Received: 22 May 2018 Revised: 19 November 2018 Accepted: 28 November 2018

DOI: 10.1002/cre2.157

ORIGINAL ARTICLE

Assessing stress associated with temporomandibular joint

disorder through Fonseca's anamnestic index among the Saudi
physicians
Samar O. Al Hayek1 | Mashael F. Al‐Thunayan2 | Amjad M. AlGhaihab2 |

Reem M. AlReshaid3 | Aamir Omair4

1
College of Dentistry, King Saud bin Abdulaziz
University for Health Sciences, National Guard Abstract
Hospital, Riyadh, Saudi Arabia The study aims to investigate signs and symptoms of temporomandibular disorders
2
College of Dentistry, King Saud bin Abdulaziz
(TMD) among physicians in a tertiary health‐care center. It has estimated the level
University for Health Sciences, Riyadh, Saudi
Arabia of symptomatology, determined the association with demographic data, and identified
3
Dental College, Riyadh Elm University, the related occupational risk factors. A cross‐sectional survey was used, and
Riyadh, Saudi Arabia
4
physicians of genders, all age groups, and nationalities from King Abdulaziz Medical
College of Medicine, King Saud bin Abdulaziz
University for Health Sciences, Riyadh, Saudi City in Riyadh, Saudi Arabia, were recruited. Subjects who had rheumatic arthritis,
Arabia osteoarthritis, trigeminal neuralgia, or temporomandibular joint (TMJ) trauma were
Correspondence
excluded. The data were collected through a self‐administered questionnaire that
Amjad M. AlGhaihab, College of Dentistry,
King Saud bin Abdulaziz University for Health measured TMD severity and oral parafunctional behaviors. Fonseca's anamnestic
Sciences, Altandeem Street, Riyadh 14215,
index (FAI) and an oral validated behavior checklist were used to assess the signs
Saudi Arabia.
Email: [email protected] and symptoms of TMD. A total of 282 physicians participated in the study, and the
prevalence of TMD signs among physicians was 37% (106); among them, 88 (83%)
were within the light dysfunction category. Female physicians reported significantly
higher FAI than males for side‐to‐side mandibular movement (12% vs. 5%,
P = 0.04), reporting ear pain (18% vs. 10%, P = 0.04), and noticing clicking when
chewing or opening the mouth (35% vs. 20%, P = 0.006). Younger practitioners
(28–31 years old) who reported clicking while chewing or opening the mouth
tended to have reported higher TMD dysfunction (35%) than those aged 40 and
above (13%; P = 0.007). Self‐reported signs of TMD were 37% among our
population. Information collected from FAI is useful in early diagnosis and preven-
tion of TMD.

KEY W ORDS

physicians, prevalence, Saudi Arabia, signs, temporomandibular joint disorders

--------------------------------------------------------------------------------------------------------------------------------
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
©2018 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

52 wileyonlinelibrary.com/journal/cre2 Clin Exp Dent Res. 2019;5:52–58.

AL HAYEK ET AL. 53

1 | I N T RO D U CT I O N 2 | THEORETICAL BACKGROUND

Temporomandibular disorders (TMD) is a group of conditions that TMD being a multifactorial etiology is associated with several factors

cause dysfunction in the temporomandibular joint leading to chronic that play an important role in the induction, perpetuation, and aggra-
recurrent pain along with its muscles and supporting tissues (McNeill, vation of TMD. Some of the previous studies have depicted that some
1997). TMD has an effect not only on its sufferers but also on the symptoms and the pain intensity of TMD were higher among females
community that endures its expensive treatment and poor productiv- (Bagis, Ayaz, Turgut, Durkan, & Özcan, 2012; Johansson, Unell,
ity (Gatchel, Stowell, Wildenstein, Riggs, & Ellis, 2006). The signs indi- Carlsson, Söderfeldt, & Halling, 2003; Macfarlane, Blinkhorn, Davies,
cating the probable presence or occurrence of a disease include Kincey, & Worthington, 2002). Johansson et al. (2003) conducted a
limited jaw motions in vertical, lateral, and retrusive mandibular move- cross‐sectional study on 50‐year‐old subjects and yielded in TMJ pain

ments; deviation of the mandible; pain during some or all joint excur- prevalence of 7% and 12% in males and females, respectively. Another
sion; muscle pain (masseter, medial, and lateral pterygoids) during study done by distributing a self‐assessment survey on patients in a
palpation; and joint clicking/crepitation sounds reported and palpated medical care center in England stated that orofacial pain prevalence

