Journal of Oral Rehabilitation, 1991, Volume 18, pages 231-242

The prevalence of craniomandibular disorders in completely edentulous denture-wearing subjects M.D.F. M E R C A D O a n ^ K . D . B . FAULKNER School of Dental Science, Faculty of Medicine and Dentistry, University of Melbourne, Melbourne, Victoria, Australia

Summary

A total of 201 completely edentulous subjects taken consecutively from the waiting list of the Royal Dental Hospital of Melbourne were examined. Data were obtained from the dental history and anamnestic and clinical examinations. Analysis revealed that parafunctional habits were prevalent among complete denture wearers, and that elderly complete denture wearers potentially present more signs and symptoms of craniomandibular disorders than do younger subjects. Introduction

According to the literature, at least five factors have an effect on the development of CMD: (i) the age of the individual; (ii) parafunctional habits; (iii) vertical dimension factors; (iv) occlusion and other complete denture factors; (v) extrinsic trauma. Age of the individual Agerberg (1988) observed that at least one symptom of mandibular dysfunction appeared in more than 50% of the entire population, its frequency being higher in the older age group. Szenpetery, Fazekas and Mari (1987) stated that the three major symptoms of pain, impaired mobility and joint sounds were considered to be the procental rates of major dysfunction symptoms, which increased significantly with ageing. Their investigations on 38 complete-denture-wearing patients who were > 70 years old revealed a strong correlation between increase in the patient's age, complete denture wearing and mandibular dysfunction. The relationship between increasing age and changes in the temporomandibular joints (TMJ) was also studied by Blackwood (1963), Bolender, Swoope and Smith (1969), Carlsson (1984), Bates, Adams and Stafford (1984) and De Bont et al. (1986). These authors were in general agreement that the onset of degenerative conditions occurred frequently in adulthood, mostly in individuals who were complete denture wearers. Furthermore, internal derangement of the TMJ was frequently observed in the elderly, with degenerative arthritic conditions being a feature of generalized osteoarthritis (Wilkinson, personal communication). MacEntee et al. (1987) observed that 15% of elderly patients have some form of Correspondence: Dr K.D.B. Faulkner, Royal Dental Hospital of Melbourne, 711 Elizabeth Street, Melbourne, Victoria 30(XJ, Australia.

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osteoarthritis which is statistically correlated with TMJ pain, while Agerberg (1988) stated that osteoarthritis of the TMJ occurred due to non-physiological loading, which resulted in arthritic remodelling and tissue injury of joint components, as was frequently observed in the elderly edentulous group. Parafunction Zarb (1979) stated that, in complete denture wearers, clenching triggered the development of a habitual non-functional occlusion caused by ehanges which resulted from denture instability and/or diminished denture control. This non-functional occlusion produced recurrent and excessive mandibular movement as the patient attempted to recover control of the prosthesis, thereby initiating or reinforcing a parafunctional habit. The clinical observations of Hickey and Zarb (1980) demonstrated that bruxism in complete denture wearers was common, and that it was probably due to the initial disorders (CMD). Monteith (1984) stated that, despite the multifactorial aetiology of behaviour in the surrounding musculature. Vertical dimension With regard to present studies, there are still discrepancies as to whether or not the loss of vertical dimension plays an important role in the aetiology of craniomandibular disorders (CMD). Monteith (1984) stated that, despite the multifactorial aetiology of CMD, faulty vertical dimension was the most frequent cause of pain among complete denture wearers, due to the muscle hyperactivity which resulted from the increased level of contraction. Similarly, Budtz-Jorgensen et al. (1985) and Togelberg and Kopp (1987) stated that the loss of occlusal support was positively correlated with the severity of CMD. Christensen and Ziebart (1986) explained that, in the absence of posterior teeth, stability of the mandible against the cranium was achieved by jaw muscle activity which increased TMJ loading, producing histomorphological, pathological and physiopathological changes. However, studies like those of Franks (1967), Wilding and Owen (1979), McCarthy and Knazan (1987), and MacEntee et al. (1987) did not indicate that discrepancies in vertical dimension of existing complete dentures affected the severity of CMD in completely edentulous patients. Occhision and other complete denture factors Carlsson (1976) reported that occlusal instability was the most important factor contributing to the development of CMD among complete denture wearers. Wilding and Owen (1979) stated that uneven distribution of load, caused by abrasion of the posterior teeth and attrition of the anterior teeth of the dentures, produced incisal interferences of the existing dentures and was thus responsible for the development of signs and symptoms of CMD. Similarly, Zissis, Karkazis and Polygois (1988) noted that non-coincidental centric occlusion and centric relation of the existing complete dentures of the patients examined represented 25% of the total number of subjects who had CMD. Franks (1967) observed marked mandibular dysfunction among patients wearing complete dentures for which there were errors in their occlusal relationships, and Agerberg (1988) stated that one of the potential risk factors for mandibular dysfunction among complete denture wearers was the existence of an unstable occlusion. However, studies by Heloe and Heloe (1978), Ponichtera, Nikojkari and Potter (1985), Butdz-Jorgensen et al. (1987), MacEntee et al. (1987), McCarthy and Knazan (1987) and Sakurai et al. (1988) found no correlation between the signs and symptoms

