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Voice-Related Disability of Iranian Patients With

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Voice-Related Disability of Iranian Patients
With Temporomandibular Disorders
*Negin Moradi, Majid Sahebi, Nader Saki, Tahereh Hosseinzadeh Nik, *Mohammad Jafar Shaterzadeh Yazdi,
Soheila Nikakhlagh, *Majid Soltani, Ehsan Naderifar, Vita Derakhshandeh, kShiva Javadipour,
and {Behrooz Mahmoodi-Bakhtiari, *zAhvaz, yk{Tehran, and xZahedan, Iran

Summary: Introduction. The relationship between handicaps because of voice disorders and temporomandibular
disorders (TMDs) severity was examined.
Method. Fifty-two Persian women with temporomandibular disorder (TMD) were examined by two dentists in sepa-
rate sessions and the assessment protocol of the Dentistry Clinic of Tehran University of Medical Sciences was filled by
both dentists and finally they gave their opinion separately about the existence of TMD and categorized the severity of
TMD as mild, moderate, and severe. To assess perceived disability resulting from voice disorders in TMD patients, the
voice handicap index (VHI) questionnaire was used.
Results. The total score of VHI in 80.8% of patients with TMD was equal to or more than 14.5. A significant positive
relationship was found between the severity of TMD and the total score of VHI (P 0.000, r 0.79).
Conclusions. It seems that a comprehensive voice assessment should be included in the evaluation of TMD, and
considering different effects of voice disorders on patients lives, a complete voice evaluation including voice-
related disability is necessary to understand the nature of pathophysiology of TMD.
Key Words: Voice disorderVoice handicap indexTemporomandibular disordersPersian.

INTRODUCTION of temporomandibular dysfunction, such as hyper tension of

Temporomandibular joint (TMJ) is necessary for normal oral
functions. This joint plays a prominent role in chewing, swallow-
ing, speech, and oral health.1 When opening the mouth, TMJ
causes forward and backward movements of mandible and limits
its lateral movements.2 According to previous studies, one of
three adults suffers from temporomandibular disorder (TMD).3
One of the most complex disorders of the body is temporoman-
dibular dysfunction. These disorders either result from abnormal
functions of the muscles of mastication, or TMJ and associated
structures, or both.1,3 Displacement of the joint leads to
abnormal connection between the articular disc and mandibular
condyle and causes loss of smooth joint function.4 The loss of
normal functions leads to increased pressure on muscles and
joints. Although this disorder can be related to stress, sex, person-
ality, and anxiety,1,5,6 the exact etiology for TMD has not been
found.6 The prevalence of TMD has been estimated between
5% and 10%, and women have found to be more susceptible
than men.1 Dysfunction of TMJ represents muscle tensions in
head and neck that are directly transmitted through the muscular
connections between jaw and hyoid bone to the larynx.7 As a
result, vocal changes can be the symptoms associated with tempo-
romandibular dysfunction. Causative factors in the development
Accepted for publication April 1, 2014.
From the *Musculoskeletal Rehabilitation Research Center, School of Rehabilitation,
Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; yProsthodonthics
Department, School of Dentistry and Dental Research Center, Tehran University of Med-
ical Sciences, Tehran, Iran; zHearing & Speech Research Center, Ahvaz Jundishapur Uni-
versity of Medical Sciences, Ahvaz, Iran; xHealth Promotion Research Center, Zahedan
University of Medical Sciences, Zahedan, Iran; kDepartment of Speech Therapy, Univer-
sity of Social Welfare and Rehabilitation Science, Tehran, Iran; and the {University of
Tehran, Tehran, Iran.
Address correspondence and reprint requests to Mohammad Jafar Shaterzadeh Yazdi,
Musculoskeletal Rehabilitation Research Center, School of Rehabilitation, Ahvaz Jundish-
apur University of Medical Sciences, Ahvaz, Iran. E-mail: mjshaterzadeh.pt@gmail.com
Journal of Voice, Vol. -, No. -, pp. 1-4
0892-1997/$36.00
2014 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.04.001
oral areasthe face and neck, limited mouth range of motion,
limited mandibular movement during speechare similar to
dysphonia that can effect acoustic features of the voice.8 TMJ
problems often lead to decreased voice range, voice fatigue,
and sound displacement changes. Changes of resonance and
voice fatigue can lead to voice complaints in patients with
TMD.7 Silva et al9 showed that in patients with severe TMDs,
reduced loudness, increased noise, and changes in resonance
lead to a change in voice quality of these patients. Disordered
vocal quality cant play its main role in delivering verbal and
emotional messages6; as a result, disordered voice, similar to
other physical problems and diseases, may be associated with
emotional consequences.7 Thus, patients with voice disorders
have been reported having emotional and psychological problems
as direct consequences of their problems.8,9 These patients
experience social, communicative, physical, and emotional
problems in their professional, daily, and personal life.10,11
Benign voice disorders have an effect on quality of life
in general12 and on quality of life associated with voice in
particular.13 As Piron and Roch14 have emphasized on the rela-
tionship between TMD and dysphonia, it seems that compre-
hensive evaluation of voice, including the impact of voice
disorders on the quality of life in patients with different degrees
of TMD, helps to better understand the nature of the relation-
ship between TMD and dysphonia. In this study, handicaps
due to voice disorders in patients with TMD and also the rela-
tionships between handicaps because of voice disorders with
TMD severity were examined.
METHOD
Fifty-two Persian women participated in this cross-sectional
study. They were selected from the Dentistry Clinic of Tehran
University of Medical Sciences in Tehran. The participants
age ranged from 20 to 48 years (mean 29.6 years).
2 Journal of Voice, Vol. -, No. -, 2014

