Temporomandibular disorders among schizophrenic patients. A case-control study
Los trastornos temporomandibulares en pacientes esquizofrenicos. Un estudio de casos-controles

 

Eugenio Velasco Ortega ⁽¹⁾, Loreto Monsalve Guil ⁽²⁾, Carmen Velasco Ponferrada ⁽²⁾, Ramon Medel Soteras ⁽³⁾, 
Juan Jose Segura Egea ⁽³⁾

(1) Profesor Titular de Odontología Integrada de Adultos y Gerodontología
(2) Profesor Colaborador Docente de Gerodontología
(3) Profesor Asociado de Odontología Integrada de Adultos. Facultad de Odontología. Universidad de Sevilla

Address:
Dr. Eugenio Velasco Ortega
C/ José Laguillo nº 18 2º-6
41003 Sevilla

Received: 21-03-2004  Accepted: 12-03-2005

Velasco-Ortega E, Monsalve-Guil L, Velasco-Ponferrada C, Medel-Soteras R, Segura-Egea JJ. Temporomandibular disorders among schizophrenic patients. Med Oral Patol Oral Cir Bucal 2005;10:315-22. © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-4447

ABSTRACT The aim of this study was to assess the prevalence of temporomandibular disorders (tmd) in schizophrenic patients compared with control patients. Patients and methods. 50 schizophrenic patients attended in the Psychiatric Unit at the Virgen Macarena Universitary Hospital of Seville were compared with 50 control patients (without systemic diseases, and drugs) attended in the School of Dentistry of Seville. TMD were assessed according to the WHO criteria. Results and Discusion. 32% of schizophrenic patients showed symptoms of TMD, clicking (24%) and self-correcting blocking (8%); compared with 8% (sounds) of control patients. Significantly, these differences support that TMD are most prevalent in patients with mental disorders. Prevalence of TMD are not related with age of patients.TMD are more frequent among male patients in both groups. There are not relationship between TMD and prosthodontic status. Clinical findings of this study showed a significantly tendency between TMD with a highest number of missing teeth in control patients. Conclusions. Schizophrenic patients constitute a high risk population for TMD because showed a more prevalence and severity of TMD. Key words: Temporomandibular disorders, schizophrenic patients, temporomandibular joint, mental disorders, case-control study.

RESUMEN El objetivo del presente trabajo era valorar la prevalencia de trastornos témporomandibulares(TTM) en pacientes esquizofrénicos comparados con pacientes control. Diseño del estudio. El estudio se realizó en 50 pacientes esquizofrénicos ingresados en la Unidad de Psiquiatría del Hospital Universitario Virgen Macarena de Sevilla y se compararon con 50 pacientes adultos de los que acuden a recepción de la Facultad de Odontología de la Universidad de Sevilla, excluyendo de este último grupo aquellos pacientes que presentaban alguna patología sistémica en el momento de la exploración o en los seis meses previos a ésta. En ambos grupos se valoró la presencia de trastornos témporomandibulares según el protocolo de la OMS. Resultados y Discusión. Entre los pacientes esquizofrénicos, el 32% presentaban síntomas de trastornos témporomandibulares, sobre todo chasquidos o ruidos articulares (24%) y autocorreción de la dislocación (8%); mientras que en los pacientes control, la frecuencia era del 8%, que se correspondía con ruidos articulares. Estas diferencias eran significativas, lo que confirma que los TTM son más prevalentes entre los pacientes que sufren trastornos mentales. El estudio demuestra que el estado de la ATM era independiente de la edad de los pacientes. Los hombres presentaban mayor frecuencia de TTM en ambos grupos. No existía relación entre la presencia de TTM y el estado prostodóncico de los pacientes. Los hallazgos del presente trabajo demuestran una tendencia significativa entre un mayor número medio de dientes perdidos y la frecuencia de TTM en los pacientes sanos control. Conclusiones. Los pacientes esquizofrénicos constituyen una población de riesgo para los TTM porque presentan una mayor prevalencia y severidad de los mismos. Palabras clave: Trastornos témporomandibulares, pacientes esquizofrénicos, articulación témporomandibular, trastornos mentales, estudio caso-control.

 

INTRODUCTION

Temporomandibular Disorders (TMD) constitute a complex and heterogeneous group of conditions and clinical problems that involve the temporomandibular joint (TMJ) and the masticatory musculature (1). TMD are an important challenge for dental profession because is a field of dentistry with many controversies in the aetiopatogenesis, diagnosis and treatment (2)

Epidemiologically, the distribution of TMD in the general population results different according to selected samples and assesssment methods (3-4). However TMD are disorders of adult age with a prevalence of signs (i.e. sounds, opening/closing disfunction) and symptoms (ej. TMJ o referred pain) reported that 11-44% of population (5-8).

Aetiology of TMD is multifactorial (1-3). Clasically, risk factors may be local (i.e. malocclusion, orthodontic treatment, occlusal disharmony) and systemic (i.e. rheumatologic diseases, emotional stress) (1). Today, the knowledge of aetiopatogenesis of TMD is moving from a dentally based to a more biologic and medical based model (9).

