Association between primary dentition SCIENTIFIC ARTICLES

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Association between primary dentition wear and clinical temporomandibular dysfunction signs
Curt Goho, DDSHerschel L. Jones, DDS


Dental wear facets often are considered indicators of temporomandibuladr ysfunction (TMD).Dental wearfacets are commonin children, but their association with TMDsigns is unknown.A reproducible, clinical evaluation of TMDsigns for youngchildren showsno statistically significant association between primarydentition wearfacets andclinical signs of TMD(P < 0.05). Wearfacets in youngchildren do not appear to warrant TMDevaluation Or treatment. (Pediatr Dent 13:263-66, 1991)

Interest in pediatric temporomandibular dysfunction (TMD)is increasing. The patient age for TMD diagnosis and treatment is getting younger (Nilner and Lassing 1981; Ogura et al. 1985; Vanderas and Ranalli 1989). Manypediatric dentists routinely evaluate TM function, and some advocate early treatment (Padamsee et al. 1985).
The TMJexhibits mature morphology and more than 50% of mature size upon complete eruption of the primary dentition (Nickel et al. 1988). After 5 years age, growth velocity diminishes significantly and the TMJis sufficiently formedat an early age to be affected by parafunctional habits.
Bruxism and grinding are parafunctional habits often implicated in TMD(Ramfjord 1961; Keith 1983; Reding et al. 1966; Seligman 1988). Wear facets are suggested as indicators of these parafunctional habits (Lindquist 1971; Ahmad1986; Cash 1988; Seligman et al. 1988; Rugh 1988). Wear faceting from bruxism is commonin the primary dentition (Lindquist 1971) and is used to justify evaluation and treatment of suspected TMD(Kirveskari et al. 1989). However,a relationship between primary dentition wear and TMDsigns and symptoms has not been shown (Bernal and Tsamtsouris 1986). The purpose of this study was to evaluate any association between wear faceting of the primary teeth and objective, clinically measurable signs suggesting TMD.
This article is a workof the United States Governmenatnd maybe reprinted without permission. The authors are employees of the UnitedStates Armyat Fort Lewis, WA, andin the Second Field Hospital in Bremerhaven,Germany.Opinions expressedtherein, unless otherwise specifically indicated, are thoseof the authors.Theydonot purportto express views of the United States Armyor any other Departmentor Agencyof the United States Government.

Materials and Methods
Children age 3 through 6 years with complete primary dentitions were used as both comparison and sample populations. Fifty children without wear facets comprised the comparison population, and 50 children with wear faceting served as the sample population. Patients with conditions affecting TMJfunction or faceting (juvenile rheumatoid arthritis, hemifacial microsomia, trauma, cerebral palsy), who could not cooperate for dental examination, or who had an incomplete or mutilated dentition (oligodontia, extractions without proper space maintenance) were excluded from the study. Population size requirements were determined using the formula for comparing two population proportions for independent samples (Rosner 1990), with a = .05, and b = .4.
Children were selected during clinic and school screening examinations. Consent for examination was obtained through written clinic consent forms and school parental consent policy. The first 50 children meeting the criteria for each study group were evaluated. Two observers were trained in examination techniques. Interrater reliability was evaluated with Cohen’sKappa (Dworkin 1988).
Parameters from other studies (Helkimo 1974; Morawaet al. 1985; Ogura et al. 1985; Vanderas 1987; Riolo et al. 1988; Okeson 1989) were used as much as possible for comparison of data. However, to prevent false positive results, examination of young children must exclude ambiguous, uncomfortable, or prolonged procedures. Therefore, intra-auricular TMJpalpation,
intraoral pt~rygoid palpation, and subjective questioning about symptoms were inappropriate. Because of these limitations, only objective, easily measurableclinical signs associated with TMDwere evaluated.


