DOI: 10.1590/1413-81232018245.

16162017 1753

Temporomandibular joint dysfunction syndrome

review
and police work stress: an integrative review

Giselle Urbani (https://orcid.org/0000-0003-1914-3514) 1

Eliana Napoleão Cozendey-Silva (https://orcid.org/0000-0003-4093-4732) 2
Lêda Freitas de Jesus (https://orcid.org/0000-0001-6935-4040) 2

Abstract This study aimed to investigate wheth-

er stress found in activities performed by Brazilian
police workers is associated with the risk of devel-
oping a temporomandibular joint dysfunction
syndrome (TMD), a disorder that is commonly
associated with stressful conditions. An integra-
tive literature review on stress, TMD and police
work was carried out. We identified several stress-
ors in the work of Brazilian police officers and
observed that stress influences the development,
aggravation and treatment of TMD symptoms.
The quality of life and health of TMD carriers is
compromised. The fact that studies have shown
the association between stress and activities car-
ried out by Brazilian police officers, as well as be-
tween stress and TMD, has led to the assumption
of a possible relationship between stress caused by
police work and the risk of these workers devel-
oping TMD. It is recommended that individuals
be thoroughly examined before being treated and
that such treatment be multidisciplinary. The lit-
1
Policlínica da Polícia erature on TMD in police workers is still incipient,
Civil José da Costa Moreira, which is why we recommend the development of
Secretaria de Estado de
Polícia Civil R. Haddock further studies on the topic.
Lobo 60, Estácio. 20260-132 Key words Occupational stress, Temporoman-
Rio de Janeiro RJ Brasil. dibular joint dysfunction, Police officers, Worker’s
giselleurbani@hotmail.com 2
health
Centro de Estudos da Saúde
do Trabalhador e Ecologia
Humana, Escola Nacional
de Saúde Pública Sérgio
Arouca, Fiocruz. Rio de
Janeiro RJ Brasil.
1754
Urbani G et al.

