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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 31-34

Correlation between prolonged nasogastric feeding and temporomandibular joint dysfunction


Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, KIMSDTU, Karad, Maharashtra, India

Date of Submission14-Mar-2022
Date of Acceptance22-Jun-2022
Date of Web Publication12-Aug-2022

Correspondence Address:
Dr. Sandeep B Shinde
Department of Musculoskeletal Sciences, Faculty of Physiotherapy, KIMSDTU, Karad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jahas.jahas_8_22

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  Abstract 

Background: Nutrition is administered via enteral feeding in the form of fluid supplements to overcome malnutrition in hospitalized patients, or enteral tubes are intubated into the stomach and small bowel if the patient is unable to feed orally. The most common procedure performed by doctors across all medical specialties is nasogastric intubation. However, it has its own complications such as nasopharyngeal pain, aspiration, and trauma while insertion of the tube, but the impact of prolonged nasogastric tube feeding on temporomandibular joint (TMJ) is unknown. There is paucity of literature focusing on the TMJ; therefore, this study focuses on the correlation of prolonged nasogastric tube feeding and temporomandibular joint dysfunction. Materials and Methods: This was an observational study conducted among 59 participants. Patients undergoing nasogastric feeding for more than a week and having pain during mouth opening and left right lateral excursion were included in the study. Subjects with previous trauma to TMJ were excluded from study. Patients who were unconscious or uncooperative, had previous trauma to TMJ, and had facial surgery were excluded from the study. Result: Multivariate analysis revealed that there was no significant limitation of range of motions (ROMs; mouth opening [P = 0.232, t = 8.800], protrusion [P = 0.315, t = 17.130], right lateral excursion [P = 0.511, t = 16.768], and left lateral excursion [P = 0.5108, t = 18.143]) when compared to the ROMs at the time of insertion of nasogastric tube and 5–14 days after the removal of nasogastric tube. Also, there was significant TMJ pain. Conclusion: The study concludes that there was a significant correlation between duration of intubation and pain in masticatory muscles such as the temporalis and masseter, and medial and lateral pterygoid muscles and weak correlation between prolonged nasogastric intubation and TMJ movements.

Keywords: Mouth opening, Nasogastric feeding, Pain, TMJ dysfunction


How to cite this article:
Shinde SB, Ghadage P, Ambali MP. Correlation between prolonged nasogastric feeding and temporomandibular joint dysfunction. J Ayurveda Homeopath Allied Health Sci 2022;1:31-4

How to cite this URL:
Shinde SB, Ghadage P, Ambali MP. Correlation between prolonged nasogastric feeding and temporomandibular joint dysfunction. J Ayurveda Homeopath Allied Health Sci [serial online] 2022 [cited 2022 Sep 26];1:31-4. Available from: http://www.dpujahas.org/text.asp?2022/1/1/31/353699




  Introduction Top


Enteral nutritional therapy is important in the care of hospitalized patients with inadequate voluntary oral intake, persistent neurological or mechanical dysphagia, or intestinal failure, as well as in the critically ill patients requiring intubation. However, in the clinical practice, this notion is far too often ignored to the point that starvation in modern hospital wards and intensive care units is not usual, even at a time when the patient can least afford the effects of undernutrition owing to illness. Despite the fact that the gastrointestinal tract and digestion are unaffected, it is obvious that failure to provide an adequate diet exacerbates the development of malnutrition. Owing to mechanical impediments to chewing and swallowing, normal enteral alimentation is the exception. Malnutrition in hospitalized patients is one of the common problems that have potentially serious consequences, which are often left unrecognized. It affects up to 40% of the patients resulting in increasing mortality and morbidity. It affects the recovery after surgeries, illness, and also there is a chance of increase in the severity of infection. It occurs when patients experience poor postoperative recovery, delayed wound and scar healing, and an increased risk of complications.[1],[2]

To overcome the consequences of malnutrition in hospitalized patients, nutrition is provided via intubation in the form of fluid intake or if the patient is not able to feed orally, enteral tubes are intubated into stomach and small bowel.[1] A study states that annually, more than 1 million enteral intubations occur in patients.[3] Enteral tube feeding can be done in a variety of ways, the most frequent of which is nasogastric tube feeding. Nasogastric feeding tubes are commonly used as a safe, short-term technique for tube feeding. In this way hydration, nutrition and medicine administration to patients becomes easy who are unable to feed orally. However, it has its own complications such as nasopharyngeal pain, aspiration, and trauma during insertion of the tube,[2] but the impact of prolonged nasogastric tube feeding on temporomandibular joint (TMJ) is not known.