(Cooper & Kleinberg, 2007; Gøtzsche, 2007). of TMD was 21% in males and 30% in females (Macfarlane et al.,
Symptoms of the disorder are clinical manifestations of temporo- 2002). The same study showed that pain was higher among the youn-
mandibular joint pain that are sensed by the patient in a subjective ger population (Macfarlane et al., 2002). In Jordan, more than two

manner, which is difficult to quantify (Gøtzsche, 2007). In a prevalence third of university students complained of at least one symptom of
study of TMD, myofacial pain was found to be the most common diag- TMD (Ryalat et al., 2009). In a recent cross‐sectional study from Saudi
nostic with a prevalence of 15% (Al‐Khotani et al., 2016). Other symp- Arabia conducted on children and adolescents, about one third of the
toms included jaw muscle stiffness, locking of the jaw, difficult or participants were diagnosed with at least one TMD sign or symptom
inadequate movement, chewing struggle, painful clicking of the joint (Al‐Khotani et al., 2016). Another study assessed the prevalence of
during opening or closing the mouth, and change in teeth articulation signs and symptoms of TMD and oral parafunction habits among Saudi
(Cooper & Kleinberg, 2007). There are symptoms of TMD that do not adolescents (Feteih, 2006). The results showed that about one fifth

encompass the musculoskeletal system such as nonotologic otalgia and one third of the participants displayed at least one sign and
(ear pian that is not caused by the ear), dizziness, tinnitus, and tooth- symptoms of TMD, respectively. Moreover, females were found to
ache. TMD can also be manifested as tension headache, migraine, be more affected as compared with males (Feteih, 2006).

neck pain, and myofascial pain in that region, which may occur in Sign and symptoms of TMD can be assessed in different methods
combination or alone (Magnusson, Egermark, & Carlsson, 2005). depending on the feasibility, time, and cost. Few of the studies have
Every individual is subjective to certain factors of external envi- assessed the signs and symptoms of TMD by FAI because of its easy
ronment and respond differently to the external stressors. It is impor- applicability comparing with other assessment tools. In Saudi Arabia,
tant to identify the stresses and deal with it, appropriately. An Habib et al. utilized this questionnaire to assess the reported signs
important role is played by the psychological factors in the onset and symptoms of TMD among the male university students. The pre-
and development of TMD. Majority of the individuals activate their viously mentioned research revealed that almost half of the partici-

stomatognathic system to relieve their stresses by limiting teeth grind- pants reported of signs and symptoms of TMD (Fonseca, Bonfante,
ing, clenching teeth, and masticatory muscle contraction (Calixtre, Valle, & Freitas, 1994; Habib et al., 2015).
Gruninger, Chaves, & Oliveira, 2014). The individuals suffering from Another study indicated an association between improper sleep,

TMD suffer from headaches that influence their functional and psy- stress, and parafunctional habits in undergraduate and postgraduate
chosocial quality of life. Previous literature investigated the presence dental students at Dow University of Health Sciences in Pakistan.
of TMD among children, adolescent, and college students. TMD The study showed that 56% of the students had stress‐related teeth

among physicians was not discussed thoroughly in literature before; grinding at night and stress was associated with improper sleep lead-
nevertheless, depressive symptoms and stress among medical special- ing to parafunctional habits (Sardar, 2015). Van der Meulen, Lobbezoo,
ties have been recognized as risk factors for this disorder (Bernburg, Aartman, and Naeije (2014) stated that there was no significant asso-
Vitzthum, Groneberg, & Mache, 2016). ciation between oral parafunctional habits and facial pain. However,
Majority of the previous studies have reviewed and addressed oral parafunctional habits were assessed using oral behavior checklist
adolescents and children. Therefore, in the present epidemiologic (OBC) for its evident validity and reliability (Ohrbach, Beneduce,
study, self‐reported signs of temporomandibular joint disorders among Markiewicz, & McCall, 2004; Van der Meulen et al., 2014).

physicians of a tertiary health‐care center have been evaluated. The aim

of this study was to assess the prevalence of TMD signs among physi- 3 | MATERIAL AND METHODS
cians and its association with oral parafunctional habits using Fonseca's
anamnestic index (FAI). This association might highlight the eventual
3.1 | Study design
causative factors that would help in investigating the elimination of
suspected factors and their relation with decreased signs of TMD. The study has employed an analytical cross‐sectional design. It was
The main strength of the study was the inclusion of medical profes- performed in different departments in National Guard Health Affairs
sionals from different areas of the hospital to compare between special- (NGHA) medical center that belongs to the governmental sector in
ties, gender, and age group with respect to TMD signs and symptoms. Riyadh, Saudi Arabia.
54 AL HAYEK ET AL.

