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Prevalence of Temporomandibular Disorders in Patients With Gastroesophageal Reflux Disease: A Case-Controlled Study
J Oral Maxillofac Surg 68:1560-1564, 2010
Prevalence of Temporomandibular Disorders in Patients With Gastroesophageal Reflux Disease: A Case-Controlled Study Tareq M. Gharaibeh, BDS, MMedSc, FDS RCS,* Khaled Jadallah, MD,† and Fuad Abul Jadayel, BDS, DPH, MSc‡ Purpose: The present study estimated the prevalence of temporomandibular disorders (TMDs) in
patients with gastroesophageal reflux disease (GERD). Patients and Methods: A study group consisting of 60 adult patients (34 women and 26 men) diagnosed with GERD was matched by age and gender to a control group of 60 patients without any signs or symptoms of GERD. The diagnosis of TMD was established using the Research Diagnostic Criteria for Temporomandibular Disorders. Results: Of the 60 patients in the study group, 22 (36.6%) had TMD compared with 11 (18.3%) in the control group (P ⫽ .025). Most patients with TMD in both groups were diagnosed with myofascial pain: 19 (31.7%) in the study group versus 9 (15%) in the control group (P ⫽ .031). Conclusions: The increased TMD prevalence in patients with GERD should be explored further to better characterize the association between TMD and GERD. The physicians treating the 2 disorders should consider the clinical implications of this association. © 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 68:1560-1564, 2010 Gastroesophageal reflux disease (GERD) develops when reflux of the stomach contents into the esophagus causes troublesome symptoms such as heartburn or regurgitation or complications such as esophagitis.1 However, other symptoms of GERD affect various tissues and organ systems beyond the esophagus.2,3 The Montreal definition and classification of GERD has described well-established associations, although
*Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Jordan University of Science and Technology Faculty of Dentistry, Irbid, Jordan. †Assistant Professor, Department of Internal Medicine, Faculty of Dentistry, Jordan University of Science and Technology Faculty of Medicine, Irbid, Jordan. ‡Senior Resident, Department of Oral and Maxillofacial Surgery, Zarka Hospital, Zarka, Jordan. Address correspondence and reprint requests to Dr Gharaibeh: Department of Oral and Maxillofacial Surgery, Jordan University of Science and Technology Faculty of Dentistry, PO Box 3030, Irbid 22110 Jordan; e-mail: [email protected] © 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6807-0014$36.00/0 doi:10.1016/j.joms.2009.06.027
not necessarily causal, between GERD and cough, laryngitis, asthma, and dental erosion.1 Associations with pharyngitis, sinusitis, idiopathic pulmonary fibrosis, and recurrent otitis media have also been proposed.2 Although the relationship between GERD and temporomandibular disorders (TMDs) has not been previously investigated directly, indirect evidence has suggested an association between the 2 diseases.4 Furthermore, a theoretical basis exists for suspecting such an association. No single proven etiology for either GERD or TMD has been recognized. However, psychological factors have been implicated for the initiation, maintenance, and alteration of the frequency and/or severity of symptoms for both GERD and TMD.5-8 Stressful tasks increase the severity of GERD compared with neutral tasks, and relaxation training can decrease the acid reflux and the symptoms it produces.9 The use of antidepressants in conjunction with frequent support and counseling has long been reported to be superior to placebo for the treatment of patients with TMD.10 Moreover, cognitive-behavioral therapy has been found to be effective in reducing the pain and disability in patients with TMD.7,11
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The present study investigated the putative association between TMD and GERD by assessing the prevalence of TMD in patients diagnosed with GERD compared with a control group of GERD-free subjects. Assuming an association between GERD and TMD, and without necessarily adopting a particular etiologic model for either, we hypothesized that the prevalence of TMD in patients with GERD would be greater than that in GERD-free subjects.
