Effect of periodontal disease on bite force and the temporomandibular joint disorders: A cross-sectional study

Effect of periodontal disease on bite force and the temporomandibular joint disorders: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of periodontal disease on bite force and the temporomandibular joint disorders: A cross-sectional study Erdem Veli Uzun, Nurcan Aksaka, Mert Çelik, Nur Balcı, Hilal Uslu Toygar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6469546/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background Alveolar bone loss (ABL), tooth mobility, tooth displacement, and tooth loss due to periodontitis can lead to temporomandibular joint (TMJ) problems and reduced masticatory function. While previous studies have examined the associations between periodontal disease, bite force (BF), and temporomandibular disorders (TMDs) separately, the combined impact of periodontal breakdown on both masticatory function and TMJ involvement has not been clearly established. Therefore, this study aimed to determine the relationship between ABL and BF and to evaluate the incidence and characteristics of TMDs in patients with periodontitis. Methods This cross-sectional study enrolled 50 patients with stage III generalized periodontitis and 50 periodontally healthy participants. Sociodemographic data and clinical periodontal parameters were collected. BF was measured and compared between patients with periodontitis and periodontally healthy individuals. The TMJ was assessed using an interview-based questionnaire and clinical examination. Results TMD pre-diagnostic classifications were not significantly different between the groups (p = 0.772, p > 0.05). Complaints of pain in the jaw upon waking (p = 0.044), clicking/locking of the jaw (p = 0.020), and daytime bruxism (p = 0.042) were significantly fewer in the periodontitis group than in the healthy group (p < 0.05). Meanwhile, TMJ-related symptoms were not significantly different between the periodontitis and healthy groups. However, BF was significantly lower in the periodontitis group than in the healthy group (p < 0.001). Conclusions BF is decreased in patients with periodontitis. Periodontal treatment should be completed, and missing teeth, if any, should be rehabilitated to enable efficient masticatory function in these patients. periodontitis bite force temporomandibular disorders Figures Figure 1 Figure 2 Background The masticatory system is a complex functional unit composed of the teeth, alveolar bone, temporomandibular joint (TMJ), masticatory muscles, and associated ligaments. These components must operate in synchrony to maintain proper occlusal relationships and ensure efficient chewing performance ( 1 ). Periodontitis is a chronic inflammatory disease, and its progression leads to decreased amount of alveolar bone around the teeth, increased tooth mobility, and teeth displacement. This ultimately results in disrupted occlusal balance ( 2 ) that may in turn cause occlusal overloading of the teeth, as well as decreased bite force (BF) ( 3 ). Additionally, structural changes in the dentition due to periodontitis may result in functional changes in the TMJ and surrounding musculature, potentially increasing the risk of temporomandibular disorders (TMDs). Recent studies have highlighted the importance of occlusal balance and the biomechanical feedback provided by periodontal mechanoreceptors in maintaining proper masticatory function ( 4 ). These receptors, located within the periodontal ligament, play a crucial role in regulating bite force (BF) by detecting mechanical stimuli and transmitting sensory feedback to the central nervous system. These mechanoreceptors provide neural control of movements, such as holding an object in the mouth, biting, and chewing ( 5 ). Their impairment due to periodontal tissue destruction may compromise neuromuscular coordination, ultimately affecting bite efficiency and force distribution. Additionally, compensatory or pathological movements—such as protrusion due to anterior tooth migration or altered incisor inclination—can further disrupt occlusal balance and TMJ biomechanics ( 6 , 7 ). Although numerous studies have independently investigated the associations between periodontal disease, bite force (BF), and temporomandibular disorders (TMDs), the potential combined influence of periodontal destruction on both masticatory function and temporomandibular joint (TMJ) integrity has not been sufficiently elucidated. Given these interrelations, this study is hypothesized that periodontal breakdown not only impairs masticatory performance through reduced BF but may also increase the susceptibility to TMDs by altering condylar loading and joint adaptation. This study aimed to investigate the relationship between alveolar bone loss (ABL) and BF, and to assess the incidence and characteristics of TMDs—such as joint pain, joint sounds, and limited mandibular movement—in patients with generalized periodontitis. A clearer understanding of these associations is essential for guiding clinical interventions that preserve both periodontal health and functional integrity of the masticatory system. Methods Study design and participants This cross-sectional study evaluated patients who visited the Istanbul Medipol University, Faculty of Dentistry, Department of Periodontics for dental treatment between July 2021 and July 2022. Those who met the inclusion criteria after clinical and radiographic examinations were invited to participate. The inclusion criteria were as follows: ( 1 ) age > 20 years and < 65 years; ( 2 ) at least 20 permanent natural teeth in occlusion except for the 3rd molars; ( 3 ) complete double molars in any hemiarch; ( 4 ) without orthodontic appliance; ( 5 ) not pregnant; ( 6 ) without inflammatory joint disease, neurological disease, or autoimmune disease; ( 7 ) not taking medications that may interfere with muscle activity; ( 8 ) not taking anti-inflammatory drugs in the last 3 months; ( 9 ) no periodontal treatment in the last 6 months; ( 10 ) no surgical periodontal treatment in the last year; and ( 11 ) no fixed prosthesis with multiple elements, dental implants, or partial removable prostheses. Clinical and radiographic periodontal measurements The periodontal status was diagnosed based on the 2017 AAP/ EFP classification of periodontal and peri-implant diseases. 8 Periodontal status was evaluated according to the plaque index (PI), bleeding on probing (BOP) index, probing depth (PD), and clinical attachment loss (CAL). All measurements were performed by a single researcher (Dt. EVU). The percentage of ABL was calculated for posterior teeth (premolars and molars). Panoramic radiographs were used for the measurements. The patients were positioned such that the Frankfurt horizontal planes were parallel to the ground, the sagittal planes were perpendicular to the ground, and the vertical guidelines of the device coincided. All panoramic radiographs were obtained using Dürr Dental (VistaPano Bietigheim-Bissingen, Germany). Radiographs were analyzed using a software program (DBSWIN 5.12.0, Dürr Dental, Bietigheim-Bissingen, Germany). The percentage of ABL was calculated using the imaging program’s ability to measure the distance between two marked points. For each posterior tooth, measurements were taken from the mesial and distal regions, and the arithmetic mean was calculated. The distance from the enamel-cement border to the most coronal part of the alveolar bone crest was measured, and this distance was defined as ABL. This distance was then divided by the distance from the enamel-cement border to the root tip to determine the percentage of ABL. The arithmetic mean of the values was calculated, and values between 0 and 100 were assigned.( 9 ) TMJ examination The TMJ was evaluated according to Research and Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) established for the diagnosis of the most common TMDs. 7 Briefly, the RDC/TMD consists of a questionnaire and examination form and helps in making a preliminary diagnosis. It consists of a dual-axis system based on the biopsychosocial pain model, a holistic approach that addresses all possible causes of pain from biological, psychological, and sociological perspectives. Axis 1 includes the criteria that help diagnose disorders of the TMJ and masticatory muscles. Axis 2 includes the criteria used to assess pain and psychosocial status, such as pain severity, pain-induced incapacity, depression, and somatization (symptoms caused by a psychological state that cannot be explained medically and have no physical cause). This form includes a total of 31 questions, including questions on whether the patient has TMR symptoms; questions that help diagnosis through clinical examination; questions that assess chronic pain status, depression, and somatization; questions that assess social function; questions that assess the patient’s general health and physical characteristics; and questions that assess parameters that may be related to TMD. All clinical examinations of the joint and completions of the RDC/TMD form were performed by one researcher (Dt. EVU) after completing the RDC/TMD online learning course. Data collected with the form were evaluated as recommended by Dworkin et al. ( 10 ). Measurement of bite force BF was measured by a self-produced device (Fig. 1 ). There were miniature strain gauges on both sides of the dental arch. Miniature strain gauges were placed at both ends of a U-shaped stainless-steel bar that mimicked the shape of the dental arch. This bar was covered with 2-mm thick plates made of polyacrylic resin and wrapped with plastic wrap to prevent the teeth from contacting the metal. Thus, the metal was prevented from damaging the teeth, and because the patient could not bite the metal comfortably, chewing force was not suppressed. The polyacrylic resin plate also served to protect the strain gauges and standardize their positions during the measurement. The plates were wrapped with latex gloves during measurement to prevent contamination. The system used to measure BF was created by a company (Yöntem Engineering, Bursa, Turkey) working on strain gauges. The signals generated in the system were monitored and calibrated in kg for the right side, left side, and total with a software developed by the same company. In all measurements, the patients were seated upright with their heads in their natural position and the Frankfurt Horizontal Plane (i.e., the