The clinical examination evaluated the following:
1. Muscle (temporalis, masseter) sensitivity palpation
2. TMJ pain upon palpation during opening and closing
3. Deviation of mandible upon opening 4. Maximumextent of opening 5. Joint noise upon opening 6. Extent of dental wear.
Patients were seated upright for examination (Okeson 1989). The examiner palpated the temporalis, masseter, and TMJbilaterally with gentle pressure (approximately 32 ounces) with two fingers (Vanderas and Ranalli 1989) while patients opened and closed their mouths (Dworkin 1988). Pain responses were categorized "none," "wincing or guarding," or "unsolicited comment about pain" (Helkimo 1974; Egermark-Eriksson et al. 1981; Nielsenet al. 1989).
Joint noise was evaluated during opening and closing, with the examiner’s ear within 5 cmof the TMJ.A
stethoscope was not used due to the high incidence of false positive noises recorded by the acuity of the stethoscope (Okeson 1989; Nielsen et al. 1989). Joint noise evaluations were "none," "soft click," "crepitus," and "harsh grating" (Dworkin 1988).
Opening deviation more than 2 mmfrom the midline plane was considered a positive finding (EgermarkErikkson et al. 1981; Nielsen et al. 1989).
Maximal opening was measured from maxillary central incisor edge to mandibular central incisor edge. Any overbite in centric occlusion was added to the maximal opening figures (Ingervall 1971; Hanson and Nilner 1975; Nielsen et al. 1989; Okeson1989). Evaluation was either "normal" or "below normal limits." The
lower limit for normal opening in this age group was considered 34 mm(Bernal and Tsamtsouris 1986).
Dental wear was evaluated using a simplification of the scale devised by Hanson and Nilner (1975) and Carlsson (1984). Primary incisors, primary canines, and primary molars were evaluated as three groups. Evaluation of wear was "none or enamel only," "dentin exposed," and "severe wear" (more than one third of the tooth abraded). Wear into dentin was considered atypical wear faceting (Ramfjord et al. 1961).
Any single positive finding in the muscle, TMJ, or opening criteria categorized the patient as having signs of TMD(Morawaet al. 1985; Ogura et al. 1985). These loose parameters were used intentionally to maximize the sensitivity of associating wear faceting with TMD signs. Data were evaluated with Chi-square testing at a 95%confidence limit. The Statistical Package for the Social Sciences was used for computer data analysis.
To maximizethe sensitivity of this study, any single finding made the patient positive for signs of TMD.In

the comparison group (no wear), 14%presented with clinical TMDsigns. Of these, 10%had single signs and 4%had multiple signs. Ten per cent had opening deviation. Eight per cent had joint noise that was noted as a "soft click." Noneof the comparison group exhibited limited opening, muscle pain, or TMJpain.
In the study group (wear facets), all subjects exhibited wear into dentin in either incisors, cuspids, or molars; 42%had wear into dentin in two groupings of primary teeth, 10%had wear in all three groupings of teeth, and 30%had severe wear in at least one subset of teeth.
Sixteen per cent presented with clinical TMD.signs. Of these, 10%had single signs and 6%had multiple signs. Fourteen per cent exhibited opening deviation and 6%had joint noise that was noted as a "soft click." One patient reported muscle pain upon palpation. None of the dental wear group had any opening limitation or TMJpain (Figure).

1142 t P R 10 ¥8 L E

........... -,-

Sh1£1e sign Multiple Signs Deviation



Muscle pain

~ Control (no wear)

~ Study group (wear)

FigureP. revalencoef TMDsignsin primarydentitionswith and without wear.

Interrater reliability had a Kappaof 0.82 (N = 12). Chisquare evaluation showedno statistically significant association betweenthe presence, severity of location of wear and clinical signs of TMDT. here was no statistical difference in incidence of single or collective TMDsigns between the comparison and study populations of the 95%confidence level.
This study developed and utilized an accurate and reliable format for TMDevaluation of the young child patient. All evaluation parameters were objective, reproducible, and involved no discomfort or lengthy procedures for the child. Nilner and Lassing (1981), Nilner (1986), and Cash (1988) showed that questioning chil-


dren younger than age 7 is unreliable. Children are unaware of parafunctional habits (Love and Clark 1978) and the manner of asking questions often leads young

Major Gohowas resident, Pediatric Dentistry, and Lieutenant Colonel Jones is deputy director, Pediatric Dentistry Residency, Ft. Lewis, WA.

children to a particular response (Riolo et al. 1988; AhmadR: Bruxism in children. J Pedod 10:105-26, 1986.