ity of patients with TMD were evaluated using the graded chronic pain scale (GCP). The GCP integrates the pain intensity and interference with daily activities into a single scale ranging from 0 to IV (0, no TMD pain; I, low disability/low-intensity pain; II, low disability/high-intensity pain; III, high disability/moderately limiting pain; and IV, high disability/severely limiting pain).13 STATISTICAL ANALYSIS
Patients and Methods PATIENTS
The present prospective case-controlled study was conducted at King Abdullah University Hospital, Irbid, Jordan. The study group consisted of 60 consecutive patients who had previously been diagnosed by a consultant gastroenterologist with GERD on the basis of a history of typical clinical symptoms and a favorable response to acid suppression medications such as lansoprazole.1 In addition, 60 GERD-free subjects attending the Department of Internal Medicine constituted the control group. The subjects of the control group were matched by gender and age (rounded to the whole year) to the study group patients. The sample size was estimated using EpiCalc 2000 software12 at a level of significance of 0.05 and power of 80% to detect an odds ratio of 2.72, obtained from a previous pilot study of 16 patients with GERD and 14 GERD-free subjects. All patients and control subjects were informed of the purpose of the study and provided consent to participate. The institutional review board for human studies at King Abdullah University Hospital and the Jordan University of Science and Technology approved the project. METHODS
The patients and control subjects were interviewed and examined clinically by the same trained and calibrated clinician to assess the presence of TMD according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).13 The RDC/ TMD is a dual axis system used to classify and quantify the physical and psychosocial components of TMDs. Axis I allows a collective physical diagnosis of TMD and a particular diagnosis of 3 distinct, but not necessarily mutually exclusive, TMD subdiagnoses: group I, myofascial pain (masticatory muscle disorders); group II, disc displacement; and group III, other joint inflammatory or degenerative conditions such as arthralgia, osteoarthritis, and osteoarthrosis.13 Axis II assesses the presence of depression and nonspecific physical symptoms (somatization) using the subscales of the Symptom Checklist-90, yielding a score of normal, moderate, or severe.14 The psychosocial functioning and adaptabil-
Statistical analysis was performed using Statistical Package for Social Sciences, version 11 (SPSS, Chicago, IL). The differences between the 2 groups were determined using the 2 test. A P value less than .05 was considered significant.
Results The demographic characteristics of the 2 groups are listed in Table 1. The distribution of the RDC/TMD axis I diagnoses for the study and control groups are listed in Table 2. A statistically significant difference was found between the 2 groups in the incidence of a collective axis I diagnosis of TMD and in group I disorders (P ⫽ .025 and P ⫽ .031, respectively). All patients with TMD in the 2 groups exhibited group Ia (myofascial pain without limited mouth opening). All subjects with disc displacement were in group IIa (disc displacement with reduction). No subjects were diagnosed with group III (joint disorders) in either the study or control group (Table 2). The distribution of axis II findings is listed in Table 3. A statistically significant difference between the 2 groups was found for the presence of moderate somatization (P ⫽ .0001). None of the subjects in either group was diagnosed with severe somatization. Severe depression was not found in any subject in either group. Those with a GCP diagnosis of grade I or II were pooled, because only 2 of 19 patients with TMD in the study group and 1 of 9 patients with TMD in the control group had GCP grade II. None of the patients with TMD in either group had GCP grade III or IV (Table 3).
Table 1. DISTRIBUTION OF AGE AND GENDER OF STUDY AND CONTROL GROUPS
Gender Patients (n) Mean Age (yr) Age Range (yr) Men 26 (43.30) Women 34 (65.70) Total 60 (100)
38.9 43.2 41.4
19 to 65 27 to 66 19 to 66
SD 13.0 11.3 12.2
Data in parentheses are percentages. Gharaibeh, Jadallah, and Jadayel. TMDs and GERD. J Oral Maxillofac Surg 2010.
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Table 2. COMPARISON OF AXIS I RDC/TMD DIAGNOSES BETWEEN STUDY AND CONTROL GROUPS
TMD Diagnosis
Study Group (n)
Control Group (n)
2
P Value
TMD (collective axis I) Group I (myofascial pain) Group II (disc displacement) Group III (joint disorders)
22 (36.7) 19 (31.7) 6 (10) 0 (0)
11 (18.3) 9 (15) 4 (6.7) 0 (0)
5.057 4.658 0.436 NA
.025* .031* .509 NA
Abbreviations: RDC/TMD, Research Diagnostic Criteria for Temporomandibular Disorders; NA, not applicable. Data in parentheses are percentages. *Statistically significant difference. Gharaibeh, Jadallah, and Jadayel. TMDs and GERD. J Oral Maxillofac Surg 2010.
