Altered Quality of Life in Patients with Temporomandibular Joint Disorders: A Review

1. Postgraduate Student, Department of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College, Mumbai, Maharashtra, India. 2. Professor, Department of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College, Nagpur, Maharashtra, India. 3. Professor and Head, Department of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College, Nagpur, Maharashtra, India. 4. Postgraduate Student, Department of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College, Mumbai, Maharashtra, India. 5. Professor, Department of Orthodontics and Dentofacial Orthopedics, Rural Dental College, PIMS, Loni, Maharashtra, India.

Abstract

Temporomandibular Joint Disorders (TMD’s) represents a cluster of disorders that include the Temporomandibular Joint (TMJ) and also the masticatory apparatus. Any alteration in its function will have an impact on the overall function of the masticatory apparatus and in turn the stomatognathic system. Though the aetiology, symptoms, and treatment modalities for TMD’s have been extensively studied, they remain a subject of prime concern for clinicians as it not only affects the form and function but also negatively affects the overall standard of living of the patient. Symptoms of TMD’s such as chronic pain, restriction of function, and psychological effects lead to a lower Quality of Life (QoL) for the patient, which is caused due to various factors such as chronic pain, sleep deprivation, and stress or anxiety. Additionally, personal, professional, and social problems directly or indirectly affect the lifestyle of the patient. Some extra-craniofacial symptoms such as otologic and neurologic symptoms tend to worsen the situation. Majority of patients reporting to an orthodontist present with atleast one symptom of TMD that has affected their QoL. Various questionnaires can be used to assess the patient’s QoL, and plan the treatment accordingly. Managing TMD’s at an early stage while considering these factors and a multidisciplinary approach may help in improving the QoL of the patient.

Anxiety disorder, Jaw diseases, Oral health, Sleep disorder, Stress

The joint between the cranium and mandible is called the Temporomandibular Joint (TMJ). It is often also named craniomandibular articulation based on its function (1). The TMJ is a complex joint in the orofacial region that is directly or indirectly involved in various functions of the stomatognathic system such as mastication, swallowing and speech (2). Any alteration in its function will have an impact on the overall function of the masticatory apparatus and in turn the stomatognathic system (2). The disorders involving the TMJ are termed as TMJ Disorders (TMD’s).

TMD is a complex entity that includes clinical dysfunction of the TMJ, muscles of mastication, and all the related masticatory apparatus (3). Several studies [1-3] revolve around this craniomandibular joint which is a prime area of interest for orthodontists, prosthodontists, and also oral surgeons. The reason for this may be the impact of TMD’s on the overall Quality of Life (QoL) of patients (4). The frequency of occurrence of TMD’s has been studied to a great extent. The prevalence rate of TMD ranges from 10% to over 50%. The prevalence broadly depends on the parameters used for diagnosis, the type of samples selected, and also the age of the patients [5,6]. It is noted that one out of every 10 patients reporting to an orthodontist has atleast one symptom of TMD’s (7). TMD’s causes functional and physical limitations to patients with different levels of morbidity depending on their severity. The aetiologic factors and symptoms of TMD’s have been extensively discussed in the light of development for assessing the QoL of the patients suffering from it and for the development of criteria that helps in grading the impact of the disorder on the QoL of an individual (8).

Persons with TMD’s constantly suffer from physical and psychological problems as a consequence of dysfunction from the disease. These sufferings are caused mainly due to orofacial pain, which is the most frequently occurring symptom of TMD’s and also the main reason of concern for the patients (9). In addition to orofacial pain; stress, anxiety, and depression are also major contributors to the disorder. According to current concepts, physical condition and systemic factors along with psychological elements are responsible for targeting and worsening TMD’s. Normal acceptance is that long-term chronic pain affects the standard with which a patient negatively lives his/her life. The impact of this pain and other dysfunctions caused by TMD’s are described scarcely (10). Patients undergoing TMJ-related evaluation or treatment are often not evaluated for psychological impact on the disorder (6). Various aspects such as anxiety, depression, and social functioning related to the aetiology or outcome of TMD’s are not been extensively discussed in the past, which has been the prime factor for decreased attention to the general health and QoL of patients (10). The prime objective of the present review is to define the correlation of TMD’s with the altered QoL and also review the elements responsible for it followed by the various problems faced by them.

Symptoms of TMD’s

The symptomatology of TMD’s is vast, ranging from mild to very severe symptoms. This may affect various orofacial, craniofacial, and also extra-craniofacial symptoms. The most frequently occurring symptoms of TMD’s are:

Tenderness: This occurs in the TMJ and adjoining orofacial region is one of the most common symptoms encountered by the patients. This is said to be associated with 17% of the patients affected (5).

TMJ sounds: This includes clicking sounds during opening or closing of the mouth and crepitus or grating sounds. These are the most common symptoms of TMD’s with around 24% of the patients being affected (5).

Tenderness in the masticatory apparatus: Tenderness is mostly evident with the Lateral Pterygoid Muscle (LPM) because of its proximity and anatomic relation with the TMJ. This symptom is present in about 15% of the population with more predilection in female patients.

