ABSTRACT
Background
Temporomandibular disorders (TMD) aetiological factors have multidimensional, biomechanical, neuromuscular, biopsychosocial and neurobiological aspects. The relationship between work environment factors or occupational stress and TMD is not sufficiently investigated and is still poorly understood.
Objective
To investigate work‐related stress and the effect of personal computer (PC) use on TMD.
Methods
A questionnaire‐based survey that was conducted among 5619 employees of three companies. The questionnaire was used to screen TMD‐related symptoms (TRS), habitual behaviours, psychosocial status, awake and sleep bruxism and time spent using a PC at work. After excluding missing data values, 4776 individuals were included in the analysis. Structural equation modelling (SEM) was used to test the hypothesised models that correlated TRS with the other factors of the questionnaire, and to examine the effect of the time spent using the PC on men and women in our sample. Statistical significance was set at p < 0.05.
Results
SEM revealed that psychosocial factors affected TRS indirectly through their direct effect on sleep bruxism and other behavioural factors which had a direct effect on TRS. The effect of PC usage time was greater for women than for men.
Conclusions
Behavioural factors, including SB, may have a direct effect on TRS, while psychosocial factors may have an indirect effect on TRS. In addition, the results suggest that prolonged PC use influences behavioural and psychosocial factors, and this was especially true for women.
Keywords: behavioural factors, personal computer, psychosocial factors, structural equation modelling, temporomandibular disorders
1. Background
The term temporomandibular disorder (TMD) is a collective term for clinical problems that are associated with the temporomandibular joint (TMJ) and associated structures or masticatory muscles [1].
Its aetiology remains under debate and no single definitive aetiology has been identified. Aetiological factors have multidimensional, biomechanical, neuromuscular, biopsychosocial and neurobiological aspects [2, 3]. The biopsychosocial model has been considered the most accepted theory among recent studies [1, 4]. Numerous factors affect the aetiology, and multifactorial assessment has been recommended throughout the literature [5].
The biopsychosocial model suggests that pain originates from physical and psychological stimuli. Patients suffering from painful chronic TMD share similar psychosocial characteristics as patients suffering from other chronic syndromes. This led to the hypothesis that TMD may be considered among other somatic symptom disorders previously known as ‘Somatoform’ or ‘Functional Somatic Disorders’. Approximately 80% of the patients with TMD are affected by psychosocial impairments; thus, it is important to address these factors to improve the efficiency of traditional therapies [6].
Psychosocial factors, including depression, stress and anxiety play important roles in the predisposition, initiation and progression of TMD. TMD risk development is highly anticipated among patients with anxiety compared with those who are less anxious. Sugisaki et al. reported that the prevalence of symptoms was higher (approximately 17%–18%) in the working population than in the general population (5%–12%) [7]. The Japan Institute for Labour Policy and Training reported that ‘approximately 60% of the employees face mental health problems’. TMD related symptoms in working population are associated with long personal computer (PC) usage. In addition, distress in the working environment is assumed to be one of the main causes of psychological irritation and chronic stress, affecting the psychological and biological behaviours of the working population. The persistence and aggravation of TMD with psychosocial and emotional impairment can be accompanied by some habits, such as bruxism, clenching or nail biting, which can be destructive to the masticatory system on the long‐term [8].
Psychosocial factors, such as stressful life events, emotional disturbances and psychosocial distress, are among the main factors that affect myofascial pain syndrome through hyperactivation of the central nervous system, which triggers excessive activity in the masticatory muscles (observed as sleep or awake bruxism). Therefore, it can be assumed that TMD results from complex biological and psychological interactions [9].
The relationship between work environment factors and occupational stress in patients with TMD has not been sufficiently investigated and remains poorly understood. Occupational stress is a category of psychological stress, defined as a process in which the individual perceives work demands as stressors, which, when exceeding the individual's coping skills, provokes adverse reactions in them. Although there is an association between occupational stress and TMD, their correlation remains unclear [10].