Craniomandibular disorders in edentulous subjects

233

of CMD and factors relating to the occlusal status and overall quality of the dentures. Fxtrinsic trauma Studies by Lader (1983), Reade (1984), Truelove et al. (1985), Brooke and Stenn (1978), and Pullinger and -Monteiro (1988) all showed significant correlations between the signs and symptoms of CMD and a history of extrinsic trauma to the head, neck or shoulder area. However, there have been no such studies on complete denture wearers, and therefore a similar correlation could not be established for this particular group of patients. The aim of this study was thus to determine the prevalence of craniomandibular disorders among a representative group of completely edentulous denture-wearing subjects who were seeking routine prosthodontic treatment at the Royal Dental Hospital of Melbourne. Materials and methods

A total of 201 subjects were selected consecutively from completely edentulous denturewearing apphcants for treatment in the Victorian Denture Scheme (VDS)*. After an oral examination, during which the patients' eligibility to be included in the VDS was established, patients were informed of the study protocol, and their voluntary participation was requested. Those who were willing to participate in the study were directed to the University clinic for an interview and an examination for craniomandibular disorders. The interview involved the following: (i) a general history; (ii) a complete denture history; (iii) a craniomandibular anamnestic investigation; (iv) a craniomandibular clinical investigation. The general history consisted of questions relating to the patient's age, sex, marital status and occupation. This was followed by a series of questions pertaining to complete denture history, including the reason for seeking new complete dentures, the duration of complete denture experience, the age of the present dentures, the number of sets of complete dentures that had been worn in the past, 'denture sleeping' habits, and discomfort related to the dentures. In the anamnestic investigation, questions relating to craniomandibular disorders and parafunctional habits were asked. A sample of the questionnaire is shown in Table 1, and the factors used for the clinical examination are shown in Table 2. Mandibular deviation on opening and closing was recorded using a millimetre ruler placed vertically along the midline of the face. Any deviation from the ruler on opening and closing was noted. In addition, the maximum interarch distance, which was calculated by means of an Inter-maxillary Distance Gauget after asking the patient to open the mouth as widely as possible while remaining comfortable, was measured. Palpation of the muscle and joints was performed using a technique described by Meyerowitz (1975). The lateral pterygoid, masseter, temporalis and medial pterygoid muscles were palpated. Finally, auscultation of the joints was performed using a standard stethoscope. * The Victorian Denture Scheme (VDS) is a Victorian State Government Funding project administered by the Royal Dental Hospital of Melbourne for the provision of complete dentures for edentulous subjects. t Designed by Dr R.W. Shepherd, School of Dental Science, The University of Melbourne (Fig. 1).

