oral habits and their association /prosthodontic courses

ORAL HABITS AND THEIR ASSOCIATION WITH SIGNS AND
SYMTPOMS OF TEMPOROMANDIBULAR DISORDERS: A GENDER
COMPARISON – A STUDY
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
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• Masticatory system is a complex unit designed to carry out the
tasks of chewing, swallowing, speaking & these functions are basic
to life
• Dorland’s medical dictionary defines parafunction as disorderly or
perverted function. Parafunctional activities are usually harmless
unless the exerted forces exceed the structural tolerance

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• Nail biting is the most common habit and mainly affects
children (28-33%), but it can be present in adults (45%) and
older people too. It is manifested by biting one’s fingernails or
toenails during periods of nervousness, stress or boredom. It
can be a sign of mental or emotional disorder .The medical
term for nail biting is chronic ‘onychophagia’. It belongs to the
group of disorders called Stereotypic movement disorders
Sir Gan / Leumg Robinson

• Chewing gum was discovered by Thomas Adams in the year
1870 Since then Gum chewing has been accepted as an adjunct
to oral hygiene, as salivary stimulant, vehicle for various
agents, as well as for jaw muscle training
• Another habit considered as a parafunctional habit is unusual
postural habits and the most important among them is the
continuous leaning of head on arm

• The American Academy of Orofacial Pain defines bruxism as “diurnal
or nocturnal parafunctional activity which includes clenching,
gnashing, gritting and grinding of teeth”. The prevalence of bruxism in
adult population is around 20% and greatest incidence is seen
between 20 -50 years after which the habit progressively decreases.
Karoly referred to the state as “neuralgia traumatica”
• In a study by Gavish et al a new parafunction “jaw play” was
described and defined as
“ A habit of performing small non-functional mandibular movements
without tooth contact”

• Pathology of the temporomandibular joint (TMJ) affects an important
part of the population though it is not viewed as a public health
problem. The literature reports great variability in the prevalence of
clinical symptoms (6-93%), probably as a result of the different clinical
criteria used
• Age is a risk factor, though with some particularities. Most
Temporomandibular Disorder (TMD) symptoms are reported in
patients between 20-40 yrs of age. Temporomandibular dysfunction is
more frequent in females

• The dental profession was first drawn into the area of TMD’s by an
article written by James Costen in 1934 where he described the
process as Costen syndrome
• The term TMD has been described as a cluster of disorders
characterized by pain in the pre auricular area, temporomandibular
joint (TMJ) or the masticatory muscles; limitations or deviations in the
mandibular range of motion ; clicking in the TMJ during mandibular
function, and they are not related to the growth or developmental
disorders , systemic diseases , or macro trauma

I. To evaluate the potential risk of oral parafunctional habits in relation
to gender
II. To evaluate the potential risk of oral parafunctional habits in relation
to signs and symptoms of temporomandibular disorders
III. To compare the prevalence of oral parafunctional habits among
males and females aged 18-25 years and to recognize the more
common parafunctional habit which can be a possible risk factor for
the occurrence of signs and symptoms of temporomandibular
disorders
IV. To compare the prevalence of signs and symptoms of
temporomandibular disorders among males and females aged 18-25
years and to recognize the more common signs and symptoms

• The current study included randomly selected 300 students from
various educational institutions of Udaipur city
 Criteria for selection:
 Individuals within the age group of 18-25 years with their both upper
and lower first permanent molars intact were included
 Individuals with negative history of trauma or any other kind of
treatment for the temporomandibular joint were included in the study
 Individuals with a history of orthodontic treatment were not taken up
 Lastly individuals with syndromes or any systemic diseases were
excluded

• Prior to the clinical examination , all students completed a
questionnaire. One experienced examiner determined
beforehand that all the questions were correctly understood
and answered. A second experienced examiner performed the
clinical examination and was purposely unaware of the results
of the questionnaire. The questionnaire and the clinical
examination forms were coded and were tabulated after the
results

ж Group I : Subjects with no parafunctional habit or signs and
symptoms
of temporomandibular disorder
ж Group II: Subjects with signs and symptoms of
temporomandibular disorder but without any parafunctional habit
ж Group III: Subjects with parafunctional habits and no signs and
symptoms of temporomandibular disorders.
ж Group IV: Subjects with parafunctional habits and signs and
symptoms of temporomandibular

26/9%
52/17%
22/7%
200/67%
GROUP I
GROUP II
GROUP III
GROUP IV

The number and percentage of subjects in Group II
Signs and symptoms Males n % Females n %
Pain / Fatigue 7 13.5% 14 26.9%
Joint Click 7 13.5% 7 13.5%
Joint Sensitivity 1 2% 4 7.7%
Muscle Sensitivity 13 25% 20 38.5%
0
2
4
6
8
10
12
14
16
18
20
PAIN/FATIGUE JOINT CLICK JOINT
SENSITIVITY
MUSCLE
SENSITIVITY
NUMBER
HABITS
MALES
FEMALES

• The female musculature differs from male; fat free mass and
muscle thickness are larger in malesand maximal voluntary
contraction is significantly greater in males. It could also be
based on the tendency of males to hide feelings of pain and
discomfort as measures of virility.
• In his study, Rafael et al suggested that the presence of
estrogen receptors in the TMJ of women modulates metabolic
functions in relation to laxity of the ligaments and this could be
relevant to TMD.

