B vs. Other
B1, B2, B3: Antagonist contacts in 3,2,1 supporting zone,
respectively In paper III
B4: No antagonist in supporting zone but the tooth contacts defined as
in the front area A
B
C1: Both jaws toothed with no antagonist contacts C
C2: One jaw toothed
C3: Both jaws have no tooth
Number of teeth < mean and ≥ mean paper II
Mean value for 35+50-year olds =27 teeth
Dental status Mean value for 65+75-year olds =14 teeth
Number of teeth < mean and ≥ mean paper III
Mean value of teeth for total sample = 24
Need for No operative treatment or advice or fluoride therapy No
treatment owing Fillings or/and extraction or endodontic treatment and need Yes
to decade teeth for more investigation
Need for No operative therapy or instructions in tooth hygiene No
periodontal Periodontal treatment or referral to specialist Yes
treatment
Need for partial No treatment No
fixed prosthesis Need for partial fixed prosthesis or referral to specialist Yes
Need for No treatment No
removable Adjustment or new dentures or referral to specialist Yes
prosthesis
Need for dental No treatment No
implant Need for dental implant Yes
Need for No treatment No
orthodontic Referral to specialist Yes
treatment
Need for oral No treatment No
surgery Need for biopsy, surgery, oral medicine or referral to specialist Yes
No treatment need No
Need for Advice to avoid jaw clenching behavior or advice in jaw Yes
treatment owing exercises or minor occlusal adjustments used in connection to
to TMD traumatizing occlusion, or splint therapy or referral to TMD
specialist for a more comprehensive examination

25
Paper V

This cross-sectional study used data from 7831 individuals who attended the
Public Dental health services for their routine dental check-ups in Västerbotten
in 2014. The individuals answered the three screening questions for possible
TMD (3Q/TMD) that was a compulsory part of the digital health declaration.
Individuals were classified based on their answers as 3Q-positives or 3Q-
negatives. The 3Q-positives (n=524) had at least one affirmative answer to the
three questions. The 3Q-negatives (n=7279) had negative responses to all three
questions. The 3Q-negatives were stratified in five 10-year age clusters (20-29,
30-39, 40-49, 50-59, and 60-69 years). All 3Q-positives were invited for
examination in a randomized order (SPSS v.22; IBM, New York, USA, random
numbers). For each 3Q-positive, an age cluster and gender-matched 3Q-negative
was invited. All participants were first invited by letter that gave brief information
about the study and an offer to participate in the clinical examination.
Participants were contacted by phone about a week later, and if they accepted to
participate, they were scheduled for the clinical examination. In this study, there
were 300 individuals (20-69 yrs) that included 140 Q-positives and 160 Q-
negatives. The sample was composed of 202 women (67%) and 98 men (33%).

Clinical examination

On the day of clinical examination, all participants completed the DC/TMD

symptom questionnaire, a pain-site drawing to mark all areas of pain on a body
mannequin, and the 3Q/TMD for a second time. Pain-site drawings were
reported to be a useful tool for screening and assessing pain in studies on chronic
musculoskeletal pain (23, 152). These responses were used in the analysis since
they most closely matched the current complains of the participants. All
individuals underwent a standardized clinical examination according to the
DC/TMD protocol. The clinical examination was done by a calibrated dentist who
was blinded to the group allocation. Reliability tests were high based on the
Cohen Kappa value for the tested diagnoses, i.e. myalgia (0.82), myofascial pain
with referral (0.88), and arthralgia (right o.87, left 0.88).

The DC/TMD diagnoses used in this study were myalgia, myofascial pain with
referral and arthralgia. For all diagnoses, the history of pain in the masticatory
system and pain modified by jaw movement, function or parafunction within the
last 30 days were compulsory. Myalgia was considered present if during clinical
examination, a familiar pain in the masseter or temporal muscle with either
muscle palpation or maximum opening was confirmed. If pain was felt outside
the muscle border during the 5-second palpation, the term myofascial pain with

26
referral was used. For arthralgia, a confirmation of pain in the TMJ(s) and
familiar pain with TMJ palpation or range of motion were mandatory.

Widespread pain was defined as seven or more pain sites in the pain-site drawing
based on the widespread pain Index (WPI)(22). The pain sites were defined as
two facial sides, the neck, two shoulder sides, two upper arm sides, two lower arm
sides, chest, abdomen, upper back, lower back, two hip sides, two upper leg sides
and two lower leg sides.

27
Statistical analysis

Data analysis was done using STATA statistical software, version 10 in the papers
I-IV. Since the sample was stratified by region (inland and coast), all prevalence
figures were adjusted in relation to the proportion of individuals living in the
respective parts of the county. Then the weighted prevalence figures were
adjusted in relation to the proportion of each age group among men and women.
A p-value less than 0.05 was considered statistically significance.

Paper I (Prevalence)

Prevalence figures were calculated for signs indicative of TMD, frequent

headaches and symptoms indicative of TMD during the last three months among
35-, 50-, 65- and 75- year olds. The prevalence figures were also calculated for the
anamnestic dysfunction index (Ai) and clinical dysfunction index (Di) for each
age group among men and women (see introduction). The combination of
moderate-to-severe clinical signs of dysfunction of the jaw system according to
the Di and frequent headaches or frequent symptoms indicative of TMD were
calculated for each age indicator among men and women. To compare the
proportions, Chi-square test and Fisher´s exact test were used. The sample for
TMD symptoms consisted of 495 men (51%) and 472 women (49%), and for TMD
signs consisted of 399 men (52%) and 368 women (48%) with no significant
differences in the gender distribution in each age group.

Paper II (Associations)

TMD was categorized into craniomandibular pain symptoms, jaw dysfunction

symptoms, TMD pain signs, and TMD dysfunction signs as dependent variables.
The definitions of dependent variables are presented in table 5. In this study, 35-
and 50-year olds were combined to constitute a middle-aged group and the 65-
and 75-year olds an elderly group. Logistic regression analysis was used to
estimate the association between socio-demographic factors, self-perceived
general health, and oral health with dependent variables among the middle-aged
group and the elderly. Owing to minor variations in missing data, the included
numbers of individuals in the regression analyses varied. After applying
univariate analysis for each of the included independent variables, all factors
significantly associated with the dependent variable were added into a
multivariate model. The results were presented as odds ratios (OR) with 95%
confidence interval (95% CI).

28
Table 5. Operational definition of dependent variables in paper II.

Dependent variables Definition

Frequent pain in craniomandibular Jaw/face pain or jaw tiredness or headache
region ≥ once a week
Frequent jaw dysfunction symptoms TMJ locking or TMJ sounds or difficulty to
open the jaw wide ≥ once a week
TMD pain signs Jaw muscle pain to palpation or TMJ pain
to palpation or pain on jaw movements
TMD dysfunction signs TMJ sounds or jaw opening <40 mm

Paper III (Treatment need)

Analysis was based on 779 individuals who participated in the clinical

examination. Prevalence figures for treatment need owing to TMD were
calculated in different age groups, among men and women. Treatment need
owing to TMD was dichotomized into no need for treatment and need for
treatment (Table 4). Logistic regression analysis was used to estimate factors
associated with treatment need owing to TMD among adult populations. After
applying univariate analysis for each of the included independent variables, all
factors significantly associated with the dependent variable were added into a
multivariate model. The results were presented as OR with 95% CI.