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Table 1 Sample questionnaire GENERAL HISTORY Patient's history Age: Sex: Marital Status: _ Occupation: Complete Denture History 1. Reason for wanting new dentures: 2. How long have you been wearing complete dentures? 3. How long have you been using your present complete dentures? 4. How many sets of complete dentures have you had, ineluding the one you are wearing at present? 5. Do you remove your dentures when you go to sleep? Yes No 6. If you should remove your dentures while sleeping, do you notice any discomfort? Yes No 7. If yes. please describe.

Table 2. Ratings of factors assessed during elinieal examination Assessment

0

1

2

(i) Retention and stability

Inadequate in either denture

Adequate in both dentures

N/A*

(ii) Centric occlusioncentric relation coincidence

Non-coincidental

Coincidental

N/A

(iii) Freeway space

< 2 mm

2-4mm

>4mm

(iv) Mandibular midline deviation opening and closing

Absent Negative

Present Positive

N/A

(v) Pain and tenderness in each muscle of mastication

Absent Negative

Present Positive

N/A

(vi) Auscultation of joints for clicks and/or crepitation

Absent

Present

N/A

* Not applicable. t The freeway space was recorded using the Willis Gauge: The S.S. White Dental Manufacturing Co. (G.B.) Ltd.

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Fig. 1. Intermaxillary distance gauge.

Table 3. Frequency and percentage distribution of signs and symptoms of craniomandibular disorders among male and female subjects Signs and symptoms Head pain Neck pain Shoulder pain Midline deviation Jaw pain and fatigue Pain during mouth opening Clenching/grinding Pushing against dentures with tongue Dislodging the dentures Biting soft tissues with dentures Biting objects with dentures Generalized parafunctional habits Pain/tenderness-lateral pterygoid Pain/tenderness-medial pterygoid Pain/tenderness-masseter Pain/tenderness-temporalis Pain/tenderness-TMJ Crepitation in the TMJ Clicking in the TMJ

Males

%

Females

%

2 3 5 14 7 4 12 21 15 15 2 34 30 1 3 4 8 14 14

4-16 6-25 10-42 29-16 14-58 8-33 25-00 43-75 31-25 31-25 4-16 70-83 62-50 2-08 6-26 8-33 16-66 29-16 29-16

30 47 28 45

19-61 30-72 18-30 29-42 22-22 5-88 36-60 37-25 24-84 30-72 13-07 68-63 71-24 14-38 16-34 13-07 18-95 24-84 30-72

34 9 56 57

38 47 20 105 109

22 25 20 29 38 47

Results

Signs and symptoms of craniomandibular disorders were tabulated according to the percentage distribution among the male and female groups. Of the 201 edentulous subjects included in the study, there were 48 male subjects, of age range 54-89 years, and 153 female subjects, of age range 47—88 years. Table 3 shows the distribution of the signs and symptoms of craniomandibular disorders among the 201 subjects, grouped according to sex. It can be seen that the

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most common signs and symptoms in both male and female groups were generalized parafunctional habits (i.e. clenching and grinding, pushing against the dentures with the tongue, dislodging the dentures, biting soft tissues with dentures and biting objects with dentures) and pain and tenderness in the lateral pterygoid muscles. These two symptoms occurred at a frequency of 70-8% and 62-5%, respectively, in male subjects and 68-6% and 71 2%, respectively, in female subjects. However, pushing against the denture with the tongue (43-8% in male subjects. 37-3% in female subjects), dislodging the dentures (31-3% in male subjects, 24-8% in female subjects), biting on the soft tissues of the cheeks and lips (31-3% in male subjects, 30-7% in female subjects), clenching and grinding of the teeth (25% in male subjects, 36-6% in female subjects), midline deviation on opening and closing the mouth (29-2% in male subjects, 29-4% in female subjects), clicking in the TMJ (29-2% in male subjects, 30-7% in female subjects), and crepitation in the TMJ (29-2% in male subjects, 24-8% in female subjects) were commonly observed. Craniomandibular disorder occurrence values were determined for each of the subjects in the study. This value was obtained by determining the total score for the presence (1) or absence (0) of the signs and symptoms of craniomandibular disorders, based on those listed in Table 3. The highest CMD score value observed among all the participating subjects was 12, while the lowest score was zero. The mean score for the total sample against their valid* percentages and CMD score is shown in Fig. 2. From the frequency distribution of the CMD score value, it was observed that only

