Journal of Advanced Clinical and Research Insights

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>Kiran, Joy, Vidya, Krishna, and Hegde:

Attitude and awareness of temporomandibular joint disorders among general dental practitioners in Southern India

M. Shashi Kiran1, E. Tatu Joy1, S. Vidya2, Sowmya Krishna3, Sushmini Hegde4

Department of Oral Medicine and Radiology, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Kanyakumari, Tamil Nadu, India, 2Department of Oral and Maxillofacial Pathology, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Kanyakumari, Tamil Nadu, India, 3Department of Oral Medicine and Radiology, VS Dental College and Hospital, Bengaluru, Karnataka, India, 4Department of Oral Medicine and Radiology, The Oxford Dental College and Hospital, Bengaluru, Karnataka, India

Correspondence Dr. Shashi Kiran M, Reader, Department of Oral Medicine and Radiology, Sree Mookambika Institute of Dental Sciences, VPM Hospital Complex, Padanilam, Kulasekharam 629161, Kanyakumari District, Tamilnadu, India. E-mail:
Received 22 January 2016;
Accepted 01 April 2016
doi: 10.15713/ins.jcri.109


Aim: To evaluate the awareness of diagnosis and management of temporomandibular disorders (TMDs) among general dental practitioners and to understand their attitude toward the relevance of these disorders.

Materials and Methods: A questionnaire containing 17 questions regarding etiology, signs and symptoms, investigations and management of temporomandibular joint disorders and about the relevance of managing the same in routine clinical practice was answered by 100 general dental practitioners in Southern India. The results obtained were tabulated and were analyzed using non-parametric Spearman’s rank correlation and Pearson (parametric) correlations.

Results: Our study found that while clinicians were well versed with the etiologic factors responsible for TMD and their diagnosis, the domain of management of TMD was an area that needed improvement.

Conclusion: General dental practitioners could benefit from education programs aimed at highlighting the management aspect of TMD.

Keywords Attitude, awareness, dental questionnaire, temporomandibular disorders


Temporomandibular disorders (TMDs) rate among the most common causes of orofacial pain of musculoskeletal origin.[1] They present as an enigmatic entity with frequent incongruous presentations that propose a diagnostic and therapeutic dilemma to the attending clinician. Although the basic examination and clinical alliteration of TMD are offered in the curriculum of dental schools all over the country, this arena of orofacial diagnosis is still much ignored in routine dental practice. Patients presenting with these disorders are frequently misdiagnosed, are often made to undergo several rounds of treatment for unrelated disorders, and are referred to other specialists without a clear idea of whom the referral should be addressed to often leading to frustration and lack of satisfactory care for the patient leading to compromised quality of life. We attempted to evaluate the awareness and attitude of general dental practitioners toward TMDs in South India with an aim to evaluate the quality of care that patients with TMD receive and to evaluate the need for continuing education programs on TMD.

Materials and Methods

We designed this cross-sectional study with a sample population consisting of general dental practitioners in South India. We included 100 dentists who have been practicing for a minimum period of 5-year. A questionnaire consisting of 17 questions formulated from relevant, reliable literature was distributed to the dentists, and they were asked to answer and return the same. The same questionnaire was also given to 5 TMD experts, and their opinion was considered as the standard against which the survey questionnaires were evaluated. The questionnaire consisted of sections pertaining to etiology, signs and symptoms, diagnosis and management, and a section regarding the need for continuing education programs on TMDs. The participants were informed about the purpose of the study and were assured of confidentiality of their response. They were requested to return the completed questionnaire in a week and in the case of failure to do so, up to three reminders were given and the completed questionnaires obtained. Their response was evaluated and the results statistically analyzed.


The practitioners were asked to give their opinion on the etiologic factors, signs and symptoms, investigations and management of TMD and the following results were obtained as in Table 1. The descriptive statistical analyzes of the results are illustrated in Tables 2-4.

Table 1: Results of the completed questionnaire


Table 2: Descriptive statistics


Table 3: Non-parametric Spearman’s rank correlations


Table 4: Pearson (parametric) correlations



We carried out this study with an aim to evaluate the attitude and awareness about temporomandibular joint (TMJ) disorders among practicing general dentists. From our questionnaire-based survey, we found that general dental practitioners were well versed regarding the etiological factors responsible for TMD. While 80% of the practitioners were of the opinion that occlusal disturbances were responsible for TMD, 76% also believed that other factors such as parafunctional habits, trauma, and psychological factors were also factorial in TMD.