Paper IV (Pain to palpation)

The analysis was based on 779 individuals who participated in the clinical
examination. The location of the elicited pain to muscle palpation was sectioned
into five groups (Table 6). Due to minor variations in missing data, the included
numbers of individuals in the regression analysis varied. In the regression
analyses, reported jaw-face pain and/or headache once a week or more during
the past 3-month period were used as dependent variables. The results were
presented as OR with 95% CI.

Table 6. Operational definition of independent variable in paper IV.

Independent variable Definition

Reference group No registered pain to palpation
Pain at jaw muscle sites only Local pain to palpation at jaw muscle sites
Pain at neck/shoulder muscle sites Local pain to palpation at neck/shoulder
only muscle sites
Regional pain Pain to palpation at both jaw and
neck/shoulder muscles sites
Generalized pain to palpation Pain to palpation at neck/shoulders,
underarm, thumb, and calf muscles sites

29
Paper V (Widespread pain and TMD pain)

The data analysis was conducted in the SPSS Statistics for Windows (Version
24.0. Armonk, NY: IBM Corp). The population-based weighted prevalence of
widespread pain was calculated based on a normative prevalence of 4.8% 3Q-
positives, among 20-69 year olds in 2014. Logistic regression analysis was used
to evaluate associations between myalgia and myofascial pain with referral,
respectively, and WSP as a dependent variable (Table 7). The models were
adjusted for gender and age. A p-value less than 0.05 was considered statistically
significant with 95% CI.

Table 7. Operational definition of dependent variable in paper V.

Dependent variable Definition

No: pain sites <7 in the pain drawings
Widespread pain Yes: pain sites ≥7 in the pain drawings

30
Results
Paper I

Prevalence of symptoms indicative of TMD

The weighted prevalence of weekly-to-daily (frequent) occurring symptoms in the

jaw-face-head region during the last 3 months for the total study population are
presented in Figure 1. Frequent headaches were the most reported symptom in
the jaw and head regions among both men and women (20% and 12%,
respectively). Among TMD symptoms, frequent TMJ sounds was the most
common symptom (13% and 9%), and TMJ locking was the least common
symptom (2% and 1%). Jaw-face pain and jaw tiredness were the third most
frequent symptoms indicative of TMD among women and men, respectively.
There were statistically significant differences for all symptoms except for TMJ
locking in relation to gender.

Figure 1. Percentage distribution of prevalence of weekly-t0-daily (frequent) occurring

symptoms in the jaw-face-head region during the last 3 months among men (n=495) and
women (n=472). Statistically significant differences in prevalence between men and
women are indicated as *p ≥0.01 and < 0.05; ***p < 0.001.

31
The prevalence patterns of both frequent and non-frequent jaw/face pain and
headaches among men and women in the four age groups are presented in Figure
2. The total prevalence of non-frequent jaw/face pain was 12 % among women
and 10% among men. Fifty-year old women had the highest prevalence of
jaw/face pain compared to the other age groups. The difference was statistically
significant among women in relation to age (p = 0.002). Among men, there were
no statistically significant differences in jaw/face pain prevalence in relation to
age. Nearly 52% of women and 43% of men reported non-frequent headaches
within the last three months. Among both men and women, the middle-aged
groups (35- & 50-year olds) had a higher prevalence of headaches compared to
the elderly (65- & 75-year olds) regardless of the time frame capturing the
frequency of the headaches. The difference was statistically significant among
women in relation to age (p <0.001).

Figure 2. Percentage distribution of prevalence of non-frequent (dotted line) and

frequent (dashed line) occurring pain in the jaw-face region and headaches, respectively,
during the last 3 months among men (blue lines) n=495, and women (red lines) n=472.

32
The prevalence patterns of both frequent and non-frequent TMJ dysfunction
symptoms among men and women in the four age groups are presented in Figure
3. Among women, a similar pattern was observed for both frequent and non-
frequent difficulties in opening the jaw wide as well as in jaw locking. Women at
50-years of age had the peak prevalence for these dysfunction symptoms
compared to the other age groups. The age difference was statistically significant
for difficulties in opening the jaw wide (p =0.03). Among men, no statistically
differences were found for difficulties in opening jaw wide and jaw locking in
relation to age.

Figure 3. Percentage distribution of prevalence of non-frequent (dotted line) and

frequent (dashed line) occurring jaw dysfunction symptoms during the last 3 months
among men (blue lines) n=495, and women (red lines) n=472.

33
Prevalence of signs indicative of TMD

In general, the clinical signs indicative of TMD were more commonly registered
among women (Figure 4). Jaw muscle pain to palpation was registered in nearly
half of the women and one-third of the men (p <0.001). TMJ sounds was the
second most registered signs among both men and women (29% and 21%,
respectively). Pain during jaw movements were registered among 11% of the
women and 6% of the men. The least common registered sign was impaired jaw
opening among both men and women (p <0.001). All clinical signs showed a
statistically significant difference in relation to gender.

60
***
49
50

40 36
**
29
30
%

21
20
*
11 **
10 6
9 ***
4 5
1
0
Jaw muscle TMJ sounds Pain on jaw TMJ pain to Jaw opening <
pain to movement palpation 40 mm
palpation

Figure 4. Percentage distribution of clinical signs of dysfunction of the jaw system

among men (n=399) and women (n=368). Statistically significant differences in
prevalence between men (blue bars) and women (red bars) are indicated as *p ≥0.01
and < 0.05; **p≥ 0.001 and < 0.01; ***p < 0.001.

The prevalence of signs indicative of TMD among men and women in different
age groups is presented according to the clinical dysfunction index (Di) in Figure
5. Approximately one-third of the women and half of the men had no signs of
TMD (Di0). A statistically significant difference for prevalence of signs of
dysfunction was observed in the 50-year olds (p< 0.001) and 65-year olds (p<
0.01) between men and women. Sixty-five-year old women and 75-year old men
had the highest proportion of mild signs (Di1) compared to the other age groups.
Moderate signs (Di2) had a similar prevalence among the 35-year old men and
women. The prevalence of severe signs (Di3) had the lowest prevalence in all age

34
groups among both men and women. Women 50 years of age had the highest
prevalence of severe signs compared to the younger and older women. There was
no significant difference in Di prevalence in relation to age either among men or
among women.