Discussion GERD and TMD are relatively common in the general adult population, with a prevalence of about 20% and 22%, respectively.15,16 Psychological factors, most notably stress, have long been implicated in the initiation and/or maintenance of both GERD and TMD.5-8 Despite this theoretical link and the anecdotal evidence from patient medical histories, to the best of our knowledge, no published study has directly investigated the putative association between GERD and TMD. In a 2004 abstract, Hargitai4 reported both GERD and TMD as comorbidities of “orofacial pain”; however, that study has yet not been published. Our results showed that the number of patients who met the clinical RDC/TMD criteria in the GERDaffected group was double that of their control counterparts. Similar to previous studies,17,18 most of these patients with TMD in the study and control groups were diagnosed with myofascial pain (Table 2). The difference of group I TMD prevalence between the study group (31.7%) and the control group (15%) was statistically significant. This association between GERD and group I TMD (myofascial pain) could be attributed to the linkage of this muscular pain with psychological factors.7,8 Moreover, increased muscular pain (group I TMD) in the GERD-affected group could also be related to muscle fatigue caused by bruxism and parafunctional habits secondary to stress
and/or to nocturnal gastroesophageal reflux in these patients.19 No subjects in either group were diagnosed with severe depression and only a relatively small percentage was diagnosed with moderate depression. However, this finding might have been a reflection of the more reserved nature of this study population in answering questions relating to depression compared with Western populations.17,20 The GERD-affected group had a 4-fold increase in somatization compared with the control group. This is consistent with reports of patients with GERD having elevated levels of somatization.9 The 2-fold increase in TMD prevalence in the study group cannot alone account for this fourfold increase in somatization among those with GERD. None of the 33 patients diagnosed with TMD in the whole sample showed evidence of severe somatization. This is in contrast to the findings of Yap et al,17 who reported a severe somatization frequency of about 25%, 27%, and 31% for their Asian, Swedish, and US samples, respectively. This notable reduction in the severe somatization level in our patients could also have been related to the sociocultural particularities of our population sample.17,20,21 Most patients with TMD in the 2 groups had low levels of pain and disability (GCP I). Only 2 patients with GERD had high-intensity pain, but with low disability
Table 3. COMPARISON OF AXIS II RDC/TMD FINDINGS BETWEEN STUDY AND CONTROL GROUPS
Axis II (Psychosocial Assessment) Depression (moderate) Somatization (moderate) GCP (grades I and II)
Study Group (n)
Control Group (n)
Chi-Square
P Value
7 (11) 24 (40) 19/22 (86.4)
2 (3.3) 6 (10) 9/11 (81.8)
3.003 14.400 0.118
.083 .0001* .731
Abbreviation: GCP, graded chronic pain (for patients diagnosed with TMD [22 and 11 patients in study and control group, respectively]). Grade I GCP, low disability/low-intensity pain; grade II GCP, low disability/high-intensity pain. Data in parentheses are percentages. *Statistically significant difference. Gharaibeh, Jadallah, and Jadayel. TMDs and GERD. J Oral Maxillofac Surg 2010.
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(GCP II), and none had high disability levels. The frequency of the disability in the patients with TMD was not significantly different between the study and control groups, suggesting that the disabling effect of TMD was not increased in patients with GERD. It was perhaps surprising that in neither group did the perception of pain by the patients with TMD have a major disabling effect. Using Bayes’ theorem22 关P共GERD\TMD兲 ⫽ P共TMD\ GERD兲P共GERD兲\ P共TMD兲兴, it is possible to combine our finding of elevated TMD prevalence in patients with GERD with the prevalence studies of GERD and TMD in the general population to compute the likelihood of GERD among patients with TMD. For instance, using the findings from our study of about 37% prevalence of TMD among patients with GERD [P(TMD\GERD)] (Table 2) and assuming a prevalence of about 20% for GERD15 [P(GERD)] and 22% for TMD16 [P(TMD)] in the general population, the likelihood of GERD among patients with TMD [P(GERD\TMD)] would be 33.6%, more than a 1.5-fold increase greater than the prevalence of GERD in the general population. Nonsteroidal anti-inflammatory drugs are routinely prescribed as first-line treatment for the acute and short-term relief of TMD symptoms.23 However, the increased likelihood of GERD in patients