Psychological factors (i.e. anxiety and depression) can play a significant role in the aetiology and maintenance of TMD (10-15). In fact, biopsychosocial factors were related with the onset of symptoms, muscle tension and chronic orofacial pain (3,16-17). It suggests that TMD are a psycophysological manifestation of stress, because TMD patients express more frequent and more severe psychologic, somatic and behavioral stress symptoms (18-19). In juveniles (6-8 years), emotional stress status can increase the probability of development muscle tension related to TMJ 20. Also TMD are more frequent among institutionalized psychiatric patients (21). Finally, psychiatric treatment of mental disorders (i.e. depression) and their positive acceptation for TMD patients can improve outcome of treatment (22-23).

Clinical research of TMD is numerous but they are not specific studies that assesses the frequency of TMD signs and symptoms among patients with mental disorders compared with control patients. The aim of this study was to assess the prevalence of TMD in schizophrenic patients compared with healthy control patients.

MATERIAL AND METHODS

This comparative study of TMD was conducted in two groups of patients, schizophrenics and healthy controls that were selected with a random stratified method according to age and sex.

Schizophrenic patients were selected from patients with diagnosis of schizophrenia attending the Psychiatry Unit of Universitary Hospital Virgen Macarena inside in The Faculty of Medicine of Seville. The control patients were selected from subjects seaking dental treatment at the School of Dentistry of Seville. Patients with systemic disease and/or taking any medication were excluded. Also were excluded any patient with acute systemic disease in six months before.

Oral examination took place in the School of Dentistry of Seville for healthy control patients and in the Psychiatry Unit of Universitary Hospital Virgen Macarena of Seville for schizophrenics patients. Oral examination, including TMJ, was determined according to criteria set by the World Health Organization (24).

Data of frequency and distribution of signs and symptoms of TMJ were assessed in both groups of patients (schizophrenics and control), according to demographic (age and sex) and clinical (dental and prosthodontic status) data. Data were analyzed by the analysis of variance (cuantitative data) and chi-square (cualitative data). Statistical significance was established at p < 0,05.

RESULTS

Fifty schizophrenic patients were examined (39 males and 11 females) with a mean age of 39.9 years (range: 17-64 years) and 50 healthy control patients (33 males and 17 females) with a mean age of 39,5 years (range: 20-67 years). Differences in age (ANOVA; p = 0,8542) and sex (chi-square; p = 0,18145) between both groups were not statistically significant.

All schizophrenic patients were treated with psychotropic drugs (mean: 3.9). Neuroleptics (72%), atypical antipsychotics (60%), benzodiazepines (50%) and antiparkinsonians (50%) were psychotropic drugs more used.

Twenty nine schizophrenics patients (58%) and 26 control patients (52%) were smokers (58%). Differences between both groups were not statistically significant (chi-square; p = 0, 12000).

Sixteen schizophrenic patients (32%) expressed signs and symptoms of TMD. Clicking (24%) and self-correcting blocking (8%) were the more frequent findings. Four healthy control patients (8%) showed clicking. These differences were significant (chi-square; p = 0,00745).

TMD according to age. Among schizophrenic patients, TMD were more prevalent in 36-45 yrs patients; clicking (28%) and self-correcting blocking (16%); while normal TMJ were more commom in older (>46 yrs) schizophrenic patients. These differences were not significant (chi-square; p = 0,23652). TMD according to age among healthy control patients did not show significant differences (chi-square, p = 0,30201).

TMD according to sex. Between schizophrenic patients, males showed a higher prevalence of clicking (25.6%); however, females showed a higher frequence of normal TMJ (72.7%) and self-correcting blocking (9.1%). These differences were not significant (chi-square; p = 0,87536). Between healthy control patients, males showed a higher prevalence of clicking (9.1%) than females (5.9%); also, normal TMJ (94.1%) was more common among females. These differences were not significant (chi-square; p = 0,69199).

TMD according to dental status. Table 1 expresses the prevalence of clinical findings of TMD according to number of missing teeth in both patient groups. Schizophrenic patients did not show significant differences (chi-square; p = 0,40638). However, relationship between TMD and number of missing teeth among healthy control patients was statistically significant (chi-square; , p = 0,00620).

TMD according to prosthodontic status. Table 2 expresses TMD prevalence according to prosthodontic maxillary status in schizophrenic patients (chi-square; p = 0,93916) and healthy control patients (chi-square; p = 0,11785). Prosthodontic mandibular status did not correlated with TMD in schizophrenic patients (chi-square; p = 0,38868) and healthy control patients (chi-square; p = 0, 53864).

DISCUSSION

Clinical findings of this study demonstrate significant differences in prevalence and distribution of TMD between schizophrenic (32%) and healthy control (8%) patients. It indicates that TMD are more prevalent in patients than suffer mental or psychological disorders 10-23. These results are confirmed by a Spanish study reported among hospitalized chronic psychiatric patients that showed the presence of signs and symptoms related TMJ of 39.3%, including clicking (28.9%), self-correcting blocking (10%) and blocking (0,5%) (21). TMD affected to all depressed patients, and to 42% of schizophrenic patients (21).