Figure 5. Percentage distribution of clinical signs of dysfunction of the jaw system

according to the clinical dysfunction index (Di) among men (n=399) and women
(n=368). Di0 denotes no signs, Di1 denotes mild signs, Di2 denotes moderate signs, and
Di3 denotes severe signs of dysfunction.

The mean prevalence of frequently occurring symptoms indicative of TMD

including frequent headaches in combination with moderate to severe signs
indicative of TMD was 10% for the total sample (15% of the women and 6% of the
men). A statistically significant gender difference was found among the 35-year
olds (p=0.04) and among the 50-year olds (p=0.001) (Figure 6).

35
Figure 6. Prevalence of those with combination of moderate-to-severe clinical signs of
dysfunction of the jaw system according to the clinical dysfunction index (Di) and
frequent headaches or frequent symptoms indicative of temporomandibular disorders
among 35-, 50-, 65-, and 75-year olds in men (n=399) and women(n=368). Statistically
significant differences in prevalence between men and women are presented.

With regards to the findings, the first hypothesis was partly rejected, the second
hypothesis was accepted, and the third hypothesis was rejected in paper I.

Paper II

Comorbidity

The majority of the participants considered that their general health was good
(72-75%) with no significant difference between age groups. Most of the 65-, and
75-year olds (65%) used medicine on a regular basis and reported a lower income
level compared to the younger age sample. The majority of the 65-, and 75-year
olds had a reduced number of antagonist tooth contacts as measured with the
Eichner index.

35- and 50-year olds sample

In the multivariate model (Table 8-A), the factors that remained associated with
signs and symptoms indicative of TMD were as follows: impaired general state of
health with craniomandibular pain symptoms, being a woman and living alone
with signs of TMD pain, education degree and chewing impairment with jaw
dysfunction symptoms, and being a woman and living on the coast with signs of
TMD dysfunction.

36
65- and 75-year olds sample

In the multivariate model (Table 8-B), the factors that remained associated with
signs and symptoms indicative of TMD were as follows: living on the coast and
impaired general state of health with craniomandibular pain symptoms, impaired
general state of health with signs of TMD pain, impaired general state of health,
perceived bad oral health and education degree with symptoms of jaw
dysfunction, being a woman and living on the coast with signs of TMD
dysfunction.

Table 8. Significant associations between signs and symptoms of pain and dysfunction,
respectively in the jaw-face-head region as well as socio-demographic factors, self-
perceived general and oral health in multivariate regression analyses for (A) 35- and 50-
year olds, and (B) 65- and 75-year olds.

With regards to the findings, the hypothesis was accepted in paper II.

37
Paper III

Treatment need

For the total sample (n=779), the estimated treatment need owing to TMD was
15%, and was 21% for women and 8% for men (Figure 7). A statistically significant
difference between men and women was found in 35- and 50-year olds (p<0.05).
The highest estimate was observed among the 35-year old (28%) and 50-year old
women (29%), and the lowest estimate was among the 65-year old (4%) and 75-
year old men (2%). Moreover, the inter-individual examiner’s estimate showed
considerable variations (2–21%).

Figure 7. Prevalence of estimated treatment need owing to temporomandibular

disorders in 35-, 50-, 65- and 75-year olds among men (n=409) and women (n=370).
Open bar = need for advice such as avoid tooth clenching behavior, jaw exercises or
minor adjustment in connection to traumatizing occlusion; grey bar= need of advice and
a bite-splint; black bar= referral to specialist for a more comprehensive examination.

In the multivariate model (Table 9), the factors associated with treatment need
owing to TMD were as follows: being a woman, living on the coast, currently
smoking, reported frequent pain in the jaw–face–head region, registered signs of
TMD pain, presence of TMD dysfunction symptoms, and registered TMD
dysfunction signs. No significant association was found between the treatment
need due to TMD and the estimated treatment need related to other oral and
dental conditions.

38
Table 9. Multivariate model for treatment need owing to TMD in an adult population.
The data represent no treatment need versus advice to avoid jaw clenching behavior or
advice in jaw exercises or minor occlusal adjustments used in connection to traumatizing
occlusion, or splint therapy or referral to TMD specialist.

Treatment need
Independent variables Multivariate model
OR (CI)
Gender
Men Ref
Women 2.1 (1.2-3.7)
Region
Inland Ref
Coast 1.8 (1.1-3.3)
Currently smoking
No Ref
Yes 2.9 (1.4-5.9)
Pain in the jaw-face-head
No Ref
Yes 2.1 (1.2-4.1)
TMD pain signs
No Ref
Yes 2.1 (1.2-3.6)
TMD dysfunction symptoms
No Ref
Yes 2.9 (1.5-5.6)
TMD dysfunction signs
No Ref
Yes 2.8 (1.5-5.2)

With regards to the findings, the first hypothesis was partly rejected, and the
second hypothesis was accepted.

Paper IV

Pain to palpation

The majority (52%) of the study sample did not have any pain on muscle
palpation, 29% (n=224) had pain elicited to palpation locally in the jaw muscles
sites, 5% (n=35) had pain only in the neck/shoulder muscles sites, 12% (n=95)
had regional pain to palpation (PtP) in the jaw and neck/shoulder muscle sites,
and 2% (n=18) had a generalized pattern of PtP at the neck/shoulders, underarm,
thumb, and calf muscles sites. The prevalence of frequent jaw-face pain and/or
frequent headache during the past 3-month period was 19% (n=148). The
relationship between pain once a week or more in the jaw-face-head region and
PtP showed a dose-response like pattern (Figure 8). There was a significant

39
relationship to local jaw muscle PtP (OR 2.3, CI 1.5 – 3.5), regional PtP (OR 4.9,
CI 2.9-8.2) and generalized PtP (OR 9.8, CI 3.5 – 27.5) (p<0.001).

Figure 8. Odds ratios and 95% confidence intervals for associations between frequent
reported pain in the jaw-face-head region during the last 3 months (dependent variable)
and different patterns of pain elicited at palpation. Those with no pain to palpation
defined as a reference group.

With regards to the findings, the hypothesis was accepted in paper IV.

Paper V

Widespread pain and TMD pain

In the study population (n=300), 110 individuals (37%) fulfilled the DC/TMD
criteria for pain diagnoses. The prevalence figures were 22% for arthralgia, 24%
for myalgia and 12% for myofascial pain with referral. The overlap between TMD
pain and WSP was 57% which is illustrated in Figure 9. The overlap between
widespread pain and myalgia was 49%, and between widespread pain and
myofascial pain with referral was 72%.

40
Figure 9. Venn diagram presents overlapping between temporomandibular disorder
pain (TMD pain) and widespread pain (WSP) among the total sample (n=300) of which
110 diagnosed as TMD pain and 94 reported WSP.

In the multivariate models (Table 10), myalgia, myofascial pain with referral, and
being a woman were significantly associated with WSP.

