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The Impact of Dizziness on Daily Activities in Patients with Temporomandibular Dysfunction
Bianca Simone Zeigelboim*1, Larissa Vianna1, Adriana Lacerda1, Vinicius Ribas Fonseca1,2, José Stechman Neto1, Rubianne Ligório de Lima2, Jair Mendes Marques1 and Angela Ribas1
1Post Graduate Program in Communication Disorders, Universidade Tuiuti do Paraná, South America
2ENT Service, Hospital da Cruz Vermelha Brasileira, South America
Submission: December 16, 2016; Published: January 06, 2017
*Corresponding author: Bianca Simone Zeigelboim, Universidade Tuiuti do Paraná (UTP) - Curitiba, Parana, Brazil, RuaGutemberg, 99, 9th floor, Postal Code: 80.420.030 – Curitiba, Parana, Brazil, Tel:(41)3331-7807, Email:firstname.lastname@example.org
How to cite this article: Bianca S Z, Larissa V, Adriana L, Vinicius R F, José S N. et al. The Impact of Dizziness on Daily Activities in Patients withTemporomandibular Dysfunction. Glob J Oto 2017; 3(2): 555606. DOI: 10.19080/GJO.2017.03.555606
Objective: the objective of the study was to evaluate the impact of dizziness on the performance of daily practices in temporomandibular disorders (TMD) patients using the Activities-specific Balance Confidence Scale (ABC) and Dizziness Handicap Inventory (DHI) questionnaires.
Methods: we evaluated 20 women with a mean age of 52.3 years from February 2014 to July 2015. The following were carried out: anamnesis, ENT examination, vestibular examination, and application of DHI and ABC questionnaires.
Results: a) alterations were observed with a prevalence of peripheral vestibular deficit dysfunction independent of the affected side and dizziness for the emotional domain in the DHI;
b) The ABC confidence scale showed less confidence for questions 15 (Stepping onto or off an escalator while holding onto parcels so that you cannot hold the railing) and 16 (Walking outside on slippery sidewalks);
c) There was no significant correlation between the ABC confidence scale and the vestibular examination results or the symptom of dizziness.
Conclusion: based on the obtained results, it is noted that the applied DHI and ABC questionnaires showed sensitivity in quantifying the level of perception for balance disorders in patients and therefore the results may assist in choosing the most appropriate intervention.
Keywords: Temporomandibular joint; Dizziness; Quality of life; Labyrinth diseases
Temporomandibular disorders (TMD) are characterized by a series of clinical signs and symptoms such as: muscle aches, headache, joint cracking, difficulty and limitation in mandibular movements, tinnitus, earache, vertigo, dizziness, and hearing loss, among others [1,2]. The association of TMDs and the origin of otological symptoms is not yet fully understood, although there are some hypotheses about their relationship. Some authors [1,3-4] correlate these symptoms with temporomandibular joint disorders (TMJ) due to anatomical and structural proximity to the middle and inner ear. Other authors [5-7] have showed that otological symptoms, especially tinnitus, may derive from complex interactions and cross-modal mechanisms between somatosensory and auditory pathways. Dizziness may hinder a person’s performance in daily activities such as those that require rapid movement of the head, and in tasks involving the trunk and head flexion .
Dizziness’ interference in the daily activities can be assessed by validated questionnaires. Currently, there are questionnaires to evaluate the perception of dizziness and body imbalance, which allows one to quantify the impact of these symptoms on the daily life of patients. These questionnaires are considered important in the verification of the damage to daily life caused by symptoms. Among the existing instruments, we highlight the Dizziness Handicap Inventory (DHI) developed by Jacobson and Newman , which evaluates and quantifies the impact of dizziness on the individual’s quality of life and the Activities-specific Balance Confidence Scale (ABC) developed by Powell and Myers , which uses a scale to measure an individual’s self-confidence in performing daily activities. The
aim of the study was to evaluate the impact of dizziness on the
performance of daily tasks in TMD patients by using the ABC and
20 female patients with temporomandibular disorders
(TMD) and dizziness participated in the study, having been
referred for evaluation to the Otoneurology Sector at Tuiuti
University of Parana, located in Curitiba, Brazil, from February
2014 to July 2015. The study included patients with TMD and
dizziness and excluded from the study TMD patients without
complaints of dizziness and/ or those who had some type of
alteration that prevented carrying out the proposed procedures.
