TO ASSESS THE RELATIONSHIP BETWEEN TEMPOROMANDIBULAR JOINT DYSFUNCTION AND CERVICAL SPINE DYSFUNCTION

Khyati Harish Sanghvi (BPT)*, Amrit Kaur (MPT)**, Ganesh Subbiah (MPT)***

ABSTRACT The temporomandibular joint is directly related to the cervical and scapular region. AIM- To assess any possible relationship between temporomandibular dysfunction (TMD) and cervical spine dysfunction (CSD) METHODS- Total 30 volunteers,15 volunteers that were presenting clinical signs and symptoms of TMD and 15 volunteers that were presenting CSD according to Temporomandibular Dysfunction Assessment Questionnaire and Neck disability Index respectively were selected for this study. Individuals having TMD were assessed for any signs and symptoms of CSD using Neck disability Index, Index of Cervical Mobility and VAS score. Individuals having CSD were assessed for TMD using Temporomandibular Dysfunction Assessment Questionnaire, Mandibular Mobility Index and VAS score RESULT-Correlation test (p 0.05) was performed to verify the relationship between CSD & TMD. The increase in TMD signs and symptoms was accompanied by increase in CSD severity. CONCLUSION- The result of this study concluded that TMD is accompanied with CSD and vice-a-versa.

KEYWORDS: Cervical pain, cervical spine dysfunction, Temporomandibular Joint; Temporomandibular joint dysfunction.

INTRODUCTION Cervical spine dysfunctions are common

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conditions affecting the cervical region and related structures, with or without radiating pain towards

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the Shoulder, Arms, Inter scapular region and Head

1, 2, 3

considered a predisposing factor for cervical spine dysfunction, and supposing that the referred neck pain is of orofacial origin7, there should be direct relationship between the increase of cervical spine dysfunction previously signs and symptoms and the

. There are estimates that 67% of the

population will suffer from neck pain at some stage of life 3. Neck pain is often the major symptom in cervical spine dysfunction related to post-traumatic or to chronic micro-traumatic lesions of the joints and periarticular structures1. Temporomandibular dysfunctions are defined as common non-dental cause of orofacial pain . Temporomandibular dysfunction is collective term applied to all problem joint and related to
4

existing

temporomandibular

dysfunction severity. Mara evaluated Ines Baptistella of Ferao (2008)

prevalance

temporomandibular

dysfunction in patients undergoing physiotherapy treatment for cervical pain. They concluded that 90% of patients with cervical pain were found to have temporomandibular dysfunction16. However study done by BEVILAQUAGROSSI (2007) concluded that, cervical signs and symptoms accompanied temporomandibular

temporomandibular

associated

musculoskeletal structures. Temporomandibular dysfunction characterizes a cluster of disorders marked by pain in the pre-auricular area, temporomandibular joint and masticatory muscles, as well as limitations or deviations during the mandible range of motion, and temporomandibular joint sounds during function 5. Anatomically, the mandible and the base of skull presents the muscular and ligamentous connections with the cervical region, forming a functional system known as cranio-cervicomandibular system6. If cervical spine dysfunction is considered a predisposing factor for temporomandibular dysfunction, and supposing that the related Orofacial pain is of cervical origin 7, there should be a direct relationship between the increase of temporomandibular dysfunction signs and

dysfunction but the inverse was not true, the temporomandibular dysfunction sign and

symptoms did not increase with cervical spine dysfunction severity in female community cases17. It is known that the balance of the body, as well as the movements of the head, originated from the positioning of the skull over the cervical and scapular region; determine the posture of the individual. Therefore, it is supposed that any alteration in these structures can bring about postural imbalance, not only in these locations, but also in other muscle groups of the body11. In this way, temporomandibular dysfunction may

represent a constant concern for Medicine, Dentistry, Physiotherapy and Public Health who wish to understand the behavior of the joint in its biomechanical activities. The present study was done to determine any possible relationship between cervical spine dysfunction and temporomandibular dysfunction in individuals aging from 18 to 40years. The

symptoms and the previously existing cervical spine dysfunction severity. Thus, cervical spine Lesions caused by repetitive movements , head and cervical posture alterations
9, 10 8

likely lead to

cervical spine dysfunctions and, subsequently, to the manifestation of temporomandibular

dysfunction signs and symptoms. If temporomandibular dysfunction is

findings of this study can be used to frame

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Scientific Research Journal of India Volume: 2, Issue: 2, Year: 2013

assessment and management goals in patients with cervical spine dysfunction and/or

Total between 70 and 100 points

Severe TMD

The mean of the patients age with primary temporomandibular dysfunction was 25 years (SD=7). Temporomandibular Joint ROM and

temporomandibular dysfunction.