Table 10. Associations between widespread pain (WSP) and myalgia (A), WSP and
myofascial pain with referral (B), when adjusted for the effect of gender and age.
A
Independent variables WSP
OR (CI)
Myalgia
No Ref
Yes 2.9 (1.6-5.1)
Gender
Men Ref
Women 2.6 (1.5-4.9)
Age
20-69 yrs 1.01 (0.99-1.03)
B
Myofascial pain with referral
No Ref
Yes 6.8 (3.2-15.6)
Gender
Men Ref
Women 2.4 (1.3-4.5)
Age
20-69 yrs 1.01 (0.98-1.03)

With regards to the mentioned findings, the hypothesis was accepted in paper V.

41
Discussion
Main findings

The prevalence of frequent headaches and symptoms indicative of TMD was

found to be high in the adult population. The prevalence of reported symptoms
was generally lower among the elderly compared to the younger groups. The
preponderance of women with TMD signs and symptoms was in accordance with
previous studies. The age and gender patterns for the symptoms in focus, i.e.
weekly to daily (frequent), showed roughly similar patterns in terms of
prevalence. If non-frequent symptoms were added in, the prevalence increased
significantly, which shows that prevalence depends highly on the criteria
(wording) used for frequency. Signs indicative of temporomandibular disorders
were commonly registered among adults and the distribution of Di was similar
between ages within the respective gender. A construct of frequent symptoms
with concurrent moderate to severe signs indicative of TMD based on Di reached
a prevalence of approximatively 10%, a figure often used as a general estimate of
TMD in the general population.

One consistent pattern in the analysis of putative factors related to the presence
of signs and symptoms was self-perceived impaired general health status; this
indicates that TMD should be regarded as a part of a general health problem. The
presence of TMD signs, symptoms, smoking, living on the coast, and being a
woman emerged as important factors in the clinical decision-making process of
treatment need due to TMD. The estimated treatment need owing to TMD
differed considerably between the examiners (2% vs 21%), which indicates that
also other factors are involved in the decision-making; this warrants further
investigation.

For a long time, pain to palpation has been used as a sign of local musculoskeletal
disorder of the jaw muscles and a necessary sign for establishment of a myalgia
diagnosis. The present study indicates that generalized hyperalgesia is related to
frequently occurring pain in the jaw-face-head region. Moreover, the
considerable overlap between TMD pain diagnoses according to the DC/TMD
and widespread pain based on the WSP index indicates that central sensitization
mechanisms may be involved in TMD, which should be acknowledged in the
clinical evaluations and diagnostic decisions.

42
Signs and symptoms indicative of TMD
Gender patterns
Symptoms indicative of TMD, as well as headaches were reported at a higher
prevalence among women compared to men, which confirms other epidemiologic
studies (153-156). Among different age groups, 50-year old women had their peak
of frequent pain and dysfunction symptoms as well as headaches. In a cross-
sectional study in Västerbotten County that used the 3Q/TMD for frequent
symptoms indicative of TMD, a similar pattern was observed (157). TMD
symptoms have been shown to be more common in adolescents and middle-aged
adults than in the elderly (158, 159).

In the study population of 35-, 50-, 65- and 75-year olds, women were
predominant for signs indicative of TMD in accordance with several
epidemiologic studies (160, 161). Among men and women, the two most common
TMD signs were tenderness to palpation at jaw muscle sites and
temporomandibular joint sounds. Previous non-patient population studies have
reported that almost every third adult presents with at least one TMD sign, with
the most common being TMJ sounds and muscle palpation tenderness (142). In
a recent meta-analysis, TMJ disc displacement with reduction was found to be
the most prevalent diagnosis among adults regardless of the used diagnostic
criteria (42). Another finding was that all signs indicative of TMD were significant
in relation to gender. The significant findings in terms of muscle pain and TMJ
pain to palpation are in line with a population-based study among Finnish adults
(162). However, the prevalence figures are lower in the mentioned study probably
due to differences in muscles included.

In the analyses of possible associations between TMD signs and symptoms and
socio-demographic factors, women 35- and 50-years old had a two-times higher
likelihood of having signs of TMD pain and dysfunction compared to men,
whereas only signs of TMD dysfunction (i.e. TMJ sounds or impaired jaw
opening) remained more common among women in the 65- and 75-year olds.

In the biopsychosocial model, the role of gender has been well established in the
literature (15, 49). The reason behind the higher prevalence of painful conditions
in women compared to men is not fully understood. From a more biological
perspective, the gender difference in experiences of pain may be related to
neuropsychological factors, which can directly affect nociceptive responses. In
other words, women report lower pain threshold, more severe pain, more
frequent pain, and pain of a longer duration compared to men (163). Another
suggested factor is sex hormones and their association with nociceptive
transmission among men and women (164). Estrogen has been proposed as a

43
possible risk factor for developing TMD by a peripheral and central action on pain
modulation (165, 166), whereas a more anti-nociceptive and protective nature has
been presented for testosterone (164). The role of sex hormones in headache
disorders has also been presented (167). Psychosocial mechanisms such as
different coping strategies (168) and sociocultural beliefs as well as gender role
with regards to pain expression are other suggested factors (169). Moreover,
genetic factors have also been advocated as sex-specific pain mediators for such
gender difference (49).

Age patterns
The pattern of a declining prevalence of TMD symptoms (both pain and
dysfunction) after the age of 50 years was in accordance with the most previous
studies in the general population (42, 159, 170). A similar pattern was also
indicated in a demographic presentation of patients referred to specialist clinics
(56), which indicates that TMD symptoms are less often recognized, less
bothering or less occurring among the elderly. In a Swedish study among 70-year
old subjects (95), the prevalence of TMD symptoms was low except for TMJ
sounds. This is in line with the outcome of the present study; also, in support is
the finding of the mainly non-significant gender difference among the elderly.
However, explanations for this development are lacking, and the decrease in
symptoms occur without a concomitant similar pattern for signs. One hypothesis
is that awareness of TMD symptoms decrease in the elderly since diseases with
more severe symptoms in other areas of the body may take precedence (171). A
self-limiting course of TMJ disorders has also been advocated due to a lower
number of individuals affected by TMD among the elderly (52). It is not known,
however, whether the observed declining prevalence of symptoms relates to
changes in the trigeminal innervations due to an aging process or if it reflects
other age-associated effects such as the presence of comorbid diseases and
changed living conditions (172). It may also be related to adaptation and
normalization processes, i.e. if a subject has had a symptom for a long time and
even adjusted his or her behavior accordingly, the awareness of the symptom may
subside. A further possibility is that the noted age difference may be related to
specific changes in an individual’s social life following retirement, and fewer
demands from work and family life. Taken together, it seems that the awareness
of TMD symptoms decrease with aging.

