Pain Res Manag. 2017;2017:2164825. doi: 10.1155/2017/2164825

Prevalence of Painful Temporomandibular Disorders and Correlation to Lifestyle Factors among Adolescents in Norway

Annika Rosén,1 Ketil Moen1, Trond Storesund,2 and Vegard Østensjø2

1Division of Oral and Maxillofacial Surgery, Department of Clinical Dentistry, University of Bergen, Bergen, Norway

2 Specialist Oral Health Centre for Western Norway, Stavanger, Norway

Correspondence should be addressed to Annika Rosén;

PMID: 28638246



Temporomandibular dysfunction or disorder (TMD) includes disorders in the masticatory muscles, the temporomandibular joint (TMJ), or both [1]. Pain in the masticatory muscles or TMJ, impaired joint function, or a combination of factors is typical signs of TMD [2].TMJ disorders are specific to the joint and encompass disc displacements and degenerative diseases [1]. TMD also includes myalgia, a nonspecific pain of muscular origin. Distinguishing between joint- and muscle-related disorders is important in the context of possible treatment. With correct diagnosis and treatment, pain resolves over time in most cases. Long-standing TMD without a correct diagnosis and treatment can sometimes give rise to chronic or persistent pain [1]. TMD is considered to be multifactorial, with both somatic and psychological components. In particular, psychopathological conditions, such as anxiety and depression, seem to play a significant role in many patients with TMD [1, 3, 4].

Severe TMD symptoms typically have a low prevalence [5]. Among children and adolescents, girls have a significantly higher prevalence than boys [6], but the prevalence is lower than for adults. In Norway, an epidemiological study on TMD among adolescents has shown a prevalence of TMD to be 11.9% and pain related to TMD 7.2% [7].

According to a Norwegian national health survey, psychological problems like stress and anxiety among adolescents are greatly increasing in Norway [8]. This trend has been partly explained by self-applied pressure to be perfect in all aspects of life, including school, the social sphere, and physical appearance. This pressure has increased with the introduction of social media in daily life, such as Facebook, Snapchat, and Instagram, according to a Finnish study [9].

Aims of the study was to estimate the prevalence of painful temporomandibular disorders (TMD-P) among adolescents and to investigate correlations with health, environment, and lifestyle factors.



For this cross-sectional case-control study, 562 patients were consecutively recruited at their yearly revision control from four dental clinics in Rogaland County, Norway. Eleven dentists working in four different clinics volunteered. One clinic was in a rural area and three were in urban areas. The study population represents 1.3% of the total population in the county. The number of clinics and dentists that performed the assessments accounts for 10% of all clinics and dentists in the county.

Patients completed a questionnaire on general health, socioeconomics, demographics, and lifestyle factors. Responses to two screening questions identified patients with TMD-P, who then underwent clinical examination to verify the TMD diagnosis. These questions were as follows: (1) Do you have pain in your temples, face, temporomandibular joint, or jaws once a week or more? (2) Do you have pain when you open your mouth wide or chew once a week or more? The clinical examination included assessment of jaw movements using a ruler (maximal opening between the incisal frontal teeth, laterotrusion, and protrusion in millimeters), registration of joint sounds (clicking or crepitations), and palpation for tenderness over the joints and masticatory muscles. Tenderness to palpation was recorded and graded as none, mild, moderate, or severe pain. A diagnosis of myalgia, arthralgia, or a combination of the two was given based on the findings. The examination was based on the RDC/TMD criteria for anatomical sites and digital pressure.

Pain intensity was assessed on a visual analogue scale (VAS) to score the pain intensity (on a scale 0 to 100; 0 = no pain, 100 = worst, unbearable pain). Patients without TMD-P constituted the control group and were not clinically examined.



Among the the cohort of 13- to 19-year-old Norwegians, 7% experienced TMD-P. The female-to-male ratio is 3:1; median age is 17 years (p < 0.001) ( (figures 1). Patients at urban clinics had higher prevalence compared with those at rural clinics In proportion to the whole country this division was in accord with the Central Statistical Agency of Norway. The prevalence of TMD-P was 8.5% in the urban area clinics (n= 387) and 3.4% in the rural district (n = 175) (p < 0.05, figure 2). TMD-P patients had headache and severe menstrual pain compared to controls. They were more likely to live with divorced/single parents and less likely to have regular physical activity (figures 3 and 4). Spending more than 3 hours per day in front of a computer did not affect the prevalence of TMD-P.

Moderate or severe pain on palpation over the TMJs was reported in 45% of the case patients. Tenderness to palpation over at least one muscle of mastication was reported in 82.5%. Moderate or severe tenderness to palpation over the muscles of mastication ranged from 35% to 45%. In summary, myalgia was present in 21 patients with TMD-P, arthralgia was found in nine, and myalgia and arthralgia in nine. Females had higher pain intensity than males.



This study is the second and by far the largest study on the prevalence of TMD-P among adolescents in a Norwegian county. The prevalence of TMD-P in Rogaland County was 7%. The findings of the present study are in accordance with a Swedish study from 1999 that included 862 adolescents (12 to 18 years old), with a prevalence of TMD-P of 7% [6]. Another Swedish study published in 2005, using the TMD-P questions on more than 28,000 adolescents in the year 2000, found a prevalence of 4.2% [10]. The discrepancy may be attributed to differences between societies in Norway and Sweden, despite these neighboring countries often being regarded as similar. The 14 years between the studies has seen the introduction of smartphones and social media. Consequently, adolescents of today are more or less constantly online and introduced to new areas in which to perform. The Norwegian media frequently reports about social media, such as Facebook, Instagram, and Snapchat, and the negative impact they have on the psychological health of adolescents. A Canadian study from 2014 found that 23% of teenagers experienced cyberbullying the last 12 months. It also found that the teenagers had lower self-esteem and showed greater psychological distress than non-victims [11]. A Norwegian national survey on adolescents reports an increase, especially among females, in anxiety and psychological distress from 2010 to 2013 [12]. This change in social interaction may explain some of the increased incidence of TMD-P from 2000 to 2014.

Two other recent studies report a prevalence of TMD among adolescents ranging from 34% to 74% [13, 14]. These studies included both subjective (e.g., pain in movement) and objective (e.g., joint sounds) symptoms to estimate the prevalence, but they did not include the two TMD-P questions and therefore cannot be compared with this study. Such a high prevalence of TMD affects half the population, and it is worth discussing whether non-painful TMD truly is TMD. In the oral and maxillofacial surgeon´s environment, this subject is often debated. According to DC/TMD criteria, clicking without pain is TMD; however, since this symptom is common and is seldom a problem for the patient, we do not think it should be classified as TMD. If so, the classification will highlight a disease rather than normalize it.

In conclusion, the prevalence of TMD-P among adolescents found in this study was 7%.This prevalence is low, but it is comparable to studies in other countries using the same methodology. Being female, living in urban areas, having severe menstrual pain, and having frequent headaches and the parent marital status are all associated with TMD-P. Regular exercise is associated with less TMD-P. Females report significantly higher pain intensity than males. Myalgia is the most frequent symptom of TMD-P.



Fig. 1. TMD-pain among a population of 563 adolescents. The sex and age are presented showing that females are highly represented.



Figure 2. Patients at urban clinics had higher prevalence of TMD-pain compared with patients at rural clinics (*p=0.018).



Figure 3. More common with TMD-pain in adolescents living in families with divorced or single parents (**p=0.008).



Figure 4. Lower prevalence of TMD-pain among physically active adolescents (*p=0,025).



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