TMD is a term that includes clinical problems affecting the masticatory muscles, TMJ, and adjacent structures. Parafunctional habits and trauma are common causes of TMD, with stress and mental problems as secondary aggravating factors.[2] 40% of the participants concurred with the experts that TMD can manifest as a headache while 54% that TMD can mimic symptoms of the ear. Cochrane collaboration studies show at least 33% of the population to be suffering from symptoms such as facial pain and joint pain.[3] Ciancaglini and Radaelli in a survey of 483 subjects to describe the relationship between TMD and headache reported a higher occurrence of headache among individuals with TMD symptoms as compared to those without.[4] Melo et al. analyzed conversely, the occurrence of signs and symptoms of TMD among individuals with the headache and found them to be more frequent among headache patients.[5] 70% of the participating dentists erroneously believed that measurement of mouth opening was a reliable means of diagnosing TMD while 84% correctly answered that disc derangement may cause clicking of the TMJ.

About 58% of the participants accorded that examination of the masticatory muscles formed an integral part of TMD diagnosis. In many TMD patients, the most common complaint is pain originating from the muscles of mastication rather than from the TMJ.[6] An analysis of condyle-disc position has shown that an anterior-superior position in the fossa is more stable, and all other positions of the condyle are less stable and are maintained at the expense of increased muscle activity.[7] Occlusal factors may affect the condyle position which is critical to the equilibrium of the masticatory system. Condylar displacement can lead to muscle spasms and subsequent pain.[8] 78% of the practitioners also were of the opinion like the experts that TMJ imaging was contributory in the diagnosis of TMD. 72% of the dentists opined that any click detected must be treated while the experts felt otherwise. The most common causes of clicking are considered to be poor coordination in lateral pterygoideus muscle function, displacement of the articular disc, and irregularities in the articular surfaces. However, the etiology of and need for treatment of clicking have been controversial; it is not known whether clicking sounds indicate a harmless condition or whether they are pathognomonic of progressive internal derangement of the TMJ.[9-12]

About 45% of the dental practitioners concurred with the experts that TMD had a psychological impact on the patient and the two were interrelated. Contradictory views exist regarding the relationship between TMD and emotional well-being. Although some studies have found a relationship between TMJ disorder syndrome and emotional well-being, there are also some opposite views.[13-16] Okeson reported that the evaluation of depression delivered better results in the management of patients with TMD and pain complaints. In addition to various treatment techniques, medical treatment, some enjoyable activities to avoid anxiety are often recommended.[17]

The dentists had incongruous opinions with respect to management of TMD. While 83% said they would use non-steroidal analgesics in the management of TMD, a mere 40% reported that they would use muscle relaxants in their treatment of TMD. 78% of the participants felt that occlusal splints were a must in the treatment of TMD, which did not concur with the experts’ opinion while 36% felt that physiotherapy played a role in the management of TMD which the experts agreed with. In a study conducted by Jamalpour et al., 36% of the dental practitioners felt that occlusal splints were the first line of treatment for TMD and 80% agreed that physical therapy was useful.[18] Considering its multifactorial etiology, while occlusal splints do play a role in the management of TMD, an etiology-based treatment plan to manage TMD would be the approach to go with rather than a “cookie cutter” approach to monotonously manage all TMD.

About 89% of the surveyed practitioners said that they would refer patients suffering from TMD to a specialist for management rather than treat it themselves. 80% of the dentists said they would refer the patient to an oral surgeon for management while a mere 9% said they would refer the patient to an exclusive TMD expert. Almost all the dentists agreed that they found it challenging to manage TMD, and 87% felt most patients were not satisfied with the treatment available for TMD. Almost all the participants (95%) relied on the internet for information on management of TMD while only 5% said they would consult an expert to educate themselves about TMD. 100% of the dentists said they would be interested in attending a continuing education program on TMD and felt it would be useful to their practice.


Our study found that while the average clinician is aware of the clinical implications of TMD and is well versed with the etiologic factors and diagnosis of TMD, the arena of management of the same does lag and continuing education programs emphasizing the same would be beneficial to both the managing clinician and the suffering patients. In our opinion, the general dental practitioner in the primary care provider to the patient. An enhanced awareness of the functioning of the masticatory system with updated knowledge of the management of disorders of the TMJ will benefit the patients suffering from TMD to a great extent and allow an opportunity for them to be relieved of pain at the point of the first contact with a clinician with sustained care in conjunction with a TMD specialist.


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