Regarding TMD signs, no clear age-related differences were observed. In a 5-year

prospective study based on subjects aged 76, 81, and 86 years at baseline, signs
and symptoms of TMD decreased at the follow-up and the most severe signs
disappeared (173). In contrast, some population-based studies have shown an
increased trend in TMD signs among the elderly (155, 160, 174). In general, the
results in the literature are controversial for the elderly in terms of TMD signs.

44
Different methods and criteria as well as reporting findings as subjective or
objective have been proposed as reasons for the inconsistencies (174, 175). A
recent 11-year follow-up study conducted on a Finnish adult population found
that masticatory muscle pain to palpation at baseline increased the presence of
this sign 11 years later. However, age itself was not found as a major contributive
factor, which suggests that other backgrounds factors prevail in certain age
groups (162).

Among adult populations, headaches affected mainly younger age groups

compared to the elderly among both genders. Moreover, frequent headaches
decreased after its peak in the 50-year olds among both men and women.
Although headache, as the most common lifetime neurologic symptom, becomes
less common with increasing age (176), primary headaches can develop for the
first time after the age of 65 years (177-179). However, no clear gender preference
after the age of 65 years was reported in previous studies (177, 180).

In the analyses of possible associations between TMD signs and symptoms on the
one hand, and socio-demographic factors on the other hand, a similar pattern, for
the most part, was disclosed for both younger and older age groups in the study
population. The most consistent pattern based on the multivariate analysis was
the relationship between craniomandibular pain symptoms and self-perceived
impaired general state of health. This observation was also found in other similar
studies (96, 159). Furthermore, the results indicate a dose-response-like pattern
with higher odds ratios for pain in the jaw-face-head region with a more severe
rating of impaired general health status in all age groups (Paper II). The
relationships between TMD pain and impaired general health may be related to
the high prevalence of pain in other parts of the body as well as widespread pain
among individuals with TMD as presented in paper IV and V, respectively. These
findings are thus concordant with the conclusion that both musculoskeletal pain
in the trigemino-cervical area and widespread body pain are associated with an
increased impairment of health status (181). It was also reported that those
affected by chronic OFP had an impaired health-related quality of life compared
to the general population (182).

Another finding of this thesis was the association between self-perceived oral
health and jaw dysfunction symptoms (i.e. TMJ locking or TMJ sounds or
difficulty to open the jaw wide) among the elderly compared to the younger age
groups. Self-perceived oral health status has been proposed as an important
factor affecting oral health-related quality of life (OHRQoL) in TMD patients
(183). A combination of impaired jaw opening as a reflection of aging (184) as
well as a higher prevalence of degenerative joint disorder among elderly (52) may
contribute to this pattern.

45
Jaw dysfunction symptoms also had a positive relationship with higher levels of
education among both age groups. Educational level may in part mirror an
individual’s financial situation. In a recent retrospective study among TMD
patients, there was no association between TMD (pain and dysfunction) and
educational level (185). The existing literature regarding an association between
TMD dysfunction and education is scarce. Even the findings of the available
studies in terms of relationship between socio-economic status and TMD pain are
not conclusive. A reason for controversial results may be related to cross-
sectional study designs and not assessing socio-economic deprivation
appropriately (186).

Residence patterns

Signs of TMD dysfunction were associated with living in the more urban areas
(the coast) in Västerbotten compared to the more rural areas (the inland) among
both age groups. On the contrary, the elderly population living in the urban area
reported less pain symptom in the jaw-face-head region compared to the
inhabitants in the rural areas. The results do not concur with studies that have
investigated the associations between residence areas and TMD. In a large
Swedish sample among 50-year olds, there was no significant difference in TMJ
pain but a higher prevalence of TMJ sounds in the rural areas (96). In a study
stratified by urban and rural areas in the USA, facial pain, TMJ pain and
crepitation sounds were more prevalent among urban compared to rural areas
(187). The findings were attributed to urban stress and increased masticatory
muscle activity (188). The inconsistent results may be related to other differences
in living conditions that are beyond the scope of this thesis.

Comorbidity patterns

The coherence of the observed comorbidity between pain in the jaw-face-head

region and different patterns of pain to palpation as signs of generalized
hyperalgesia as well as widespread pain conditions were outcomes of this thesis.
The findings indicate that spinal pain may affect symptoms, diagnosis and
interpretations of pain conditions in the jaw-face-head region. This is in line with
previous findings regarding a dose-response like pattern between spinal pain and
symptoms in the jaw-face region (189). One perspective in relation to these
outcomes is that conditions classified as myalgia or myofascial pain may instead
be regarded as TMD pain associated with or without generalized hyperalgesia or
TMD pain associated with or without widespread pain. Likewise, arthralgia may
be regarded as TMJ pain associated with or without generalized hyperalgesia, or
TMJ pain associated with or without widespread pain. This profiling in turn will

46
allow more accurate classification of the pathophysiology mechanisms that
characterize subgroups of patients.

Previous efforts to disclose etiological factors for TMD may have been hampered
by study populations with a combination of local TMD condition and TMD as a
manifestation of general pain conditions. This may have concealed significant
causations. Furthermore, pain comorbidity may have a negative influence on
treatment outcomes (98), but the outcomes are not conclusive (190).

In general, headache disorders are accompanied with pain in the musculoskeletal

system that has been attributed to increased tension in the muscles (191). In a
population-based study, nearly 70% with headache had some types of TMD
symptoms (192). In a Swedish study, disability due to chronic TMD pain was
reported in about half of the headache patients (101). Regional interdependency
models of connections between the upper cervical spine and orofacial region
(anatomical, biomechanical, and neurophysiological) contribute to
understanding of possible pathophysiological mechanisms (193). In paper IV in
this thesis, the most common elicited pain locations were within the trigeminal
innervation area and in both the cervical and trigeminal innervated areas on
clinical examination; this is in line with the findings of other studies (194). These
areas are closely integrated in sensori-motor functions that include convergence
of afferent signals to the brainstem and in nociceptive transmission (195). In a
study by Vivaldi et al, a higher number of painful sites upon palpation in the neck
and head region were registered among those with headache attributed to TMD
(196). In summary, the cervical spine and jaw system should be considered as a
functional entity in patients with TMD (27, 197), in order to manage and help the
patients.

Associations between TMD pain and bodily pain were also found previously (82,
198, 199). The presence of muscle pain in spinally innervated parts of the body
has been suggested as predictors for developing chronic TMD (200, 201). In
paper IV, around 18% of the study population with reported frequent jaw/face
pain had a pattern of generalized pain to palpation. This figure is in line with the
work by Plesh et al who reported that 75% of the patients with fibromyalgia had
TMD, whereas 18 % of the cases with TMD met the diagnostic criteria for
fibromyalgia syndrome (202). Fibromyalgia has been proposed as a medium- to
long-term risk factor for the development of TMD (199).