plane between the upper middle edge of the earhole and the lower edge of the eye socket) parallel to the floor. Strain gauges were placed at the level of the patient’s first molars, and the patient was asked to bite the plate. The patients were asked to bite as hard as possible and repeat the bite three times, and the highest values were recorded ( 11 ). Statistical analysis Kolmogorov-Smirnov and Shapiro–Wilk tests were performed to determine whether the parameters were normally distributed. In addition to descriptive statistical methods (mean, standard deviation, and frequency), the Student’s t-test was used for between-group comparisons of normally distributed parameters, while the Mann–Whitney U test was used for non-normally distributed parameters. Chi-square test, Fisher-Freeman-Halton exact chi-square test, and Yates’ continuity correction were used for comparison of qualitative data. Spearman’s rho correlation analysis was used to examine relationships between non-normally distributed parameters. Statistical analysis was conducted using SPSS version 19, with significance set at p < 0.05. Results Patient characteristics A total of 100 participants were included in the study: 50 healthy controls and 50 patients with generalized stage III, grade B periodontitis. The mean age of the all participants was 35.12 ± 11.06 years (range, 21–65 years), and 51% were female. The mean ages of the periodontitis and healthy groups were 42.60 ± 9.98 years and 27.64 ± 5.77, respectively. Periodontal measurements As shown in Table 1 , all clinical periodontal parameters, including PD, CAL, BOP, and PI, were significantly higher in the periodontitis group compared to the healthy group (p < 0.001 for all). Table 1 Periodontal parameters Healthy group Periodontitis group n = 50 n = 50 p Value Mean ± SD Mean ± SD PD (mm) 1.67 ± 0.22 5.05 ± 0.7 p < 0.001* CAL (mm) 0.34 ± 0.74 5.86 ± 0.77 p < 0.001* BOP (%) 3.9 ± 2.75 51.04 ± 14.23 p < 0.001* PI 0.68 ± 0.26 2.01 ± 0.31 p < 0.001* ABL 0 43.88 Mann-Whitney U test, PD: Probing depth, CAL: Clinical attachment loss, BOP: Bleeding on probing, PI: Plaque index, ABL: Alveolar bone loss *p < 0.05 RDC/TMD data The frequency of TMJ-related symptoms detected by the RDC/TMD assessments is shown in Table 2 . The rates of pain in the jaw upon waking (p = 0.044), sticking/locking of the jaw (p = 0.020), and daytime bruxism (p = 0.042) were significantly lower in the periodontitis group than in the healthy group (p < 0.05). Other symptoms, including tinnitus, difficulty in biting or eating, joint sounds, and nocturnal bruxism, showed no significant between-group differences. Table 2 TMJ-related complaints Total population Healthy group Periodontitis group n = 100 n = 50 n = 50 p Value n (%) n (%) n (%) Pain in the jaw upon waking 14 (14%) 11 (22%) 3 (6%) 0.044* Tinnitus 28 (28%) 12 (24%) 16 (32%) 0.504 Difficulty in biting 17 (17%) 5 (10%) 12 (24%) 0.110 Sticking/locking 10 (10%) 9 (18%) 1 (2%) 0.020* Difficulty in eating 23 (2%3) 9 (18%) 14 (28%) 0.342 Noise when opening and closing the mouth 22 (22%) 15 (30%) 7 (14%) 0.091 Nocturnal bruxism 54(54%) 32 (%64) 22 (%44) 0,071 Daytime bruxism 41(41%) 26 (%52) 15 (%30) 0,042* Yates’ correction for continuity; *p 0.05). Most participants were classified as "healthy" (68% overall), followed by myofascial pain (14%), disc displacement with reduction (11%), and disc displacement without reduction (7%). Table 3 Preliminary TMJ classification according to RDC/TMD questionnaire assessments Total population Healthy group Periodontitis group n = 100 n = 50 n = 50 p Value n (%) n (%) n (%) Pre-diagnoses Healthy 68 (68%) 33 (66%) 35 (70%) 0.772 Myofascial pain 14 (14%) 6 (12%) 8 (16%) Disc displacement with reduction 11 (11%) 7 (14%) 4 (8%) Disc displacement without reduction 7 (7%) 4 (8%) 3 (6%) Fisher Freeman Halton Exact Test , *p 0.05). In total, 72% and 78% of the participants in the periodontitis and healthy groups had grade 0 disease, respectively. Pain intensity, inadequacy score, depression score, painful somatization score, and painless somatization score were also not significantly different (p > 0.05 for all, Table 4 ). Table 4 Pain intensity according to RDC/TMD questionnaire assessments Healthy group Periodontitis group n = 50 n = 50 p Value n (%) n (%) Chronic pain scale Grade 0 39 (78%) 36 (72%) 1 0.216 Functional Chronic 1 8 (16%) 5 (10%) Functional Chronic 2 3 (6%) 6 (12%) Dysfunctional Chronic 3 0 (0) 3 (6%) Mean ± SD Mean ± SD Pain intensity 11.59 ± 21.61 15.58 ± 26.34 2 0.600 Limitation 0.15 ± 0.4 0.18 ± 0.66 2 0.409 Depression 1.09 ± 0.5 0.93 ± 0.54 3 0.126 Somatization with pain 0.74 ± 0.57 0.76 ± 0.38 2 0.509 Somatization without pain 0.53 ± 0.5 0.65 ± 0.44 2 0.167 1 Yates’ continuity correction; 2 Mann-Whitney U test; 3 Student’s t test; *p < 0.05 SD: standard deviation Bite force BF was significantly lower in the periodontitis group than in the healthy group (29.58 ± 6.01 kg vs 35.89 ± 8.13 kg; p < 0.05). Figure 2 illustrates the comparison of the BF between the groups. BF showed a statistically significant, weak-to-moderate inverse correlation with PD (r = -0.300, p = 0.002), a moderate inverse correlation with CAL (r = -0.431, p < 0.001), and a moderate inverse correlation with PI (r = -0.301, p = 0.002). A weak but significant negative correlation was also observed with BOP (r = -0.197, p = 0.049). The correlation between BF and ABL was weak and not statistically significant (r = -0.235, p = 0.100) (Table 5 ). Table 5 Correlations between bite force and periodontal parameters in the total population Bite force (kg) PD (mm) r -0.300 p 0.002* CAL (mm) r -0.431 p p < 0.001 PI r -0.301 p 0.002* BOP (%) r -0.197 p 0.049* ABL (%) r -0.235 p 0.100 Spearman’s rho correlation test *p < 0.05 Discussion In the present study, patients with periodontitis demonstrated significantly lower bite force (BF) compared to periodontally healthy controls. Additionally, BF was found to be inversely correlated with several clinical periodontal parameters, including PD, CAL, PI, and BOP. These findings suggest that periodontal tissue destruction may compromise the efficiency of the masticatory system, potentially due to the disruption of periodontal mechanoreceptors that are essential for neuromuscular feedback and bite regulation. However, no statistically significant differences were observed between the two groups in terms of temporomandibular disorder (TMD) diagnosis based on RDC/TMD criteria, despite a lower frequency of some TMJ-related symptoms—such as jaw pain upon waking, locking, and daytime bruxism—in the periodontitis group. This outcome may reflect the compensatory adaptations of the masticatory system in patients with long-standing periodontitis. As the periodontal disease progresses slowly, structural and functional adaptations within the stomatognathic system could help mitigate the onset of clinical TMJ symptoms. Although the exact etiology of TMDs has not been elucidated, occlusal disharmony has been identified as a significant contributing factor ( 12 ). Periodontitis, by compromising occlusal support and neuromuscular feedback mechanisms through the loss of periodontal mechanoreceptors, may influence condylar positioning and overall joint function. Igarashi et al. reported that unilateral removal of occlusal support led to supero-anterior displacement of the TMJ on the affected side. When occlusal support was removed bilaterally, both joints showed varying degrees of supero-anterior displacement ( 13 ). Alterations in interarch distance and condylar positioning—often due to partial edentulism—can disrupt occlusal contacts, diminish occlusal stability, and reduce masticatory efficiency, ultimately impairing TMJ function. Huang et al. demonstrated that in cases of unilateral edentulism, the two TMJs did not share the mechanical load equally. Histological findings revealed that the imbalance initiated a degenerative process within the condylar cartilage( 14 ). Similarly, Jean et al. found a significant association between periodontitis-induced unilateral chewing habits and the prevalence of TMDs. They highlighted the importance of early diagnosis and timely intervention in periodontal therapy to prevent potential TMJ complications ( 15 ). Furthermore, Bezamat et al. emphasized that the chronic inflammatory processes associated with periodontitis could pose a risk for the development of TMDs ( 16 ). Despite these associations, our study found no significant difference in the clinical distribution of TMD pre-diagnoses between groups. This may be attributed to differences in diagnostic methodology; while this study employed clinical assessments and validated questionnaires (RDC/TMD), imaging techniques such as MRI—which are considered the gold standard for making a definitive diagnosis of intra-articular irregularities, disc displacement, and type of displacement (with or without reduction)—were not utilized. Therefore, the diagnoses should be interpreted as preliminary. The most common diagnosis in Axis I evaluations according to previous studies is myofascial pain with or without mouth opening restriction ( 17 ). In this study, 14% of the participants were diagnosed with myofascial pain; 11%, disc displacement with reduction; and 7%, disc displacement without reduction. TMD pre-diagnosis classification was not significantly different between the periodontitis and healthy groups. Epidemiological data indicate that temporomandibular disorder (TMD) symptoms are most commonly reported between the ages of 20 and 40, with clinical manifestations affecting approximately 6–12% of the general population ( 18 ) Noise while opening and closing the mouth, difficulty eating, headache, decreased mouth opening, nighttime or daytime bruxism, and tinnitus are some of the patient complaints. The prevalence of daytime and night-time bruxism differs, especially according to age, sex, and continence. A meta-analysis by Archer et al. showed that awake bruxism was prevalent in 15.44% of the adult population ( 19 ). Ferrari-Piloni et al. also observed bruxism in the sleep and wakefulness states in 25.8% of children living in Brazil ( 20 ). Moreover, Zielinski et al. reported that sleep and awake bruxisms were prevalent in 21% and 23% of the global population, respectively ( 21 ). Bruxism prevalence in our study (54% nocturnal, 41% daytime) was higher than previously reported in some epidemiological reviews. Factors such as stress, stimulant use, sleep disturbances, and methodological