Temporomandibular joint dysfunction (TMD) is a term used to describe a set of orofacial disorders that include problems that affect the TMJs and muscles in both functional and structural ways. The following are the most common signs of TMD: a dull discomfort or pain that radiates from the ear to the face, head, and neck; grade I masticatory muscle tenderness, including temporalis, masseter, and medial and lateral pterygoid; clicking of the joint(s); and limitation of jaw movements because of any injury to the jaw or the TMJ, inflammation, overuse or under use of the muscles, and forceful intubations.[4],[5]

During the nasogastric intubation, SORT maneuver is performed by the medical professionals i.e. sniffing position—combination of flexion of neck (atlantoaxial joint) and extension of head (atlanto-occipital joint), nasogastric tube orientation, contralateral rotation, and twisting movement; this will cause discomfort to the nostril, and laryngeal and pharyngeal structures.[6] As the nasogastric tube blocks one nostril, the patient tends to mouth breathe. This will result into the abnormal position of the TMJ, which puts stress on the muscles and ligaments of the TMJ, which are collateral, temporomandibular, stylomandibular, and sphenomandibular ligaments. Because of the constant stress, it can lead to pain and discomfort at the TMJ. Also, previous research suggests that the consequences of articular forces should be considered, particularly if the joints are loaded asymmetrically. During jaw motions, the muscles not only move the jaw but also maintain articular stability. When the jaw reaches its mobility restriction, passive structures such as ligaments become dominant to perform the movement.[7]

Also, the branches of the trigeminal, facial, and glossopharyngeal nerve innervate the face muscles, which share sensory innervation with other head and neck structures such as the jaws, teeth, pharynx, and larynx.[8]

As a result, the goal of this research was to see if nasogastric tube feeding causes any temporomandibular dysfunction in individuals. There are studies that show nasogastric feeding affects swallowing performance; however, there is no evidence that nasogastric feeding affects the TMJ. The main aim of this study was to find out and determine if there is any correlation between prolonged nasogastric feeding and TMD.


  Materials and Methods Top


This was an experimental study conducted among 59 participants. Patients undergoing nasogastric feeding for more than a week and having pain during the mouth opening and left and right lateral excursion were included in this study. Patients who were unconscious or uncooperative and had previous trauma to TMJ were excluded from the study. The study was approved by the Institutional Ethics Committee. The patients were informed about the study procedure and written informed consent was signed by the patients before participation.

Procedure

The study was done in 6 months duration and was conducted in Karad. Subjects were selected according to the inclusion and exclusion criteria. The procedure was explained and consent was taken from those willing to participate. They were evaluated for facial pain and all the TMJ range of motions (ROMs): mouth opening and lateral excursion toward right and left sides. The pain was evaluated by the Numerical Pain Rating Scale (NPRS), and the ROM was taken using a digital inclinometer. For mouth opening, the ROM subject laid supine with hip and knee flexed and hands resting on side. The instruction to the subject was open your mouth as much as possible without any discomfort. The accessor was then placed on the end of the caliper and middle incisor of the upper jaw and lower on the central jaw line. For ROM of protrusion of mandible, the distance between the lower central incisor and upper central incisor was measured by a scale. For ROM of lateral excursion of right and left sides, the distance between the most lateral points of the lower and upper cuspid or first bicuspid teeth was measured by a scale on each side. Three consecutive measurements were made with a resting period of 30 seconds between each. The ROM was taken on the day of nasogastric tube insertion and after the removal of nasogastric tube.

Statistical analysis

After collection of the data, statistical analysis was done by using GraphPad InStat. The quantitative variables were expressed as mean ± standard deviation, and unpaired student’s t-test was used to compare the pre- and postvalues of ROM. Pearson’s correlation test was used to rule out the correlation between the duration of nasogastric feeding and NPRS score and post ROM values. The statistical significance was set as P < 0.05.


  Results Top


A total of 59 samples were included in the study. The clinical and demographic characteristics of the participants are shown in [Table 1]. Their ROM for mouth opening, protrusion, and right and left lateral excursion was taken and also the facial pain was noted using the NPRS.
Table 1: Demographic information of patients

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The samples were between the age group of 35–85 years because wide variety of patients with TMD were seen in between this age group during sample collection, and the patients considered had mostly postsurgical conditions, pneumonia, abdominal surgeries, etc.