Introduction Considering that stress is directly related to

TMD3,16 and that the police officers’ work process
Stress is part of the physiological nature of the hu- generates stress15, this study aimed to investigate
man being and is associated with the individual’s whether the stress found in the activities of Bra-
adaptive capacity in the face of a relevant event or zilian police workers may be related to the devel-
situation1. However, when stress becomes intense opment of TMD, a disease commonly associated
or persistent, exceeding the individual’s physical, with stressful conditions.
cognitive and emotional capacity to cope with
the stressful situations, it will generate a disorga-
nizing effect in the organism and can lead to a Methods
pathological condition2.
The temporomandibular joint dysfunction This is a qualitative, exploratory and descriptive
syndrome (TMD)3 is a term used to character- study developed through an integrative review
ize a group of diseases that affect the masticatory of the literature on stress, TMD and activities
muscles, the temporomandibular joint (TMJ) of police workers. The research was guided by
and adjacent structures4. TMD patients evidence the following questions: What sources of stress
symptoms ranging from discomfort, such as are related to the activities performed by police
cracking joint, muscle tenderness and limited workers? What is the importance of stress in the
mouth opening5, to profoundly disabling symp- etiology of TMD?
toms, such as orofacial pain and difficulties in the The scientific production was retrieved from
masticatory function4. Also, otologic symptoms the Latin American and Caribbean Literature
are noted, such as tinnitus, otalgia, dizziness/ver- in Health Sciences (Lilacs), Scientific Electron-
tigo, hearing fullness, hypoacusis and hyperacu- ic Library Online (SciELO), Medical Literature
sis6. All these factors interfere in the daily social Analysis and Retrieval System online (Medline)
and work activities of the individual, as well as in and the Virtual Library in Health of the Ministry
their emotional and physical health7. of Health (BVS/MS). Considering that the sub-
The scientific literature points to work as ject, particularly TMD, is less explored in public
a vital source of stress1,8, where there is a theo- health, course completion papers (dissertation
retical distinction about stress acting, or being and monographies), available in Google Scholar,
perceived as a positive source of motivation (eu- that were pertinent and could support the ques-
stress), when some individuals experience feel- tions raised by the study were also used.
ings of self-confidence, optimism, robustness to In order to retrieve the information, we used
overcome challenges9. Conversely, Rossi et al.9 terms that are controlled and indexed in Descrip-
denominate as distress the one related to the per- tors in Health Sciences (DeCS), and their combi-
ceived stimuli as “negative stress”, associated with nations in the Portuguese and English languages:
the prevailing sensation of frustration, excess of “occupational stress”, “temporomandibular joint
fatigue and feeling unable to control situations or syndrome”, “police”, “etiology” and “risk”. Bool-
facts, causing physical and emotional imbalances. ean operators (AND, OR, NOT) were used in the
This paper is in the field of Occupational combination of descriptors to increase sensitivi-
Health, with due connotation in Brazil, which ty (retrieval of studies aligned with the research
can be understood as “a body of interdisciplinary questions) and avoid studies addressing TMD
– technical, social, human – and interinstitution- therapeutic procedures.
al theoretical practices, developed by different Inclusion criteria were applied as follows:
actors located in different and informed social publication between 2005-2014, full-text papers
places from a common perspective”.10 It address- published in Portuguese and English. Also, in
es the individual and organizational aspects of order to be eligible, studies should address TMD
work-related stressors, sources of distress, be- issues and the occupation/activity of Brazilian
cause of their association with reduced quality police officers; and, raise discussion or informa-
of life and higher costs for individuals, organiza- tion that would fit the guiding questions of this
tions and society11,12. study. We chose studies with Brazilian police of-
In this context, some studies have exposed ficers since the authors assume that the reality of
the situation of vulnerability, which generates a public security in Brazil may be different from
high degree of stress, in which Brazilian public that in other countries.
security staff work, and also drawn the attention For purposes of critical analysis, the selected
to the need for studies and actions that contrib- papers were organized into three categories: (1)
ute to changing this situation1,13-15. sources of occupational stress in police workers;
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Ciência & Saúde Coletiva, 24(5):1753-1765, 2019