differences may contribute to this variation ( 22 ). Notably, bruxism rates, jaw sticking/locking, and jaw pain upon waking were lower in the periodontitis group, which could relate to their higher average age and possible neuromuscular adaptation over time. Periodontitis is a chronic disease, and stage III periodontitis as an advanced periodontal disease develops gradually within a long period of time ( 2 ). In this process, the components of the masticatory system can adapt and maintain the continuity of the masticatory system by creating modifications organically and in their movements and roles. Therefore, minimal symptoms are acceptable in these patients. Additionally, some studies have only conducted self-report evaluations without clinical examinations. Without a thorough clinical examination, TMJ pain can be confused with different types of pain, such as headache, earache, and toothache. This may be one reason for the differences in the results obtained. The distribution of chronic pain classification was not significantly different between the periodontitis and healthy groups. Depression and somatization scores were also not significantly different. In the study by Olivo et al., 27%, 7,%, 50%, and 16% of the patients had grades I, II, III, and IV chronic pain severity ( 23 ). The worse severity of pain in previous studies than in the current study might be due the differences in populations evaluated. Previous studies study groups evaluated patients presenting with myofascial and temporomandibular pain, whereas the current study evaluated patients who presented with dental and gingival complaints. Masticatory function depends on many factors such as the texture and hardness of the food, amount of food taken into the mouth, muscles working during this process, and BF. ( 24 ). Therefore, it is important to assess BF, especially in patients with reduced periodontium and naturally reduced periodontal mechanoreceptors. In the current study, the maximum BF was significantly lower in the periodontitis group than in the healthy group (29.58 kg (295 N) vs. 35.89 kg (358 N)). These findings are consistent with those reported by Kleinfelder and Ludwig who also found lower BF in the periodontitis group than in the healthy group (357 N vs 378 N) ( 25 ). While our findings were similar to those of some studies, they were also in conflict with those of other studies. For example, Laurell and Lundgren compared the BF of two-membered cantilever bridges with that of healthy teeth and found no significant results. The concluded that mechanoreceptors in the periodontal ligament area did not affect BF control and that masticatory muscles completely determined BF ( 26 ). Edel and Wills reported that BF is controlled by the periodontal ligament and is affected by periodontal inflammation ( 27 ). Alkan et al. compared the BF between chronic periodontitis patients and periodontally healthy patients using pressure-sensitive films ( 28 ). The initial periodontal treatment of periodontitis patients was completed before the measurements were made. The results showed significantly lower BF in patients with periodontitis, and this was attributed to reduced biting ability from reduced periodontal tissue rather than from inflammation. In an electromyography (EMG) study of 14 patients by Fernandes et al., an occlusion consisting of teeth with 50% reduced periodontal support was found to equally withstand masticatory loads ( 29 ). However, another EMG study showed significant improvements in masticatory function after periodontal treatment ( 30 ). The controversial results of the few studies on the relationship of the TMJ with the periodontium and on masticatory function in patients with periodontitis can be explained by the number of participants, sensitivity of the measuring devices used, and differences in the measurement area. Factors such as the definition of periodontitis, severity of periodontitis, and localized/generalized periodontitis also affect results. Using pressure-sensitive films, Takeuchi et al. found that bite function decreased with increasing attachment loss ( 31 ). Heath also suggested that patients with reduced periodontal support unknowingly limit their masticatory function with differences in dietary selection ( 32 ). The absence of a significant correlation between alveolar bone loss (ABL) and BF in our results may stem from the measurement method or variability in individual adaptation mechanisms. Nonetheless, the moderate inverse relationships between BF and CAL/PD support the hypothesis that periodontal destruction negatively affects bite efficiency. This study has several limitations. First, although clinical and questionnaire-based assessments were performed for TMD evaluation, no imaging techniques such as MRI or CBCT were employed, limiting the diagnostic accuracy of TMJ conditions. Second, the cross-sectional design does not allow for causal inference between periodontal parameters and BF or TMJ symptoms. Third, potential confounding factors such as dietary habits, psychological stress, and parafunctional activities were not controlled for, which may have influenced bruxism prevalence and BF outcomes. Additionally, the sample size, although adequate for statistical comparisons, may not fully represent the broader population. Future longitudinal studies incorporating imaging diagnostics and a more comprehensive assessment of behavioral and functional variables are needed to clarify these relationships further. Conclusions Symptoms of jaw pain upon waking, sticking/locking of the jaw, and daytime bruxism are significantly less common in individuals with periodontitis than in healthy individuals. Meanwhile, the incidence of tinnitus, difficulty biting, difficulty eating, and joint sounds is not significantly different between these populations. Temporomandibular discomfort was also less prevalent among individuals with periodontitis. Moreover, bite force was found to be lower in periodontitis patients and was inversely correlated with clinical indicators such as probing depth and clinical attachment level. Collectively, these results support that decreased BF in patients with periodontitis may lead to decreased masticatory function and thus impair quality of life. Therefore, early and appropriate periodontal treatment, prosthetic rehabilitation of missing teeth, and regular dental visits are important for preserving oral function. Abbreviations ABL alveolar bone loss BF bite force CAL clinical attachment loss EMG electromyography PD probing depth PI plaque index RDC/TMD Research and Diagnostic Criteria for Temporomandibular Disorders TMDs temporomandibular disorders TMJ temporomandibular joint Declarations Ethics approval and consent to participate: This study was approved by the Istanbul Medipol University Ethics Committee (protocol no: 738, approval date: 23.06.2021) and was conducted according to the principles of the Declaration of Helsinki, as revised in 2013. Verbal and written consent were obtained from all participants using a Voluntary Consent Form. All individuals gave oral informed consent and signed the form. Clinical trial number: not applicable. Consent for publication: Not applicable Availability of data and materials: Available upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: None Authors’ contributions: Dr. EVU conceived and designed the study, performed the statistical analysis, and was a major contributor in writing the manuscript. Dr. NA. contributed to data collection and interpretation, and critically revised the manuscript for important intellectual content. Dr. MÇ participated in the clinical examinations and contributed to the literature review. Dr. NB assisted in methodology design and helped with data analysis and visualizations. Dr. HUT coordinated the study, supervised the research process, and provided final approval of the version to be published. All authors read and approved the final manuscript. Acknowledgements: The authors have no individuals or organizations to acknowledge for this study. References Bordoni B, Varacallo M, Anatomy. Head and Neck, Temporomandibular Joint. PMID: In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2023. p. 30860721. Loesche WJ, Grossman NS. Periodontal Disease as a Specific, albeit Chronic, Infection: Diagnosis and Treatment. Clin Microbiol Rev. 2001;14. https://doi.org/10.1128/cmr.14.4.727-752.2001 . Johansson AS, Svensson KG, Trulsson M. Impaired masticatory behavior in subjects with reduced periodontal tissue support. J Periodontol. 2006;77(9):1491–7. Piancino MG, Isola G, Cannavale R, Cutroneo G, Vermiglio G, Bracco P, Anastasi GP. From periodontal mechanoreceptors to chewing motor control: a systematic review. Arch Oral Biol. 2017;78:109–21. Türker KS. Reflex control of human jaw muscles. Crit Reviews Oral Biology Medicine;2002. 13(1), 85–104.). Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol. 1997;68:967–72. Lundgren D, Nyman S, Heıjl L, Carlsson GE. Functional analysis of fixed bridges on abutment teeth with reduced periodontal support. J Rehabil, 1975; 2(2), 105–16.). Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: consensus report of workgroup 1 of the 2017 World workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol. 2018;89:S74–84. https://doi.org/10.1111/jcpe.12940 . Machado V, Proença L, Morgado M, Mendes JJ, Botelho J. Accuracy of panoramic radiograph for diagnosing periodontitis comparing to clinical examination. J Clin Med. 2020;9(7):2313. Dworkin SF, LeResche L. Research Diagnostic Criteria For Temporomandibular Disorders: Review Criteria, Examinations and Spesifications, Critique. J Craniomandib Disord Facial Oral Pain. 1992;6:301–55. Karakis D, Dogan A. The craniofacial morphology and maximum bite force in sleep bruxism patients with signs and symptoms of temporomandibular disorders. CRANIO®. 2015;33(1):32–7. Rutkiewicz T, Könönen M, Suominen-Taipale L, Nordblad A, Alanen P. Occurrence of clinical signs of temporomandibular disorders in adult Finns. J Orofac Pain. 2006;20(3):208–17. PMID: 16913430. Igarashi Y, Yamashita S, Kuroiwa A. Changes in interarch distance and condylar position related to loss of occlusal support for partially edentulous patients. A pilot study. Eur J Prosthodont Restor Dent. 1999;7(4):107–11. Huang Q, Opstelten D, Samman N, Tideman H. Experimentally induced unilateral tooth loss: histochemical studies of the temporomandibular joint. J Dent Res. 2002;81(3):209–13. Jeon HM, Ahn YW, Jeong SH, Ok SM, Choi J, Lee JY, Kwon EY. Pattern analysis of patients with temporomandibular disorders resulting from unilateral mastication due to chronic periodontitis. J Periodontal Implant Sci. 2017;47(4):211–8. Bezamat M, Cunha EJ, Modesto AM, Vieira AR, Taboas JM. Aquaporin locus (12q13.12) might contribute to susceptibility of temporomandibular joint disorder associated with periodontitis. PLoS ONE. 2020;15(3):e0229245. https://doi.org/10.1371/journal.pone.0229245 . Manfredini D, Guarda-Nardini L, Winocur E, et al. Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings. Oral Surgery, Oral Medicine, Oral Pathology. Oral Radiol Endodontics. 2011;112(4):453–62. 10.1016/j.tripleo.2011.04.021 . PMID: 21835653.). Lipton JA, Ship JA, Larach-Robinson D. Estimated Prevalence and Distribution of Reported Orofacial Pain in the United States. J Am Dent Assoc. 1993;124:115–21. 10.14219/jada.archive.1993.0200.) . Archer AB, Da-Cas CD, Valesan LF, Cunha TCA, Januzzi E, Garanhani RR. Torre Canales G, de Souza BDM. Prevalence of Awake Bruxism in the Adult Population: A Systematic Review and Meta-Analysis. Clin. Oral Investig. 2023; 27, 7007–7018. Ferrari-Piloni C, Barros LAN, Evangelista K, Serra-Negra JM, Silva MAG, Valladares-Neto J. Prevalence of Bruxism in Brazilian Children: A Systematic Review and Meta-Analysis. Pediatr Dent. 2022;44:8–20. Zieliński G, Pająk A, Wójcicki M. Global Prevalence of Sleep Bruxism and Awake Bruxism in Pediatric and Adult Populations: A Systematic Review and Meta-Analysis. J Clin Med. 2024;13:4259. https://doi.org/10.3390/jcm13144259 . Melo G, Duarte J, Pauletto P, Porporatti AL, Stuginski-Barbosa J, Winocur E. De Luca Canto G. Bruxism: an umbrella review of systematic reviews. J Rehabil. 2019;46(7):666–90. Olivo SA, Fuentes J, Major PW, Warren S, Thie NMR, Magee DJ. The association between neck disability and jaw disability. J Rehabil. 2010;37(9):670–9. Zhao L, Monahan R. Functional assessment of the stomatognathic system. Clin Plast Surg. 2007;34:e1–9. Kleinfelder JW, Ludwig K. Maximal bite force in patients with reduced periodontal tissue support with and without splinting. J Periodontol. 2002;73(10):1184–7. Laurell L, Lundgren D. Periodontal ligament areas and occlusal forces in dentitions restored with cross-arch unilateral posterior two‐unit cantilever bridges. J Clin Periodontol. 1986;13(1):33–8. Edel A, Wills DJ. method of studying the effects of reduced alveolar support on the sensibility to axial force on the incisor teeth in humans. J Clin Periodontol. 1975;2(4):218–25. Alkan A, Keskiner I, Arici S, Sato S. The effect of periodontitis on biting abilities. J Periodontol. 2006;77(8):1442–5. Fernandes CP, Psarras V, Freitas LB, Ahlgren J. Jaw-closing muscles: electromyographic activity of human subjects with reduced periodontal support. J Rehabil. 1994;21(2):165–75. Sasahara H, Morishita M, Iwamoto Y, Tamura H, Nagasawa T, Tsuru H. Effect of plaque control on masticatory function of patients with periodontal disease. Changes of electromyogram and clenching force. Hiroshima Daigaku shigaku zasshi. J Hiroshima Univ Dent Soc. 1988;20(2):334–42. Takeuchi N, Yamamoto T. Correlation between periodontal status and biting force in patients with chronic periodontitis during the maintenance phase of therapy. J Clin Periodontol. 2008;35(3):215–20. Heath MR. The effect of maximum biting force and bone loss upon masticatory function and dietary selection of the elderly. Int Dent J. 1982;32:345–56. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 23 May, 2025 Reviews received at journal 22 May, 2025 Reviews received at journal 18 May, 2025 Reviewers agreed at journal 12 May, 2025 Reviews received at journal 09 May, 2025 Reviewers agreed at journal 09 May, 2025 Reviewers agreed at journal 08 May, 2025 Reviewers invited by journal 29 Apr, 2025 Editor assigned by journal 29 Apr, 2025 Editor invited by journal 29 Apr, 2025 Submission checks completed at journal 28 Apr, 2025 First submitted to journal 28 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6469546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451729742,"identity":"45c5e259-ba74-4dd1-909a-fba2087de921","order_by":0,"name":"Erdem Veli Uzun","email":"","orcid":"","institution":"Istanbul Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Erdem","middleName":"Veli","lastName":"Uzun","suffix":""},{"id":451729743,"identity":"76159a9a-16ae-4177-b019-45293b636456","order_by":1,"name":"Nurcan Aksaka","email":"","orcid":"","institution":"Istanbul Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Nurcan","middleName":"","lastName":"Aksaka","suffix":""},{"id":451729744,"identity":"a438fb0a-3f81-4b5a-8208-bcbb2bc6d924","order_by":2,"name":"Mert Çelik","email":"","orcid":"","institution":"Istanbul Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Mert","middleName":"","lastName":"Çelik","suffix":""},{"id":451729745,"identity":"1d29995d-236d-422a-ae0b-3a6e1e640e50","order_by":3,"name":"Nur Balcı","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYDACCQbGAwwGNkBWYgMDQwGQPkBYC1CNQRpUiwFYC2MDYS0Mh4GsBAbitJhLNz848KPgfDQ/e3Lbgw8GDHJ8NxLYH1fg0WI555jBwR6D27kzex62G84wYDCWvJHA2HgGjxaDGwkGhxmAWjbcSGyT5jFgSNwA0oLPZQY30j8AtZzL3Q/VUk+ElhyQLQdyN0hAtCQYENRy50wB0C/JuTPOgP0iYTjzzMPGmXi13G7f+ODHH7vc/vb0Zw8+VNjI8x1PPvARnxZkwMYAjiZCMYmuZRSMglEwCkYBJgAAp+lY06k0DSEAAAAASUVORK5CYII=","orcid":"","institution":"Istanbul Medipol University","correspondingAuthor":true,"prefix":"","firstName":"Nur","middleName":"","lastName":"Balcı","suffix":""},{"id":451729746,"identity":"9efbea9a-ad05-4f3c-b06b-444aa9238fc4","order_by":4,"name":"Hilal Uslu Toygar","email":"","orcid":"","institution":"Istanbul Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Hilal","middleName":"Uslu","lastName":"Toygar","suffix":""}],"badges":[],"createdAt":"2025-04-17 08:08:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6469546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6469546/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-026-07896-5","type":"published","date":"2026-02-21T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82153769,"identity":"f53add70-9d49-4470-951e-55915ef24f7d","added_by":"auto","created_at":"2025-05-07 07:28:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2185581,"visible":true,"origin":"","legend":"\u003cp\u003eBite force recording device\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6469546/v1/056b008910803e7341722087.png"},{"id":82151267,"identity":"63cbb32c-886e-432a-abaa-d45fdd5bb164","added_by":"auto","created_at":"2025-05-07 07:20:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":102817,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of bite force between the periodontitis and healthy groups\u003c/p\u003e\n\u003cp\u003eMann-Whitney U test p\u0026lt;0.05\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6469546/v1/4b0e38edb95cec1119e6a6b5.png"},{"id":103251377,"identity":"e4e5d650-50a5-49f9-b8cf-7368ca52b1e7","added_by":"auto","created_at":"2026-02-23 16:08:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3153690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6469546/v1/52d462a2-aaf2-4a43-ab3a-cd9e8164a68e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of periodontal disease on bite force and the temporomandibular joint disorders: A cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe masticatory system is a complex functional unit composed of the teeth, alveolar bone, temporomandibular joint (TMJ), masticatory muscles, and associated ligaments. These components must operate in synchrony to maintain proper occlusal relationships and ensure efficient chewing performance (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Periodontitis is a chronic inflammatory disease, and its progression leads to decreased amount of alveolar bone around the teeth, increased tooth mobility, and teeth displacement. This ultimately results in disrupted occlusal balance (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) that may in turn cause occlusal overloading of the teeth, as well as decreased bite force (BF) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Additionally, structural changes in the dentition due to periodontitis may result in functional changes in the TMJ and surrounding musculature, potentially increasing the risk of temporomandibular disorders (TMDs).\u003c/p\u003e \u003cp\u003eRecent studies have highlighted the importance of occlusal balance and the biomechanical feedback provided by periodontal mechanoreceptors in maintaining proper masticatory function (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These receptors, located within the periodontal ligament, play a crucial role in regulating bite force (BF) by detecting mechanical stimuli and transmitting sensory feedback to the central nervous system. These mechanoreceptors provide neural control of movements, such as holding an object in the mouth, biting, and chewing (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Their impairment due to periodontal tissue destruction may compromise neuromuscular coordination, ultimately affecting bite efficiency and force distribution. Additionally, compensatory or pathological movements\u0026mdash;such as protrusion due to anterior tooth migration or altered incisor inclination\u0026mdash;can further disrupt occlusal balance and TMJ biomechanics (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough numerous studies have independently investigated the associations between periodontal disease, bite force (BF), and temporomandibular disorders (TMDs), the potential combined influence of periodontal destruction on both masticatory function and temporomandibular joint (TMJ) integrity has not been sufficiently elucidated. Given these interrelations, this study is hypothesized that periodontal breakdown not only impairs masticatory performance through reduced BF but may also increase the susceptibility to TMDs by altering condylar loading and joint adaptation. This study aimed to investigate the relationship between alveolar bone loss (ABL) and BF, and to assess the incidence and characteristics of TMDs\u0026mdash;such as joint pain, joint sounds, and limited mandibular movement\u0026mdash;in patients with generalized periodontitis. A clearer understanding of these associations is essential for guiding clinical interventions that preserve both periodontal health and functional integrity of the masticatory system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThis cross-sectional study evaluated patients who visited the Istanbul Medipol University, Faculty of Dentistry, Department of Periodontics for dental treatment between July 2021 and July 2022. Those who met the inclusion criteria after clinical and radiographic examinations were invited to participate. The inclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) age\u0026thinsp;\u0026gt;\u0026thinsp;20 years and \u0026lt;\u0026thinsp;65 years; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) at least 20 permanent natural teeth in occlusion except for the 3rd molars; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) complete double molars in any hemiarch; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) without orthodontic appliance; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) not pregnant; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) without inflammatory joint disease, neurological disease, or autoimmune disease; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) not taking medications that may interfere with muscle activity; (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) not taking anti-inflammatory drugs in the last 3 months; (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) no periodontal treatment in the last 6 months; (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) no surgical periodontal treatment in the last year; and (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) no fixed prosthesis with multiple elements, dental implants, or partial removable prostheses.