3.2 | Study population frequencies and percentages (e.g., gender and specialty) and numerical
variables that were described in terms of mean ± standard deviation
Saudi/non‐Saudi medical physicians of both genders of all age groups (e.g., age and years of experience). With respect to age, the partici-
from the NGHA in Riyadh, Saudi Arabia, were selected for the study. pants were divided into four groups based on the percentile‐derived
The total study population was estimated to be 2,200 physicians, with intervals (25th percentile was 27 years, 50th percentile was 31 years,
a ratio of 3:1 male to females. The prevalence of TMD as found in the and 75th percentile was 39 years). Chi‐square test was used to com-
literature ranged between 7% and 30%. Assuming a prevalence of pare categorical variables (e.g., OBC according to the presence of
30% (Al‐Khotani et al., 2016; Johansson et al., 2003), a population size TMD dysfunction, gender and age group, and also TMD dysfunction
of 2,200, a confidence level of 95%, and a precision of 5%, the optimal with respect to gender, age group, and to specialties). A P value
sample size was estimated to be 282 subjects. Sample size was calcu- <0.05 was considered to show a significant association.
lated using the prevalence formula in nQuery software (Hodges &
Pihlstrom, 1998). Subjects who had rheumatic arthritis, trigeminal neu-
ralgia, or trauma to the TMJ were excluded. 4 | RESULTS

A total of 400 questionnaires were distributed; 282 (70.5%) were

3.3 | Ethical considerations
answered. The missing 118 included 51 questionnaires not returned,

Permission from the Executive Director of the Medical Services in and 67 were excluded based on the exclusion criteria. There were 179

NGHA was obtained to distribute the questionnaires. Moreover, IRB (64%) male and 103 (36%) female respondents. The mean age of the

approval from King Abdullah International Medical Research Center respondents was 33.9 ± 8.7 years, the majority (70%) of them having

was obtained before starting the data collection. In addition, an 1 to 10 years (median = 6 years) of practice since graduation (Table 1).

informed consent was signed from the participants for their participa- TMD dysfunction in this study was identified on the basis of self‐

tion in the study. reported scores using the FAI (Fonseca et al., 1994; Nomura et al.,
2007). According to FAI score, 176 (62%) of the participants did not
have any signs of TMD dysfunction, whereas 88 (31%) had signs of
3.4 | Data collection methods, instruments used, and light TMD dysfunction, 17 (6%) with moderate TMD dysfunction,
measurements and 1 (0.4%) with severe TMD dysfunction. TMD highest signs of dys-
function were among gynecology/urology (47%), followed by anesthe-
Convenient sampling was used to approach towards all the available
siology (46%), and surgery (43%), whereas the lowest was among
physicians in the wards or departments. The physicians were then
internal medicine (25%) and family/emergency medicine (16%;
given the questionnaire to be filled. The adopted self‐administered
Figure 1). Out of 146 of the respondents with high OBC, 76 (52%)
questionnaire is composed of three sections: (A) demographic data,
of them had reported TMD dysfunction as compared with those with
(B) TMD severity, and (C) oral parafunctional behavior. Section A
low OBC (n = 114) where only 27 (24%) reported TMD dysfunction
reported the social demographic data, participants' specialties, and and only three out of 22 of those who did report any parafunctional
years of practice since graduation.
habits (14%) reported TMD dysfunction (Table 2).
Section B measured the TMD severity using FAI (Nomura et al.,
The comparison between respondents with signs of TMD dys-
2007). FAI composes of 10 questions with three options (yes, some-
function (n = 106) and those without TMD (n = 176) with the items
times, and no) for each question. Each answer has its score with
on the OBC has been shown in Table 3. Most items on the OBC were
2 = yes, 1 = sometimes, and 0 = no. One question was omitted in this
found to be significantly associated with TMD dysfunction except for
questionnaire because of cultural difference because this research
pressing tongue forcibly between teeth, using chewing gum, eating
was conducted in Saudi Arabia. Total scores ranged from 0 to 18,
between meals, sustained talking, and holding the telephone between
which were categorized to no TMD (0–3), mild (4–8), moderate (9–
the head and shoulder.
13), or severe TMD (14–18; Fonseca et al., 1994; Nomura et al., 2007).
The respondents were categorized into four age groups according
Section C was adopted from the Research Diagnostic Criteria for
to the quartiles (24–27, 28–31, 32–39, and 40+ years). Table 4 has
TMD questionnaire axis II. A validated OBC is used to better determine
shown the items on the OBC that were found to be significantly asso-
the presence of oral parafunctional behaviors, which are any abnormal
ciated with age group. It was found that respondents in the older age
behavior or functioning of the oral structures and associated muscles. group of 40+ years had relative lower percentages of reporting on the
OBC originally composes of 21 items; however, two items were omitted
OBC as compared with those in the younger age groups.
due to cultural reasons (Schiffman et al., 2014). The sum of scoring had
The most commonly reported symptom in this study was stress
the following scheme: none = 0, low = 1–16, and high = 17–76.
(53%) followed by headache (42%) and neck/nape pain (31%). Female
physicians (n = 103) were more likely to report symptoms on the FAI
3.5 | Statistical analysis as compared with males (n = 179) regarding moving the mandible side
to side (12% vs. 5%, P = 0.04), feeling pain in the ear of the temporoman-
Data were analyzed using the Statistical Package for Social Sciences dibular joint (18% vs. 10%, P = 0.04), and noticing clicking when chewing
(SPSS 23 software, Chicago, IL, USA). Descriptive statistics were pre- or opening the mouth (35% vs. 20%, P = 0.006). Younger practitioners
sented as categorical variables that are described in terms of (28–31 years old) who reported clicking while chewing or opening the
AL HAYEK ET AL. 55