(II) stress as an etiological or risk factor for the dissatisfaction with the profession due to low
development of TMD, regardless of the profes- salaries and non-recognition of their work1,14,17,18.
sional category; and (III) stress as a risk factor for Souza and Minayo19 highlighted the increased vic-
the development of TMD in a study population timization of public security workers.
of police workers. Among the elements that generate stress,
The synthesis of the scientific production and organizational and operational issues of work
critical analysis of the contributions on the sub- are cited as damaging to police welfare14,20,21.
ject were used to describe and correlate the data Likewise, police officers understand that soci-
to investigate the relationship between the police ety and government do not recognize the work
activity’s stress and the risk of TMD occurrence performed by the service of public safety, which
in this population. Although the focus of the according to them leads to the devaluation of
study is the Brazilian police, works from other the profession, and in turn generates stress17,18,21.
countries were used in the discussion to expand Some police officers carry out another profes-
the analysis of the findings. sional activity in their spare time, which trans-
Table 1 shows the synthesis of the scientific lates into little time available to rest and have an
production retrieved, according to the databases, adequate diet14,22.
and used according to the inclusion criteria. The Studies have shown a high level of stress
final sample consisted of 26 materials, between among policewomen, caused by discrimination,
papers and final works of postgraduate studies the working woman’s workload and the phys-
(dissertation and monography). iological and psychological features of women
who, as the authors would have it, make them
more susceptible to stress13.
Results However, despite being unhealthy and risky,
police activity has few alternatives to ease the
Of the total of 383 jobs recovered, only 26 were stress it generates15.
classified in the categories analyzed. The boxes Chart 2 shows the synthesis for category (II),
shown next summarize the main findings of the consisted of 11 papers (10 papers and 01 monog-
research, by author, year, documentary type, type raphy) that address stress as an etiological or risk
of study, the primary objective of the work and factor for the development of TMD, regardless of
the main factors found on stress, TMD and po- the professional category.
lice. TMD is a syndrome whose carriers may
Chart 1 shows the synthesis of the primary range from simple discomfort5 to painful and
sources of occupational stress in the Brazilian sometimes disabling symptoms. Among the eti-
police officers, as pointed out by the scientific ological and risk factors for TMD is stress, and
production. In this category of analysis, eleven there is proper documentation of the relation-
work works were used, which mainly address ship between the development of the syndrome
stress in public security workers. and the presence of stress3,16,24-27. There are cita-
As can be verified in the studies, police activity tions of bruxism, a sign of stress, as a risk factor
carries several stressors, namely: pressure, respon- for TMD24,28. TMD adversely affects the quality
sibility, work overload, inefficient work infrastruc- of life, health and work of those who suffer from
ture, personal and third-party life risk, authoritar- the disease because of the pain it causes5,7,29,30 and
ian environment, centralized decisions, besides is a disease more commonly found in women27.
Psychosocial factors may make pain caused by
TMD7 a chronic one.
In Chart 3, referring to category III, four pa-
Table 1. Synthesis of scientific production retrieved pers and one dissertation were included, totaling
and used. five studies that explain stress or its manifesta-
Studies tions as a risk factor for TMD in police officers.
Base Studies used
retrieved Only jobs in which the study population consist-
Lilacs 168 06 ed of military police officers were found. Howev-
SciELO 51 14 er, it should be noted that both activities carried
Medline 149 02 out by military police and those carried out by
BVS/MS 09 02 civilian police have similarities and peculiarities.
Google Acadêmico 06 02 Among the studies on TMD on police officers
Total 383 26 found by this study, some had a dental focus23,31,
1756
Urbani G et al.

Chart 1. Sources of occupational stress in police workers, 2005-2014.

Type of
Author, Key data on police officers stress
Title document – Objective
Year generators
Type of study

Andrade et Intervention Paper To show data on They perform unhealthy and risky
al., 200915 aiming at the self- - the self-esteem and activities in their daily life and
esteem and quality Research- quality of life of civil almost do not have alternatives to
of life of the civil Action police officers in Rio perform the catharsis of the stress
police officers of de Janeiro, from an generated by such activities
Rio de Janeiro intervention process
Bezerra et Occupational stress Paper To present and discuss Work organizational and
al., 201320 in female police – the occupational stress managerial issue; gender
officers Cross- experienced by military discrimination; harassment;
sectional police women occupation of managerial
positions; operational activities
Caria et al., Efficiency of Paper To evaluate the effect of Constantly face danger and risk
201423 occlusal splints on – two occlusal splints on life at any time
police officers with Cross- different police officers
TMD sectional with TMD
Costa et Stress: diagnosis Paper To diagnose the Higher level of stress among
al., 200713 of military police – occurrence and women, perhaps due to double
officers in a Cross- the stress phase in working hours, domestic
Brazilian city sectional military police offices obligations, female tendency to
of Natal, Brazil, present more sources of stress,
besides determining since they suffer more from
the prevalence of poor interpersonal relationships,
physical and mental and also from physiological and
symptomatology. psychological characteristics
women.
Dela Occupational stress Paper To identify occupational Main stressors: working
Coleta and coping factors – stress factors and verify conditions, employment
e Dela among civilian Cross- coping strategies used conditions (salary and stability),
Coleta, police officers sectional by civilian police officers relationships with colleagues and
200817 superiors, negative image of the
class by society and the media, and
lack of legal and governmental
support to police work.
Gomes The identity of Paper To analyze the Negative image that the police
e Souza, police officers – perceptions of civilian officers believe that society has
201318 and successive Cross- police officers about on them, which implies and
mirroring sectional their professional reinforces a devaluation of the
identity and the profession.
institution in which they
operate, as well as their
opinion about the image
that society has about its
performance.
Minayo et Impact of Paper To know the health Having two jobs, working night
al., 201122 professional – conditions of the civil and day, spending 12 hours in the
activities on the Cross- and military police street having had only one meal,
physical and sectional officers of Rio de working under pressure, having to
mental health of Janeiro, from several stay alert and sleep little.
civil and military angles: that of pleasure
police officers in and suffering
Rio de Janeiro (RJ,
Brazil)
it continues
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Ciência & Saúde Coletiva, 24(5):1753-1765, 2019