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical and radiographic periodontal measurements\u003c/h3\u003e\n\u003cp\u003eThe periodontal status was diagnosed based on the 2017 AAP/ EFP classification of periodontal and peri-implant diseases.\u003csup\u003e8\u003c/sup\u003e Periodontal status was evaluated according to the plaque index (PI), bleeding on probing (BOP) index, probing depth (PD), and clinical attachment loss (CAL). All measurements were performed by a single researcher (Dt. EVU). The percentage of ABL was calculated for posterior teeth (premolars and molars). Panoramic radiographs were used for the measurements. The patients were positioned such that the Frankfurt horizontal planes were parallel to the ground, the sagittal planes were perpendicular to the ground, and the vertical guidelines of the device coincided. All panoramic radiographs were obtained using D\u0026uuml;rr Dental (VistaPano Bietigheim-Bissingen, Germany). Radiographs were analyzed using a software program (DBSWIN 5.12.0, D\u0026uuml;rr Dental, Bietigheim-Bissingen, Germany). The percentage of ABL was calculated using the imaging program\u0026rsquo;s ability to measure the distance between two marked points. For each posterior tooth, measurements were taken from the mesial and distal regions, and the arithmetic mean was calculated. The distance from the enamel-cement border to the most coronal part of the alveolar bone crest was measured, and this distance was defined as ABL. This distance was then divided by the distance from the enamel-cement border to the root tip to determine the percentage of ABL. The arithmetic mean of the values was calculated, and values between 0 and 100 were assigned.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eTMJ examination\u003c/h3\u003e\n\u003cp\u003eThe TMJ was evaluated according to Research and Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) established for the diagnosis of the most common TMDs.\u003csup\u003e7\u003c/sup\u003e Briefly, the RDC/TMD consists of a questionnaire and examination form and helps in making a preliminary diagnosis. It consists of a dual-axis system based on the biopsychosocial pain model, a holistic approach that addresses all possible causes of pain from biological, psychological, and sociological perspectives. Axis 1 includes the criteria that help diagnose disorders of the TMJ and masticatory muscles. Axis 2 includes the criteria used to assess pain and psychosocial status, such as pain severity, pain-induced incapacity, depression, and somatization (symptoms caused by a psychological state that cannot be explained medically and have no physical cause). This form includes a total of 31 questions, including questions on whether the patient has TMR symptoms; questions that help diagnosis through clinical examination; questions that assess chronic pain status, depression, and somatization; questions that assess social function; questions that assess the patient\u0026rsquo;s general health and physical characteristics; and questions that assess parameters that may be related to TMD. All clinical examinations of the joint and completions of the RDC/TMD form were performed by one researcher (Dt. EVU) after completing the RDC/TMD online learning course. Data collected with the form were evaluated as recommended by Dworkin et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eMeasurement of bite force\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eBF was measured by a self-produced device (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There were miniature strain gauges on both sides of the dental arch. Miniature strain gauges were placed at both ends of a U-shaped stainless-steel bar that mimicked the shape of the dental arch. This bar was covered with 2-mm thick plates made of polyacrylic resin and wrapped with plastic wrap to prevent the teeth from contacting the metal. Thus, the metal was prevented from damaging the teeth, and because the patient could not bite the metal comfortably, chewing force was not suppressed. The polyacrylic resin plate also served to protect the strain gauges and standardize their positions during the measurement. The plates were wrapped with latex gloves during measurement to prevent contamination. The system used to measure BF was created by a company (Y\u0026ouml;ntem Engineering, Bursa, Turkey) working on strain gauges. The signals generated in the system were monitored and calibrated in kg for the right side, left side, and total with a software developed by the same company. In all measurements, the patients were seated upright with their heads in their natural position and the Frankfurt Horizontal Plane (i.e., the plane between the upper middle edge of the earhole and the lower edge of the eye socket) parallel to the floor. Strain gauges were placed at the level of the patient\u0026rsquo;s first molars, and the patient was asked to bite the plate. The patients were asked to bite as hard as possible and repeat the bite three times, and the highest values were recorded (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eKolmogorov-Smirnov and Shapiro\u0026ndash;Wilk tests were performed to determine whether the parameters were normally distributed. In addition to descriptive statistical methods (mean, standard deviation, and frequency), the Student\u0026rsquo;s t-test was used for between-group comparisons of normally distributed parameters, while the Mann\u0026ndash;Whitney U test was used for non-normally distributed parameters. Chi-square test, Fisher-Freeman-Halton exact chi-square test, and Yates\u0026rsquo; continuity correction were used for comparison of qualitative data. Spearman\u0026rsquo;s rho correlation analysis was used to examine relationships between non-normally distributed parameters. Statistical analysis was conducted using SPSS version 19, with significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eA total of 100 participants were included in the study: 50 healthy controls and 50 patients with generalized stage III, grade B periodontitis. The mean age of the all participants was 35.12\u0026thinsp;\u0026plusmn;\u0026thinsp;11.06 years (range, 21\u0026ndash;65 years), and 51% were female. The mean ages of the periodontitis and healthy groups were 42.60\u0026thinsp;\u0026plusmn;\u0026thinsp;9.98 years and 27.64\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77, respectively.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePeriodontal measurements\u003c/h3\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, all clinical periodontal parameters, including PD, CAL, BOP, and PI, were significantly higher in the periodontitis group compared to the healthy group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePeriodontal parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeriodontitis group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAL (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOP (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e51.04\u0026thinsp;\u0026plusmn;\u0026thinsp;14.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eABL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e43.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eMann-Whitney U test, PD: Probing depth, CAL: Clinical attachment loss, BOP: Bleeding on probing, PI: Plaque index, ABL: Alveolar bone loss\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eRDC/TMD data\u003c/h2\u003e \u003cp\u003eThe frequency of TMJ-related symptoms detected by the RDC/TMD assessments is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The rates of pain in the jaw upon waking (p\u0026thinsp;=\u0026thinsp;0.044), sticking/locking of the jaw (p\u0026thinsp;=\u0026thinsp;0.020), and daytime bruxism (p\u0026thinsp;=\u0026thinsp;0.042) were significantly lower in the periodontitis group than in the healthy group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Other symptoms, including tinnitus, difficulty in biting or eating, joint sounds, and nocturnal bruxism, showed no significant between-group differences.