ABSTRACT
To determine the level of dental attrition and its relation to signs of TMJ dysfunction adding to condylar alterations analyzed by conventional TMJ Tomography and to propose the correlation between dental attrition and signs of TMJ dysfunction and condylar changes. Patients for the study were selected from the regular outpatient Department of Oral Medicine, Diagnosis and Radiology, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, with performed criteria. The radiographic examination of TMJ is performed by the PLANMECA OPG machine using the tomographic program. Statistical analysis was performed using a Chi-square test to determine the relation between attrition and temporomandidular disorders [TMD] signs and symptoms. The study group comprises 60 subjects who are having dental attrition, and they are divided into three groups according to their age: Group I, 20-40 age; Group II, 41-60 age; Group III, more than 60 age 80% of the samples had one or more tooth with significant attrition with grades of two or more on a 0-4 scale The prevalence of changes in condylar morphology was more in individuals above 40 yrs (33.33%) as compared to those below the age of 40 with a total prevalence of 41.67%. The most common symptom reported is tooth sensitivity, joint sounds, and muscle tenderness. The last reported are scalloped tongue, buccal mucosa ridging, referred pain, and limitation of mouth opening. Out of the 25 subjects who showed condylar changes, 10 subjects had symptoms of TMD. The symptoms reported are strain in the mouth opening, tenderness in jaw movements, and TMJ clicking sounds. Attrition is not a predictable sign of TMJ dysfunction, yet a finite association was defined between attrition and signs and symptoms of TMJ dysfunction. Studies involving larger samples compared with additional radiographic modalities are recommended.
KEYWORDS: Attrition, condyle, ortho pantamogram, temporomandibular joint
INTRODUCTION
Temporomandibular joint (TMJ) is the specialized joint in the body that maneuvers freely between the condyle of the mandible and the squamous portion of the temporal bone present at the base of the skull. The function and health of TMJ is crucial for a healthy life. The functions of the TMJ are to provide stable, smooth, efficient movement of the mandible during the process of mastication, swallowing, and speech and to prevent dislocation from external forces. Condylar remodeling is a physiologic process that is essential for the adaptation of the TMJ to meet functional needs. The parts of the TMJ retain their capacity for remodeling even after growth has ceased.[1] The masticatory system is an extremely circuitous mechanism. In most instances, it functions without deleterious dysfunction or disarrangement, but when a breakdown occurs in one unit of the TMJ, it can produce serious complications in other components of the TMJ system.
Parafunctional habits like bruxism and clenching are of deliberate concern because of its firm clinical association with TMJ disorders. The majority reported signs of these parafunctional habits are attrition, hypersensitive teeth, scalloped tongue, buccal mucosa ridging, fine cracks and fracture lines on teeth, chipped teeth, and broken restoration. Morphological changes are thought to be interlinked to TMJ dysfunction, which may be due to factors like bone remodeling, age changes, and osteoarthrosis, yet the exact reason is still a mystery.[2]
The morphological appearance of mandibular condyle varies greatly among different age groups, ethnicity, and individuals, which is categorized into five basic types: flattened, convex, angled, rounded, and concave. Morphologic changes in condyle occur due to developmental variations, remodeling, various ailments, trauma, endocrine disturbances, and radiation exposure. Genetic predisposition, acquired, functional factors, age, and individual well-being play a prominent role in these alterations of the condyle. Thus, variability in the shape and size of the condyle should be considered an important criterion in analyzing TMJ disorders.[3] Panoramic radiography has been recommended as a reliable screening tool for patients complaining about their TMJ function. Thus, the present study was undertaken to evaluate the level of dental attrition and to analyze its association with age, clinical signs, and symptoms of TMJ dysfunction and its condylar changes using a conventional tomography program utilizing OPG radiographic modality.
AIM AND OBJECTIVES
To determine the level of dental attrition and its association with signs of TMJ dysfunction like tenderness, joint sounds, variations in jaw movements, and osseous condylar changes analyzed by conventional TMJ tomography with open and closed view and to propose the significant relation between dental attrition and signs of TMJ dysfunction and condylar changes
METHODOLGY
Patients for the study were selected from the regular outpatient Department of Oral Medicine, Diagnosis and Radiology, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram. The study group will comprise a sample size of 60 subjects with dental attrition.