METHODS 30 patients were selected to participate in the study on basis of inclusion criteria; Individuals aging from 18 to 40 years. 15 Individuals having temporomandibular joint dysfunction (Group 1). 15 Individuals having cervical spine dysfunction (Group 2). Exclusion criteria was General Joint Disorder involving Head and Neck (e.g. Rheumatoid Arthritis); History of Jaw Fracture; Individuals suffering through Facial Palsy; History of Cervical vertebra fracture; Patients having Trigeminal Neuralgia and Patients having braces applied for proper alignment of teeth. 15 volunteers that were primarily presenting clinical signs and symptoms according of to

VAS were recorded. Then they were assessed for any signs and symptoms of cervical spine dysfunction using Neck disability Index13, index of cervical mobility (ICM)14 and VAS score. Other 15 volunteers that were primarily presenting cervical spine Dysfunction according to Neck disability Index13 were selected as Group 2 for this study. They were screened for any exclusion criteria and then divided into severity i.e., mild, moderate or severe Cervical spine dysfunction on basis of their scoring in Neck disability Index13. The Neck Disability Index is divided into 10 set of multiple choice questions which have 6 options for each and each 5 options are scored from 0 to 5 on basis of severity. Maximum score can be 50 and minimum 0.
Table 2: NDI scoring Total between 0 and 4 Total between 5 and 14 Total between 25 and 34 Total between 35 and 50 No CSD Mild CSD Moderate CSD Severe CSD

temporomandibular Temporomandibular Questionnaire

12

dysfunction Dysfunction

Assessment

were selected as Group 1 to The mean of the patients age with primary cervical spine dysfunction was 24.1 years (SD=6.65). Cervical Spine ROM and VAS were recorded. Then they were assessed for using Assessment

participate in the study. They were screened for any exclusion criteria and then divided into severity i.e., mild, moderate or severe of Temporomandibular dysfunction on basis of their scoring in temporomandibular
12

dysfunction

assessment

temporomandibular Temporomandibular

dysfunction Dysfunction

questionnaire . The questionnaire is set of 10 questions regarding Temporo-mandibular

Questionnaire, Index of Mandibular mobility (IMM)15 and VAS score. The movements following were Temporomandibular maximal mouth

dysfunction and the symptoms. Answers were collected in terms of YES, SOMETIMES or NO and were scored 10, 5 or 0 respectively. Maximum score can be 100 and minimum 0.
Table 1: TMDQ Scoring Total between 0 and 15 points Total between 20 and 40 points Total between 45 and 65 points No TMD Mild TMD Moderate TMD
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recorded:

opening (MMO), maximal lateral deviation to right and left (MLDR and MLDE) and maximal protrusion (MP). The cervical movements of flexion, extension, right and left rotations and right

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and left lateral flexions were recorded. To measure Temporomandibular and Cervical range of motion, a ruler (mm) and a universal Goniometer () were used respectively. This study was approved by the

correlation

coefficient

(SRCC) =

0.223214,

p>0.05. As coefficient of correlation value is between 0 and +1, we can say that the two sets of data show weak, positive correlation. But as P value is more than 0.05, the result is not significant, i.e., there is no correlation between scores of IMM and CMI scores. The correlation test was applied to check prevalence of cervical spine dysfunction in

Committee for Ethics and Research of the NDMVP medical college and the patients signed a term of free and informed consent confirming their agreement to participate in the study. Spearmans rank correlation test was

patients with temporomandibular dysfunction. The result was, spearmans rank correlation coefficient (SRCC) = 0.62857, p<0.05. As coefficient of correlation value is between 0 and +1, we can say that the two sets of data show good,

performed to verify the relationship between cervical spine dysfunction & temporomandibular dysfunction.