with TMD should promote a thorough gastrointestinal history and nonsteroidal anti-inflammatory drugs should be prescribed with caution, because they are known to cause gastrointestinal symptoms and exacerbate erosive esophageal conditions.24 The findings of the present study suggest that TMD is more prevalent in patients with GERD. Likewise, we believe the prevalence of GERD is elevated in patients affected by TMD. Therefore, a referral to a gastroenterologist should be considered part of the treatment of certain patients with TMD. Additionally, gastroenterologists should be made aware of the increased likelihood of TMD among their patients with GERD. This is particularly relevant for patients undergoing upper gastrointestinal endoscopy, a diagnostic procedure typically performed under intravenous sedation, because it involves the wide opening of the mouth by the insertion of a certain mouthpiece throughout the procedure. Dislocation of the temporomandibular joint is a frequently reported complication after upper gastrointestinal endoscopy.25-31 A recent multicenter randomized study from Korea32 found an increased incidence of “masticatory fatigue” and “masticatory pain” after upper endoscopy with intravenous sedation in patients using the traditional mouth piece in contrast to a smaller, teeth-protecting mouthpiece that tends to cushion the teeth and prevent excessive masticatory force of the sedated patient during the procedure. In a fashion similar to the
surgical removal of lower third molars,33 upper gastrointestinal endoscopy might play a role in the development or exacerbation of TMD symptoms. The need to open the mouth wide for an extended period might result in muscular and joint pain, subluxation of the condyle, or disc displacement. The use of intravenous sedation or general anesthesia during these procedures tends to decrease the patient’s protective mechanisms.32,33 In conclusion, the results of the present study suggest an increased prevalence of TMD in patients with GERD. Oral and maxillofacial surgeons, as well as gastroenterologists, should be aware of this association. Additional studies are needed to better characterize the nature of the association between these 2 comorbid disorders. Acknowledgment We thank Dr Waleed Gharaibeh for his help with the statistical analyses and his support and advice in the preparation of this report.
References 1. Vakil N, van Zanten SV, Kahrilas P, et al: The Montreal definition and classification of gastro-esophageal reflux disease (GERD)—A global evidence-based consensus. Am J Gastroenterol 101:1900, 2006 2. Hungin AP, Raghunath AS, Wiklund I: Beyond heartburn: A systematic review of the extra-oesophageal spectrum of refluxinduced disease. Fam Pract 22:591, 2005 3. Napierkowski J, Wong RK: Extraesophageal manifestations of GERD. Am J Med Sci 326:285, 2003 4. Hargitai IA: Comorbid findings in an orofacial pain population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97:450, 2004 5. Bradley LA, Richter JE, Pulliam TJ, et al: The relationship between stress and symptoms of gastroesophageal reflux: The influence of psychological factors. Am J Gastroenterol 88:11, 1993 6. Fass R, Naliboff BD, Fass SS, et al: The effect of auditory stress on perception of intraesophageal acid in patients with gastroesophageal reflux disease. Gastroenterology 134:696, 2008 7. Yap AU, Tan KB, Chua EK, et al: Depression and somatization in patients with temporomandibular disorders. J Prosthet Dent 88:479, 2002 8. Auerbach SM, Laskin DM, Frantsve LM, et al: Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients. J Oral Maxillofac Surg 59:628, 2001 9. McDonald-Haile J, Bradley LA, Bailey MA, et al: Relaxation training reduces symptoms reports and acid exposure in patients with gastroesophageal reflux disease. Gastroenterology 107:61, 1994 10. Feinmann C, Harris M, Cawley R: Psychogenic facial pain; presentation and treatment. BMJ 288:436, 1984 11. Dworkin SF, Turner JA, Mancl L, et al: A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain 16:259, 2002 12. Gilman J, Myatt M: 1998 EpiCalc 2000, version 1.02. Available at: http://www.brixtonhealth.com. Accessed March 11, 2008 13. Dworkin SF, LeResche L: Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 6:301, 1992 14. Derogatis LR, Cleary PA: Confirmation of the dimensional structure of the SCL-90: A study in construct validation. J Clin Psychol 33:981, 1977 15. Locke GR III, Talley NJ, Fett SL, et al: Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study