The inclusion criteria were: age range between 18 and 50, ex- TMD, and total score of VHI. The Shapiro-Wilk test was
istence of functional TMD under the dentist diagnosis, no history used to evaluate the normality of the distribution of the research
of trauma/face surgery, no craniofacial anomalies, no history of data.
hearing problems, no history of laryngeal diseases, no history The correlation between severity of TMD and the total score
of neurological and hormonal diseases, nonsmokers, lack of his- of VHI was assessed using Pearson product-moment correla-
tory of speech and voice therapy, Persian language, and nonpro- tion coefficient.
fessional voice users. None of the women participating in the The Statistical Package for the Social Sciences, version 16.0
study, based on self-reporting, were in menopause period. One (SPSS, Inc., Chicago, IL) was used to run the statistical ana-
of the participants was excluded from the study when she was lyses. The significance level of the derived data was considered
perceived by two dentists to have different severities of TMD. as less than 0.05.
First, subjects were examined by a dentist and the assessment
protocol of the clinic was filled by him, and finally, he gave his RESULTS
opinion about the existence of TMD and categorized the sever- The results of the ShapiroWilk test indicated normal distribu-
ities of TMD as mild, moderate, or severe. According to the tion of data (P 0.37).
assessment protocol of the clinic, the dentist examined the Demographic data of the three groups as mild, moderate, and
excursive movements of the mandible and performed the palpa- severe are presented in Table 1. The average age of mild, mod-
tion of mandibular and cervical muscles, and the analysis of erate, and severe groups were 29.7 8.3, 28.8 8.8, and
static and dynamic occlusion. 32 7.7, respectively.
The dentist confirmed the existence of TMD when partici- The results showed that the highest frequency was related to
pants represented pain in the masticatory muscles and/or patients with severe TMD and lowest frequency was related to
TMJ, during mandibular function and on palpation of the struc- patients with mild TMD.
tures, limitation or deviation of mandibular movements, an The mean of total VHI score and its subtests in patients with
abnormal static or dynamic occlusal relation, TMJ noises, various degrees of TMD is shown in Table 2. The results
abnormal biting, unilateral chewing and bilateral ear pain.1,15 showed that the total score of VHI in 80.8% of patients with
Based on Kitsoulis et al,1 subjects were categorized based on TMD was equal to or higher than 14.5.
having less than two of the previously mentioned signs as mild, Based on the results of the Pearson product-moment correla-
more than two of them as moderate, and more than four of them tion coefficient, a significant positive relationship was found
as severe. between the severity of TMD and the total score of VHI
All subjects were examined by two independent certified (P 0.000, r 0.79).
dentists who scored the severity of TMD blindly. Results
were then compared and if any major discrepancy was
DISCUSSION
observed between examiners the patients was excluded from
In the present study, perceived disability due to voice disorders
the study.
was surveyed using VHI questionnaire in fifty-two women with
To assess the perceived disability resulting from voice disor-
TMD. The results indicated that the number of patients with se-
ders in TMD patients, the voice handicap index (VHI) question-
vere TMD were prominently higher than the number of patients
naire was used. This questionnaire, developed by Jacobson
with mild and moderate TMD. This finding was in agreement
et al16 in 1997, evaluates disability resulting from dysphonia.
with Ferreira et als19 study, who reported that the number of
VHI contains three subtestsnamely physical, emotional,
subjects with high-grade TMD disorders is significantly greater
and functional. Each subset consists of 10 items, and each of
than other subjects. It seems that patients with severe TMD
the overall 30 items of VHI is responded by a rating scale of
went to dentistry clinics more than other groups. This result
five, graded from zero to four (never to always). The Persian
may be due to the fact that patients with TMD complain and
version of VHI17 was used in the present study. The cutoff point
report symptoms demonstrating pain in the joint or associated
of the Persian version of VHI questionnaire is 14.5.18 As Mor-
structures, that is, when the degree of the disorder increases.
adi et al18 reported, the score of 14.5 is considered as a factor
As Ferreira et al19 reported, there is a positive correlation
which distinguishes individuals with voice disorders from those
without voice disorders, and this score should be assumed to be
a threshold for rating the handicap owing to voice disorders.
TABLE 1.
Based on the instruction of VHI, participants filled in the Demographics of Research Participants
questionnaire without any help or additional explanation. The
instruction of VHI was: Mean
Age
These are statements that many people have used to Height Weight Standard
describe their voices and the effects of their voices on their Participants Number (m) (kg) Deviation
lives. Choose the response that indicates how frequently Mild 10 1.6 0.04 62 8.5 29.7 8.3
you have the same experience. Moderate 15 1.68 0.05 63 9.2 28.8 8.8
Severe 27 1.66 0.08 65 7.9 32 7.7
Descriptive statistical analyses were performed to illustrate
Total 52 1.65 0.05 64 8.6 29.6 7.3
demographic and clinical features such as age, severity of
Negin Moradi, et al Handicaps Due to Voice Disorders and TMD in Iranian Patients 3