In paper V, the prevalence of widespread pain was estimated at 15% in the total
sample, which is within the estimated range (10%-15%) presented in a meta-
analysis study of the general population (17). Furthermore, the comorbid pattern
was considerable between TMD pain and WSP, of which the highest overlap was
observed for myofascial pain with referral, and the lowest overlap was for

47
arthralgia. A higher degree of dysfunction in the central nervous system in those
affected by myofascial TMD compared to those with articular diagnosis was
proposed for such pattern (203). Some previous studies have reported overlap
between pain in the trigeminal area and WSP. In a 4-year follow-up study in the
general population, WSP in the baseline predicted persistence OFP in the follow-
up (204). Turp et al also observed WSP as a common condition among those
affected by persistent facial pain (205). In another study, facial pain (pain in the
face during the last year) was a manifestation of WSP in half of the cases, and this
pattern was more prevalent among women (206). In a study by Masuda et al
(207), referred pain evoked by standard palpation of the masseter muscle in
healthy subjects suggested that a referred pain mechanism is common in the
orofacial region even in pain free subjects. A combination of central sensitization,
convergence of sensory nerve fibers from multiple sites, changes in second
neuron connectivity and descending facilitation with in the nervous system has
been proposed as mechanisms underlying referred pain (208, 209). Previous
studies have proposed the same pathophysiological pathway for coexisting pain
conditions among TMD patients (116, 210). Thus, the association in the thesis
between myofascial pain with referral and WSP might be due to central
sensitization as a widely accepted theory (83, 211). Another finding was, the
association between gender and WSP, which was in line with other studies (17,
206).

In summary, signs and symptoms indicative of TMD may in part be considered

as a manifestation of other widespread syndromes such as fibromyalgia and
chronic widespread pain. Central sensitization is presumed as a probable key
mechanism in these chronic pain conditions (212), thus this mechanism should
also be considered in TMD diagnosis and treatment. In contrast, in local TMD
pain, hypersensitivity of trigeminal nerve endings is caused by peripheral
sensitization (113). Such local hyperalgesia is counteracted by an adequate central
serotonergic response mechanism that limits the occurrence of more widespread
pain (69). Koutris et al found that the concept of familiar pain as an outcome
measure decreases and does not omit the influence of comorbidity on the
palpation test (25). Therefore, palpation of muscles outside regions of the jaw
system should be accounted for in the diagnostic algorithms when examining
patients with pain in the jaw-face-head region.

Treatment need patterns

The prevalence of estimated treatment need owing to TMD was 15% for the
sample drawn from the general population. This was in line with a meta-analysis
of 17 studies that presented a mean estimate of 16% for general population (120,
121). Furthermore, according to a suggested classification system for TMD
treatment need by Kuttila (121), 4% of men and 13% of women in the study sample

48
were judged to have an active treatment need. As expected, the prevalence figures
were higher among younger age groups compared to the elderly in both men and
women. The estimated prevalence figures were thus in line with previous studies
(121, 153).
Large discrepancies have been observed between the estimated treatment for
TMD in the population and related traceable treatments performed in dental
health care (44, 122, 129). The pattern of undertreatment was also highlighted by
the Swedish National Board of Health and Welfare (213); while estimates of
treatment need based on surveys normally fall within the range of 5–15%, the
traceable treatments performed in dental health care in Sweden are
approximately one-tenth of these estimates. This is puzzling and constitutes a gap
of knowledge within dentistry. Time-consuming in counselling the TMD patient
(214), lack of evidence-based practice (214, 215) and lack of routines for making
diagnoses and therapies decisions in terms of TMD (216) were suggested as
possible reasons for uncertainties among clinicians. Consequently, the dental
general practitioner chose to refer their patient to more competent physician for
treatment (128, 217). Although the diagnosis of TMD, especially TMD pain, has
been debatable and predominantly classified on anatomical location as well as
signs and symptoms (218), a golden standard such as the DC/TMD together with
its decision-tree, has been available since 2014 worldwide. Thus, this raises the
question regarding other possible factors in the decision-making process about
TMD treatment.

In this thesis, the estimated treatment need owing to TMD differed considerably
between the four experienced and calibrated examiners (2-21%) despite no
statistically significant difference in prevalence of symptoms indicative of TMD
among those they examined. The inter-individual estimate was still within the
range of previous studies (45), and the calculated weighted mean value was close
to the mean value based on a previous meta-analysis (120). The results may be
explained by different attitudes, interactions between dentist and patient, and
gender bias (219, 220). Different studies have reported women and men being
treated differently because of gender stereotyped attitudes among physicians
(221, 222). In a study in Sweden, the undertreatment of TMD within the general
dental practice was related to the gender of the examiner (129). Thus, the clinician
must be aware of possible systemic and discriminatory behaviors.

Patient characteristics such as age and gender may influence health care provider
decisions in pain assessment and treatment (223). In paper III in the multivariate
model, women had a two-times higher likelihood to be estimated for treatment
need owing to TMD compared to men, but age did not remain as a significant
factor in the model. This probably reflects that age in itself did not influence the
decision-making. In a study among 65+ year olds, behavioral, social, and health
factors influenced dentists’ decisions when determining treatment needs of older

49
individuals (224). The relatively lower treatment need related to TMD among the
elderly in this thesis, however, deserves further scrutiny.

General state of health was significantly related to the presence of signs or

symptoms indicative of TMD, but was not associated with treatment need in the
multivariate model. These results are in line with studies that reported that the
strongest predictive factor to TMD treatment need was diagnostic sub-groups
(121, 129).

Current smokers compared to non-smokers had a nearly three-folded higher

odds of being estimated for treatment need owing to TMD. Generally, the
relationship between smoking and TMD is contraindicative. Several studies have
not found associations between TMD signs and symptoms and smoking (96, 156,
225). On the other hand, a significant association between smoking and TMD
symptoms, except TMJ clicking was reported in another study (226). In a pilot
study, higher TMD pain intensity was found in smokers compared to non-
smoker; however, the effect of smoking on pain intensity was not correlated with
any particular TMD diagnosis (227). Sanders et al found that among women,
current smokers had higher odds of having TMD compared to former
smokers (228). The authors proposed that smoking might influence pain either
through allergic or inflammatory pathways or both. Smoking may also indirectly
represent effects of TMD psychological risk factors such as perceived stress,
anxiety, and depression (229, 230). Another possible interpretation of the
findings may be a general higher awareness among dentists of smoking as a
significant risk factor related to both impaired general health and dental
problems, i.e. periodontitis and bruxism.

Individuals living in the more densely populated regions on the coast in

Västerbotten were judged to have a higher treatment need compared to those in
the inland. Accessibility to dental health care may thus have played a part in the
decision-making. Health care organization was also reported as a factor affecting
the clinical decision-making process by workload, attitudes, leadership and
guidelines (231); however, this was not evaluated in this thesis.