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in Olmsted County, Minnesota. Gastroenterology 112:1448, 1997 De Kanter RJ, Kayser AF, Battistuzzi PG, et al: Demand and need for treatment of craniomandibular dysfunction in the Dutch adult population. J Dent Res 71:1607, 1992 Yap AU, Dworkin SF, Chua EK, et al: Prevalence of temporomandibular disorder subtypes, psychologic distress, and psychosocial dysfunction in Asian patients. J Orofac Pain 17:21, 2003 Rammelsberg P, LeResche L, Dworkin S, et al: Longitudinal outcome of temporomandibular disorders: A 5-year epidemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain 17:9, 2003 Miyawaki S, Tanimoto Y, Araki Y, et al: Association between nocturnal bruxism and gastroesophageal reflux. Sleep 26:888, 2003 Hamdi E, Amin Y, Abou-Saleh MT: Problems in validating endogenous depression in the Arab culture by contemporary diagnostic criteria. J Affect Disord 44:131, 1997 Winocur E, Steinkeller-Dekel M, Reiter S, et al: A retrospective analysis of temporomandibular findings among Israeli-born patients based on the RDC/TMD. J Oral Rehabil 36:11, 2009 Sokal RR, Rohlf FJ: Biometry, the Principles and Practice of Statistics in Biological Research (ed 5). New York, WH Freeman, 1998, p 70 Ta LE, Dionne RA: Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: A randomized placebo-controlled comparison of celecoxib to naproxen. Pain 111:13, 2004
TMDs AND GERD 24. Gutthann SP, García Rodríquez LA, Raiford DS: Individual nonsteroidal antiinflammatory drugs and other risk factors for upper gastrointestinal bleeding and perforation. Epidemiology 8:18, 1997 25. Fayman MS, Dunne SE, Wellsted M: Two unusual complications related to fibre-optic endoscopy: Case reports. S Afr Med J 65:354, 1984 26. Lacy PD, Lee JM, O’Morain CA: Temporomandibular joint dislocation: An unusual complication of upper gastrointestinal endoscopy. Am J Gastroenterol 95:3653, 2000 27. Nijhawan S, Nepalia S: Dislocation of temporomandibular joint after upper gastrointestinal endoscopy. Trop Gastroenterol 15: 232, 1994 28. To EN, Pang PC, Lee DW: Temporomandibular joint dislocation during endoscopic retrograde cholangiopancreatography examination. Endoscopy 32:S36, 2000 29. Mangi Q, Ridgway PF, Ibrahim Z, et al: Dislocation of the mandible. Surg Endosc 18:554, 2004 30. Savas MC, Gulsen MT, Kadayifci A: Habitual dislocation of the temporomandibular joint during upper endoscopy. Gastrointest Endosc 60:325, 2004 31. Rosemore J, Nikoomanesh P, Lacy BE: Bilateral temporomandibular joint dislocation after PEG tube placement. Gastrointest Endosc 59:146, 2004 32. Min BH, Lee H, Jeong JS, et al: Comparison of a novel teethprotecting mouthpiece with a traditional device in preventing endoscopy-related complications involving teeth or temporomandibular joint: A multicenter randomized trial. Endoscopy 40:472, 2008 33. Huang GJ, Rue TC: Third-molar extraction as a risk factor for temporomandibular disorder. J Am Dent Assoc 137:1547, 2006
Prevalence of Temporomandibular Disorders in Patients With Gastroesophageal Reflux Disease: A Case-Controlled Study Tareq M. Gharaibeh, BDS, MMedSc, FDS RCS,* Khaled Jadallah, MD,† and Fuad Abul Jadayel, BDS, DPH, MSc‡ Purpose: The present study estimated the prevalence of temporomandibular disorders (TMDs) in
patients with gastroesophageal reflux disease (GERD). Patients and Methods: A study group consisting of 60 adult patients (34 women and 26 men) diagnosed with GERD was matched by age and gender to a control group of 60 patients without any signs or symptoms of GERD. The diagnosis of TMD was established using the Research Diagnostic Criteria for Temporomandibular Disorders. Results: Of the 60 patients in the study group, 22 (36.6%) had TMD compared with 11 (18.3%) in the control group (P ⫽ .025). Most patients with TMD in both groups were diagnosed with myofascial pain: 19 (31.7%) in the study group versus 9 (15%) in the control group (P ⫽ .031). Conclusions: The increased TMD prevalence in patients with GERD should be explored further to better characterize the association between TMD and GERD. The physicians treating the 2 disorders should consider the clinical implications of this association. © 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 68:1560-1564, 2010 Gastroesophageal reflux disease (GERD) develops when reflux of the stomach contents into the esophagus causes troublesome symptoms such as heartburn or regurgitation or complications such as esophagitis.1 However, other symptoms of GERD affect various tissues and organ systems beyond the esophagus.2,3 The Montreal definition and classification of GERD has described well-established associations, although
*Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Jordan University of Science and Technology Faculty of Dentistry, Irbid, Jordan. †Assistant Professor, Department of Internal Medicine, Faculty of Dentistry, Jordan University of Science and Technology Faculty of Medicine, Irbid, Jordan. ‡Senior Resident, Department of Oral and Maxillofacial Surgery, Zarka Hospital, Zarka, Jordan. Address correspondence and reprint requests to Dr Gharaibeh: Department of Oral and Maxillofacial Surgery, Jordan University of Science and Technology Faculty of Dentistry, PO Box 3030, Irbid 22110 Jordan; e-mail: [email protected] © 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6807-0014$36.00/0 doi:10.1016/j.joms.2009.06.027
not necessarily causal, between GERD and cough, laryngitis, asthma, and dental erosion.1 Associations with pharyngitis, sinusitis, idiopathic pulmonary fibrosis, and recurrent otitis media have also been proposed.2 Although the relationship between GERD and temporomandibular disorders (TMDs) has not been previously investigated directly, indirect evidence has suggested an association between the 2 diseases.4 Furthermore, a theoretical basis exists for suspecting such an association. No single proven etiology for either GERD or TMD has been recognized. However, psychological factors have been implicated for the initiation, maintenance, and alteration of the frequency and/or severity of symptoms for both GERD and TMD.5-8 Stressful tasks increase the severity of GERD compared with neutral tasks, and relaxation training can decrease the acid reflux and the symptoms it produces.9 The use of antidepressants in conjunction with frequent support and counseling has long been reported to be superior to placebo for the treatment of patients with TMD.10 Moreover, cognitive-behavioral therapy has been found to be effective in reducing the pain and disability in patients with TMD.7,11
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The present study investigated the putative association between TMD and GERD by assessing the prevalence of TMD in patients diagnosed with GERD compared with a control group of GERD-free subjects. Assuming an association between GERD and TMD, and without necessarily adopting a particular etiologic model for either, we hypothesized that the prevalence of TMD in patients with GERD would be greater than that in GERD-free subjects.
ity of patients with TMD were evaluated using the graded chronic pain scale (GCP). The GCP integrates the pain intensity and interference with daily activities into a single scale ranging from 0 to IV (0, no TMD pain; I, low disability/low-intensity pain; II, low disability/high-intensity pain; III, high disability/moderately limiting pain; and IV, high disability/severely limiting pain).13 STATISTICAL ANALYSIS
Patients and Methods PATIENTS
The present prospective case-controlled study was conducted at King Abdullah University Hospital, Irbid, Jordan. The study group consisted of 60 consecutive patients who had previously been diagnosed by a consultant gastroenterologist with GERD on the basis of a history of typical clinical symptoms and a favorable response to acid suppression medications such as lansoprazole.1 In addition, 60 GERD-free subjects attending the Department of Internal Medicine constituted the control group. The subjects of the control group were matched by gender and age (rounded to the whole year) to the study group patients. The sample size was estimated using EpiCalc 2000 software12 at a level of significance of 0.05 and power of 80% to detect an odds ratio of 2.72, obtained from a previous pilot study of 16 patients with GERD and 14 GERD-free subjects. All patients and control subjects were informed of the purpose of the study and provided consent to participate. The institutional review board for human studies at King Abdullah University Hospital and the Jordan University of Science and Technology approved the project. METHODS
The patients and control subjects were interviewed and examined clinically by the same trained and calibrated clinician to assess the presence of TMD according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).13 The RDC/ TMD is a dual axis system used to classify and quantify the physical and psychosocial components of TMDs. Axis I allows a collective physical diagnosis of TMD and a particular diagnosis of 3 distinct, but not necessarily mutually exclusive, TMD subdiagnoses: group I, myofascial pain (masticatory muscle disorders); group II, disc displacement; and group III, other joint inflammatory or degenerative conditions such as arthralgia, osteoarthritis, and osteoarthrosis.13 Axis II assesses the presence of depression and nonspecific physical symptoms (somatization) using the subscales of the Symptom Checklist-90, yielding a score of normal, moderate, or severe.14 The psychosocial functioning and adaptabil-
Statistical analysis was performed using Statistical Package for Social Sciences, version 11 (SPSS, Chicago, IL). The differences between the 2 groups were determined using the 2 test. A P value less than .05 was considered significant.