The subjects’ ages ranged from 26 to 72 years (mean 52.3 years
and standard deviation of 12.2 years). After completion of the
vestibular examination, the DHI and ABC protocols were given.
This is a descriptive cross-sectional study approved by the Ethics
Committee in Opinion No. 0005769/12 and patients signed a
consent form. Patients were subjected to a questionnaire with
emphasis on otoneurological symptoms and ENT examination
in order to rule out any alteration that could influence the
adopted procedures. First, we checked for nystagmus and
positional vertigo using the Brandt and Daroff exercise  and
spontaneous and semi-spontaneous nystagmus.
Next, a electronystagmography (ENG) test was performed
using a Berger VN316 model thermosensitive, São Paulo/SP/
Brazil device with three recording channels. After cleaning the
skin in the periorbital region with alcohol, an active electrode
was put on each patient, using conductive gel, on the lateral angle
of each eye and the frontal midline, forming an isosceles triangle,
which allowed for the identification of horizontal, vertical, and
oblique eye movements. A Ferrante brand rotational chair was
used along with a NeurograffEletromedicinaLtda, EV VEC visual
stimulator, and a NeurograffEletromedicinaLtda, São Paulo/SP/
Brazil, NGR model 05 air calorimeter. The following ENG eye
and labyrinthine tests were carried out according to the criteria
proposed by several authors .
Calibration of ocular movements, test for spontaneous
(open and closed eyes) and semi-spontaneous (open eyes)
nystagmus, pendular tracking, optokinetic nystagmus, tests for
pre- and post-rotatory and pre- and post-caloric nystagmus. The
irrigation time of each ear with air at 42oC, 18oC, and 10oC lasted
80 seconds at each temperature. Criteria used in the air caloric
test: absolute value: between 2 and 24 degrees/ sec (<2deg/ sec
(hyporeflexia), > 24 degrees/ sec (hyperreflexia); relative values:
labyrinth predominance (PL) <41% and directional nystagmus
preponderance (PDN) <36% .
This questionnaire was developed by Jacobson and Newman
 and culturally adapted to the Brazilian population by Castro
et al.  it aims to check the degree of disadvantage caused
by dizziness in daily practice. The questionnaire consists of
25 questions, divided into questions about physical (seven
questions), emotional (nine questions), and functional (nine questions) sub-scales. Patients can respond to questions using
“yes” (worth four points), “sometimes” (worth two points), or
“no” (worth zero points). The score ranges from 0 to 100 points
and the closer to 100, the greater the disadvantage caused by
dizziness in the patient’s life.
This questionnaire was developed by Powell and Myers
, and culturally adapted for Brazilians by Marques et al. 
its objective is to evaluate an individual’s level of confidence
in his ability to maintain balance while performing specific
daily activities. The questionnaire includes 16 questions about
how confident the individual is in performing such tasks (no
confidence = 0% and fully confident in carrying out the activity
without losing balance = 100%). Therefore, the higher the
percentage, the greater the subject’s confidence level.
A descriptive analysis was conducted for symptoms, the
results of the vestibular examination, and the DHI. The Fisher
test was used to verify the relationship between the results
of the vestibular examination and dizziness symptoms. The
Kruskal-Wallis test was used to compare the results of the DHI
scores with the physical, functional and emotional domains.
The Spearman correlation coefficient was applied to assess the
relationship between the ABC questionnaire and dizziness (time
of onset) and between the questionnaires ABC and DHI. The
Fisher test verified the relationship between the DHI and ABC
questionnaires with the results of vestibular examination and the DHI with dizziness symptoms. The rejection level of the null
hypothesis was set at 0.05 or 5%.
Regarding complaints higher incidence of dizziness (100%)
was observed, followed by tinnitus, and headache with 80%
each, as shown in (Table 1).