This study aimed to evaluate the relationship between psychosocial factors, PC usage time and behavioural factors with TMD‐related symptoms (TRS) and validate the proposed correlation hypothesis through delicate statistical techniques using structural equation modelling (SEM) to identify the factors that have a high impact on TRS, which helps in improving the efficiency of traditional therapies through better diagnosis and treatment planning.
2. Materials and Methods
A cross sectional study was performed using an anonymous questionnaire. All procedures performed in this study were conducted ethically according to the ethical standards of the ethics committee of Institute of Science Tokyo (formerly: Tokyo Medical and Dental University), Japan with the approval (No. 1285) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
2.1. Participants
A total of 5619 individuals with age ranges between 20 and 65 participated in our survey conducted between April 2012 and March 2014. The participants were employees of three Japanese companies in Tokyo and nearby prefectures. The questionnaire was administered during health check‐ups for each company. A detailed explanation of the content and purpose of the study was provided to all participants along with the questionnaire. Among the participants, only 4776 (approximately 85%) successfully completed the full questionnaire. The participants were informed before completion of the questionnaire that all their answers would be anonymously used in the present study. Written informed consent was deemed irrelevant as the identification of participants was not required, and answering the questionnaire was considered approved consent for participation.
2.2. Questionnaire
The questionnaire used in this study consisted of 18 items, including age and sex, as shown in Table 1. Items from 1 to 17 were answered using 5 points Likert scale ranging from (0 to 4) where 0 corresponds to ‘Never or Not at all’ and 4 corresponds to ‘Always’ while the responses of item no. 18 were recorded as numerical value.
TABLE 1.
Questionnaire.
| Question items | Abbreviated form | |
|---|---|---|
| Q1 | If you open your mouth wide, is the opening range less than 3 fingers? | Limited mouth‐opening |
| Q2 | Do you experience pain in the face, jaw, temple or in the front of the ear when you open and close your mouth? | Mouth‐opening pain |
| Q3 | If you open your mouth wide, dose the opening path deviate? | Mouth‐opening deviation |
| Q4 | Do you experience pain in the face, jaw, temple or in the front of the ear when you eat hard foods such as beef jerky, dried cuttlefish or octopus? | Chewing‐induced pain |
| Q5 | Do you often chew gum? | Gum chewing |
| Q6 | Have you been warned about having bad posture? | Bad posture |
| Q7 | Do you chew food with only one side of your mouth? | Unilateral chewing |
| Q8 | Do you rest your chin on your hand? | Rests their chin on their hand |
| Q9 | Do you bite your nails or chew on pencils? | Nail bite |
| Q10 | Do you experience stress at work, school, home or in relationships? | Stress |
| Q11 | Do you experience anxiety at work, school, home or in relationships? | Anxiety |
| Q12 | Do you experience depression at work, school, home or in relationships? | Depressed |
| Q13 | Do you experience tension at work, school, home or in relationships? | Tension |
| Q14 | Are your upper and lower teeth to make continuous contact during work or at rest? | Tooth contact intensity |
| Q15 | Do you experience jaw muscle fatigue or pain when you are awake? | Wakeup symptoms |
| Q16 | Have you been warned about grinding your teeth in the past 3 months? | Indication of grinding |
| Q17 | Have you been noticed tooth clenching in the past 3 months? | Clenching consciousness |
| Q18 | How many hours do you use a personal computer per day? (h) | PC usage time |
Note: The following scale was used to answer each question: Q1–4: (0) Never, (1) Rarely, (2) None of the above, (3) Frequently, (4) Always. Q5–17: (0) Not at all, (1) Rarely, (2) Sometimes, (3) Frequently, (4) Always. Q18: Numerical entry.