50
Methodological considerations

In this thesis, different classification systems were used from the early established
Helkimo indices to the recent advocated DC/TMD as a common diagnostic
system. Although substantial time has passed since the Helkimo index was
introduced as a tool to measure severity of mandibular dysfunction in
epidemiological studies, the core variables have practically remained the same.
Both systems are based on clinically registered impaired jaw movement capacity,
pain to palpation of the temporomandibular joints and the jaw muscles, pain on
jaw movements, and the presence of TMJ sounds as signs indicating
temporomandibular disorders. The DC/TMD examination protocol has included
familiar pain as a criterion for establishment of a DC/TMD diagnosis (35).

Papers I-IV

Questionnaire

The questions regarding the occurrence of symptoms indicative of TMD and

headaches were captured in a time frame as occasional, once a week, more in a
week, and daily. Once a week or more often was defined as a frequent symptom
in the analysis. This has been shown to increase the reliability of the measurement
(232), specifically when recall of TMD pain is known to be poor (233). Such
frequency may also increase the clinical relevance. The chronicity of the TMD
nature was also captured by using a distinct time frame as ¨the last 3 months¨.
The questionnaire did not assess the intensity of symptoms or related
impairment. The purpose of this questionnaire was to obtain information about
oral health and not communication with patients regarding their pain experience
and response to treatment. In the analysis, the Helkimo indices were applied to
categorize the severity of TMD.

Some time has passed since the data were gathered. It may thus be questioned if
the prevalence figures and patterns of signs and symptoms match the present
situation. Variations in signs and symptoms indicative of TMD between different
studies are most likely dependent on study design and methods even though some
time trends have been noticed (159). Analyses of gender and age patterns in
relation to TMD has shown congruent results between different studies in
agreement with paper I. Whereas analyses of the associations in papers II-IV may
be limited due to the cross-sectional design, they are not likely impacted by the
time or period when these studies were conducted.

51
In this thesis, different independent variables were applied to evaluate their
relative importance on the complex nature of TMD. The chosen factors covered
different aspects of socio-economic factors, living conditions, general health and
oral health status. However, some included factors are highly time-specific (i.e.
levels of financial recourses and income per month), and therefore, the results
should be considered with reference to the time period when the data were
gathered. Some factors that might have had an effect on TMD and treatment need
owing to TMD were not included in the analysis. They were either reported at a
too low prevalence (e.g. taking oral contraceptive or other hormonal replacement
among women), or not included in the questionnaire (e.g. psychosocial factors,
parafunctional habits, trauma, hypermobility syndrome) or in the clinical
examination (e.g. tooth wear). Altogether, the results of this thesis are considered
contemporarily relevant and of interest regarding different perspectives on TMD.

The questionnaire was mailed to the home address of participants indicating that
it was not filled in under the same circumstances. There is a possibility that some
patients may not have understood some of the questions in the questionnaire.
Also, patients may have given biased answers on some questions such as
inaccurate recall. Therefore, the reliability of the entire project might be
influenced by such biases, but there were no other options to collect data with
regards to the large sample size. In order to obtain representative results for the
target population, participants were randomly selected. However, data are not
available for comparing respondents and non-respondents (17%). Such a
comparison may have given insight on whether the data were biased in any way.

In summary, the design of the questionnaire with mentioned limitations was

adequate for capturing different perspectives on TMD in an adult population at
the time of study (about 20 years ago). Owing to the cross-sectional design, it is
not possible to identify a direct causal relationship in the studies.

Clinical examination

Clinical examination in the first four papers was performed by four experienced
examiners who were thoroughly calibrated. The percentage agreement and
Kappa value obtained for the clinical variables varied 85-93% and 0.68-0.84,
respectively. The kappa value was fair to moderate (234). All participants were
given the same information and were examined under the same conditions
resulting in reasonably reliable results. The registration of sign of pain to
palpation was done when it elicited a palpebral or protection reflex to improve
the reliability of measurement (235). Palpation of the region of the lateral
pterygoid muscle was included in the examination protocol even though there
was a risk for¨false positive¨responses. However, the palpated muscles and
tendon sites were those commonly used at the time of study. In 2014, a Delphi

52
based consensus document advocated to palpate primarily extra oral muscle
sites. The criterion of ¨familiar pain¨ elicited during the palpation with a pressure
of 1.0 kg, added an increase in both sensitivity and specificity for the diagnostic
decision-making process (35).

Paper V

Clinical examination
The study population was extracted from those who had a routine dental checkup
in Public dental clinics in Västerbotten County in 2014. The cases were selected
randomly from those who had given affirmative answers to 3QTMD in the health
declaration. The controls were selected randomly in stratified ages to match the
cases. The sample size was calculated based on a previous study (148). Pain-site
drawing and the widespread index were applied as valid tools to collect data and
define widespread pain. The examination was done by a calibrated dentist. All
participants were examined under the same conditions. The examiner was
blinded to the participants (with or without symptoms indicative of TMD).

The study was conducted in the North part of Sweden and the prevalence of
widespread pain was weighted based on the estimates of the previous studies in
Västerbotten.

Ethical considerations

The Oral health-2002 project (Papers I-IV) was approved by the Human Ethics
Committee, Faculty of Medicine and Odontology, Umeå University (ref no 02-
325).

The widespread pain and TMD pain study (Paper V) was approved by the
Regional Ethical board at Umeå university (ref no 2012-331-31 M).

The study protocols followed Good Clinical Practice. The ethical principles for
medical research involving human subjects according to the World Medical
Association Declaration of Helsinki were applied in all studies. Voluntary
participation, informed consent, confidentiality, the potential for harm, and
communicating the results were considered. However, anonymity was not
possible since the individual’s identity could be disclosed by key codes.
Questionnaires were read optically and then stored and locked in a location
separate from the code keys. All the participants were assured the right to
withdraw from the study at any time without specific reasons and confidentiality.
The participants were informed orally and in writing about the purpose of the
studies, and written informed consent was obtained before the start of the

53
studies. All the individuals were treated equally based on the principle of justice.
The analyses were done at the group level in all papers.

Access to the all examination centers (Public dental clinics) were possible for the
entire study population. All individuals received compensation for transportation
costs. In the oral health project, the participants received two lottery tickets
(Triss), and in paper V, participants were also compensated with 200 Swedish
crowns.

Overall, the benefit of the studies was larger than the harm. One possible harm
might be experiencing pain during the clinical examination. The average clinical
examination was around 30 minutes; thus, this should not cause any extra
unpleasantness or physical injury compared to a routine dental examination. The
benefit of the study was considered both at the individual and population levels.
Those with chronic TMD pain and dysfunction could receive a free clinical
examination and diagnosis. There was also the possibility for receiving advice for
pain relief and referring to the TMD specialist for more investigations if it was
needed.

On group level, the knowledge generated from the entire thesis would increase
the opportunities for a better understanding of signs and symptoms indicative of
TMD with clinical relevance especially in terms of comorbidities.