Chart 1. Sources of occupational stress in police workers, 2005-2014.
Type of
Author, Key data on police officers stress
Title document – Objective
Year generators
Type of study

Minayo et Perceived risks Paper To analyze and compare Working conditions and
al., 200714 and victimization – victimization involvement in other activities
of civilian and Cross- and risks perceived during the time off
military police sectional by military and civil
offices in public police officers from the
(in) security State of Rio de Janeiro,
Brazil, in the exercise of
their profession, within
and outside the work
environment.
Oliveira e Stress and Paper To evaluate the levels Direct confrontation with crime
Bardagi, commitment to – of occupational stress and emergencies, which eventually
20091 career in military Cross- and career commitment expose them to risks, in relation
police officers sectional among military police not only to their own life and
officers of the First physical integrity, but also that of
Military Brigade of third parties
Santa Maria, RS.
Souza e Police officer, risk Paper To analyze deaths Victimization growth in the three
Minayo, as a profession: – and health problems categories studied;
200519 work-related Bibliographic to the civil, military The servants of the three
morbimortality review and municipal police corporations make up a specific
officers of Rio de Janeiro category of workers at high risk
within and outside their for deaths and morbidity due
working day, due to to violence and accidents, with
their social activity internal differences between the
three groups.
Spode e Police work and Paper To understand the Work organization; Pressures
Merlo, mental health: a – relationship between imposed by disciplinary
200621 survey with the Cross- the work of the Military surveillance and control
Military Police sectional Brigade Captains - name mechanisms; Non-recognition of
Captains received by the Military the work actually carried out and
Police in the State of Rio efforts to carry it out with quality
Grande do Sul / Brazil -
and their mental health

but all the studies were unanimous in pointing Discussion

out the professional category investigated as be-
ing very likely to develop chronic diseases and The production of knowledge is a fundamental
disorders such as TMD, due to the very high level element for promoting health and improving
of stress inherent to the profession23,31-34. the quality of life. In the face of the still incipi-
Studies with police with TMD correlated the ent number of national and international pub-
symptomatology of the syndrome with biopsy- lications on TMD in police officers, this work
chosocial symptoms, such as stress, sleep disor- shows the need to develop research that provides
ders, pain and smoking33,34, as well as with para- information that increases the knowledge about
functional habits. the relationship between police activity and the
development of the syndrome to analyze and in-
tervene in the factors involved in the problem.
1758
Urbani G et al.

Chart 2. Stress as an etiological or risk factor for the development of TMD, 2005-2014.

Type of Main data on stress

Author,
Title document – Objective as an etiologic or risk
Year
Type of study factor for TMD