Valid /o/ 1 [ lo]

6-6

15-2 14- 1 1 1-6 1 1 ' 1 13-1 9- 1

Number of subjects 13

3-5 2-5 0-5 1-0

30 28 23 22 26 18 15 8 7 5 1 2

100

198

7-6

4 0

One symbol equals appraximately 0-6 occurrences

Volue 0-00 1-00 2-00 3-00 4-00 5-00 6-00 7-00 8-00 9-00 10-00 1 1 -00 12-00

xxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx-xxxxxx* fXXXX xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx> t x XXXXXXXXXXXXXXXXXXXXKXXXXKXXXXXX^XXXXX

xxxxxxxxxxxxxxxxxxxx-xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxx XX

x-xx I 0

I 6

I 12

I 18

I 24

30

Histogram frequency Mean

4-030

Minimum 0-000 Volid cases = 198

Median 4-000 Maximum 12000 Missing cases = 3

STD dev 2-765

Total sample = 201

Fig. 2. Histogram frequency, valid precentagc and count of the sample, and corresponding CMD score value. of the original 201 cases were designated as statistically invalid due either to missing data or information misread by the computer. Therefore only 1*^8 cases were considered to be statistically valid.

Craniomandibular disorders in edentulous subjects

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6-6% (13 cases) of the total valid sample were free of symptoms, i.e. had a CMD score value of zero. The histogram indicates a high prevalence of CMD among the 198 statistically valid edentulous subjects in the study, 93-3% of whom had at least one of the signs or symptoms. However, the largest group consisted of subjects with only one sign or symptom. The relationship between the patient's age and CMD score values was examined. Regression analysis indicated that, with increasing age, the CMD score value was likely to increase. The R-square value (0-0693) was low and therefore had a weak predictive power (Table 4). Nevertheless, such a relationship did exist in the population. The scatter graph (Fig. 3) illustrates this relationship. Discussion

The literature reviewed in this study revealed that controversy still exists as to whether craniomandibular disorders in the completely edentulous population are more prevalent than in the general population. In addition, doubt still remained as to whether the prevalences observed in the previous studies were related to any aspect that might have evolved from the wearing of complete dentures, or whether the signs, symptoms and manifestations of craniomandibular disorders had an underlying systemic factor, such as the patient's age or metabolism. Some of our results (Table 3) showed a trend similar to those of Choy and Smith (1980). According to their study, the lateral pterygoid muscles were the masticatory muscles most frequently involved in pain or tenderness elicited by palpation. In addition, they reported that a high proportion of their study population had the parafunctional habit of pushing the denture with the tongue. They also reported that this parafunctional habit was the single most frequently occurring habit (38-8%), compared to clenching and grinding (33-8%), dislodging the dentures with the tongue (26-4%), biting the soft tissues (30-8%) and biting objects (10-9%). Table 4. Regression analysis between the patient's age and the total CMD score Multiple R R-square Adjusted R-square Standard error

0-26324 0-06930 0-06455 2-67402

Analysis of variance Degrees of freedom 1 196

Regression Residual F = 14-59327 Variables in the equation Variable Patienfs age (constant)

Sum of squares 104-34714 1401-47104

Mean square 104-34714 7-15036

Significance of F = 0-0(X)2

b* -0-090261 10-168960

SE bt 0-023628 1-618128

* Regression coefficient. t Standard error of the regression coefficient. X Relationship coefficient.