Items 1–4 are screening questions for TMD (SQ‐TMD), that were validated and extracted by Sugisaki et al. from a 20‐item questionnaire previously administered to 2360 dental patients [7]. Nishiyama et al. demonstrated the validity of the SQ‐TMD when the RDC/TMD was used as a control, and the present study used the questionnaire developed by Nishiyama et al. in their survey [8]. Items 5–9 were not validated. Items 10–13 assessed psychosocial factors, including stress, anxiety and depression, as described by Sugisaki et al., where the validity of those items was not tested [7]. Items 14–17 were related to habitual behaviour, including tooth‐contacting habit (TCH), in which the upper and lower teeth are continuously brought together with minimal force in a nonfunctional context [10, 11, 12, 13].
2.3. Statistical Analysis
The total SQ‐TMD score was used as a measure of TRS, and based on Sugisaki and Nishiyama's report, participants who scored 5 or higher were classified as ‘TRS‐positive’ and those who scored 4 or less were classified as ‘TRS‐negative’. Cross tabulation, student's t‐tests and chi‐square tests were used to compare the age, sex and prevalence of TRS‐positive participants between the two groups. Pearson's correlation coefficient between TRS and the factors assessed in questionnaire items 5–17 was analysed to determine the covariates.
The SEM consisted of two phases. The first phase was exploratory factor analysis (EFA) and the second phase was confirmatory factor analysis (CFA). EFA was conducted using SPSS (version 28.0, SPSS Japan) and CFA was conducted using AMOS (version 28.0, SPSS Japan). Prior to SEM analysis, all participants' data were randomly divided into two groups (Groups A and B) using the algorithm available in SPSS.
EFA was performed on the data of Group A to define separate factorial groups. Principal factor analysis (Promax solution) was employed as an EFA method to determine the item groups in the questionnaire. A hypothetical model was constructed using factorial groups.
Using data from Group B, CFA was performed to test the hypothesised structural models using SEM. The overall data were divided by sex and the hypothesised structural model was tested separately for men and women.
To adequately assess model fitness during SEM, three indices for goodness‐of‐fit were included to evaluate the model: goodness of fit index (GFI), adjusted goodness of fit index (AGFI) and root mean square error of approximation (RMSEA). The model was deemed to be a good fit if the GFI and AGFI were > 0.90 and the RMSEA was < 0.05. Furthermore, the standardised path coefficients were considered statistically significant if the critical ratio was > 1.96 (p < 0.05).
3. Results
A total of 5619 questionnaires were administered. Of these, 843 (15%) questionnaires were incomplete and were excluded from the statistical analysis. The remaining 4776 questionnaires (approximately 85%) were used for data analysis. The total number of TRS‐positive participants was 366 (7.7%), with a mean age of 37 years in both sexes. A significant difference was observed in the number of positive female and male TRS participants with regard to their total number, as shown in Table 2. No significant differences were observed in age, female ratio or TRS‐positive ratio between the two randomly assigned groups (Groups A and B) in Table 3.
TABLE 2.
Characteristics of all analysis subjects.
| Total | TRS | p | ||
|---|---|---|---|---|
| Negative | Positive | |||
| Number (%) | 4776 (100%) | 4410 (92.3%) | 366 (7.7%) | |
| Age: year (SD) | 38.7 (9.5) | 38.9 (9.5) | 35.8 (9.2) | < 0.001 a |
| Male | 3375 (100%) | 3187 (94.4%) | 188 (5.6%) | < 0.001 b |
| Female | 1401 (100%) | 1223 (87.3%) | 178 (12.7%) | < 0.001 b |
Abbreviations: SD, standard deviation; TRS, temporomandibular disorders—related symptoms.
t‐Test.
Chi‐square test.
TABLE 3.
Characteristics of subjects in the A‐group and the B‐group.
| A‐group | B‐group | p | |
|---|---|---|---|
| Total N | 2388 | 2388 | |
| Age: year (SD) | 38.7 (9.5) | 38.7 (9.5) | 0.804 a |
| Female | 700 (29.3%) | 701 (29.4%) | 0.975 b |
| Total TRS‐positive | 181 (7.6%) | 185 (7.7%) | 0.828 b |
Abbreviation: TRS, temporomandibular disorders—related symptoms.
t‐Test.
Chi‐square test.