The duration of the intubation was related with a complaint of TMD pain at either the day 7 or day 14 assessments in the complete population of individuals in [Table 2]. At 7 days, both gender (female) and age (increasing age) were linked to a complaint of TMJ pain. [Table 1] shows the correlations between and each parameter for both groups. Association was determined using Pearson correlation coefficient which revealed that there was significant correlation with nasogastric intubation and TMJ pain (r = 0.5) and correlation with TMJ movement was statistically insignificant.
Table 2: Multivariate linear regression analysis for the association between duration and other variables

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  Discussion Top


The TMJ is a unique, modified hinge joint that requires osteokinematic and arthrokinematic movements for optimal TMJ activities. In addition to the familiar hinge-like rotation and sliding movement between the mandibular condyle and the inferior surface of the articular disc, an anterior gliding movement of the mandible’s condylar process and the superior disc surface toward the articular tubercle of the temporal bone can occur to allow the mouth to open widely. TMJ carries out various functions such as chewing, swallowing, and talking.[8] Masticatory and face pain, earache, and headache are all symptoms of this disorder. As a result, clinicians have thoroughly investigated it. It is assessed using radiological and anthropometric approaches. The main aim of the study was to determine if there is any correlation between prolonged nasogastric feeding and TMD. Nasogastric tube feeding is the most commonly used technique for enteral feeding, but its impact on the TMJ is unknown.

In this study, the patients who were on nasogastric feeding for a week or more than a week were evaluated; their ROM for mouth opening, and right and left lateral excursion was recorded at the time of the tube insertion and after removal of the tube, and pain in facial muscles or TMJ was noted. We found that there was a significant correlation between the nasogastric intubation and TMJ pain but no significant correlation between TMD. According to the study of Eweka and Ogundana, the pain around the TMJ and the facial muscles, known as the masticatory myalgia, is a dull chronic aching that affects the jaw and temporal muscles, with references to additional structures such as the head, neck, ear, and teeth. Restricted opening, tiredness, and stiffness are all possible symptoms. Muscle discomfort and reduced ROM are signs. Sore and painful muscles are the most common symptoms of localized myalgia, which commonly affects both sides at the region of masseter and temporalis muscles.[9]

Masticatory function is vital for feeding and swallowing, i.e. from food ingestion to swallowing, and it has an impact on the quality of life. The physical presence of the tube in the throat causes a lot of nasopharyngeal discomfort. Owing to mouth breathing and no eating, there may be a lack of saliva production[10],[11],[12]. Nasogastric tube feeding has been linked to sore mouth, dysphagia, thirst, and dry mucous membranes.[13] Grip strength, number of existing teeth, maximum voluntarily occlusal force, occlusal contact area, and maximum voluntary tongue pressure (TP) are significant determinants for masticatory performance, according to a study conducted by Morita et al. Masticatory performance was strongly affected by grip strength and maximum voluntary occlusal force, according to a stepwise regression analysis.[14]

Also, Hara and colleagues conducted research on the correlation between tongue muscle strength and masticatory muscle strength, concluding that because age and maximum occlusal force are linked to TP in both elderly and adult patients, age-related TP decline can be avoided with regular lingual exercises, even before the onset of old age.[15] In addition, worsening of maximum occlusal force in the elderly may imply a decrease in TP.[16] Bohnker et al. had done literature review on narrow bore nasogastric feeding tube complications and concluded that narrow bore nasogastric feeding tubes are useful to provide access for enteral nutrition. However, the use may result in considerable morbidity and mortality in patients. To provide optimal patient care, clinicians and nursing staff must be knowledgeable of the risk factors, verification criteria, and manifestations related with those problems.

Koolstra’s study on the masticatory system in humans is dynamic. From a biomechanical perspective, the human masticatory system’s movement properties are explored in this study. The topic is founded on the application of fundamental mechanics to the numerous anatomical elements that make up the masticatory system. To determine the determinants of jaw movement, researchers looked at the stresses and torques delivered to the mandible by muscles, ligaments, joints, articular capsules, and teeth. The concept of connecting force movement to the lower jaw’s center of gravity, rather than a hinge axis at its joints, is introduced. The muscles are clearly the primary factors of jaw movement. The mass and moments of inertia of the jaw, as well as the structures that are securely coupled to the masticatory system, determine the ratio between linear and angular accelerations. It is important to examine the impact of articular forces, especially if the joints are loaded asymmetrically. During jaw motions, the muscles not only move the jaw but also maintain articular stability. Only when the jaw’s movement restrictions are reached, passive structures, such as ligaments, become prominent. These ligaments are thought to keep non-midline jaw movements from dislocating the joint.[15]

In this study, we investigated the correlation between nasogastric tube feeding and TMD as the above studies also attempted to determine the effects of the nasogastric tube on TMJ. The result indicated the facial pain, reduced ROM of TMJ, and reduced strength of masticatory muscles.


