Use of Fonseca’s Questionnaire to assess the prevalence and severity of Temporomandibular disorders among university students-a cross sectional study

Aim: Temporomandibular disorders (TMD) are one of the main causes of non-dental orofacial pain. It has been reported that TMD occurred more frequently among individuals in stressful situations and that university students are more likely to have a high risk of anxiety related disorders. This study aims to assess the prevalence and severity of TMD in undiagnosed population consisting of students of different faculties in a university campus in Bengaluru using the Fonseca’s questionnaire. Material and Methods: Descriptive cross-sectional study conducted at a University Campus, Bengaluru. Completed forms of Fonseca’s questionnaire were collected from the sample consisted of 300 students. The questionnaire had two main parts. First part collected demographic information and past relevant histories. Second part had Fonseca’s 10 questions. The TMD severity was categorized as no TMD (0-15), mild TMD (20-40), moderate TMD (45-65) and severe TMD (70-100). Results: 33.3% on the sample showed varying signs of TMD. There was no statistically significant differences found between the TMD and non TMD groups with respect to age and sex. But when comparing varying grades of TMD there was a statistically highly significant difference seen in relation to age of the subjects. Conclusions: A high prevalence of TMD was found in the university students with majority of the cases having milder signs of TMD.


Introduction
Temporomandibular disorders (TMD) are one of the main causes of non-dental orofacial pain. The pain is generally located on the masticatory muscles, in the preauricular area and the temporomandibular joint (TMJs). [1] The term temporomandibular disorders is a collective term which includes all the problems involving painful orofacial disorders, complaints of pain in TMJ region and fatigue of the craniocervicofacial muscles, especially masticatory muscles, limitation of mandible movement, and presence of articular clicking. [2] Many factors such as oral habits, fatigued masticatory muscles and premature loss of natural teeth have been linked to the disorder. [3] Other important aetiological factors include emotional stress and high anxiety levels. [4] Previous studies of various populations have reported a high prevalence of TMD.
[5] The presence of TMD signs has been reported in more than 50% of nonpatients, with the presence of at least one symptom being reported among more than 30% of subjects.
[6] The variability in prevalence may be attributed to differences in the race of the population, in the sampling design and criteria, and in the methods used for collecting information. [7] Due to the high prevalence and variability of the complaints, TMD is diagnosed by associating signs and symptoms, as some characteristics may be frequent even in a non-patient population. [8] It has been reported that TMD occurred more frequently among individuals in stressful situations.
[9] It has been reported that university students are more likely to have a high risk of anxiety-and depression-related clinical disorders.
[10] In a study on an Indian population, among all the participants examined sixty participants had no TMD (30%), 110 participants had mild TMD (55%); 28 patients had moderate TMD (14%) and two participants had severe TMD (1%). [ Despite the advantages, the DC/TMD is quite a cumbersome assessment tools in that it requires the individual to be present in order to render a TMD diagnosis, and it is difficult to use on large samples. Due to the need of simpler assessment procedures that can be widely applicable and to standardize research samples involving TMD patients, questionnaires have been created to address the main clinical TMD findings and assign clinical indexes for patient classification in terms of severity levels.
[15] According to Oliveira, a simple selfadministered questionnaire would offer the advantage of faster application and, thus, low cost. [16] An additional advantage is that a self-applied questionnaire would provide a severity index with less influence from the examiner and less variability in the measures. The anamnestic index (AI) presented by Campos JA, et al. is one of the available instruments in Portuguese language for characterization of TMD symptoms, and it was developed to classify patients according to severity of those symptoms. [17] Anamnesis questionnaires have the limitation of providing data only on TMD symptoms and it cannot provide TMD diagnosis.
In 1992 Fonseca developed his anamnestic questionnaire based on many earlier indices. The Fonseca's anamnestic index (FAI) is a self-administered questionnaire that has been proposed as a low-cost, easily applied alternative TMD assessment tool for the nonpatient population. [18] Hence in this study we have evaluated, using the Fonseca's questionnaire (table 1), the prevalence and severity of TMD in undiagnosed Indian population consisting of students of different faculties in a university campus. The assessment of volunteers with undiagnosed TMD would help understanding its prevalence in the Indian university population. The aim of this study was to assess the prevalence and the severity of TMDs in the students of different faculties in a university in Bengaluru using Fonseca's questionnaire.