3.1. Exploratory Factor Analysis
As a result of the correlation analysis, Q5 and Q9 were excluded from the factor analysis because no correlation was found between them and the TRS. The factor analysis of Group A resulted in the extraction of three factorial groups, as shown in Table 4, where each factor group was used as a latent variable.
TABLE 4.
Questionnaire items and factor loading of factor analysis on the A‐group.
| Factor | ||||
|---|---|---|---|---|
| 1st | 2nd | 3rd | ||
| Anxiety | 0.948 | 0.003 | −0.063 | Psychosocial factors |
| Stress | 0.899 | −0.008 | −0.037 | |
| Tension | 0.714 | −0.036 | 0.1 | |
| Depression | 0.682 | 0.033 | 0.038 | |
| Clenching consciousness | −0.008 | 0.982 | −0.029 | Sleep bruxism |
| Indication of grinding | −0.039 | 0.715 | −0.024 | |
| Wakeup symptoms | 0.057 | 0.664 | 0.064 | |
| Rests their chin on their hand | −0.006 | −0.014 | 0.551 | Behavioural factors |
| Unilateral chewing | 0.004 | 0.033 | 0.521 | |
| Bad posture | 0.032 | −0.026 | 0.422 | |
| Tooth contact intensity | 0.128 | 0.106 | 0.146 | |
| Proportion of variance (%) | 28.4 | 16.4 | 5 | |
The factor groups were named psychosocial, sleep bruxism (SB) and behavioural factors (Table 4), and a hypothesised structural model, including the observed variables that was generated from these results (Figure 1a).
FIGURE 1.
Hypothesised structural model and results of confirmatory factor analysis.
3.2. Confirmatory Factor Analysis
Using group B data, CFA was conducted on the hypothesised model. The significant standardised path of coefficients in the final model are shown in Figure 1b. The fit indices of the final model were as follows: GFI = 0.976, AGFI = 0.967 and RMSEA = 0.039, indicating a strong structural correlation among the model components and reliability of the hypothesised model. The standardised path coefficients of ‘behavioural factors to TRS’, ‘SB factors to TRS’, ‘psychosocial factors to behavioural factors’, ‘psychosocial factors to SB factors’, ‘PC time to behavioural factors’ and ‘PC time to psychosocial factors’ were statistically significant (Table 5a).
TABLE 5.
Critical ratio and p‐value in standardised path coefficients.
| (a) B‐group | Critical ratio | p | ||
|---|---|---|---|---|
| Behavioural factors | ⇒ | TRS | 6.197 | < 0.001 |
| Sleep bruxism | ⇒ | TRS | 7.188 | < 0.001 |
| Psychosocial factors | ⇒ | TRS | 1.278 | 0.201 |
| Psychosocial factors | ⇒ | Behavioural factors | 12.047 | < 0.001 |
| Psychosocial factors | ⇒ | Sleep bruxism | 7.912 | < 0.001 |
| PC time | ⇒ | TRS | 0.595 | 0.552 |
| PC time | ⇒ | Behavioural factors | 2.389 | 0.017 |
| PC time | ⇒ | Sleep bruxism | 1.043 | 0.297 |
| PC time | ⇒ | Psychosocial factors | 2.157 | 0.031 |
| (b) Male group | Critical ratio | p | ||
|---|---|---|---|---|
| Behavioural factors | ⇒ | TRS | 7.032 | < 0.001 |
| Sleep bruxism | ⇒ | TRS | 5.946 | < 0.001 |
| Psychosocial factors | ⇒ | TRS | 1.388 | 0.165 |
| Psychosocial factors | ⇒ | Behavioural factors | 13.450 | < 0.001 |
| Psychosocial factors | ⇒ | Sleep bruxism | 7.635 | < 0.001 |
| PC time | ⇒ | TRS | 1.890 | 0.059 |
| PC time | ⇒ | Behavioural factors | 1.460 | 0.144 |
| PC time | ⇒ | Sleep bruxism | 0.441 | 0.659 |
| PC time | ⇒ | Psychosocial factors | 3.138 | 0.002 |
| (c) Female group | Critical ratio | p | ||
|---|---|---|---|---|
| Behavioural factors | ⇒ | TRS | 4.210 | < 0.001 |
| Sleep bruxism | ⇒ | TRS | 6.604 | < 0.001 |
| Psychosocial factors | ⇒ | TRS | 0.587 | 0.557 |
| Psychosocial factors | ⇒ | Behavioural factors | 9.472 | < 0.001 |
| Psychosocial factors | ⇒ | Sleep bruxism | 4.414 | < 0.001 |
| PC time | ⇒ | TRS | −0.100 | 0.921 |
| PC time | ⇒ | Behavioural factors | 4.150 | < 0.001 |
| PC time | ⇒ | Sleep bruxism | 1.634 | 0.102 |
| PC time | ⇒ | Psychosocial factors | 3.449 | < 0.001 |
Abbreviations: PC, personal computer; TRS, temporomandibular disorders—related symptoms.