Results The demographic characteristics of the 2 groups are listed in Table 1. The distribution of the RDC/TMD axis I diagnoses for the study and control groups are listed in Table 2. A statistically significant difference was found between the 2 groups in the incidence of a collective axis I diagnosis of TMD and in group I disorders (P ⫽ .025 and P ⫽ .031, respectively). All patients with TMD in the 2 groups exhibited group Ia (myofascial pain without limited mouth opening). All subjects with disc displacement were in group IIa (disc displacement with reduction). No subjects were diagnosed with group III (joint disorders) in either the study or control group (Table 2). The distribution of axis II findings is listed in Table 3. A statistically significant difference between the 2 groups was found for the presence of moderate somatization (P ⫽ .0001). None of the subjects in either group was diagnosed with severe somatization. Severe depression was not found in any subject in either group. Those with a GCP diagnosis of grade I or II were pooled, because only 2 of 19 patients with TMD in the study group and 1 of 9 patients with TMD in the control group had GCP grade II. None of the patients with TMD in either group had GCP grade III or IV (Table 3).
Table 1. DISTRIBUTION OF AGE AND GENDER OF STUDY AND CONTROL GROUPS
Gender Patients (n) Mean Age (yr) Age Range (yr) Men 26 (43.30) Women 34 (65.70) Total 60 (100)
38.9 43.2 41.4
19 to 65 27 to 66 19 to 66
SD 13.0 11.3 12.2
Data in parentheses are percentages. Gharaibeh, Jadallah, and Jadayel. TMDs and GERD. J Oral Maxillofac Surg 2010.
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Table 2. COMPARISON OF AXIS I RDC/TMD DIAGNOSES BETWEEN STUDY AND CONTROL GROUPS
TMD Diagnosis
Study Group (n)
Control Group (n)
2
P Value
TMD (collective axis I) Group I (myofascial pain) Group II (disc displacement) Group III (joint disorders)
22 (36.7) 19 (31.7) 6 (10) 0 (0)
11 (18.3) 9 (15) 4 (6.7) 0 (0)
5.057 4.658 0.436 NA
.025* .031* .509 NA
Abbreviations: RDC/TMD, Research Diagnostic Criteria for Temporomandibular Disorders; NA, not applicable. Data in parentheses are percentages. *Statistically significant difference. Gharaibeh, Jadallah, and Jadayel. TMDs and GERD. J Oral Maxillofac Surg 2010.
Discussion GERD and TMD are relatively common in the general adult population, with a prevalence of about 20% and 22%, respectively.15,16 Psychological factors, most notably stress, have long been implicated in the initiation and/or maintenance of both GERD and TMD.5-8 Despite this theoretical link and the anecdotal evidence from patient medical histories, to the best of our knowledge, no published study has directly investigated the putative association between GERD and TMD. In a 2004 abstract, Hargitai4 reported both GERD and TMD as comorbidities of “orofacial pain”; however, that study has yet not been published. Our results showed that the number of patients who met the clinical RDC/TMD criteria in the GERDaffected group was double that of their control counterparts. Similar to previous studies,17,18 most of these patients with TMD in the study and control groups were diagnosed with myofascial pain (Table 2). The difference of group I TMD prevalence between the study group (31.7%) and the control group (15%) was statistically significant. This association between GERD and group I TMD (myofascial pain) could be attributed to the linkage of this muscular pain with psychological factors.7,8 Moreover, increased muscular pain (group I TMD) in the GERD-affected group could also be related to muscle fatigue caused by bruxism and parafunctional habits secondary to stress
and/or to nocturnal gastroesophageal reflux in these patients.19 No subjects in either group were diagnosed with severe depression and only a relatively small percentage was diagnosed with moderate depression. However, this finding might have been a reflection of the more reserved nature of this study population in answering questions relating to depression compared with Western populations.17,20 The GERD-affected group had a 4-fold increase in somatization compared with the control group. This is consistent with reports of patients with GERD having elevated levels of somatization.9 The 2-fold increase in TMD prevalence in the study group cannot alone account for this fourfold increase in somatization among those with GERD. None of the 33 patients diagnosed with TMD in the whole sample showed evidence of severe somatization. This is in contrast to the findings of Yap et al,17 who reported a severe somatization frequency of about 25%, 27%, and 31% for their Asian, Swedish, and US samples, respectively. This notable reduction in the severe somatization level in our patients could also have been related to the sociocultural particularities of our population sample.17,20,21 Most patients with TMD in the 2 groups had low levels of pain and disability (GCP I). Only 2 patients with GERD had high-intensity pain, but with low disability
Table 3. COMPARISON OF AXIS II RDC/TMD FINDINGS BETWEEN STUDY AND CONTROL GROUPS
Axis II (Psychosocial Assessment) Depression (moderate) Somatization (moderate) GCP (grades I and II)
Study Group (n)
Control Group (n)
Chi-Square
P Value
7 (11) 24 (40) 19/22 (86.4)
2 (3.3) 6 (10) 9/11 (81.8)
3.003 14.400 0.118
.083 .0001* .731
Abbreviation: GCP, graded chronic pain (for patients diagnosed with TMD [22 and 11 patients in study and control group, respectively]). Grade I GCP, low disability/low-intensity pain; grade II GCP, low disability/high-intensity pain. Data in parentheses are percentages. *Statistically significant difference. Gharaibeh, Jadallah, and Jadayel. TMDs and GERD. J Oral Maxillofac Surg 2010.