Material and Methods
This was a descriptive crosssectional study. The study was carried out between September 2019 and February 2020. The study subjects were students from various disciplines of professional and degree courses which included medical, dental, business management, commerce & finance and allied sciences.
Initially 340 undergraduate students from the university campus were randomly selected and were requested to answer the fonseca's questionnaire. Prior to that, the volunteers received proper instructions about the goals of the research and experiment procedure, risk and benefits and signed an informed consent form. Questionnaires and a cover letter stating the instructions, rationale, and purpose of the survey were distributed to a conveniently selected sample of university students from the university campus. Subjects who were willing to participate in the study filled the questionnaire by hand and returned it in person. Participants were not given a time limit for completing the questionnaire. Informed consent was signed and collected from the sample. Since it was questionnaire-based study and no intervention was done, the clearance was given after assessment of the study protocol and the study was approved by the university's ethical committee (Ramaiah University of Applied Sciences, Bengaluru). The research project protocol number was EC-2020/UG/076.
Participants having a history of TMJ trauma, receiving orthodontic treatment or treatment for TMD, and/or suffering from any immunocompromised disease were excluded from the study. The sample size estimated at 300 based on previous studies.
[13] The minimum sample size was calculated, following these input conditions: power of 95% , alpha error of 0.05 and the effect size was 0.35. Initially the questionnaire was given to 340 students and based on the exclusion criteria and after removing incompletely filled questionnaires, we reached the sample size of 300.
The study tool used was the Fonseca's questionnaire (table 1) because it ensures collection of large quantity of information in a relatively short period of time. It evaluates the degree of TMD in the participant. It does not diagnose the presence of TMD. The questionnaire is framed in such a way that it assesses for the presence of pain in TMJ and head while chewing, parafunctional habits, limitations of movement, joint clicking, perception of malocclusion and emotional stress. The Fonseca questionnaire is an already validated and standardized questionnaire for the evaluation of TMD in relation to various orofacial movements and exercises, with each question having a scale of calibration to answer ranging from yes, no and sometimes in order to assess the degree of severity. The questionnaire comprised two main parts. The first part collected demographic information and past medical, dental, TMJ, and facial trauma histories. The second part asked Fonseca's 10 questions. Participants were requested to select one answer: yes, no, or sometimes. Each ''yes'' answer was assigned a value of 10, each ''sometimes'' answer a value of 5, and each ''no'' answer a value of 0. The sum of the values for all 10 answers was used to classify each subject according to the criteria shown in Table 1.
Hence, the collective score of each questionnaire ranged from 0 to 100. Incomplete and partially completed questionnaires were excluded. A clinical index was described on the basis of collective score of key questions (Table 1). TMD severity was categorized as no TMD (0-15), mild TMD (20-40), moderate TMD (45-65) and severe TMD (70-100). The frequency and severity of TMD were compared in terms of students' gender, age and college. After collecting the data all the subjects who were diagnosed as having any stomatognathic system impairment either TMD or orofacial pain were subjected to appropriate treatment.

Sl. no
Fonseca's key question Yes Sometimes No

Do you feel that it is difficult
to open your mouth?

2.
Do you feel that right and left movement of your jaw is difficult?

3.
Do you feel muscular pain and feel tired while chewing?

4.
Do you have headaches frequently?

5.
Do you feel stiffness in your neck?

6.
Do you feel pain in your ears or TMJ?  Table 2 shows the distribution of socio demographic characteristics of the study participants. Table 3 shows the distribution of varying grades of TMD among study participants based on Fonseca Questionnaire Total Score. 66.7% of the subjects showed no signs of TMD while 33.3% showed varying signs of TMD. Table 4 includes the age and gender wise comparison of prevalence of TMD among study participants using Chi Square Test. There was no statistically significant differences found between the groups.  Use of Fonseca's Questionnaire to assess the prevalence and severity of Temporomandibular disorders among university students -a cross sectional study. http://dentistry3000.pitt.edu

Discussion
The distribution of socio demographic characteristics of the study participants is shown in Table 2. Majority of the subjects in this study were between 17-25 years and 66.3% were females. Among the subjects, 33.7% were medical students and 33% were dental students.    The association between the individual parameters of Fonseca's Questionnaire and the subjects with and without temporomandibular disorders according to Fonseca Criteria using Chi Square Test is presented in table 6. In all the parameters there was a statistically significant difference seen. Hence the individual parameters of this questionnaire can be considered to be valid. The responses which were positive for temporomandibular disorders according to Fonseca Criteria are shown in figure 2.
In a study on TMD, nearly onethird of participants had a history of psychological stress. [18] In our study 79.6% of the people who had TMD reported that they felt they were tensed. These outcomes are in agreement with those of Pesqueira and colleagues[4] and Bonjardim and colleagues[10] who asserted that stress and anxiety play important roles in TMDs by acting as predisposing or aggravating factors.
The limitations of this study are that of limited sample size, nonhomogeneous ethnicity of the sample and possible errors in recording information in questionnaire such as underreporting, overreporting etc. Also the emotional factors were not considered which play a role in symptoms of TMD.
The Fonseca's questionnaire allows collecting a large quantity of information in a relatively short period and at low cost, it is easy to understand and has almost no influence from the examiner.
[15] The potential uses could be regular public health and screening services, using this questionnaire, for a wide population coverage. With proper diagnosis and treatment, this could manage orofacial pain at early stages in a large contingent of people.