  Conclusion Top


The study concludes that there was a significant correlation between duration of intubation and pain in masticatory muscles such as the temporalis, masseter, and medial and lateral pterygoid muscles and weak correlation between prolonged nasogastric intubation and TMJ movements.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pearce CB, Duncan HD Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: Its indications and limitations. Postgrad Med J 2002;78:198-204.  Back to cited text no. 1
    
2.
Pryor LN, Ward EC, Cornwell PL, O’Connor SN, Finnis ME, Chapman MJ Impact of nasogastric tubes on swallowing physiology in older, healthy subjects: A randomized controlled crossover trial. Clin Nutr 2015;34:572-8.  Back to cited text no. 2
    
3.
Halloran O, Grecu B, Sinha A Methods and complications of nasoenteral intubation. JPEN J Parenter Enteral Nutr 2011; 35:61-6.  Back to cited text no. 3
    
4.
Herb K, Cho S, Stiles MA Temporomandibular joint pain and dysfunction. Curr Pain Headache Rep 2006;10:408-14.  Back to cited text no. 4
    
5.
Pundkar SU, Patil DE, Naqvi WA Effectiveness of Rocabado approach and conventional physiotherapy on pain, ROM and QOL in patients with TMJ dysfunction: Comparative study. J Crit Rev 2019;6:925.  Back to cited text no. 5
    
6.
Najafi M Improving the safety of nasogastric tube insertion by the “SORT maneuver” during the novel coronavirus pandemic (COVID-19). Patient Saf Surgery 2021;15:4.  Back to cited text no. 6
    
7.
Gawade KD, Shinde SB Effect of early physiotherapy for endotracheal intubation-induced temporomandibular joint dysfunction: An experimental study. Int J Otorhinolaryngol Clin 2019;11:41-4.  Back to cited text no. 7
    
8.
He T, Stavropoulos D, Hagberg C, Hakeberg M, Mohlin B Effects of masticatory muscle training on maximum bite force and muscular endurance. Acta Odontol Scand 2013;71:863-9.  Back to cited text no. 8
    
9.
Yilmaz A, Elevli L, Mesut R, Tuna H Measurement of temporomandibular joint mobility with an inclinometer in Turkish males and females. Trakya Univ Tip FakDerg 2008;25:228-32.  Back to cited text no. 9
    
10.
Sharav Y, Benoliel R Acute orofacial pain. In: Orofacial Pain and Headache. London: Elsevier; 2008. p. 75-90.  Back to cited text no. 10
    
11.
Bohnker BK, Artman LE, Hoskins WJ. Narrow bore nasogastric feeding tube complications: A Literature Review. Nutr Clin Pract 1987;2:203-9.  Back to cited text no. 11
    
12.
Koolstra JH Dynamics of the human masticatory system. Crit Rev Oral Biol Med 2002;13:366-76.  Back to cited text no. 12
    
13.
Eweka OM, Ogundana OM, Agbelusi GA Temporomandibular pain dysfunction syndrome in patients attending Lagos University Teaching Hospital, Lagos, Nigeria. J West Afr Coll Surg 2016;6:70-87.  Back to cited text no. 13
    
14.
Wang L-K, Lin M-C, Yeh F-C, Chen Y-H Temporomandibular joint dislocation during orotracheal extubation. Acta Anaesthesiol Taiwan 2009;47:200-3.  Back to cited text no. 14
    
15.
Hara K, Tohara H, Kenichiro K, Yamaguchi K, Ariya C, Yoshimi K, et al. Association between tongue muscle strength and masticatory muscle strength. J Oral Rehab 2019;46:134-9.  Back to cited text no. 15
    
16.
Morita K, Tsuka H, Kato K, Mori T, Nishimura R, Yoshida M, et al Factors related to masticatory performance in healthy elderly individuals. J Prosthodont Res 2018;62:432-35.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2]



 

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