Biasotto- Quality of life in patients Paper To classify TMD patients There is a direct
Gonzalez et with temporomandibular – and correlate with impact influence of the
al., 200929 dysfunction - a cross- Cross- on quality of life degree of TMD on
sectional study sectional the quality of life
of the symptomatic
participants
Bortolleto, Analysis of parafunctional Paper To verify the prevalence Bruxism, which has
et al., 201324 habits and association – of the most common one of its etiologies in
with temporomandibular Cross- parafunctional habits stress, is a risk factor
joint dysfunction sectional found among students for the development
and servants of the State of TMD
University of Campinas
(Unicamp), São Paulo,
Brazil and to analyze its
association with TMD in
this population
Campi et Influence of Paper To carry out a literature Positive results
al., 20137 biopsychosocial - review on the impact of regarding the
approaches and self-care Literature education and simple application of
in the control of chronic review modes of self-care on pain education and self-
temporomandibular and dysfunction related to care methods in
disorders chronic painful TMD. chronic painful TMD,
contributing to the
improvement of
pain symptoms and
discomfort.
Figueiredo Prevalence of signs, Paper To analyze the prevalence TMD patients are
et al., 20095 symptoms and associated - of signs, symptoms and afflicted with a high
factors in patients with Cross- associated factors in patients prevalence of signs
temporomandibular sectional with temporomandibular and symptoms that
dysfunction dysfunction. can directly affect
quality of life.
Goyatá et Evaluation of signs Paper To evaluate the clinical Correlation between
al., 201016 and symptoms of - signs and symptoms of emotional factors and
Temporomandibular Cross- temporomandibular temporomandibular
Dysfunction among the sectional dysfunction among the dysfunction
students of the course students enrolled in the
of Dentistry of Severino course of Dentistry of the
Sombra University, Severino Sombra University
Vassouras-RJ
Kuroiwa et Temporomandibular Paper To evaluate the quality Patients with TMD
al., 201130 disorders and orofacial - of life of patients with and OFP had a
pain: a study on the Cross- temporomandibular negative impact on
quality of life as measured sectional dysfunction and / or quality of life due
by the Medical Outcomes orofacial pain to impairment of
Study 36 - Item Short physical and mental
Form Health Survey aspects.
Manfredi et Enviromental stress and Paper To identify individuals Positive association
al., 200625 temporomandibular - with TMD and correlate between TMD and
disorder (TMD) among Cross- with environmental stress environmental stress
members of a public sectional among members of a public
university in Brazil university

it continues
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Ciência & Saúde Coletiva, 24(5):1753-1765, 2019

Chart 2. Stress as an etiological or risk factor for the development of TMD, 2005-2014.
Type of Main data on stress
Author,
Title document – Objective as an etiologic or risk
Year
Type of study factor for TMD

Martins et Association between Paper To verify the association Economy class

al., 20073 economic class and - between economic class and does not influence
stress in the occurrence stress with the occurrence the occurrence of
of temporomandibular Cross- of TMD TMD, but there is
dysfunction sectional a direct association
between stress and
temporomandibular
dysfunction
Michelotti Oral parafunctions as Paper To investigate the possible Teeth grinding is a
et al., 201028 risk factors for diagnostic - association between significant risk factor
TMD subgroups Case control parafunctional habits for the occurrence of
(grinding teeth and nail TMD
biting) and TMD
Monteiro et Relationship between Paper To evaluate the relationship Possible relationship
al., 201126 anxiety and chronic - between anxiety levels between TMD chronic
orofacial pain of and degrees of severity of orofacial pain and
Temporomandibular Cross- TMD chronic orofacial anxiety
Disorder in a group of sectional pain in Brazilian university
university students students.
Schmidt, Temporomandibular Monography To show through the TMDs have
200727 dysfunction associated – national and international multifactorial causes
with stress Literature bibliographic survey the and are directly
review relationship between related to stress; they
temporomandibular are found with higher
dysfunction, its possible prevalence in females.
causes, signs, symptoms,
diagnoses and possible
treatments suggested in the
literature related to stress