Okeson 1989). Parental questioning about a child’s

Bernal M, Tsamtsouris A: Signs and symptoms of temporomandibu-

parafunctional habits or symptomsalso is unreliable (Cash 1988). Other inappropriate or uncomfortable diagnostic procedures for young children include TMJ

lar joint dysfunction in 3 to 5 year old children. J Pedod10:127-40, 1986.
Carlsson GE: Epidemiological studies of signs and symptoms of temporomandibular joint-pain-dysfunction: a literature review.

palpation with fingers in the auditory meatus, and

Aust Prosthodont Soc Bulletin 14:7-12, 1984.

intraoral palpation of the pterygoid muscles. The examination used in this study is realistic for a pediatric dental practice and still includes the majorclinical signs

Cash RG: Bruxism in children. Review of the literature. J Pedod 12:107-27, 1983.
Droukas B, Lind6e C, Carlsson GE: Relationship between occlusal factors and signs and symptoms of mandibular dysfunction. A

associated with TMD.

clinical study of 48 dental students. Acta Odontol Scand 42:277-

The incidence of TMDassociated signs was low, even though just one finding was sufficient to categorize a patient as positive for TMDsigns. Comparedto

83, 1984. Dworkin S: Reliability of clinical measurements in temporomandibu-
lar disorders. Clin J Pain 4:89, 1988. Egermark-Erikkson I, Carlsson GE, Ingervall B: Prevalence of man-

other child studies, this study finds even lower incidence of some TMDassociated signs (Table). This probably due to the use of only objective, reproducible examination procedures that minimized false positive

dibular dysfunction and orofacial parafunction in 7-, 11- and 15year old Swedish children. Eur J Orthod 3:163-72, 1981. Grosfeld O, Czarnecka B: Musculo-articular disorders of the stomatognathic system in school children examined according to clinical criteria. J Oral Rehabil 4:193-200, 1977.

results. All findings were mild, confirming Carlsson’s (1984) observation that children’s TMDsymptomsare seldom severe.
Interrater reliability was good. However,most of the

Hansson T, Nilner M: A study of the occurrence of symptoms of diseases of the temporomandibular joint masticatory musculature and related structures. J Oral Rehabil 2:313-24, 1975.
Helkimo M: Studies on function and dysfunction of the masticatory system II. Index for anamnestic and clinical dysiunction and

subjects exhibited negative findings and the reliability testing often measured agreement in finding absence of signs. To further validate interrater reliability either a larger subsample size (N) or a select subsample with

occlusal states. Sven Tandlak Tidskr 67:101-19, 1974. Ingerval B: Variation of the range of movmentof the mandible in
relation to facial morphology in young adults. Scand J Dent Res 79:133-40, 1971. Keith DA: Etiology and diagnosis of temporomandibular pair and

positive findings is needed.

dysfunction: organic pathology (other than arthritis). The

President’s Conference on the Examination, Diagnosis, and Man-

Even with evaluation parameters that maximized

agement of Temporomandibular Disorders. Chicago: ADA,1983, pp 118-22. Kirveskari P, Alanen P, Jgmsa T: Association between

any dental wear/TMDsign association, and pediatric specific examination procedures, there was no statisti-
cally significant association betweenprimary tooth wear facets and TMD-associated

craniomandibular disorders and occlusal interferences. J Prosthet Dent 62:66-69, 1989. Lindquist B: Bruxismin children. Odontol Revy 22:413-23, 1971. LoveR, Clark G: Bruxismand periodontal disease: a critical review. J West Soc Periodont 26:104-11, 1978.

signs. This lack of association

in young children parallels Table. Cross-study comparisonof TMDsign prevalence in children

similar findings in studies of

dental wear and TMJsigns in adults (Droukas et al. 1984;


Patient age

At least one sign

Opening Opening deviation limitation

TMJ noise

TMJ pain

Muscle pain

Seligman et al. 1988). These Present study








similar results in both pedi- (control and study

atric and adult populations group data pooled)

strongly suggest that dental Bernal and








wear at any age is not reason Tsamtsouris 1986

to suspect other TMDsigns Ogura 1985





9* o/o



or TMJ. Therefore, lengthy

examination, diagnosis of Grosfeld and



3* 60/o





TMD,and TMDtreatment for Czarnecka 1977

young children cannot be jus- Egermark-Erikkson






6% 20%

tified solely by the presence 1981

of wear faceting.