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(GCP II), and none had high disability levels. The frequency of the disability in the patients with TMD was not significantly different between the study and control groups, suggesting that the disabling effect of TMD was not increased in patients with GERD. It was perhaps surprising that in neither group did the perception of pain by the patients with TMD have a major disabling effect. Using Bayes’ theorem22 关P共GERD\TMD兲 ⫽ P共TMD\ GERD兲P共GERD兲\ P共TMD兲兴, it is possible to combine our finding of elevated TMD prevalence in patients with GERD with the prevalence studies of GERD and TMD in the general population to compute the likelihood of GERD among patients with TMD. For instance, using the findings from our study of about 37% prevalence of TMD among patients with GERD [P(TMD\GERD)] (Table 2) and assuming a prevalence of about 20% for GERD15 [P(GERD)] and 22% for TMD16 [P(TMD)] in the general population, the likelihood of GERD among patients with TMD [P(GERD\TMD)] would be 33.6%, more than a 1.5-fold increase greater than the prevalence of GERD in the general population. Nonsteroidal anti-inflammatory drugs are routinely prescribed as first-line treatment for the acute and short-term relief of TMD symptoms.23 However, the increased likelihood of GERD in patients with TMD should promote a thorough gastrointestinal history and nonsteroidal anti-inflammatory drugs should be prescribed with caution, because they are known to cause gastrointestinal symptoms and exacerbate erosive esophageal conditions.24 The findings of the present study suggest that TMD is more prevalent in patients with GERD. Likewise, we believe the prevalence of GERD is elevated in patients affected by TMD. Therefore, a referral to a gastroenterologist should be considered part of the treatment of certain patients with TMD. Additionally, gastroenterologists should be made aware of the increased likelihood of TMD among their patients with GERD. This is particularly relevant for patients undergoing upper gastrointestinal endoscopy, a diagnostic procedure typically performed under intravenous sedation, because it involves the wide opening of the mouth by the insertion of a certain mouthpiece throughout the procedure. Dislocation of the temporomandibular joint is a frequently reported complication after upper gastrointestinal endoscopy.25-31 A recent multicenter randomized study from Korea32 found an increased incidence of “masticatory fatigue” and “masticatory pain” after upper endoscopy with intravenous sedation in patients using the traditional mouth piece in contrast to a smaller, teeth-protecting mouthpiece that tends to cushion the teeth and prevent excessive masticatory force of the sedated patient during the procedure. In a fashion similar to the
surgical removal of lower third molars,33 upper gastrointestinal endoscopy might play a role in the development or exacerbation of TMD symptoms. The need to open the mouth wide for an extended period might result in muscular and joint pain, subluxation of the condyle, or disc displacement. The use of intravenous sedation or general anesthesia during these procedures tends to decrease the patient’s protective mechanisms.32,33 In conclusion, the results of the present study suggest an increased prevalence of TMD in patients with GERD. Oral and maxillofacial surgeons, as well as gastroenterologists, should be aware of this association. Additional studies are needed to better characterize the nature of the association between these 2 comorbid disorders. Acknowledgment We thank Dr Waleed Gharaibeh for his help with the statistical analyses and his support and advice in the preparation of this report.
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