Betat -0-263241

f-value -3-820 6-284

Significance of / 0-0002 0-0000

238

M.D.F. Mercado and K.D.B. Faulkner Plot of TMJPDS score with age ++

+

H

+

1

I I 11+ I I I II 8-25 +

+

1-

+

^-

1-

+

+-f I I

1

1 1

1 1

+ I I

2

I 1

1

1

3

1 1

1

1 1 1 1

21

1

1

22

1

I

+

I

i

I

5 o

R 5-5 +

I 1 1

1

I

3

I

I

I I I I

1

31 1

1 21 122 1 1

1 1

I 1 I I

1

2-75+ 1

++ 46-75

1

1 1 21 12

1

1

1 2 22 1

I

+

12 22 1 12 1 1

11 I I

1

1 11 11 12 2 1 322 1 11

I 0+

1 1 1

13

1

MM 1 1323311 3 1

12 13

1 1

1

I + R I

21

32312 41 1 1 13 1

2

1 I I

1

1 11 1 1

+ + \+ 55-25 63-75 51 59-5

1 1 12

1

1

+ \11 72-25 80-75 68 76-5

+

1++ 89-25 85

Patient's age (years)

Fig. 3. Graphical presentation of the regression analysis comparing the patient's age with the total CMD score.

In this study, pain and tenderness of the lateral pterygoid muscles were observed to be present in 69-2% of the 201 subjects, whilst tenderness of the medial pterygoid, masseter and temporalis muscles occurred in only 11-4%, 13-9% and 11-9% of subjects, respectively. Dawson (1984) has postulated that the reason for this frequent involvement of the lateral pterygoid muscles is that its functional anatomy appears to predispose the lower head of the muscle to be overworked, in the presence of occlusal disharmony, by a recurrent necessity to reposition the jaw and teeth against the powerful elevator muscles in order to correct the displaced occlusion. The clinical sign of palpatory tenderness of the masticatoiy muscles has always been a strong indication of craniomandibular disorders, and is routinely included in any examination of disturbances in mandibular dysfunction. Meyerowitz (1975), BudtzJorgensen et al. (1985), and McCarthy and Knazan (1987) all observed high prevalences of palpatory pain and tenderness of almost all masticatory muscles. However, in the present study it was noted that only the lateral pterygoid muscle showed a high prevalence of pain and tenderness to palpation, as compared to the remaining masticatory musculature. Instead of muscular pain and tenderness, it was noted that the generalized parafunctional habits* of pushing the tongue against the dentures, clenching * The symptom of generalized parafutietional habits consisted of any one of the speeific habits listed in Table 3. Therefore a patient who had one or more parafunctional habits was categorized both under a speeific habit and under generalized parafunctional habits.