The tests for positional nystagmus, eye movement
calibration, spontaneous and semi-spontaneous nystagmus,
pendular tracking, optokinetic and post-rotatory nystagmus,
showed no alterations. The observed alterations occurred only
in the caloric test. The caloric test showed a higher prevalence
of normal reflexes in 11 cases (55%), followed by unilateral
hyporeflexia in seven cases (35%), unilateral hyperreflexia and
bilateral hyporeflexia both with one case (5%) each. In nine
subjects (45%) there was peripheral vestibular dysfunction,
eight cases of peripheral vestibular deficit dysfunction (40%)
and one case (5%) of peripheral vestibular irritative dysfunction.
The vestibular examination was normal in 11 cases (55%).
The relationship between the results of the vestibular
examination and dizziness found that there was no significant
relationship using the Fisher test (p = 0.7105). Two categories
of results from the vestibular examination, normal and altered,
were used in applying the test. The descriptive statistics in the
DHI with their respective domains were: 2.0 was the minimum
and 24.0 was the maximum, with an average of 11.7 and a
standard deviation of 6.7 for the physical domain; 0 minimum,
32.0 maximum, 14.3 average, 10.7 standard deviation for the
emotional domain; 0 minimum, 28.0 maximum, 12.0 average, 9.0
standard deviation for the functional domain. In the application
of the Kruskal-Wallis test, there was no statistically significant
difference found (p = 0.8055) between the results of the DHI
scores and the evaluated domains.
The relationship of the DHI with the results of vestibular
examination and dizziness can be seen in (Table 2).
The Fisher test showed that there was no significant
difference between the results of the vestibular examination, the
DHI and dizziness, but there was a higher prevalence between
the emotional domain and dizziness. In applying the test, two
categories from the DHI (scale were used – less than 12 or 12 or
higher) for each domain.
The result of the ABC questionnaire can be seen in (Table 3).
Note that questions 15 and 16 were the ones that had the lowest
percentages of self-confidence in performance.
The relationship of the ABC questionnaire with dizziness
(time of onset) and the results of vestibular examination, are
listed in (Tables 4 & 5).
The Spearman correlation coefficient showed that there
was no significant correlation between the ABC questionnaire
and the time of onset of dizziness. The Fisher test showed that
there was no significant relationship between the result of the ABC questionnaire and that of the ENG. In applying the test there
were two categories used - less than 50% and 50% or more. The
unanswered questions were not taken into consideration.
The relationship between the ABC and DHI questionnaires
is shown in (Table 6). The Spearman correlation coefficient
showed that there is no significant correlation between the ABC
and DHI questionnaires.
Symptoms of vertigo, tinnitus and headache observed in this
study were also cited by authors [3,16-18]. Some authors 
state that vertigo is responsible for approximately 54% of cases,
being the most frequent otological symptom in patients with
TMD. Some studies [20-24] correlated otoneurological signs and
symptoms with TMD due to anatomical and structural proximity.
Although Ramirez et al.  state that the abnormal activity
of the tensor tympani muscle is associated with auditory and
vestibular symptoms such as ear fullness, tinnitus, vertigo, hypo-
/ hyperacusis, and earache, for Mota et al. , the association of
TMDs and the origin of otological symptoms are not very clear.
There are several hypotheses about the relationship between
otological symptoms and TMD. Studies  hypothesize this correlation based on three theories. The first one addresses the
possibility of the mechanical transmission of force from the TMJ
to the middle ear through the discomalleolar ligament.
The second refers to the possible direct irritation of the
mandibular condyle of the auriculotemporal nerve. While the
third, and most recent theory, focuses on the hypertonicity of
the tensor muscles in the tympanum and the palatine veil, based
on the common trigeminal innervation of these muscles and the
masticatory muscles inserted in the mandible. For Watanabe et
al.  this hypertonicity is related to tinnitus, due to spasms in
the tensor muscle of the palatine veil which change the opening
of the auditory tube, causing a tubal dysfunction that can lead to
complaints of ear fullness, loss of hearing, tinnitus, otalgia and
headaches. It can be verified that there is a correlation between
the auditory and stomatognathic components. Such a connection
may trigger auditory symptomatology in individuals with TMD.