TABLE 1 Characteristics of the respondents (N = 282) a high number of patients is a difficult and stressful responsibility. The

Description n (%)
association of TMD signs and symptoms to stress has been discussed
and linked with some of the previous studies (Habib et al., 2015;
Age (n = 281) 24 to 27 years 77 (27%)
28 to 31 years 71 (25%) LeResche, Mancl, Drangsholt, Saunders, & Von Korff, 2005; Sardar,
32 to 39 years 63 (22%) 2015; Yap et al., 2003).
40+ years 70 (25%)
In the present study, females had significantly higher FAI values
Years of practice since 1 to 10 years 197 (70%)
graduation (n = 279) 11 to 20 years 52 (18%) for moving the mandible side to side, having tinnitus or pain related
21 to 30 years 26 (9%) to the temporomandibular joint, and noticing clicking when chewing
31 to 40 years 4 (1%)
or opening the mouth. Similar results were reported in a study in Brazil
Gender (n = 282) Male 179 (64%)
Female 103 (37%)
associating between age and gender with TMD symptoms concluded
that higher chances of presenting pain symptoms and dysphonia were
more in the female group than the male (Ferreira, Silva, & Felício,
2016). The orofacial pain distribution regarding gender especially in
the TMD suggested a possible association between the female sex
hormones or the pain modulation mechanisms and the TMD, acknowl-
edging that women are more sensitive to pain modalities (LeResche,
Mancl, Sherman, Gandara, & Dworkin, 2003; McEwen, Alves, Bulloch,
& Weiland, 1998; Sarlani, Garrett, Grace, & Greenspan, 2007). A study
similar to the present analysis reported prevalence of male students in
Riyadh who reported TMD signs and symptoms using FAI. The results
showed that 10% of the respondents reported moderate to severe
TMD (Habib et al., 2015). In the present study, almost one third of
the physicians were found to have one or more of TMD symptoms,
with 6% of them in the moderate to severe category. The prevalence
could have been higher if the study included physicians with osteoar-
FIGURE 1 Prevalence of temporomandibular joint disorder among thritis, rheumatic arthritis, trigeminal neuralgia, or any trauma to the
physicians by specialty (N = 282). Pearson chi‐square for
temporomandibular joint.
temporomandibular disorders between different specialties: P
value = 0.58 The present study has identified three specialties to report the
highest TMD signs and symptoms including gynecology/urology,
anesthesiology, and surgery. Previous studies have reported the risk
mouth tend to have reported TMD dysfunction based on FAI scores
factors of the TMD such as stress and depressive symptoms. For
more than those aged 40 years and above (35% vs. 13%, P = 0.007).
instance, a study conducted in German hospitals showed that psy-
Figure 2 has illustrated the significant differences in OBC items
chosocial distress was highest in surgical medicine whereas depres-
based on gender differences. A greater proportion of females, that is,
sive symptoms were highest in internal medicine followed by
58 (56%) out of 103, reported the use of chewing gum as compared with
gynecology specialty (Bernburg et al., 2016). The findings regarding
73 (41%) out of 179 males (P = 0.01). The males (16%) were more likely
the patterns for TMD age‐related signs and symptoms reported were
to report placing the tongue between teeth as compared with 4% of the
consistent with results of the present study (Manfredini, Piccotti,
females (P = 0.002) and jutting the jaw forward (15% vs. 5%, P = 0.01).
Ferronato, & Guarda‐Nardini, 2010). Reporting any clicking while
opening or closing the mouth was common among population youn-
5 | DISCUSSION ger than 40 years old. Manfredini et al. (2010) reported an interesting
finding in which the mean age of TMD with a diagnosis of disc dis-
The present study was conducted in one of the main tertiary health‐ placement with or without pain was 32.7 years, whereas inflamma-
care hospitals in Riyadh to assess the self‐reported signs of TMD tory disorders (osteoarthritis/osteoarthrosis) had a mean age of
among physicians and its associated signs and symptoms using FAI. 54.2 years. This made clear that the patients with symptoms of a
King Abdul‐Aziz Medical City is known to have highly qualified physi- clicking sound accompanied with pain were mostly young aged
cians and high number of patients, and providing good quality care to (Manfredini et al., 2010).