¯ Did not count patients with "asynchronousmovement"*. Nomeasuremenptarametersgiven.

¯ Stethoscopuesedto detect noise, -- Parametenr ot evaluated.


MorawaAP, Loos PJ, Easton JW: Temporomandibular joint dysfunction in children and adolescents: incidence, diagnosis, and treatment. Quintessence Int 16:771-77,1985.
Nickel JC, McLachlan KR, Smith DM: Eminence development of the postnatal human temporomandibular joint. J Dent Res 67:896902, 1988.
Nielsen L, MelsenB, Terp S: Prevalence, interrelation, and severity of signs of dysfunction from masticatory system in 14-16-year-old Danish children. CommunityDent Epidemiol 17:91-96, 1989.
Nilner M: Functional disturbances and diseases of the stomatognathic system. A cross-sectional study. J Pedod 10:211-38, 1986.
Nilner M, Lassing S-A: Prevalence of functional disturbances and diseases of the stomatognathic system in 7-14 year olds. Swed Dent J 5:173-87, 1981.
Ogura T, Morinushi T, Ohno H, Sumi K, Hatada K: An epidemiological study of TMJdysfunction syndrome in adolescents. J Pedod 10:22-35, 1985.
Okeson JP: Temporomandibular disorders in children. Pediatr Dent 11:325-29, 1989.
Padamsee M, Ahlin JH, Ko C-M, Tsamtsouris A: Functional disorders of the stomatognathic system: Part II, a review. J Pedod 10:1-21, 1985.

Ramfjord SP: Bruxism, a clinical and electromyographic study. J Am Dent Assoc 62:21-44, 1961.
Reding GR; Rubright WC, ZimmermanSO: Incidence of bruxism. J Dent Res 45:1198-1204, 1966.
Riolo ML,Ten HaveTR, Brandt D: Clinical validity of the relationship between TMJsigns and symptoms in children and youth. ASDCJ Dent Child 55:110-13, 1988.
Rosner B: Fundamentals of Biostatistics. 3rd ed. Boston: PWS-Kent, 1990.
Rugh J, Harlan J: Nocturnal bruxism and temporomandibular disorders. Adv Neuro149:329-41, 1988.
Seligman DA, Pullinger AG, Solberg WK:The prevalence of dental attrition and its association with factors of age, gender, occlusion, and TMJsymptomatology. J Dent Res 67:1323-33, 1988.
Vanderas AP: Prevalence of craniomandibular dysfunction in children and adolescents: a review. Pediatr Dent 9:312-16, 1987.
Vanderas AP, Ranalli DN: Evaluation of craniomandibular dysfunction in children 6 to 10 years of age with unilateral cleft lip or cleft
lip and palate: a clinical diagnostic adjunct. Commentary.Cleft Palate J 26:332-38, 1989.

FDAto test, set standards for gloves
The Food and Drug Administration (FDA) approved test methods and minimum quality levels for the billions of rubberandplastic gloves wornby dentists andother health care workers.
The new regulations, which becameeffective March12, 1991, standardize manufacturer testing anddefine the maximufmailure rate for the test, accordingto an item in the March1991 issue of DentaIManagementT. he FDAwill examine randomlyselected samples for tears, holes, andany foreign matter embeddedin the gloves.
Gloves also will be subjected to a water leak test, andmaynot be sold for medical use if leaks are foundin morethan 25 per 1,000 of surgeons’gloves and40 per 1,000 of patient examination gloves. The FDAsays that these limits can be reproduced in its field laboratories, thus providing a standardlevel of quality.
Foreign glove manufacturersmaybe placed on an import detention list if their gloves consistently fail to meet the new FDArequirements. Domestic gloves that do not meet requirementswill be seized, if necessary, to keepthemoff the market.


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Association between primary dentition SCIENTIFIC ARTICLES