Craniomandibular disorders in edentulous subjects

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and grinding, biting the soft tissues in the mouth and audible clicking in the TMJ were the five most frequently recorded signs, symptoms and/or manifestations of craniomandibular disorders, since they had higher percentage distributions than the remaining items listed in Table 3. Of these five signs and symptoms, the first four reflected mainly parafunction in general and specific parafunctional habits. Because of their higher percentage distribution compared to the remaining signs and/or symptoms, it would appear that parafunctional habits among complete denture wearers were prevalent, and might be regarded as a valid manifestation of craniomandibular disorders. The lower percentage distribution among the remaining signs and symptoms of craniomandibular disorders in this study may have been due to the fact that these complete denture wearers were probably more aware of the problems which they immediately associated with their dentures, such as looseness or a worn-down denture, rather than any head, neck or shoulder pain which they would perceive as totally unrelated to the dentures. Audible sounds emanating from the TMJ, such as clicking and crepitation, were also observed to be of markedly frequent occurrence (30-4% and 25-9%, respectively). The frequency of these two clinical signs, together with deviation of the midline of the lower jaw during opening, were similar to observations in studies conducted by Laskin (1980), Wilkinson (personal communication). Bates etal. (1986), Fish (1969), Carlsson et al. (1979), Kopp (1977), de Bont (1986), Agerberg (1988), and MacEntee et al. (1987) among elderly patients, although the latter were not necessarily edentulous. Furthermore, these studies have provided evidence that mandibular dysfunction in very elderly patients presented signs of crepitation in the TMJ which had been attributed to remodelling and degenerative changes in the joint, known to be prevalent in the older age group. However, clicking of the TMJ does not necessarily indicate agerelated degenerative disturbances which could have taken place in the TMJ. Rather it has been considered that these clicking sounds within the TMJ area are associated with meniscus condyle discoordination (Mahan, 1980). Ash (1986) observed that painless clicking in the TMJ appeared to be a common symptom in the general population, even in the absence of mandibular dysfunction. Such clicking commonly occurred as a result of the development of hypermobility in the TMJ in order to accommodate changes in the masticatory structures. These changes were predominantly observed in dentate subjects, as a means of avoiding function on fractured or carious teeth, favouring one side while chewing, or following orthodontic treatment when the mandible was no longer restrained by elastics. However, in completely edentulous individuals, the changes in masticatory structure were of a different nature. The loss of occlusal support and/or centric stops allowed the patient to open and close freely, thus reinforcing the hypermobility of the TMJ. Wilkinson (personal communication) explained that the habit of testing the click each day lead to continuous elongation of the joint capsule and perpetuation of hypermobility. A regression analysis was applied, using the patient's age as an independent variable to test against the total CMD score value (Fig. 3). A somewhat randomly scattered graph is observed, rendering it difficult to detect a definitive linear relationship. However, from the computation shown in Table 4, a significant relationship is observed at the 0-0002 level. Consequently it can be concluded that, as the age of the patient increases, there is a tendency for the total CMD score to increase as well. Figure 3 shows that the majority of the subjects fall within the age range 65-76 years, and the corresponding y-axis showed a maximum CMD score of 10 or 11, with the majority

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M.D.F. Mercado and K.D.B. Faulkner

having a score of 1 to 2-75. From the R-square value (0-0693), the predictive power of this variable could be interpreted to be very low. However, because the level of significance is 0-0189 (Table 4), it is still possible that this relationship does exist in the population. The epidemiological studies of Fish (1969), Helkimo (1974), Choy and Smith (1980), Budtz-Jorgensen et al. (1987), McCarthy and Knazan (1987), MacEntee et al. (1987) and Szentpetery et al. (1987) have noted varying prevalences of craniomandibular disorders in thc older age group. The studies of Choy and Smith (1980) and MacEntee et al. (1987) reported low prevalences, and attributed this to the fact that elderly persons readily accept any form of discomfort or dysfunction as being due to the normal process of ageing, and therefore do not present with any dental complaint of mandibular dysfunction. However, other investigations have reported higher prevalences of craniomandibular disorders in the elderly, basing their findings on thc results of clinical examinations of masticatory dysfunction rather than the patients' complaints of problems with regard to mandibular dysfunction. In the present study, the significant relationship between the age of the patient and the CMD score was obtained from data collected by means of clinical examinations and questionnaires. The factors that were postulated to support this relationship were the various changes which occur in elderly individuals during the physiological process of ageing. Such changes generally take the form of degenerative diseases of the TMJ, i.e. osteoarthritis, a decrease in the sensorimotor perception of the remaining structures in the oral cavity of edentulous individuals, changes in the tone of the masticatory and facial muscles, some oral manifestations of systemic disease that usually accompany ageing, and the psychological changes which result from the subject's emotional reaction to the complete loss of natural teeth, and acceptance of the disabilities and limitations of being old. Therefore, whether the prevalence of craniomandibular disorders among the edentulous is higher, lower, or equal to that among the general population, the results obtained in the present study have demonstrated that the relationship between increasing age and an increased potential for the development of signs and/or symptoms of craniomandibular disorders may be considered valid, and may exist in the edentulous population. Conclusions