TABLE 2 Comparison of severity of temporomandibular disorders based on classification of oral behavior checklist (N = 282)
TMD severity classification based on FAI
With moderate to severe Without dysfunction/light
OBC classification Total (N = 282) dysfunction (9–18) n = 18 dysfunction (0–8) n = 264 P value

No 22 (8%) 0 (0%) 22 (100%) 0.005

Low (1–16) 114 (40%) 2 (2%) 112 (98%)
High (17–76) 146 (52%) 16 (11%) 130 (89%)

Note. TMD: temporomandibular disorders; FAI: Fonseca's anamnestic index; OBC: oral behavior checklist.
56 AL HAYEK ET AL.

TABLE 3 Association between oral behavior checklist and TMD dysfunction

Without TMD
With TMD dysfunction
Oral behavior Total dysfunction (n = 176)
checklist (n = 282) (n = 106) P value
Clench or grind teeth when asleep, based on any information you may have 52 29 (27%) 23 (13%) 7
Sleep in a position that puts pressure on the jaw 117 61 (58%) 56 (32%) <0.001
Grind teeth together during waking hours 37 25 (24%) 12 (7%) <0.001
Clench teeth together during waking hours 59 38 (36%) 21 (12%) <0.001
Press, touch, or hold teeth together other than while eating 76 45 (42%) 31 (18%) <0.001
Hold, tighten, or tense muscles without clenching or bringing teeth together 40 21 (20%) 19 (11%) 0.03
Hold or jut jaw forward or to the side 31 18 (17%) 13 (7%) 0.01
Press tongue forcibly against teeth 29 15 (14%) 14 (8%) 0.09
Place tongue between teeth 33 19 (18%) 14 (8%) 0.01
Bite, chew, or play with your tongue, cheeks, or lips 78 40 (38%) 38 (22%) 0.003
Hold jaw in rigid or tense position 32 22 (21%) 10 (6%) <0.001
Hold between the teeth or bite objects 52 31 (29%) 21 (12%) <0.001
Use chewing gum 131 54 (51%) 77 (44%) 0.24
Lean with your hand on the jaw, such as cupping or resting the chin in the hand 103 49 (46%) 54 (31%) 0.009
Chew food on one side only 110 52 (49%) 58 (33%) 0.007
Eating between meals 146 58 (55%) 88 (50%) 0.44
Sustained talking 122 53 (50%) 69 (39%) 0.08
Yawning 139 62 (58%) 76 (43%) 0.01
Hold telephone between your head and shoulders 118 52 (49%) 66 (38%) 0.06

Note. Those who answered “yes” and “sometimes” were grouped into one category (with TMD dysfunction). Those who answered “>1 night/month” were
considered as yes. TMD: temporomandibular disorders.