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTMJ-related complaints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeriodontitis group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;100\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain in the jaw upon waking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.044*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTinnitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty in biting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSticking/locking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty in eating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (2%3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoise when opening and closing the mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNocturnal bruxism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (%64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (%44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaytime bruxism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41(41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (%52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (%30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,042*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eYates\u0026rsquo; correction for continuity;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003cp\u003eThe preliminary diagnoses based on RDC/TMD Axis I (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) revealed no statistically significant differences in TMD classification between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Most participants were classified as \"healthy\" (68% overall), followed by myofascial pain (14%), disc displacement with reduction (11%), and disc displacement without reduction (7%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreliminary TMJ classification according to RDC/TMD questionnaire assessments\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealthy group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeriodontitis group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;100\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePre-diagnoses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.772\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyofascial pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisc displacement with reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisc displacement without reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eFisher Freeman Halton Exact Test\u003c/em\u003e,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003cp\u003eChronic pain severity was not significantly different between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In total, 72% and 78% of the participants in the periodontitis and healthy groups had grade 0 disease, respectively. Pain intensity, inadequacy score, depression score, painful somatization score, and painless somatization score were also not significantly different (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePain intensity according to RDC/TMD questionnaire assessments\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeriodontitis group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic pain scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFunctional\u003c/p\u003e \u003cp\u003eChronic 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFunctional\u003c/p\u003e \u003cp\u003eChronic 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDysfunctional Chronic 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.59\u0026thinsp;\u0026plusmn;\u0026thinsp;21.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.58\u0026thinsp;\u0026plusmn;\u0026thinsp;26.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomatization with pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomatization without pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eYates\u0026rsquo; continuity correction;\u003c/em\u003e \u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eMann-Whitney U test;\u003c/em\u003e \u003csup\u003e\u003cem\u003e3\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eStudent\u0026rsquo;s t test;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eSD: standard deviation\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section4\"\u003e \u003ch2\u003eBite force\u003c/h2\u003e \u003cp\u003eBF was significantly lower in the periodontitis group than in the healthy group (29.58\u0026thinsp;\u0026plusmn;\u0026thinsp;6.01 kg vs 35.89\u0026thinsp;\u0026plusmn;\u0026thinsp;8.13 kg; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the comparison of the BF between the groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBF showed a statistically significant, weak-to-moderate inverse correlation with PD (r = -0.300, p\u0026thinsp;=\u0026thinsp;0.002), a moderate inverse correlation with CAL (r = -0.431, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a moderate inverse correlation with PI (r = -0.301, p\u0026thinsp;=\u0026thinsp;0.002). A weak but significant negative correlation was also observed with BOP (r = -0.197, p\u0026thinsp;=\u0026thinsp;0.049). The correlation between BF and ABL was weak and not statistically significant (r = -0.235, p\u0026thinsp;=\u0026thinsp;0.100) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between bite force and periodontal parameters in the total population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBite force (kg)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAL (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.301\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOP (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.049*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eABL (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSpearman\u0026rsquo;s rho correlation test\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, patients with periodontitis demonstrated significantly lower bite force (BF) compared to periodontally healthy controls. Additionally, BF was found to be inversely correlated with several clinical periodontal parameters, including PD, CAL, PI, and BOP. These findings suggest that periodontal tissue destruction may compromise the efficiency of the masticatory system, potentially due to the disruption of periodontal mechanoreceptors that are essential for neuromuscular feedback and bite regulation. However, no statistically significant differences were observed between the two groups in terms of temporomandibular disorder (TMD) diagnosis based on RDC/TMD criteria, despite a lower frequency of some TMJ-related symptoms\u0026mdash;such as jaw pain upon waking, locking, and daytime bruxism\u0026mdash;in the periodontitis group. This outcome may reflect the compensatory adaptations of the masticatory system in patients with long-standing periodontitis. As the periodontal disease progresses slowly, structural and functional adaptations within the stomatognathic system could help mitigate the onset of clinical TMJ symptoms.\u003c/p\u003e \u003cp\u003eAlthough the exact etiology of TMDs has not been elucidated, occlusal disharmony has been identified as a significant contributing factor (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Periodontitis, by compromising occlusal support and neuromuscular feedback mechanisms through the loss of periodontal mechanoreceptors, may influence condylar positioning and overall joint function. Igarashi et al. reported that unilateral removal of occlusal support led to supero-anterior displacement of the TMJ on the affected side. When occlusal support was removed bilaterally, both joints showed varying degrees of supero-anterior displacement (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Alterations in interarch distance and condylar positioning\u0026mdash;often due to partial edentulism\u0026mdash;can disrupt occlusal contacts, diminish occlusal stability, and reduce masticatory efficiency, ultimately impairing TMJ function. Huang et al. demonstrated that in cases of unilateral edentulism, the two TMJs did not share the mechanical load equally. Histological findings revealed that the imbalance initiated a degenerative process within the condylar cartilage(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Similarly, Jean et al. found a significant association between periodontitis-induced unilateral chewing habits and the prevalence of TMDs. They highlighted the importance of early diagnosis and timely intervention in periodontal therapy to prevent potential TMJ complications (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Furthermore, Bezamat et al. emphasized that the chronic inflammatory processes associated with periodontitis could pose a risk for the development of TMDs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these associations, our study found no significant difference in the clinical distribution of TMD pre-diagnoses between groups. This may be attributed to differences in diagnostic methodology; while this study employed clinical assessments and validated questionnaires (RDC/TMD), imaging techniques such as MRI\u0026mdash;which are considered the gold standard for making a definitive diagnosis of intra-articular irregularities, disc displacement, and type of displacement (with or without reduction)\u0026mdash;were not utilized. Therefore, the diagnoses should be interpreted as preliminary. The most common diagnosis in Axis I evaluations according to previous studies is myofascial pain with or without mouth opening restriction (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In this study, 14% of the participants were diagnosed with myofascial pain; 11%, disc displacement with reduction; and 7%, disc displacement without reduction. TMD pre-diagnosis classification was not significantly different between the periodontitis and healthy groups.\u003c/p\u003e \u003cp\u003eEpidemiological data indicate that temporomandibular disorder (TMD) symptoms are most commonly reported between the ages of 20 and 40, with clinical manifestations affecting approximately 6\u0026ndash;12% of the general population (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Noise while opening and closing the mouth, difficulty eating, headache, decreased mouth opening, nighttime or daytime bruxism, and tinnitus are some of the patient complaints. The prevalence of daytime and night-time bruxism differs, especially according to age, sex, and continence. A meta-analysis by Archer et al. showed that awake bruxism was prevalent in 15.44% of the adult population (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Ferrari-Piloni et al. also observed bruxism in the sleep and wakefulness states in 25.8% of children living in Brazil (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Moreover, Zielinski et al. reported that sleep and awake bruxisms were prevalent in 21% and 23% of the global population, respectively (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBruxism prevalence in our study (54% nocturnal, 41% daytime) was higher than previously reported in some epidemiological reviews. Factors such as stress, stimulant use, sleep disturbances, and methodological differences may contribute to this variation (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Notably, bruxism rates, jaw sticking/locking, and jaw pain upon waking were lower in the periodontitis group, which could relate to their higher average age and possible neuromuscular adaptation over time. Periodontitis is a chronic disease, and stage III periodontitis as an advanced periodontal disease develops gradually within a long period of time (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In this process, the components of the masticatory system can adapt and maintain the continuity of the masticatory system by creating modifications organically and in their movements and roles. Therefore, minimal symptoms are acceptable in these patients. Additionally, some studies have only conducted self-report evaluations without clinical examinations. Without a thorough clinical examination, TMJ pain can be confused with different types of pain, such as headache, earache, and toothache. This may be one reason for the differences in the results obtained.