Factors generating occupational stress as well as between operational issues and psycho-
in police workers somatic symptoms35.
The environment, pressure and police work
Exposure to stressful working conditions can discipline mechanisms can hinder the relation-
have a direct influence on the individual’s phys- ship between colleagues and bosses, becoming
ical and emotional health. Occupational stress agents of stress17,20-22.
is established when the job requirements do not Factors triggering stress in Brazilian police
correspond to the worker’s skills, resources or officers are also cited by police officers from Ita-
needs8. Oliveira and Bardagi’s study1 reported ly35, India36, Malaysia37, Australia38 and the United
psychological symptoms and, to a lesser degree, States39, corroborating studies indicating that due
physical symptoms in military police officers to direct and constant contact with danger and
diagnosed with stress, which, according to the violence, as well as by the in situations of conflict
authors, may be related to insecurity with the and tension, the police officers are the workers
professional career that, in turn, results from a with the highest level of exposure to stress20,21,23,
context of vulnerability in which military activity regardless of their country of residence. Howev-
is inserted. In Italy, a study found an association er, the number of police officers killed in Brazil
between organizational issues of police work and is significantly higher when compared to devel-
emotional exhaustion/cynicism among workers, oped and non-violent countries (Table 2), which
1760
Urbani G et al.

Chart 3. Stress as a risk factor for the development of TMD in a study population of police workers.
Type of Principal findings on stress
Author,
Title document – Objective as a risk factor for TMD in
Year
Type of study police officers
Caria et al., Efficiency of occlusal Paper To evaluate the effect of Police officers are highly
201423 splints on police – two occlusal splints on likely to develop chronic
officers with TMD Cross-sectional different police officers diseases and disorders such
with TMD as TMD because they are
exposed to extremely high
levels of stress
Carvalho Association between Paper To measure the prevalence Citation of a study
et al., bruxism and stress in – of bruxism and stress in that related bruxism,
200833 military police Cross-sectional military police officers biopsychosocial symptoms
and their possible (stress, sleep disorders
association and pain symptoms)
and smoking to TMD
symptoms
Cavalcanti Degree of severity of Paper To estimate the occurrence Significant
et al., temporomandibular – of TMD and its degree association between
201132 dysfunction and Cross-sectional of severity, as well as the temporomandibular
parafunctional habits presence of parafunctional dysfunction and
in military police habits in a population of parafunctional habits of
officers non-patients represented grinding or clenching teeth
by military police officers and biting objects (linked
to stress)
Faria, Clinical and Dissertation To investigate, High incidence of TMD
200631 electromyographic - through clinical and in military police officers,
evaluation of chewing Cross-sectional electromyographic more frequent in women
muscles in military examination, the behavior
police with TMD, of the temporal, masseter
before and after the and suprahyoid muscles
use of inter-occlusal in Military Police Officers
devices of the 18th Military Police
Battalion of the State of
São Paulo, with myogenic
or mixed TMD, before
and after use of different
inter-occlusal devices for
four weeks
Graciola Evaluation of the Paper To verify the influence Medium correlation
e Silveira, influence of stress – of a professional activity between TMD and stress
201334 on the prevalence of Cross-sectional seen as quite stressful, as is
temporomandibular the case of military police
disorders in the officers, and its correlation
state military of Rio with the prevalence of
Grande do Sul temporomandibular
dysfunction

suggests a situation of vulnerability, generating United States (0.01%) and 30 times that of the
a high degree of stress for Brazilian workers in United Kingdom (0.001%)40-42.
this professional category. Table 2 shows that, in It should be emphasized that in Brazil there
2015, deaths of police officers on duty in Brazil is an aggravation of the number of police officers
accounted for 0.03% of the total number of po- (civil and military) who are homicide victims
lice workers, triple the percentage of deaths in the outside working hours, and the conditioning fac-
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Ciência & Saúde Coletiva, 24(5):1753-1765, 2019