RESULT Descriptive data is given in table 3.

positive correlation. As P value is less than 0.05, the result is significant, i.e., there is prevalence of cervical spine dysfunction in patients with temporomandibular dysfunction. Group 2 Total 15 individuals were selected under the category of cervical spine dysfunction after performing screening test (NDI). The mean of the

Table 3: Descriptive Data Group 1 Total 15 individuals were selected under the category of temporomandibular dysfunction after performing screening test (TMDQ). The mean of the patients age was 25 years (SD=7). On analysis it was found that 26.67% patient had no cervical spine dysfunction, 60% had mild, 6.67% had moderate and 6.67% had severe cervical spine dysfunction. The mean VAS of two groups was; Cervical pain: 2.64 Temporomandibular Joint pain: 4.25 The correlation test was applied to check the association between the scores of index of mandibular mobility and index of cervical mobility. The Result was, spearmans rank
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patients age was 24.1 years (SD=6.65). On analysis it was found that, 40% had mild, 33% had moderate and 26.67% had severe

temporomandibular dysfunction. The mean VAS of two groups was; Cervical pain: 4.66 Temporomandibular Joint pain: 1.6 The correlation test was applied to check the association between the scores of index of mandibular mobility and index of cervical mobility. The Result was, spearmans rank correlation coefficient (SRCC) = 0.076786,

p>0.05. As coefficient of correlation value is between 0 and +1, we can say that the two sets of data show very weak, positive correlation. But as P value is more than 0.05, the result is not

Scientific Research Journal of India Volume: 2, Issue: 2, Year: 2013

significant, i.e., there is no correlation between scores of IMM and CMI scores. The correlation test was applied to check prevalence of temporomandibular dysfunction in patients with cervical spine dysfunction. The result was, spearmans rank correlation coefficient (SRCC) = 0.657143, p<0.05. As coefficient of correlation value is between 0 and +1, we can say that the two sets of data show good,

neck

are

anteriorly

sternocleidomastoid

and

posteriorly the levator scapula. The mandible is controlled by the muscle of mastication and it is connected to cranium through its articulation of the teeth and the temporomandibular joint. This complex relationship is important since mandible is attached to both cranium and cervical spine and any positional changes of either will produce postural changes of mandible and hence

positive correlation. As P value is less than 0.05, the result is significant, i.e., there is a prevalence of temporomandibular dysfunction in patients with cervical spine dysfunction. DISCUSSION The result of this study demonstrated that there is prevalence of temporomandibular

disturbances in its articulation. The inverce is also true that if there is disturbances in

temporomandibular joint articulation, it can alter the position of mandible and in turn cervical spine and shoulder girdle. Thus there is relationship between the mandible, the cranium, the cervical spine,

suprahyoid and infrahyoid structures, shoulder girdle, the thoracic spine and ultimately the lumbosacral spine. These structures function as inter related biomechanical unit. Dysfunction in any one part of this unit may often lead to dysfunction of unit as a whole. However in reviewed literature, there were no studies that varified the time required for development of of orofacial pain signs and symptoms caused by head postuer alteration and vice-versa. The result of this study suggest that almost all the individual with cervical spine dysfunction had temporomandibular dysfunction and about 73% of individuals with temporomandibular dysfunction had cervical spine dysfunction.

dysfunction in patients with cervical spine dysfunction or cervical spine dysfunction is one of the predisposing factors for temporomandibular dysfunction and vice-a-versa. However, significant differences in the values of Mandibular range of motion among temporomandibular dysfunction severity groups and in values of cervical range of motion among cervical spine dysfunction severity groups were not verified. The ideal posture of head places the center of gravity slightly anterior to the cervical spine. For this reason, when sitting or standing the head falls anteriorly if the muscles of the head and neck are totaly relaxed. To maintain this postural position, strong posterior cervical muscles are needed. The anterior cervical muscles are small and thin muscles which come from the clavicle, sternum and rib cage to the hyoid bone (infrahyoid muscles) and from the hyoid to the mandible (suprahyoid muscles). Two other important muscle which controls position and stability of head and
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CONCLUSION The result of this study concluded that

temporomandibular dysfunction is accompanied with cervical spine dysfunction and vice-a-versa. Almost all the individual with cervical spine dysfunction had temporomandibular dysfunction