Inclusion criteria
Subjects with various levels of dental attrition above the age of 20.
Exclusion criteria
Subjects under artificial prosthesis for intermittent period of time
Subjects with developmental anomalies of oral cavity and its associated structures
Subjects underwent trauma and reconstruction surgery in dentofacial complex
Pregnancy
Hypersensitive tooth, tooth fracture, broken restoration, scalloped tongue, ridging of buccal mucosa, TMJ clicking sounds, tenderness in muscles of mastication, TMJ tenderness, referred pain, pain on jaw opening associated with limitation and deviation of mouth opening were recorded along with attrition score in a proforma. The radiographic examination of TMJ is performed by the PLANMECA OPG machine using the tomographic program. The results of the study were subjected to statistical analysis by using a Chi-square test to determine the relation between attrition and TMD signs and symptoms.
RESULTS
The study group will comprise a sample size of 60 subjects who are having dental attrition, and they are divided into three groups according to their age: Group I, 20-40 age; Group II, 41-60 age; Group III, more than 60 age. Forty percent of the subjects were in the age group 21–40, 26.7% of the subjects were in the age group 41–60, and 33.3% of the subjects were in the age group above 60.
The study revealed that the subjects were more in the range of 1.0 to 2.0 attrition score and least in 0.5 and 2.5. Attrition score does not show any correlation with gender, which is statistically insignificant, but the prevalence of attrition is seen more in males compared to females in the ratio of 1.6: 1. Attrition score increases as age increases, the common range of attrition score lies between 1.0 and 2.0, which is statistically significant. The prevalence of tooth sensitivity in study groups is 76%, the least of count zero is seen in the range below 0.5 attrition score, and the highest of 100% is seen in the range of 1.5 to more than 2.5, which is statistically significant.
The severity of level of attrition is not related to tooth or restoration fracture, which is 10% in the total study group; it is 22% in the range of 1.5–2.0, which is statistically insignificant. Attrition is not related to scalloping of the tongue; it is seen in one subject in a total study group and is not related to 3% ridging of buccal mucosa.
Joint sounds are 33.33% prevalent in the total study group, which is more commonly seen in the range of 1.5 to more than 2.5, and muscle tenderness is 33.33% prevalent in the total study group, which is more commonly seen in the range of 1.5 to more than 2.5 attrition score. Attrition score has a positive correlation with TM joint tenderness with 20% prevalence, and it is common in the range of attrition scores of more than 2.5.
Attrition score is not associated with referred pain, which is 10% prevalent and most commonly seen in the range of 2.5, and it is related to pain during mouth opening, which is 20% prevalent in the total study group and commonly seen in the range of 1.5 to 2.5. Deviation of the mandible is 20% prevalent in total study groups, which is more common in the range of 2.5. The limitation of mouth opening is not related to attrition, which is 10% prevalent in a total study group. The prevalence of condylar changes in total study group is 41.67%; it increases linearly with attrition score, whereas condylar changes are more in the age group above 60 with morphologic alterations seen, and it decreases linearly with age [Graph 1]. The most common type of condylar change is flattening, which is 35% prevalent, and the least common type is Ely’s cyst [Table 1].
Graph 1.
Prevalance of Radiographic condylar changes
Table 1.
Variations of Condylar changes
| Condylar Changes | Groups | Total | χ2 | P | ||
|---|---|---|---|---|---|---|
|
| ||||||
| Group I | Group II | Group III | ||||
| Flattening | 4 | 6 | 11 | 21 (35%) | 6.201 | 0.40 (NS) |
| Osteophyte | 0 | 1 | 0 | 1 (1.7%) | ||
| Erosion | 0 | 1 | 1 | 2 (3.3%) | ||
| Sclerosis | 1 | 0 | 0 | 1 (1.7%) | ||
| Ely’s cyst | 0 | 0 | 0 | 0 | ||
| Total | 5 | 8 | 12 | 25 (41.67) | ||
The most common symptom reported in the study is tooth sensitivity, joint sounds, and muscle tenderness, and the least reported is scalloping of the tongue, ridging of buccal mucosa, referred pain, and limitation of mouth opening [Graph 2].
