Journal of Oral Rehabilitation, 1985, Volume 12, pages 189-194

Association between tooth loss and TMJ

dysfunction
P. KIRVESKARI and P. ALANEN Institute of Dentistry, University of
Turku, Turku,Finland

Summary
An analysis of the distribution of tooth losses in 521 subjects having lost one to
fourteen teeth, disclosed a statistically significant association between the loss of
maxillary first premolar and the presence of TMJ dysfunction. The association
was evident on both sides. Maxillary first premolars have earlier been shown to
contact prematurely on hinge closure more often than the other teeth. The loss of
other teeth seemed independent of the functional state of the stomatognathic
system. It is suggested that TMJ dysfunction may predispose to the loss of the
maxillary first premolar by direct trauma to the tooth and/or by speeding up
periodontitis.

Introduction
Few students of stomatognathic physiology totally deny dental occlusion a role in
the development of temporomandibular joint (TMJ)dysfunction. However, the
relative importance of occlusal factors and the causal relationship between them
and dysfunction are far from clear (De Boever, 1979; Kirveskari, 1980; Greene &
Marbach, 1982). Correlations between occlusal factors and masticatory muscle
function have been found in many studies (Ramfjord, 1961; Schaerer, Stallard &
Zander, 1967; Hannam el al., 1981).
Tooth loss is usually considered to be a predisposing factor to dysfunction.
Tipping and over-eruption of teeth as well as altered muscular function are some
of the factors resulting from tooth loss and ultimately leading to dysfunction. The
number of remaining teeth or occluding pairs of teeth is, according some studies,
correlated with the presence of dysfunction (Helkimo, 1974; Carlsson, 1976), and
the risk of developing osteoarthrosis of the TMJ increases when the posterior
teeth are lost (Oberg, Carlsson & Fajers, 1971).
The possibility that dysfunction might cause loss of teeth has drawn less
attention, except for the discussion and studies on the role of occlusal trauma in
the aetiology of periodontal disease. While such a role has been emphatically
denied (Waerhaug, 1979). it nevertheless remains unclear whether occlusal
trauma can accelerate the progress of pocket formation or influence the
attachment level (Ramfjord & Ash, 1981; Arnold, 1981). In the light of current
research, however, occlusal trauma plays at best a minor role in the pathogenesis
of early to moderate periodontitis (Ramfjord & Ash, 1981).
The association between TMJ dysfunction and tooth loss is usually studied by
Correspondence: Dr Pentti Kirveskari, Institute of Dentistry, University of Turku, SF-20520 Turku
52, Finland.
13 189
190 P. Kirveskari and P. Alanen
analysing the number of missing teeth. Another possibility is to study the location
of the missing teeth, because occlusal interferences are not randomly distributed
among the posterior teeth (Carwell & McFall, 1981). Therefore, tooth loss should
also be non-random if TMJ dysfunction has any effect on it. A simple way to test
such a hypothesis is to compare the frequency of loss of the upper first
premolar-the tooth with most common interferences-in subjects with an equal
number of teeth lost but with a different functional state of the stomatognathic
system.

Materials and methods

The dental status of 898 male (mean age 37.2, range 17-62 years) and
eighty-seven female (mean age 39-8, range 17-57 years) metal industry workers
was recorded in connection with a more extensive odontological study (Alanen,
1982). The subjects were originally divided into four groups according to the
functional state of the stomatognathic system: ortho-function, mild, moderate or
severe dysfunction. The classification was based on the functional examination,
not on anamnestic information or any occlusal variables. The main criterion was
pain: painless signs (joint sounds, deviations on opening-closing) were considered
indicative of mild dysfunction, and painful signs, either elicited (muscle and joint
palpation) or spontaneous, were considered indicative of moderate or severe
dysfunction depending on the subject’s description of or reaction to the pain. The
details of the classification method have been presented earlier (Alanen &
Kirveskari, 1982).
The material was analysed step by step; first separately in each group of equal
number of lost teeth and then combined cumulatively up to the group of fourteen
lost teeth. There were 521 subjects with one to fourteen lost teeth. They had lost.

Table 1. Distribution of subjects according to the functional

state of stornatognathic organ and the number of missing
teeth
Number of Ortho- Mild dys- DYS-
missing function function function
teeth n n n N
I____ __ ___
1 46 34 33 113
2 37 23 29 89
3 18 20 17 55
4 14 11 17 42
5 18 16 17 51
6 13 13 16 42
7 9 8 7 24
8 13 7 7 27
9 8 5 6 19
10 3 10 1 14
11 11 3 2 16
12 4 0 4 8
13 5 3 2 10
14 3 2 6 11
.____-_
_.___--__

202 155 164 521

 Tooth loss and TMJ dysfunction 191
Table 2. Frequencies of missing upper right and left first premolars according to functional group. The
highest frequencies underlined
d. 14 d. 24
-.
Number of
missing Ortho- Mild Ortho- Mild
teeth function dysfunction Dysfunction function dysfunction Dysfunction
1 0 0.029 0 0 0 0
2 0 !um 0 0.027 -
0443 0
3 0 0.050 -
0.117 0.055 0.050 -
0.059
4 0 0091 0.059 0 -
0.090 0
5 0.055 0.143 -
0-235 -
0.167 0 0-117
6 0 0-300 -
0.313 0 o.100 0.063
7 0-250 0 0.222 0.250 -
0.286
a 0.250 0.430 -
0.714 0.500 0.286 -
0.571
9 0 -
0.800 0.200 0.143 0.200
10 0.667 0-556 0 0.333
11 0-636 0-667 -
1~OOO 0.636
12 0.500 0 rn 0.750
13 0.750 0.500 -
1.MKl 0.750
14 0 0 0.750 0
-~
_-~________. ---
Distribution
of the highest 2 4 8 1 5 7
frequencies