\u003c/p\u003e \u003cp\u003eThe distribution of chronic pain classification was not significantly different between the periodontitis and healthy groups. Depression and somatization scores were also not significantly different. In the study by Olivo et al., 27%, 7,%, 50%, and 16% of the patients had grades I, II, III, and IV chronic pain severity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The worse severity of pain in previous studies than in the current study might be due the differences in populations evaluated. Previous studies study groups evaluated patients presenting with myofascial and temporomandibular pain, whereas the current study evaluated patients who presented with dental and gingival complaints.\u003c/p\u003e \u003cp\u003eMasticatory function depends on many factors such as the texture and hardness of the food, amount of food taken into the mouth, muscles working during this process, and BF. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Therefore, it is important to assess BF, especially in patients with reduced periodontium and naturally reduced periodontal mechanoreceptors. In the current study, the maximum BF was significantly lower in the periodontitis group than in the healthy group (29.58 kg (295 N) vs. 35.89 kg (358 N)). These findings are consistent with those reported by Kleinfelder and Ludwig who also found lower BF in the periodontitis group than in the healthy group (357 N vs 378 N) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). While our findings were similar to those of some studies, they were also in conflict with those of other studies. For example, Laurell and Lundgren compared the BF of two-membered cantilever bridges with that of healthy teeth and found no significant results. The concluded that mechanoreceptors in the periodontal ligament area did not affect BF control and that masticatory muscles completely determined BF (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Edel and Wills reported that BF is controlled by the periodontal ligament and is affected by periodontal inflammation (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Alkan et al. compared the BF between chronic periodontitis patients and periodontally healthy patients using pressure-sensitive films (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The initial periodontal treatment of periodontitis patients was completed before the measurements were made. The results showed significantly lower BF in patients with periodontitis, and this was attributed to reduced biting ability from reduced periodontal tissue rather than from inflammation.\u003c/p\u003e \u003cp\u003eIn an electromyography (EMG) study of 14 patients by Fernandes et al., an occlusion consisting of teeth with 50% reduced periodontal support was found to equally withstand masticatory loads (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, another EMG study showed significant improvements in masticatory function after periodontal treatment (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The controversial results of the few studies on the relationship of the TMJ with the periodontium and on masticatory function in patients with periodontitis can be explained by the number of participants, sensitivity of the measuring devices used, and differences in the measurement area. Factors such as the definition of periodontitis, severity of periodontitis, and localized/generalized periodontitis also affect results.\u003c/p\u003e \u003cp\u003eUsing pressure-sensitive films, Takeuchi et al. found that bite function decreased with increasing attachment loss (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Heath also suggested that patients with reduced periodontal support unknowingly limit their masticatory function with differences in dietary selection (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The absence of a significant correlation between alveolar bone loss (ABL) and BF in our results may stem from the measurement method or variability in individual adaptation mechanisms. Nonetheless, the moderate inverse relationships between BF and CAL/PD support the hypothesis that periodontal destruction negatively affects bite efficiency.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, although clinical and questionnaire-based assessments were performed for TMD evaluation, no imaging techniques such as MRI or CBCT were employed, limiting the diagnostic accuracy of TMJ conditions. Second, the cross-sectional design does not allow for causal inference between periodontal parameters and BF or TMJ symptoms. Third, potential confounding factors such as dietary habits, psychological stress, and parafunctional activities were not controlled for, which may have influenced bruxism prevalence and BF outcomes. Additionally, the sample size, although adequate for statistical comparisons, may not fully represent the broader population. Future longitudinal studies incorporating imaging diagnostics and a more comprehensive assessment of behavioral and functional variables are needed to clarify these relationships further.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSymptoms of jaw pain upon waking, sticking/locking of the jaw, and daytime bruxism are significantly less common in individuals with periodontitis than in healthy individuals. Meanwhile, the incidence of tinnitus, difficulty biting, difficulty eating, and joint sounds is not significantly different between these populations. Temporomandibular discomfort was also less prevalent among individuals with periodontitis. Moreover, bite force was found to be lower in periodontitis patients and was inversely correlated with clinical indicators such as probing depth and clinical attachment level. Collectively, these results support that decreased BF in patients with periodontitis may lead to decreased masticatory function and thus impair quality of life. Therefore, early and appropriate periodontal treatment, prosthetic rehabilitation of missing teeth, and regular dental visits are important for preserving oral function.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eABL alveolar bone loss\u003c/p\u003e \u003cp\u003eBF bite force\u003c/p\u003e \u003cp\u003eCAL clinical attachment loss\u003c/p\u003e \u003cp\u003eEMG electromyography\u003c/p\u003e \u003cp\u003ePD probing depth\u003c/p\u003e \u003cp\u003ePI plaque index\u003c/p\u003e \u003cp\u003eRDC/TMD Research and Diagnostic Criteria for Temporomandibular Disorders\u003c/p\u003e \u003cp\u003eTMDs temporomandibular disorders\u003c/p\u003e \u003cp\u003eTMJ temporomandibular joint\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: This study was approved by the Istanbul Medipol University Ethics Committee (protocol no: 738, approval date: 23.06.2021) and was conducted according to the principles of the Declaration of Helsinki, as revised in 2013. Verbal and written consent were obtained from all participants using a Voluntary Consent Form. All individuals gave oral informed consent and signed the form.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Available upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: None\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: Dr. EVU conceived and designed the study, performed the statistical analysis, and was a major contributor in writing the manuscript. Dr. NA. contributed to data collection and interpretation, and critically revised the manuscript for important intellectual content. Dr. M\u0026Ccedil; participated in the clinical examinations and contributed to the literature review. Dr. NB assisted in methodology design and helped with data analysis and visualizations. Dr. HUT coordinated the study, supervised the research process, and provided final approval of the version to be published. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors have no individuals or organizations to acknowledge for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBordoni B, Varacallo M, Anatomy. Head and Neck, Temporomandibular Joint. PMID: In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2023. p. 30860721.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoesche WJ, Grossman NS. Periodontal Disease as a Specific, albeit Chronic, Infection: Diagnosis and Treatment. Clin Microbiol Rev. 2001;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1128/cmr.14.4.727-752.2001\u003c/span\u003e\u003cspan address=\"10.1128/cmr.14.4.727-752.2001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohansson AS, Svensson KG, Trulsson M. Impaired masticatory behavior in subjects with reduced periodontal tissue support. J Periodontol. 2006;77(9):1491\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiancino MG, Isola G, Cannavale R, Cutroneo G, Vermiglio G, Bracco P, Anastasi GP. From periodontal mechanoreceptors to chewing motor control: a systematic review. Arch Oral Biol. 2017;78:109\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026uuml;rker KS. Reflex control of human jaw muscles. Crit Reviews Oral Biology Medicine;2002. 13(1), 85\u0026ndash;104.).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTowfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol. 1997;68:967\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLundgren D, Nyman S, Heıjl L, Carlsson GE. Functional analysis of fixed bridges on abutment teeth with reduced periodontal support. J Rehabil, 1975; 2(2), 105\u0026ndash;16.).