Using male group data, CFA was conducted on a hypothesised model. The significant standardised path coefficients in the final model are shown in Figure 1c. The fit indices of the final model were GFI = 0.977, AGFI = 0.968 and RMSEA = 0.040, indicating a strong structural model. The standardised path coefficients of ‘behavioural and SB factors to TRS’, ‘psychosocial factors to behavioural factors’, ‘psychosocial factors to SB factors’ and ‘PC time to psychosocial factors’ were statistically significant (Table 5b).
Using female group data, CFA was conducted on a hypothesised model. The significant standardised path coefficients in the final model are shown in Figure 1d. The fit indices of the final model were GFI = 0.976, AGFI = 0.966 and RMSEA = 0.037, indicating a strong structural model. The standardised path coefficients of ‘behavioural factors to TRS’, ‘SB factors to TRS’, ‘psychosocial factors to behavioural factors’, ‘psychosocial factors to SB factors’, ‘PC time to behavioural factors’ and ‘PC time to psychosocial factors’ were statistically significant (Table 5c).
4. Discussion
The results of this study suggest that psychosocial factors may augment the presence of TRS, whereas factors such as sleep, awake bruxism and other parafunctional behaviours and habits may directly influence TRS. In addition, it is suggested that the PC use at work may escalate the effect of the psychosocial factors and other parafunctional habits with greater tendency in women.
Research indicates that women are more likely to suffer from TMD than men, with studies reporting that the prevalence rate of TMD is approximately 2:1 when compared between men and women. This has been attributed to several factors, including hormonal differences, variations in pain perception and psychosocial stressors, which may affect women more profoundly than men. The findings of the present study are consistent with these results. Our results showed a slightly higher prevalence of TRS in female participants than in male participants, reinforcing the need for sex‐specific approaches in both research and treatment [14, 15, 16].
The data obtained from company office workers were analysed using SEM to test the hypothesis and to estimate the level of significance and correlation between TRS, SB, psychosocial factors and parafunctional habits in this population. The significant correlation between psychosocial factors and TRS highlights the importance of addressing psychological factors in TMD management. De Leeuw et al. mentioned in their study that approximately 80% of patients with TMD exhibit psychosocial impairments, and it is evident that traditional therapeutic approaches should incorporate psychological evaluations and interventions. Our results showed a significant relationship between TMD and the targeted psychological factors, with bad posture and unilateral chewing being the most significant factors contributing to TRS. These findings align with those of a similar study by de Leeuw and Klasser (2010), who found that patients with chronic TMD often share psychosocial characteristics with individuals suffering from other chronic pain syndromes [17].
In a study by Hedwig et al., psychosocial factors, including anxiety, depression, somatisation, catastrophising and optimism, were assessed using validated questionnaires and included as potential predictors of pain outcomes in patients with painful TMDs and headaches. The results of our study showed that psychosocial factors may play an important role in pain intensity and pain‐related disability in patients with painful TMDs [18].