Graph 2.
Prevalance of TMD symptoms
DISCUSSION
Attrition is of paramount concern because of its firm clinical correlation to TMJ disorders. Repetitive chronic trauma induced due to clenching and grinding habits may stimulate altered improper muscle activity and remodeling of joints, which may occasionally ignite a degenerative process. Considering the deleterious effects of attrition on the masticatory system, this study was structured to determine the severity of dental attrition in adults of both sexes of various age groups and its possible link to TMJ disorders by signs and symptoms and also by radiographic examination of TMJ.[4]
It was observed that 80% of the samples had one or more teeth with significant attrition with grades of two or more on a 0-4 scale of a standard attrition index. This is in agreement with the study performed by Seligman and Pullinger in 1988.[5] A rise in attrition score with age advancement was noted in this study, proving that as age advances, attrition becomes more severe. Results of this study suggested that functional wear was directly proportional to an increase in age, and attrition was not a result of only tooth grinding or other parafunctional habits but also due to functional activities. This observation is also relevant to our study population. This can be explained by the fact that the type of food consumed is primarily coarse and non-refined. Additionally, men showed higher grades of attrition scores than women; at the same time, men had fewer TMJ dysfunction symptoms. This is likely to the findings of Seligman and Pullinger and Solberg in 1988.[5,6]
In this study, it was found that there was no association of attrition with scalloped tongue, tooth chipping or restoration fracture, and ridging of the buccal mucosa. However, there was a consistent correlation of attrition with tooth sensitivity, which showed 100% prevalence in the range of 1.0 to more than 2.5 ranges and 76% prevalence in the total study group. The frequency of TMJ jaw movement sound is 33% in study groups, which reassures the results of studies performed by Solberg et al. and Spencer in 1980,[6,7] which showed 17% clicking and 12% crepitation. Mastication muscle tenderness was observed in 33.33% of subjects, which was consistent with the studies performed by Pullinger et al. in 1988. This study showed a stable association between the presence of muscle tenderness and the severity of attrition scores, which is analogous to a study performed by Egermark-Eriksson in 1982 and De Laat et al. in 1985. Joint tenderness was seen in 20% of the sample, and this is consistent with studies performed by Mundt in 2005.[8,9]
Referred pain was noted in 10% of the study group. Pain in mouth opening was reported in 20%. A correlation could be established between pain in mouth opening and the severity of attrition. This can also be explained by taking into consideration the prolonged altered muscle activity. On mouth opening, 20% showed a deviation of the mandible, which is slightly lower than the 22% reported by Pullinger and White in 1988.[9] A strong association was found between the severity of attrition and deviation of the mandible during mouth opening.
The prevalence of alterations in condylar morphology was higher in individuals above 40 yrs (33.33%) as compared to those below the age of 40 (8.34%), with a total prevalence in the whole study group of 41.67%. It was also observed that, as age increased, condylar changes also rose. Group II and Group III had increased condylar changes as compared to Group I. This observation is identical to the observations of the study performed by Muir and Goss in 1990, Huumonen et al. in 2007, and Takayama et al. in 2008.[10] This study showed a statistically significant value showing a strong positive correlation between increased attrition score and condylar morphological alterations.
In this study, flattening was observed in 21 subjects (35%), and this was the most common finding, followed by erosion, osteophyte, and sclerosis. Ely’s cyst was the minimal common type; none was reported in our study. Flattening was observed more in the older age group. This finding is analogous to the findings of Sato et al. in 1996.[11] Out of the 25 subjects who showed condylar alterations, 10 subjects had symptoms of TMD (40%). The symptoms were in the form of strain during the opening and closing of mouth, pain in jaw movements, and TMJ sounds.
CONCLUSION
The results of this study were that attrition is not a 100% reliable sign of TMJ dysfunction, but a finite association was established between attrition and signs and symptoms of TMJ dysfunction. The small sample size and usage of only panoramic radiographs to assess the condylar changes were the limitations. Further studies with larger sample sizes and other advanced radiographic modalities for studying condylar morphological changes are highly recommended.
Abbreviations used
TMJ, TMD, OPG
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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