Difficulty during mouth opening and lateral deviation: Some patients with TMD’s suffer from locking of the jaw during the opening of the mouth while difficulty during lateral deviation which is another symptom is said to be the least common symptom associated (5).

Psychological effects of TM D’s: Psychological factors are considered both a causative factor and also as a symptom of TMD’s following a vicious cycle. Various studies have concluded stress to be the prime aetiologic factor causing or aggravating TMD’s [11,12].

Extra-craniofacial symptoms: Apart from these routinely encountered symptoms of TMD’s present in the orofacial region, the pain from TMJ is also referred to distant regions such as the neck, back, and shoulders. Neural symptoms and auditory symptoms are also evident in some cases’ and are also said to affect the mobility of the cervical spine and in turn, affect the overall posture of the body and also cause cervical spine pain (5). Headaches and migraine as a symptom of TMD’s have also been noted in the literature. So, due to the well-distributed symptomatology of TMD’s we can estimate the amount of dysfunction it can cause in an individual’s life and hence lead to an altered QoL [13,14].

The related studies to these symptoms are listed in (Table/Fig 1) [11-24].

FACTORS AFFECTING QoL

Pain

Pain has been considered to be one of the primary reasons, a person seeks medical attention [25,26]. Pain is said to be the main factor responsible for impaired QoL in patients with TMD’s. It is responsible for the impact on the functioning of life and the well-being of a person in a negative way. This causes disability, dysfunction, and sleep deprivation as an outcome [27,28]. The pain associated is mainly orofacial pain, which is a broad entity that comprises painful conditions involving the oral cavity, masticatory apparatus, and the maxillofacial region. While evaluating TMD’s, the pain is to be differentiated from pain originating from periodontal and pulpal tissues though they can be present as a secondary feature in patients (29).

Pain due to TMJ problems is considered one of the index symptoms of non odontogenic origin encountered around the craniofacial area by clinicians. An observation done by Shueb SS et al., noted that pain in patients with TMD’s had an Oral Health Impact Profile (OHIP) score similar to trigeminal neuralgia, which is considered to be a very painful condition (26). Orofacial pain is considered to impact a patient’s economic life too through a decreased working capacity of an individual and also by increasing the cost of healthcare (27). QoL may also be affected to different extents depending upon the nature and intensity of pain encountered by the patient. The pain may be acute sudden onset pain or chronic pain of long duration (27). In comparison with acute pain sufferers, patients with chronic painful conditions have a greater impact on lifestyle, relationships, and mental health. So, the efforts of any clinician treating TMD’s should be focused on decreasing the severity and chronicity of the condition and hence decreasing the intensity of pain. Chronic pain may make it compulsive for the patient to skip work at various instances in his/her life or the patient may not be able to perform the tasks at work with full efficiency because of the disturbing pain which may lead to deduction of pay at work. This will have an impact on the economic condition of the patient and a deteriorated standard of living leading to compromised QoL for them and their families. Deprivation of sleep due to pain also causes decreased concentration during the daily routine and an impaired lifestyle. Patients suffering from pain suffer from mental distress, which further ruins their personal and professional relationships (30). Many studies have been conducted on the effect of pain on QoL of patients [31-33].

Stress, Depression, and Psychological Factors

Stressful situations are those which threaten to exceed the management option or resources available to a person. Everyone at some point of time in their life is exposed to stressful encounters or situations at a personal, professional, or social level. This supports the concept of stress and anxiety altering the QoL of an individual [34,35].

Various studies in the literature have pointed out an altered QoL of TMD patients due to psychological factors that have been known to be both, symptoms and also one of the main aetiologic factors [33-42].

Psychological factors encountered in a patient with TMD’s can be divided into behavioural symptoms, including bruxism, emotions like stress, anxiety, and depression, cognitive behaviour, and also elements related to long-term memory (36). All the above-mentioned factors relating to the psychology-related elements for example stress, anxiety, depression, and distress cause a straight impact on the overall well-being of an individual and hence affect their QoL. The majority of patients reporting to the orthodontist are teenagers or young adults. Stress is an important factor during this period of life that plays a key role in the development of an individual. If a patient is suffering from TMD’s during this phase of life and causing psychological effects, it will hamper the productivity of the individual in their student life or career and lead to a lack of concentration. This will have an ill effect on the patient on a personal as well as professional level and simultaneously alter the social relations. All these factors summed up will lead to impaired QoL [34,35].

Sleep: Sleep disturbances have been reported mainly due to pain, stress, or anxiety which is in turn caused by dysfunction present in TMD’s. Patients suffering from acute as well as chronic pain face difficulties falling asleep and also mid-sleep disturbances. Also, those having TMD’s experienced poor quality of sleep and reduced duration of sleep in comparison with the majority of the population (30). Sleep is a very important factor in maintaining a higher virtue of life and is also considered one of the basic needs of the body. Deprivation of sleep is not a direct symptom of TMD’s but an indirect effect due to other prevalent symptoms. Sleep quality can be readily assessed using self-administered questionnaires which can then be correlated with the severity of the disorder (43). Numerous studies in the literature have demonstrated the impact of sleep on QoL of TMD patients [44-47].