Saczuk et al. suggested a strong relationship between TMD and stress, which has been identified as a contributing factor to the onset and exacerbation of TMD symptoms. Bruxism and psychosocial factors, such as anxiety, depression and perceived stress, are also associated with TMD. The relationship between TMD and stress is bidirectional, with TMD symptoms causing stress and vice versa. However, while stress is considered a contributing factor to TMD, it may not be the only cause, as other factors, such as genetics, trauma, occlusal factors and parafunctional habits, can also play a role [19].
The results in our study showed that habitual behaviour and SB directly influenced TRS, suggesting that when both factors are present, the risk of TRS increases. Moreover, Psychosocial factors have a significant strong direct effect on behavioural factors, and thus a strong indirect effect on TRS and the risk of TMD. The standardised path of coefficients in Group B showed that habitual behaviours including (bad posture unilateral chewing, resting the hand on the chin—tooth contact) had the highest significant correlation with TRS, whereas unilateral chewing had the highest significance between these three factors.
The working population in Japan, especially the office employees, share many similarities in terms of office‐related symptoms (sick building syndrome) because of general routines, occupational stress and lack of psychosocial support [20].
Golanska et al. reported that in their study the prevalence of myofascial TMD pain reached 45.3% among patients with myofascial pain in their studied sample. They also mentioned that myofascial pain syndrome mostly inflicts lazy individuals at the ages between 27.5 and 50, with more tendency in females [21].
Poor ergonomics can significantly affect the prevalence of TMD when combined with prolonged PC usage time, suggesting that the more time one spends on a PC, the more their posture and other parafunctional habits can develop over time [22]. To control the prevalence of TMD among the working office population in Japan, a multidisciplinary approach, including cognitive behavioural treatment (CBT), psychosocial support and improved office ergonomics, is recommended [20, 21, 22, 23, 24, 25].
The use of SEM in this study enhanced the validity of the findings by assessing the relationships between various factors, such as behavioural habits, psychosocial factors and TMD symptoms, which helped in understanding the contributing factors leading to TMD.
Further research is recommended to investigate the specific aspects of occupational stress that contribute to TMD. Longitudinal studies could provide insights into causality, which would help us understand whether interventions aimed at reducing workplace stress could mitigate TMD symptoms or not. Participants were drawn from only three Japanese companies, which may not be representative of the general population. The working environment and cultural factors in these companies may influence the results. Broader sampling, including individuals from different industries, regions and backgrounds, could make the findings more generalisable. The sample is composed primarily of employees, which is not representative of nonworking individuals, limiting the external validity of the study.
Future studies should study more about the nature of workplace stress (e.g., work demands, work environment, interpersonal relationships) and its differential impact on TMD symptoms. Other relevant factors to TMD that were not assessed, such as personality traits, coping strategies or social support, should be of future interest. Additionally, the scale used to measure psychosocial factors may not fully capture the complexity of these constructs.
5. Conclusions
This study aims to clarify how PC usage time and work‐related stress affect temporomandibular disorder‐related symptoms, including their relationship with behavioural and psychosocial factors, using SEM.
Behavioural factors, including SB, may have a direct effect on TRS, while psychosocial factors may have an indirect effect on TRS. In addition, the results suggest that prolonged PC use influences behavioural and psychosocial factors, and this is especially true for women.
Author Contributions
Akira Nishiyama contributed through data collection, sample preparation and theory development. Fares Moustafa took the lead in writing the manuscript, analysing the data and refining the theory in consultation with Akira Nishiyama and Hiroyuki Ishiyama. Kenji Fueki directed and supervised the whole project. All authors discussed the results and commented on the manuscript.
Conflicts of Interest
The authors declare no conflicts of interest.
Peer Review
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/joor.14006.
Acknowledgements
We would like to thank the employees of the various companies who cooperated with the questionnaire survey for this research. This research was also conducted using a MEXT Grant‐in‐Aid for Scientific Research (No. 23592837).
Funding: This work was supported by MEXT grant‐in‐aid for scientific research (No. 23592837).
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article.
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Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article.