The following conclusions may be drawn from this study: (i) parafunctional habits, whether observed as clenching or grinding or any other form of non-functional jaw movement, are prevalent among complete denture wearers; (ii) elderly complete denture wearers have the potential to present more signs and symptoms of craniomandibular disorders than younger complete denture wearers, even in the absence of organic problems related to the masticatory apparatus. References (1988) Mandibular function and dysfunction in complete denture wearers. A literature review. Journal of Oral Rehabilitation, 15, 327. ASH, M.M. (1986) Current concepts in the aetiology, diagnosis and treatment of temporomandibular joint and muscle dysfunction. Journal of Oral Rehabilitation. 13. 1. BATES, J.F.. ADAMS D . A . & STAFFORD. G . D . (1984) Dental treatment of the Elderly, p.69. Wright, Bristol. BLACKWofjD. H.J. (1963) Arthritis and the mandibular joint. British Dental Journal, 115, 317. BoLENDHR, C.L., Sw(X)PE, C C . & SMFIH, D . E . (1969) The Cornell medical index as a prognostic aid for complete patients. Journal of Prosthetic Dentistry, 22, 20. AGIRHKRC, G .

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& STENN, P . G . (1978) Post-injury myofascial paid dysfunction syndrome: its aetiology and prognosis. Oral Surgery, Oral Medicine and Oral Pathology, 45, 846. BUDTZ-JORGENSEN, E . . LUAN. W.M., HOLM-PEDERSON, P. & FEJERSKOV, O . (1985) Mandibular dysfunction related to dental occlusion and prosthetie eonditions in a seleeted elderly population. Gerodontics, 1, 28. CARLSSON, G . E . (1976) Symptoms of mandibular dysfunction in complete denture wearers. Journal of Dentistry, 4. 265. CARLSSON, G.E. (1984) Mastieatory eflicieney; the effect of age. loss of teeth and prosthetie rehabilitation. International Dental Journal, 34, 93. CHOY. E . & SMOH, D . E . (1980) The prevalence of temporomandibular joint disturbanees in complete denture patients. Journal of Oral Rehabilitation, 1, 331. CHRISTENSEN, L . V . & ZIEBART, G . J . (1986) The effeets of experimental loss of teeth on the temporomandibular joint. Journal of Oral Rehabilitation, 13, 587. DE BONT. L.G.M.. BOIRING, G . , LIEN, R.S.B., EULDERINK, F . & WATESSON. P. (1986) Osteoarthritis and internal derangement of the TMJ: a light mieroseopic study. Journal of Oral and Maxillofacial Surgery, 44, 634. FISH, F . (1969) Adaption and habituation to full dentures. British Dental Journal. 127, 19. FRANKS, A . S . T . (1967) The dental health of patients presenting with temporomandibular joint dysfunctions. British Journal of Oral Surgery, 5, 157.

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M.D.F. Mercado and K.D.B. Faulkner

& SCHUBERT, M . (1985) Incidence of trauma asoeiated with temporomandibular disorders. Journal of Dental Research, 64, 339 (Abstract 1482). WILDING, R . J . C . & OWEN, C . P . (1979) The prevalenee of temporomandibular joint dysfunction in edentulous non-denture-wearing individuals. Journal of Oral Rehabilitation, 14, 175. ZARB, G . A . (1979) Mandibular dysfunetion and the ageing prosthodontie patient. In: Proceedings of the Second International Prosthodontie Congress (ed. W. Lefkowitz), p. 361. The C.V. Mosby Company. St Louis. Zissis, A.J., KARKAZIS, H.C. & POLYGOIS, G . L . (1988) The prevalence of tomporomandibular joint dysfunction among patients wearing complete dentures. Australian Dental Journal, 33, 299.

TRUELOVE, E . , BURGESS, J.. WARK(N, D . , LAWTON, L., SOMERS, E .

The prevalence of craniomandibular disorders in completely edentulous denture-wearing subjects.

A total of 201 completely edentulous subjects taken consecutively from the waiting list of the Royal Dental Hospital of Melbourne were examined. Data ...
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