Scientific literature indicate that psychological factors related with TMD are important. It demonstrates a relationship between psychosocial disorders and the onset, symptomatology, prognosis and treatment of TMD (10,16,22-23). Stress (18-20), anxiety (10-12) and depression (14-15,23) are the more important psychological factors associated with TMD. In fact, an American study assesses psychological disorders in 50 patients with chronic TMD and 51 patients with acute TMD showing a higher frequency of psychopathological disturbances in both groups that in general population 12. Anxiety disturbances (47-53%) are more frequent in acute TMD patients, and affective disorders (i.e. depression) are more prevalent among chronic TMD patients (78%). Also, this study suggest the need of follow-up to identify psychological characteristics of acute TMD patients for control the tendency to TMD chronicity and TMD pain symptoms (12). In fact, pain symptoms in TMD patients decreased significantly when psychological problems are diagnosed and treated (22).

Emotional disturbance related with stressful life events experience (i.e. health, economic and work problems) can affect to a important group of patients suffering TMD triggering the onset of TMJ referred symptomatology (24-26). In fact, patients with TMJ dysfunction pain experienced twice as many stressful life events in the 6 months before onset as did control patients. These life events related with TMD aetiopatogenesis could play a role in depression and schizophrenia (26). Moreover, many TMD patients show other stress-associated syndromes as fibromyalgia and chronic fatigue syndrome, suggesting a common pathophysiologic basis involving psychosocial and neuroendocrine mechanisms (17,19).

Depression can be strongly related with TMD, as aetiologic factor and/or response to physical and pain disturbance of these patients (14-15,17,23). It is generally agreed that negative life events, personality disturbances or inadaptation of patients (i.e. depression) are involved in the multifactorial aetiology of TMD, playing a important role in the onset and outcome of TMD, specially in TMD pain (17). An epidemiological study confirmed these findings showing an important relationship between depression and TMD symptomatology (14). In fact, a sample of 5.696 Finland subjects was examined. The results showed significant higher proportion of depression in subjetcs with pain-related symptoms of TMD compared with non-pain subjects (14).

Many TMD patients are depressed (39%) and have a high degree of nonespecific physical symptoms (55% of somatization) as gastrointestinal symptomatology (i.e. nausea, vomiting), pain (i.e. back pain), neurologic symptoms (i.e. memory changes) and psychosexual complaints (i.e. impotence) (15).

Other risk factors (age, sex, dental and prosthodontic status) related with TMD are assessed in clinical studies involving a multifactorial aetiologic model and an interdisciplinary therapeutic approach (1-2,9). The present study demonstrate that TMD are independent of age of patients. However, highest prevalence of TMD (44%) was found in 36-45 yrs schizophrenic patients. This highest frequency of TMD in midle-age patients is confirmed by several studies in patients with psychologic disorders (10,15,19,23,27) and in the general population (7,28). In fact, the results of the 1994 Spanish National Oral Health Survey show that 23% of 35-44 yrs subjects present any clinical finding related with TMD (29). This intervale of age may be associated a more stressful life events as work, marriage and money problems (26). However, others studies demonstrate a higher prevalence of TMD with increased age suggesting a higher trend to TMD as result of general and oral health impairment (i.e. tooth loss, inadequate prosthodontics) and degenerative changes in TMJ (4,28,30).

The present study does not show arelationship between TMJ status and sex of patients, in agreement with the results reports by other case-control study over the importance of stress in TMD patients (18). However, males of both groups (schizophrenics and healthy control subjects) showed high degree of TMD, while that the majority of studies reported a more frequency of TMD in females patients (8,19,31-33). In fact, it is suggest a higher perception in women of TMD symptomatology by influence of psychologic and hormonal factors, and a stronger tendency in the care-seeking behaviour compared with men (23,33-34).

Relationship between tooth loss and TMJ status has been investigated (34-35). High incidence of TMD have been reported after loss of posterior teeth because the condyle has increased mobility and this mobility allows increased contraction of supporting musculature (36). In the present study, significant relationship between number of missing teeth and TMD in healthy control patients has been showed. However, has been not a clear tendency of TMD related with a higher mean number of missing teeth (Table 1).

The present study demonstrate that TMD are independent of prosthodontic status of patients (Table 2). The possible relationship between prosthetics and TMD is controversial (30,36-37). One reason is that complete-denture wearers have a impaired oral function and will accept mandibular dysfunction (36). However, few studies concerning TMD in complete-denture wearers with difficulty or pain during mandibular movements, pain in the TMJ, deviation of the mandible during opening and, tenderness of the masticatory muscles (30,34,36).

CONCLUSIONS

TMD are a group of conditions involving stomatognatic system with a multifactorial aetiopathogenesis basis. Psychologic factors (stress, anxiety, depression) increased the frequency of TMD among patients with mental disturbances. It has been evidenced the importance of assessment diagnosis of psychologic disorders for improve the medical and dental care in TMD patients with special prevention of chronic symptomatology, specially TMJ related pain.

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