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: consensus report of workgroup 1 of the 2017 World workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol. 2018;89:S74\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpe.12940\u003c/span\u003e\u003cspan address=\"10.1111/jcpe.12940\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachado V, Proen\u0026ccedil;a L, Morgado M, Mendes JJ, Botelho J. Accuracy of panoramic radiograph for diagnosing periodontitis comparing to clinical examination. J Clin Med. 2020;9(7):2313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDworkin SF, LeResche L. Research Diagnostic Criteria For Temporomandibular Disorders: Review Criteria, Examinations and Spesifications, Critique. J Craniomandib Disord Facial Oral Pain. 1992;6:301\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarakis D, Dogan A. The craniofacial morphology and maximum bite force in sleep bruxism patients with signs and symptoms of temporomandibular disorders. CRANIO\u0026reg;. 2015;33(1):32\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutkiewicz T, K\u0026ouml;n\u0026ouml;nen M, Suominen-Taipale L, Nordblad A, Alanen P. Occurrence of clinical signs of temporomandibular disorders in adult Finns. J Orofac Pain. 2006;20(3):208\u0026ndash;17. PMID: 16913430.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIgarashi Y, Yamashita S, Kuroiwa A. Changes in interarch distance and condylar position related to loss of occlusal support for partially edentulous patients. A pilot study. Eur J Prosthodont Restor Dent. 1999;7(4):107\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang Q, Opstelten D, Samman N, Tideman H. Experimentally induced unilateral tooth loss: histochemical studies of the temporomandibular joint. J Dent Res. 2002;81(3):209\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeon HM, Ahn YW, Jeong SH, Ok SM, Choi J, Lee JY, Kwon EY. Pattern analysis of patients with temporomandibular disorders resulting from unilateral mastication due to chronic periodontitis. J Periodontal Implant Sci. 2017;47(4):211\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBezamat M, Cunha EJ, Modesto AM, Vieira AR, Taboas JM. Aquaporin locus (12q13.12) might contribute to susceptibility of temporomandibular joint disorder associated with periodontitis. PLoS ONE. 2020;15(3):e0229245. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0229245\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0229245\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManfredini D, Guarda-Nardini L, Winocur E, et al. Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings. Oral Surgery, Oral Medicine, Oral Pathology. Oral Radiol Endodontics. 2011;112(4):453\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tripleo.2011.04.021\u003c/span\u003e\u003cspan address=\"10.1016/j.tripleo.2011.04.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 21835653.).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipton JA, Ship JA, Larach-Robinson D. Estimated Prevalence and Distribution of Reported Orofacial Pain in the United States. J Am Dent Assoc. 1993;124:115\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14219/jada.archive.1993.0200.)\u003c/span\u003e\u003cspan address=\"10.14219/jada.archive.1993.0200.)\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArcher AB, Da-Cas CD, Valesan LF, Cunha TCA, Januzzi E, Garanhani RR. Torre Canales G, de Souza BDM. Prevalence of Awake Bruxism in the Adult Population: A Systematic Review and Meta-Analysis. Clin. Oral Investig. 2023; 27, 7007\u0026ndash;7018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrari-Piloni C, Barros LAN, Evangelista K, Serra-Negra JM, Silva MAG, Valladares-Neto J. Prevalence of Bruxism in Brazilian Children: A Systematic Review and Meta-Analysis. Pediatr Dent. 2022;44:8\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZieliński G, Pająk A, W\u0026oacute;jcicki M. Global Prevalence of Sleep Bruxism and Awake Bruxism in Pediatric and Adult Populations: A Systematic Review and Meta-Analysis. J Clin Med. 2024;13:4259. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm13144259\u003c/span\u003e\u003cspan address=\"10.3390/jcm13144259\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelo G, Duarte J, Pauletto P, Porporatti AL, Stuginski-Barbosa J, Winocur E. De Luca Canto G. Bruxism: an umbrella review of systematic reviews. J Rehabil. 2019;46(7):666\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlivo SA, Fuentes J, Major PW, Warren S, Thie NMR, Magee DJ. The association between neck disability and jaw disability. J Rehabil. 2010;37(9):670\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao L, Monahan R. Functional assessment of the stomatognathic system. Clin Plast Surg. 2007;34:e1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKleinfelder JW, Ludwig K. Maximal bite force in patients with reduced periodontal tissue support with and without splinting. J Periodontol. 2002;73(10):1184\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaurell L, Lundgren D. Periodontal ligament areas and occlusal forces in dentitions restored with cross-arch unilateral posterior two‐unit cantilever bridges. J Clin Periodontol. 1986;13(1):33\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdel A, Wills DJ. method of studying the effects of reduced alveolar support on the sensibility to axial force on the incisor teeth in humans. J Clin Periodontol. 1975;2(4):218\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlkan A, Keskiner I, Arici S, Sato S. The effect of periodontitis on biting abilities. J Periodontol. 2006;77(8):1442\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes CP, Psarras V, Freitas LB, Ahlgren J. Jaw-closing muscles: electromyographic activity of human subjects with reduced periodontal support. J Rehabil. 1994;21(2):165\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSasahara H, Morishita M, Iwamoto Y, Tamura H, Nagasawa T, Tsuru H. Effect of plaque control on masticatory function of patients with periodontal disease. Changes of electromyogram and clenching force. Hiroshima Daigaku shigaku zasshi. J Hiroshima Univ Dent Soc. 1988;20(2):334\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakeuchi N, Yamamoto T. Correlation between periodontal status and biting force in patients with chronic periodontitis during the maintenance phase of therapy. J Clin Periodontol. 2008;35(3):215\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeath MR. The effect of maximum biting force and bone loss upon masticatory function and dietary selection of the elderly. Int Dent J. 1982;32:345\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"periodontitis, bite force, temporomandibular disorders","lastPublishedDoi":"10.21203/rs.3.rs-6469546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6469546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAlveolar bone loss (ABL), tooth mobility, tooth displacement, and tooth loss due to periodontitis can lead to temporomandibular joint (TMJ) problems and reduced masticatory function. While previous studies have examined the associations between periodontal disease, bite force (BF), and temporomandibular disorders (TMDs) separately, the combined impact of periodontal breakdown on both masticatory function and TMJ involvement has not been clearly established. Therefore, this study aimed to determine the relationship between ABL and BF and to evaluate the incidence and characteristics of TMDs in patients with periodontitis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study enrolled 50 patients with stage III generalized periodontitis and 50 periodontally healthy participants. Sociodemographic data and clinical periodontal parameters were collected. BF was measured and compared between patients with periodontitis and periodontally healthy individuals. The TMJ was assessed using an interview-based questionnaire and clinical examination.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTMD pre-diagnostic classifications were not significantly different between the groups (p\u0026thinsp;=\u0026thinsp;0.772, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Complaints of pain in the jaw upon waking (p\u0026thinsp;=\u0026thinsp;0.044), clicking/locking of the jaw (p\u0026thinsp;=\u0026thinsp;0.020), and daytime bruxism (p\u0026thinsp;=\u0026thinsp;0.042) were significantly fewer in the periodontitis group than in the healthy group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Meanwhile, TMJ-related symptoms were not significantly different between the periodontitis and healthy groups. However, BF was significantly lower in the periodontitis group than in the healthy group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBF is decreased in patients with periodontitis. Periodontal treatment should be completed, and missing teeth, if any, should be rehabilitated to enable efficient masticatory function in these patients.\u003c/p\u003e","manuscriptTitle":"Effect of periodontal disease on bite force and the temporomandibular joint disorders: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 07:20:02","doi":"10.21203/rs.3.rs-6469546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-23T09:35:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-22T14:58:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-18T23:29:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3415486246823788087659090394775365109","date":"2025-05-12T12:10:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-10T00:53:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204698408932638853963602995978198451791","date":"2025-05-09T11:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114295405714607985007362405083572413825","date":"2025-05-09T03:19:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-30T00:49:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-30T00:45:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-29T10:32:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-28T19:16:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-04-28T19:14:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d326c4ee-fab6-420e-a566-2b7fd6bf25e7","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:04:10+00:00","versionOfRecord":{"articleIdentity":"rs-6469546","link":"https://doi.org/10.1186/s12903-026-07896-5","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-02-21 15:57:09","publishedOnDateReadable":"February 21st, 2026"},"versionCreatedAt":"2025-05-07 07:20:02","video":"","vorDoi":"10.1186/s12903-026-07896-5","vorDoiUrl":"https://doi.org/10.1186/s12903-026-07896-5","workflowStages":[]},"version":"v1","identity":"rs-6469546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6469546","identity":"rs-6469546","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}