TABLE 2.
The Mean and Standard Deviation of Total VHI Scores and the Emotional, Physical, and Functional Subscale Scores in Three
Different Groups of Patients With TMD
Participants Physical Functional Emotional Total
Mild 7.7 6.1 4 3.82 2.5 2.4 13 8.37
Moderate 13.8 3.22 11.7 1.86 7 1.85 32.6 4.45
Severe 24.55 4.69 15.33 4.69 13.33 3.74 53.22 14.7
Total 19.34 9.4 12.7 5.49 10 5.38 42.05 19.22

between the severity of TMD and complaints such as orofacial
pain and motor dysfunction of associated structures. In other
words, the more severe the disorder, the more the patients
awareness of the fact that he needs to see a physician to receive
treatment.
Based on the results of the present study, a significant posi-
tive correlation was observed between the severity of TMD
and the mean of total VHI scores. This finding is in agreement
with Pereira et als8 findings, who reported the correlation be-
tween TMD severity, based on the patients opinions, and
voice-related quality of life.
Previous investigations indicated that there are direct and
indirect relationships between various components of vocal
tract-related structures and functional activity, and that func-
tional relationships among these structures in the process of
voice production should not be neglected.2023 One of these
categories is related to the changes in jaw opening which can
affect the larynx and the voice.24 Patients with TMD often
have difficulty when opening the jaw.1 These patients open
the jaw lower than healthy people, and they report tensions
and stiffness in jaw muscles.1,19
The greater severity of TMD results in more tension in jaw
and less opening of the mouth.1 Low opening of the jaw during
phonation and tension in jaw changes voice characteristics and
can lead to voice problems in people.7 Thus, it is expected that
people with TMD have voice problems which have an impact
on their quality of life. VHI questionnaire reflects the impact
of voice-related disabilities in life. Higher VHI total score
means that voice disorders have a more damaging effect on a
persons life.16 Thus, it appears that in patients with TMD,
increasing the severity of the disorder results in greater impacts
of voice-related disabilities on a persons life.
The results showed that the total score of VHI in 80.8% of pa-
tients with TMD is equal to or higher than 14.5. Moradi et al18
reported the score 14.5 as the cutoff point for VHI questionnaire,
indicating that people in this questionnaire who get the score
14.5 or higher, have voice disorders. Thus, 80.8% of patients
with TMD in the present study suffered from a voice problem,
based on their opinion. This finding of the present study is
consistent with Silva et als9 findings. They surveyed acoustic
characteristics of the voice of 24 women with TMD and reported
decreased loudness, increased noise, altered resonance, and
changed voice quality in patients suffering from severe TMD.
This finding is not in agreement with Carna
uba et als25
study, who found no correlation between vocal changes and
temporomandibular dysfunction. However, they emphasized
that this may be due to the number of their participants.
It seems that a comprehensive voice assessment should be
included in the evaluation of TMD, and in considering the
different effects of voice disorders on the patients lives, the
evaluation of voice-related disability is necessary to understand
the nature of pathophysiology of TMD.
CONCLUSIONS
In the present study, a correlation was found between voice-
related disabilities and the severity of TMD. It seems that
voice-related quality of life is affected by TMD. Therefore, it
should be included in the evaluation of TMD by clinicians.
Acknowledgments
This research was supported by grants (number: pht 9121) pro-
vided from Musculoskeletal Rehabilitation Research Center,
affiliated to the Ahvaz Jundishapur University of Medical Sci-
ences in Iran.
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