TABLE 4 Oral behavior checklist factors of respondents who reported presence of the habit at least one night a month showing significant
difference by age quartiles
Age quartiles
Q1 (24–27 years; Q2 (28–31 years; Q3 (32–39 years; Q4 (40+ years;
Oral behavior checklist n = 77) n = 71) n = 63) n = 70) P value

Sleep in a position that puts pressure on the jaw 36 (47%) 34 (48%) 29 (46%) 17 (24%) 0.01
Clench teeth together during waking hours 18 (23%) 21 (30%) 14 (22%) 6 (9%) 0.01
Press, touch, or hold teeth together other than while eating 27 (35%) 23 (32%) 17 (27%) 9 (13%) 0.01
Hold, tighten, or tense muscles without clenching or bringing 12 (16%) 17 (24%) 8 (13%) 3 (4%) 0.009
teeth together
Bite, chew, or play with your tongue, cheeks, or lips 25 (33%) 28 (39%) 15 (24%) 10 (14%) 0.006
Hold between the teeth or bite objects 18 (23%) 13 (18%) 16 (25%) 5 (7%) 0.02
Use chewing gum 44 (57%) 37 (52%) 33 (52%) 17 (24%) <0.001
Lean with your hand on the jaw 38 (49%) 29 (41%) 24 (38%) 12 (17%) <0.001
Eating between meals 45 (58%) 41 (58%) 34 (54%) 26 (37%) 0.03
Yawning 46 (60%) 36 (51%) 33 (52%) 23 (33%) 0.01
Hold telephone between your head and shoulders 35 (46%) 34 (48%) 31 (49%) 17 (24%) 0.008

Quartile 4 percentages were significantly less than the other three quartiles.

A similar study conducted among university students in Riyadh significant when measuring stress, which is associated with TMD
showed that one third of males reported the presence of psychological (Goodfellow, Varnam, Rees, & Shelly, 1997; Sardar, 2015). Nonethe-
stress (Habib et al., 2015). However, the present study has revealed less, the same study concluded that the job itself for a physician is
that more than half of the respondents were stressed. The high per- not the cause of stress. Oral parafunctional habits would contribute
centage of stress that is reported by both genders in the present study to TMD onset and could be considered a risk factor if only a score in
is evidence of the heavy workload that is experienced by the physi- the 17–76 range is reported from the OBC (Schiffman et al., 2014).
cians in NGHA. On the contrary, a study done in the United Kingdom Occurrence of these habits increases the probability of having one
concluded that both age and sex of medical doctors were not or more TMD sign and symptoms. Half of the physicians who reported
AL HAYEK ET AL. 57

DISC LOSURE
This study was approved by institutional review board of King Abdul-
lah International Medical Research Center (KAIMRC).

Fund ing Informa ti on

No funding information provided.

ACKNOWLEDGMENTS

The authors would like to show appreciation to KAIMRC for providing

the opportunity for this research to be done. In addition, we wish to
FIGURE 2 Frequency and percentage of oral behavior checklist
thank the National Guard Hospital Affairs and all those who agreed
according to gender (males = 179, females = 103). Pearson chi‐
square significance for oral behavior checklist according to gender: to participate in this project.
*
P = 0.06, **P = 0.01, ***P < 0.01
CONFLIC T OF INT E RE ST

TMD dysfunction were categorized in the high oral parafunctional habits; None declared.
likewise, a study in São Paulo, Brazil, on adolescents identified sleep
bruxism, awake bruxism, and other parafunctional habits to have TMD ORCID
pain (Fernandes, van Selms, Gonçalves, Lobbezoo, & Camparis, 2015). Samar O. Al Hayek https://orcid.org/0000-0003-0655-5624
The results of present study revealed that the habit of holding Mashael F. Al‐Thunayan https://orcid.org/0000-0002-4527-8183
objects between teeth or biting objects, grinding, or clenching the teeth Amjad M. AlGhaihab https://orcid.org/0000-0001-8222-0602
has been significantly associated with signs of temporomandibular joint Reem M. AlReshaid https://orcid.org/0000-0003-2709-0707
dysfunction. Winocur, Littner, Adams, and Gavish (2006) found similar Aamir Omair https://orcid.org/0000-0002-1168-7341
results on association of oral habits and signs and symptoms of TMD
for adolescents. Their results revealed significant association of brux- RE FE RE NC ES
ism to several TMD signs and symptoms including joint disturbances, Al‐Khotani, A., Naimi‐Akbar, A., Albadawi, E., Ernberg, M., Hedenberg‐
pain/fatigue during chewing, and joint sensitivity to palpation (Winocur Magnusson, B., & Christidis, N. (2016). Prevalence of diagnosed tempo-
romandibular disorders among Saudi Arabian children and adolescents.
et al., 2006). The present study has depicted that leaning with the hand
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pain/fatigue during chewing and joint sensitivity to palpation (Winocur difference in prevalence of signs and symptoms of temporomandibular
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