According to some authors , the mandible and ossicles of
the middle ear have the same embryological origin, explaining
why several malformations of the middle ear are associated with
The anatomy and biomechanics of the TMJ are interrelated
because they are closely related to aural structures and
functions. Analyzing the results of the vestibular examination,it
was observed that 45% of patients with TMD presented
vestibular disorder with prevalence deficit. Zeigelboim et al.
, in a study with TMD patients, observed labyrinthine
alteration in 74% of cases with prevalence in labyrinthine
deficit dysfunction. Hallan and Hinchcliffe  described that
there is not always synchronicity between the malaise caused by
vertigo and the results of otoneurological tests. The interference
of dizziness in an individual’s daily activities can be assessed
by validated questionnaires to quantify its impact on patients’
lives, and these questionnaires are considered important in
the verification of the damage caused by this symptom. Among
such questionnaires, the DHI used in this study showed that
the emotional domain showed a higher average (14.3 points)
followed by the functional and physical domains with 12.0 and
11.7 points, respectively.
The emotional domain indicates the involvement of the
mental structure, that is, patients may present anxiety, panic,
fear leaving the house unattended and/ or staying home alone,
concern as to self-image, concentration disorders, feelings of
inadequacy, and depression. These events were also observed
by authors [30,31] who also observed a higher score in the
emotional domain. In a study by Takano et al.  in an
elderly population, it was possible to see greater difficulty in
the functional domain, followed by emotional and physical.
Kammerlind et al.  showed that individuals with symptoms
had a lower quality of life and higher levels of anxiety and
depression, which corroborated the present study in which the
DHI emotional domain was the most affected, encompassing
The DHI scores were compared with the altered results
from the vestibular examination and dizziness in order to verify
the degree of harm to the subject’s quality of life. Although
there was no statistical significance, there was a prevalence of
peripheral vestibular deficit dysfunction (PVDD) independent
of the affected side and dizziness for the emotional domain on
the DHI. Jacobson and Calder  also reported worse quality
of life in patients with PVDD related to the total score of the
domains evaluated in the DHI. PVDD clinically correlates with
vestibular disorders in which there is partial or total reduction
of vestibular function, with worse diagnosis regarding the
peripheral vestibular irritative dysfunction. Usually, such cases
can cause the destruction of the neurosensory epithelium of the
membranous labyrinth and/ or fibers of the vestibular nerves,
which in turn may cause intense and progressive dizziness .
Regarding the implementation of the ABC questionnaire, it
was observed in the study that despite not having demonstrated
statistical significance, the confidence level addressed in
questions 15 (36%) and 16 (48%) were worse than those from
other questions. The total score of this scale is the average of individual items, and, the lower the score, the less confident
the individuals feel when performing such an activity. In the
present study, less than 50% of subjects felt confident in the
performance of these activities. For Lajoie and Gallagher  the
ABC confidence scale had a sensitivity of 84.4% and specificity
of 87.5% in a study of elderly. In another study in patients with
hemiparesis, the authors, Braun et al. , also observed a
confidence level of less than 50% in the ABC scale, but did not
indicate in which of the 16 activities this percentage occurred.
The correlation between the ABC confidence scale, DHI
domains, and the result of the vestibular examination, did
not show a significant relationship. Dizziness may hinder the
performance of an individual’s daily activities, such as those that
require rapid movement of the head and tasks involving trunk
and head flexion . Such movements may occur in the activities
for questions 15 and 16, for which patients experienced greater
difficulties. Also corroborating our findings were Munaro and
Silveira  who reported that 40.8% of patients complained
of dizziness related to change in head position. Koga et al. 
also said that this finding may be related to the high incidence
of dizziness due to certain positions of the head or changing
head position. The authors Cole et al.  studied patients with
Parkinson’s disease and observed that the major changes in the
ABC questionnaire occurred in questions 6 and 16.
Based on the obtained results, it is noted that the applied
DHI and ABC questionnaires showed sensitivity in quantifying
the level of perception for balance disorders in patients and
therefore the results may assist in choosing the most appropriate