54
Clinical implications and future directions

The findings of this thesis illuminate some different perspectives on the condition
of TMD. It is practically impossible to plan for a condition without knowing the
community burden. It is also difficult to obtain a comprehensive picture of the
true prevalence of TMD with a large variation in estimations. The prevalence of
different signs and symptoms indicative of TMD differ between men and women
and between ages. Knowledge of how TMD varies according to features such as
age, gender, residence area, general health and oral health offers insights into
possible etiology. This in turn helps clinicians to consider contributed etiological
factors and to target them in the treatment plan to achieve satisfactory results. A
deeper insight into what factors target decisions of treatment need owing to TMD
is of significant value, and may help lead to improved health care with less
disparities and undertreatment. The findings of this thesis are also a guide for
clinicians to interpret the presence of pain to palpation over the jaw/face muscles
as a local condition or as a manifestation of the widespread syndromes.
Therefore, pain drawings and palpation of muscles outside regions of the
masticatory system should be accounted for in the diagnostic algorithms when
examining patients with pain in the jaw-face-head region. This will in turn
address patients’ complaints in a more holistic approach and allow for
individually tailored treatment in order to reduce pain and improve function.
This could thereby increase patients’ quality of life and reduce societal costs.

There is a need for good quality epidemiological studies of TMD in the general
population-based on valid variables and diagnostic tools. Future studies should
recruit adequately sized samples for precise determination of the estimate
figures. One possibility is to follow-up the same sample from 2002 to examine
how the prevalence figures have been changed on an individual basis. To enable
comprehensive examination of the etiology of TMD both in pain and dysfunction
domains, it is necessary to address a broad range of factors within the
biopsychosocial model. This may reveal factors that influence the need and
demand for treatment. More research is needed to assess the factors associated
with a dentist’s clinical decision-making in relationship to TMD. There is also a
need for studies to modify the current diagnostic criteria for local myalgia in the
temporomandibular region.

55
Summary of main findings

• Prevalence of TMD symptoms and headaches was dependent on gender, age

and its frequency.

• Prevalence of TMD signs was predominantly pain to palpation and

temporomandibular joint sounds.

• Impaired general state of health was associated with TMD pain signs and
symptoms.

• Estimated treatment need owing to TMD was related to the presence of TMD
signs and symptoms, gender, smoking, and residence area.

• Signs of generalized hyperalgesia were strongly associated with the presence

of frequent jaw/face pain and headaches.

• The overlap between TMD pain diagnoses according to the DC/TMD and the
presence of widespread pain indicates that the diagnoses may be confounded
by central sensitizations mechanisms.

56
Conclusions

• The age and gender differences on signs and symptoms indicative of TMD
among adults are likely related to factors included in the biopsychosocial
model.

• The associations between comorbidities and TMD may influence demand

for treatment among the affected. Thus, TMD treatment should be included
in the medical health care payment systems.

• A significant proportion of the adult population has a need of treatment

related to TMD.

• Generalized hyperalgesia and widespread pain conditions are related to

pain in the jaw-face-head region and should be acknowledged in clinical
evaluations, diagnostic decisions, treatment planning as well as in research
settings.

57
Acknowledgement
I would like to express my genuine gratitude to all those who have supported me
in my journey, especially with the work of this thesis. In particular, I feel both
obliged and pleased to acknowledge:

Ulrich von Pawel-Rammingen, for letting me develop my knowledge as a

PhD student by participating in wonderful courses at Umeå University.

Anders Wänman, my supervisor and inspiring mentor, for believing in me, for
the generous support and scientific guidance since 2013. There is no doubt that
you have played a key role in my development as a researcher, clinician and of
course as a person. You will be my mentor forever.

Malin Ernberg, for being a wonderful supervisor in the clinical research at the
Karolinska Institute. I will never forget your kind words and prompt replies to my
questions, even during the weekends. I believe our project was one of the reasons
why I am here today.

Miguel San Sebastian, for sharing your profound knowledge within the field
of epidemiology with such patience. You are a wonderful person and outstanding
researcher.

Susanna Marklund, Ewa Lampa, Catharina Österlund, Anna

Lövgren and Christina Storm, for good times and for valuable feedback on
my thesis.

Susanne Eriksson, for kindly accommodating me with your office.

Gunilla Mårald, Elin Enqvist, Sari Korva and Malin Järnskog, for
professional support with courses and administration. It meant a lot to me
particularly when I lived in Stockholm.

Albert Crenshaw, for making this fruitful journey possible. And now I am
grateful to have your valuable language skills in my thesis.

Nikolaos Christidis, for invaluable support and encouragement during these

years. A combination of your kind and friendly attitude, with a profound
knowledge within TMD is unique.

58
Björn-Ove Ljung and Inga Marie Törnblom, for care and generous support
to allow me to be in Umeå anytime. You helped me even when I was hesitating to
ask.

Jon Lindgren, for your genuine support and simplifying the combination of
clinical and research work with wise planning here in Umeå.

Gunilla Hjernestam and Josefine Von Ahn, for support and cheerful talks
during the days in the clinic. You gave me joy and energy to concentrate on this
thesis.

Colleagues at the specialist dental care, especially Chatrin Isaksson

and Mona Rosander, for your kind words and care from the first day I started
to work in the clinic in Umeå.

Colleagues in the oral rehabilitation centre, Västmanland Hospital,

for letting me be a part of this friendly family. You are always in my mind and I
miss you every day.

Nils Oscarson, for allowing me to start my resident education in Umeå in 2020.

Thank you for believing in me.

Björn Appelgren, for sharing with me your experience in the clinic, research
and even in life. It was my honour to meet you as one of the most knowledgeable
and humblest persons I have ever met. You have inspired me since the day I met
you. You are in my heart and mind for ever.

Cristina Linde and Mohamad Schumann, for your time, patience, generous
support and making a considerable clinical development in my knowledge to treat
patients with TMD. I am forever indebted to you.

Göran Isaksson, for your time, knowledge, and being the person you are.

Thomas List, for opening opportunities to help me reach my goal.

Annie Borgwardt, for sharing your happiness and your knowledge within the
field of TMD. You were a light in the dark.

Jan Ekenbäck and Carl-Gustav Svensson, for generously sharing your

time, deep knowledge and superior skills in prosthodontics.

59
Group A Term 5 (January-June 2021), for making me enjoy every Monday
afternoon. I started my wonderful teaching experience with you, and it will stay
in my mind forever.

Last, but by no means least,

My wonderful parents, for endless love and support throughout my entire

life. Your warm voices and encouragement gave me strength to chase my dreams.
You are my role models and inspiration.

My brother, Ramin, for being the best brother I could ever wish for.

My dear Kevin and our precious treasure Chris and Melody. I am lucky to have
a family like you.

60
Amendments
In paper 1, result (page 460), there was statistically significant difference for TMJ
sounds in relation to age among men.

In paper 2, statistical method (page 1057), the analysis was based on 987
individuals.

61
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