Other factors: Apart from being dependent on pain, stress, and sleep quality, the overall QoL also depends on various other factors such as employment, personal relationships, social life, professional relationships, etc. Patients with TMD’s have also reported problems managing their personal, professional and social life due to morbidity and also due to the psychological impact of the disorder (48).

(Table/Fig 2) enlists the studies on the effects of pain, sleep, anxiety and other factors on QoL of patients with TMD’s [31-33,36-42,44-48].

ASSESSMENT OF QoL

To evaluate one’s QoL that is impacted by TMD’s, assessing the OHRQoL is important. The OHIP was developed by Slade GD and Spencer AJ in the year 1994 and originally consisted of a 49-item checklist. This list was further modified as per requirements for the assessment of the QoL in TMD’s patients (49).

The World Health Organisation (WHO) QoL questionnaire can also be used. This contains two questions related to the patient’s perception regarding his/her QoL and an additional list of 24 questions divided into four categories relating to physical, psychological, social, and environmental domains which can then be related to the severity of TMD’s (50).

Hawthorne G et al., developed another method for assessing the HRQoL known as the, ‘Assessment of QoL Instrument’, which was developed using psychometric procedures. This consisted of a total of 15 items that embraced both the physical and social aspects of HRQoL (51). Based on this assessment, it can be decided to what extent the QoL of a patient is affected due to TMD’s, following which subsequent measures can be undertaken to improve the patient’s lifestyle and provide appropriate treatment.

The Global Mental Health Assessment Tool (GMHAT) and Warwick-Edinburgh scale have also been used most frequently for assessment and grading QoL and the mental health of patients with TMD’s [52,53].

Reason for Lower QoL in Victims with TMD’s

Victims with TMD’s are forced to live a compromised life in the context of QoL when correlated with the normal community. Chronic pain in addition to the loss of energy restricts their daily activities and also it becomes difficult for patients to indulge in various outdoor activities, be it exercise or sports. The tasks that others can perform with ease are difficult for these patients. Restriction of movement may be one of the reasons. Food is considered the fuel of the body which is in linear association with QoL. In TMD patients, there is difficulty in eating food and frequently pain associated with it, which sometimes makes it obligatory for the patient to avoid eating food or having food in less quantity leading to an unhealthy lifestyle [54,55]. Change in voice is also a matter of concern for patients as this becomes a hindrance in communication. The patient is unable to develop good social, personal, and professional relations due to a lack of communication which may sometimes create a problem at the workplace and may lead to psychological effects due to an unfavourable workplace environment (45).

Apart from all the physical restrictions that lead to poor QoL, the effect on the mental health of an individual is a major problem. Patients with severe TMD’s are often termed as handicapped by society which leads to lower self-esteem which results in worst psychological status (43). Knowing these reasons, a clinician can help the patients overcome these difficulties and give way to a good QoL while their disorder is being treated.

How can the QoL be Improved in Patients Suffering from TMD’s?

Managing TMD’s and simultaneously improving the QoL should be of chief concern for an orthodontist or any clinician dealing with a case of TMD. Patients with severe TMD’s require a customised approach to management (54). QoL can be improved by decreasing the severity of symptoms like pain and reducing the physical restrictions of patients caused due to decreased mobility. Symptomatic relief from pain early in the treatment can immediately improve the patient’s QoL. A reduction in pain will automatically improve the patients’ sleep patterns and also improve the quality of sleep. But the reduction in pain, dysfunction, and improvement in sleep quality will only partly have an impact on the psychological effects caused by the disease. A problem-oriented approach is best suited to finding a solution for the psychological impacts (56). Various studies have shown that specific interventions improve QoL in patients with TMD’s (Table/Fig 3) [54,55,57,58].

So, while treating a patient with TMD’s, as a clinician, one should look beyond the clinical constraints of the illness followed by planning a treatment taking into consideration the elements that may alter the patient’s class of life and aim at improving it.

In present times, more attention has been paid to QoL attributed to oral health and also life’s quality related to general health. Disorders of the TMJ are no less a contributor to altering the QoL of a patient. In past literature, much focus is given to improving this aspect of TMD’s. The overall target of a treatment plan for a case of TMD’s should be focused to reduce the severity of symptoms and at the same time relieve chronic pain and increasing the mobility of the joint and improving the quality of sleep [55,59,60]. This will in turn pave the way for overall upliftment in the virtue of a life of an individual by improving their life in all aspects of life, including somatic, psychological, communal as well as environmental. More research and discussion are needed on this topic as the QoL is partly an occurrence of personal perception too.

Conclusion

Patients with disorders of the TMJ are likely to have a high association with an inferior QoL in comparison to the general population. A multidisciplinary and problem-oriented approach is essential in treating TMD patients and planning a treatment that not only aims at treating the ailment but at the same time aims at improving the patient’s quality and standard of life.

DOI and Others

DOI: 10.7860/JCDR/2023/58474.17584

Date of Submission: Jun 15, 2022
Date of Peer Review: Aug 19, 2022
Date of Acceptance: Oct 12, 2022
Date of Publishing: Mar 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

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