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and

about

73%

of

individuals

with

dysfunction.

temporomandibular dysfunction had cervical spine

REFERENCES

1. Ciancaglini R, Testa M and Radaelli G (1999). Association of neck pain with symptoms of temporomandibular disorders in the general adult population. Scand J Rehabil Med.;31(1):17-22. 2. De Wijer A, Steenks MH, Bosman F, Helders PJ and Faber J (1996). Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders. J Oral Rehabil; 23(11):733-741. 3. Visscher CM, Lobbezoo F, Boer W, van der Zaag J, Verheij JG and Naeije M (2000). Clinical tests in distinguishing between persons with or without craniomandibular or cervical spinal pain complaints. Eur J Oral Sci; 108(6):475-483. 4. Mcneill C (1997). Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent; 77(5):510-522. 5. Dworkin SF, Huggins KH, Leresche L, Von Korff M, Howard J, Truelove E, et al (1990). Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. J Am Dent Assoc; 120:273-281. 6. Arrelano JCV (2002). Relaes entre postura corporal e sistema estomatogntico. JBA; 2: 155-164. 7. Browne PA, Clark GT, Kuboki T and Adachi NY (1998). Concurrent cervical and craniofacial pain: a review of empiric and basic science evidence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 86(6):633-640. 8. Kirveskari P, Alanen P, Karskela V, Kaitaniemi P, Holtari M, Virtanen T, et al (1988). Association of functional state of stomatognathic system with mobility of cervical spine and neck muscle tenderness. Acta Odontol Scand; 46(5):281-286. 9. Gonzalez HE and Manns A (1996). Forward head posture: its structural and functional influence on the stomatognathic system, a conceptual study. Cranio; 14(1):71-80. 10. Mannheimer JS and Rosenthal R (1991). Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dent Clin North Am; 35:185-208. 11. Amanta DV, Novaes AP, Campolongo GD and Barros TP(2004). A importncia da avaliao postural no paciente com disfuno temporomandibular. Acta Ortop Brs; 12:1-8. 12. Kariny Nomura, Mathias Vitti, Anamaria Siriani de Oliveria, Thas Cristina Chaves, Marisa Semprini, Selma Siessere, Jaime Eduardo Cecilio Hallak and Simone Cecilio Hallak Regalo (2007). Use of the Fonsecas Questionnaire to assess the prevalence and Severity of Temporomandibular Disorders in Brazilian Dental Undergraduates. Braz Dent J; 18(2): 163-167. 13. Joy C. Macdermid, David M. Walton, Sarah Avery, Alanna Blanchard, Evelyn Etruw, Cheryl Mcalpine and Charlie H. Goldsmith (2009). Measurement Properties of the Neck Disability Index: A Systematic Review. Journal of orthopaedic & sports physical therapy; 39, 5:400-417.

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14. Wallace C and Klineberg IJ (1993). Management of craniomandibular disorders. Part 1. A craniocervical dysfunction index. J Orofac Pain; 7(1):83-88. 15. Helkimo M (1974). Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Swed Dent J; 67(2):101-21. 16. Mara Ines Baptistella Ferao and Jefferson Traebert (2008). Prevalence of temporomandibular dysfunction in patients with cervical pain under physiotherapy treatment. Fisioter; 21(4):63-70. 17. Dbora Bevilaqua-Grossi, Thas Cristina Chaves and Anamaria Siriani de Oliveira (2007). Cervical spine signs and symptoms: perpetuating rather than predisposing factors for temporomandibular disorders in women. J Appl Oral Sci; 15(4):259-64.

CORRESPONDING AUTHOR: * N.D.M.V.P College of Physiotherapy, Email: drkhyati_26@yahoo.co.in ** Assistant Professor, Department Of Community Based Rehabilitation, N.D.M.V.P College of Physiotherapy, Email: dr_amritkaur@yahoo.co.in *** Associate Professor, Department of Musculoskeletal Sciences, N.D.M.V.P College of Physiotherapy, Email: ganeshmpt2006@yahoo.co.in

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