The Number and percentage of subjects in Group III
Parafunctional
Habits
Males
n %
Females
n %
Gum chewing 4 18.2% 2 9.1%
Nail biting 2 9.1% 4 18.2%
Leaning of head on arm 2 9.1% 3 13.6%
Jaw play 3 13.6%
Bruxism 3 13.6%
0
0.5
1
1.5
2
2.5
3
3.5
4
GUM
CHEWING
NAIL
BITING
LHA JAW PLAY BRUXISM
MALES FEMALESwww.indiandentalacademy.com

• Prevalence of nail biting in females is in accordance with the studies by Gavish
et al & Agerberg and Carlsson who found nail biting to be at a higher
prevalence among oral habits among females.
• These findings are in accordance with the literature which states that
parafunctional behaviors are common and usually do not harm the
stomatognathic apparatus unless they exceed the individual’s physiological
tolerance.

• In females Jaw play and Bruxism were found with almost
equal frequency . The percentage of females indulging in
the habit of bruxism was 12% which is within the 7-32%
range of other studies by Agerberg and Carlsson & Molin
et al

Distribution of habits and associated signs and symptoms in Group IV
males
Habits
Signs And Symptoms
Pain/fatigue Joint Sensitivity Joint Clicks Muscle Sensitivity
Gum Chewing 15(7.5%) 5(2.5%) 11(5.5%) 12(6%)
LHA 17(8.5%) 6(3%) 10(5%) 14(7%)
Jaw Play 25(12.5%) 9(4.5%) 19(9.5%) 21(10.5%)
Nail Biting 24(12%) 11(5.5%) 17(8.5%) 23(11.5%)
Bruxism 12(6%) 10(5%) 15(7.5%) 15(7.5%)
0
10
20
30
gum
chewing
LHA jaw play nail
biting
bruxism
PAIN FATIGUE
JOINT SENSITIVITY
JOINT CLICKS
MUSCLE
SENSITIVITY

Distribution of habits and associated signs and symptoms in Group IV females
Habits
Signs And Symptoms
Pain/fatigue Joint Sensitivity Joint Clicks Muscle Sensitivity
Gum Chewing 21(10.5%) 10(5%) 17(8.5%) 22(11%)
LHA 26(13%) 7(3.5%) 19(9.5%) 32(16%)
Jaw Play 21(10.5%) 9(4.5%) 23(11.5%) 23(11.5%)
Nail Biting 39(19.5%) 8(4%) 21(10.5%) 44(22%)
Bruxism 17(8.5%) 7(3.5%) 18(9%) 24(12%)
0
10
20
30
40
50
gum
chewing
LHA jaw play nail
biting
bruxism
PAIN FATIGUE
JOINT
SENSITIVITY
JOINT CLICKS
MUSCLE
SENSITIVITY

Prevalence of oral habits and signs and symptoms in relation to
gender
0
10
20
30
40
50
60
70
80
90
100
Pain Fatigue Joint
Sensitivity
Joint Click Muscle
Sesitivity
Number
Fig.1 Prevalance of signs and symptoms of TMD
between genders
Male
Female
0
20
40
60
Gum
Chewing
Leaning
of Head
on Arm
Jaw Play Nail
Biting
Bruxism
Number
Fig.2 Distribution of oral habits and their prevalence between
genders
Male
Female

• Schiffman et al found a positive correlation between biting
objects and the level of mandibular dysfunction in a joint
disorder population, as well as in the muscle disorder group
• Also the effects of continuous leaning of head on arm is in
accordance with the studies by Gavish et al where it was found
to be associated with joint tension and joint noises

• Jaw play and Bruxism were found to be associated with all the signs
and symptoms of TMD. In a review by Rafael et al, jaw play has been
found to be the parafunctional habit with the greatest deleterious
potential which supports the finding of our study.
• Jaw play is carried out to relieve tension or to prevent it, or whether
continuous jaw play contributes to sensation of tension in joint is yet
to be discovered.
• A study by Saheeb says that Bruxers and clenchers are prone to
developing hyperactivity in the lateral pterygoid muscle(superior
head), which tends to put the meniscus under strain.

• According to the studies by Saheeb myalgia in chewing
muscles is the stress induced hyperactivity , which is thought
to built up through oral habits and other self destructive
behavior as seen in this study also
• A study by Miyake et al also found a significant association
between parafunctional activities and TMD symptoms and also
it was found to be higher among females as observed in our
study also

 There was higher prevalence of parafunctional habits in
females
 All oral parafunctional habits except gum chewing was found to
be a risk factor for one or more signs and symptoms of
temporomandibular disorder
 Among all the signs and symptoms of TMD ,the prevalence of
Muscle sensitivity to palpation was seen to be significantly
higher among females

 TMD is now recognized as a group of bio psychosocial illnesses
 The influence of psychological factors on TMD is of therapeutic importance.
 Thus parafunctional activities that contribute to the signs and symptoms of
TMD combined with the emotional state of the individual are probably good
predictors of stomatognathic dysfunction in both the affected and healthy
subjects.

REFERENCES
• Jeffery P Okeson, Editor, Management of temporomandibular
disorders and occlusion (5th ed.), CV Mosby (2003), p.146
• Ricardo Ciancaglini, Enrico F Gherlone, Giovanni Radaelli, The
relationship of bruxism with craniofacial pain and symptoms
from the masticatory system in the adult population, J Oral
Rehabil 2001;28:842-848
• R Miyake, R Ohkubo, J Takehara, M Morita, Oral parafunctions
and association with symptoms of temporomandibular
disorders in Japanese university students, J Oral Rehabil
2004;31:518-523
• Oral habits and their association with signs and symptoms of
temporomandibular disorders: A Gender comparison , Oral
surgery, oral pathology, Oral medicine, 2005

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