in total, 146 upper first premolars. There were only a few teeth extracted for
orthodontic reasons. These were not counted as lost. Third molars were excluded
from the study because it was impossible to know if the tooth was extracted or
impacted. Since the prevalence of dysfunction did not differ significantly between
sexes (Alanen & Kirveskari, 1982), the material was pooled.
The association between tooth loss pattern and functional state was analysed
as follows: (i) all subjects were grouped according to the number of missing teeth
and each group was divided according to the functional state of the stomatog-
nathic system into orthofunction, mild dysfunction and dysfunction groups
(moderate and severe dysfunctions combined) thus forming 3x 14 groups (see
Table 1). (ii) The distribution of tooth losses within dental arches was counted in
each group. The absolute figures of lost upper first premolars (not shown in the
tables) were made comparable between ortho- and dysfunction groups by dividing
the absolute figures by the size of the corresponding group (Table 2). (iii) The
association between the highest frequency of missing upper first premolar and
functional state was tested by ?-test with Yate’s correction. The corresponding
analysis of association was then made for all other teeth.

Results
The loss of upper first premolar was associated with the functional state (Table 2).
In the twenty-seven comparisons (one comparison is missing because none of the
subjects with a single tooth loss had lost the left upper first premolar, d 24) the
highest frequency was most often found in dysfunction groups, yielding an
increasingly significant difference in the cumulative distribution after twelve
192 P. Kirveskari and P . Alanen
Table 3. Cumulative distribution of the highest frequencies of lost upper first
premolars (based on data in Table 2); right and left sides combined
Number of
missing Ortho- Mild
teeth function dysfunction Dysfunction xz P<
1 0 1 0
1-2 0 3 0
1-3 0 3 2
1-4 0 5 2
1-5 1 5 3
1-6 1 6 4
1-7 2 5 5
1-8 2 6 7
1-9 2 7 8
1-10 3 7 9 2.0 0-2
1-1 1 3 7 11 3.5 0.1
1-12 3 7 13 5.3 0-05
1-13 3 8 14 6.0 0.025
1-14 3 9 15 8.0 04125

Table 4. Distribution of the highest frequencies of lost teeth in subjects having

lost one to fourteen teeth; left and right sides combined (n=521)
~ ~ ~~ ~

Pair of Ortho- Mild

teeth function dysfunction Dysfunction xz P<
-~ ~ ~

11.21 9 5 4 1-45 N.S.

12.22 11 5 5 2.4 N.S.
13.23 8 7 5 0.3 N.S.
14.24 3 9 15 8.0 U*UIZ5
15.25 7 8 12 0.97 N.S.
16.26 10 5.5 11.5 1.46 N S.
17.27 6.5 13.5 8 2-08 N.S.
31.41 3 1 1 - N.S.
32.42 4 1 3 - N.S.
33.43 4 3 2 - N.S.
34.44 12 9 4 2.97 N.S.
35.45 10 9.5 8.5 0405 N.S.
36.46 6 6 I4 3-76 0-1
37.47 8 4.5 13.5 3.70 0.1

comparisons (Table 3). No other tooth showed statistically significant difference

between expected and observed distributions (Table 4).

Discussion
The present material was suitable for the purpose of studying the interrelationship
between TMJ dysfunction and tooth loss, because both of these occur frequently
in the study population (Alanen, 1982; Alanen & Kirveskari, 1982). Age was not
considered a confounding factor since an earlier study (Alanen, 1982) showed no
correlation between age and dysfunction in the same population. A similar finding
is common in epidemiological studies (Helkimo, 1979).
When the number of missing teeth becomes large, the reasons for further
 Tooth loss and TMJ dysfunction 193
extractions are not always associated with the clinical state of the teeth to be
extracted. It is probable, for instance, that some teeth have been extracted for
prosthetic reasons alone, in patients wearing a full upper denture. That is why we
decided to exclude subjects having lost more than fourteen teeth.
In principle, two reasons for the association between the loss of the upper first
premolar and TMJ dysfunction seem possible. The loss of the upper first premolar
could somehow predispose to dysfunction. However, we found it hard to find a
natural explanation to such a relationship. The other alternative is that dysfunc-
tion predisposes to the loss of the upper first premolar. The coincidence of the
highest frequency of precontacts on hinge closure (Carwell & McFall, 1981) and
the disproportionate rate of loss of the same tooth is highly suggestive. If the
unphysiological forces connected with TMJ dysfunction affect the upper first
premolars more than other teeth, sequences of events leading to the loss of the
upper first premolars can be surmized.
The upper first premolar appears more susceptible to occlusal traumatic forces
than its lower antogonists for morphological reasons. Both the periodontium and
the tooth itself can be damaged by the occlusal forces. Since the current opinion is
that occlusal trauma can be a significant factor in the loss of periodontal support
only in the advanced stage of periodontitis (Ramfjord & Ash, 1981), damage to
the periodontium alone can hardly explain why the tooth is lost so often. Damage
to the tooth probably accounts for a considerable part of the tooth losses.
Particularly filled teeth are susceptible to fracturing. Endodontic treatment
increases the risk of fractures, and the treatment may be complicated by
unphysiological occlusal forces (Arnold, 1981). That this might be the course of
events is further suggested by the preponderance of subjects with dysfunction in
the comparison of subjects having lost only a few teeth, i.e. the factor(s) causing
the loss of the tooth are operative already when the dentition is still relatively
intact.

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Manuscript accepted 9 November 1983