tor is the profession-related aspects. Data from Table 2. Police officers killed on duty in relation to
the Brazilian Yearbook of Public Safety (2016)40 the total workforce - Brazil, United States and United
reveal that such workers are killed almost three Kingdom – 2015.
times more while off-duty (73.79%) than while Country Police officers - 2015
on duty (26.21%), and that Brazilian police offi- Total Deaths while on
cers’ deaths were 113% those of American police workforce duty
officers while on duty, between 2009 and 201540. Brazil 256,053 91 (0.03%)
The strategies used by police officers to United States 402,978 41 (0.01%)
cope with stress include symptom management United Kingdom 207,140 4 (0.001%)
(self-control, family support, leisure, exercise, Sources: FBSP40; United Kingdom’s National Police Rollof
Honour41; GOV.UK42.
support in religion and positive attitude), avoid-
ance (separating social life from work or isolating
oneself), efficient behaviors at work (assuming,
organizing and distributing tasks, solving prob- assessment of TMD patients must consider the
lems without delay, seeking information and influence of psychological factors45.
doing the best they can)17,20. Absenteeism can However, it is not a matter of fact that the
also represent a strategy for coping with stress mere presence of stress can sufficient to gener-
at work, with leave meaning a “day of mental ate the occurrence of TMD. Studies indicate that,
health” or a change in the stressful routine39. usually, a single factor alone is not sufficient to
According to Minayo et al.22, as a result of ag- establish a TMD condition, but that the associa-
ing, police officers accumulate effects associated tion between factors may converge to the devel-
with work stress, such as inadequate behavior, opment of some signs or symptoms of the syn-
alcoholism, uncontrolled gambling, aggressive drome7,25,27,46.
behavior, increased exposure to accidents, anxi- Therefore, stress associated with intrinsic
ety, insomnia, emotional outbursts and various etiological (pathologies, bad joint formations,
types of chronic pain. This result shows the im- bad muscular formations) or extrinsic (occlu-
portance of the fight against stress to avoid the sal problems, mechanical trauma, orthodontic
risk of increasing damages to the quality of life treatments, accidents) factors can generate a
and health of police workers. functional imbalance in the biodynamics of TMJ
For the improvement of pain symptoms and and leave the individual predisposed to the onset
discomfort, Campi et al.7 reported a positive of TMD3,46.
approach to adopting approaches based on the There is controversy over the role of dental
biopsychosocial model of pain, through the ap- malocclusion47,48 and orthodontic treatment49-51
plication of educational methods and self-care in in the development of TMD. Thus, it may be
TMD. appropriate to suggest that the development of
Dåderman and Colli43 have recommend- future research on the relationship between stress
ed a greater focus of salutogenesis in research and TMD should exclude from its study popu-
on workplaces with a high level of occupation- lation those individuals who may have orthog-
al stress since the enhanced forces opposing the nathic issues or who have undergone orthodon-
disease stimulus could prevent the sickness of tic treatment.
workers undergoing this type of condition. It should be noted that TMD compromises
the quality of life and general health of the in-
Stress as an etiological or risk factor for the dividuals affected by the problem5,7,29, although
development of temporomandibular joint many are not aware of the presence of the dis-
dysfunction syndrome ease and the existence of treatment32. Thus, the
individual patient must be evaluated and treated
TMD is a multifactorial etiology syndrome, by a suggested multidisciplinary that consists of
and stress is pointed as one of these factors. dental surgeons, psychologists, speech therapists,
Studies have found a direct relationship between physiotherapists and neurologists, so as not to
stress and TMD3,16,27 since the syndrome is closely fragment health actions, due to the anatomical
related to stressors such as depression, sleep dis- and functional complexity of the stomatognathic
order, psychiatric problems27 and anxiety16,26. In system (consisting of bone structures, temporo-
fact, the influence of stress does not occur only mandibular joint, ligaments and masticatory
on the appearance of the disease, but also its muscles, glands and nerve and lymphatic vascu-
progression and treatment44. In this context, the lar systems, as well as teeth and their structures)
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Urbani G et al.

that, although with characteristics of its own, Final considerations

can influence and is influenced by the nervous,
digestive, respiratory, circulatory and endocrine Several sources of stress related to police activ-
systems, for example52. According to the propos- ities were identified. These sources range from
al of Kuroiwa et al.30, providing comprehensive those directly involved in police work, such as
actions and better treatment to the individuals the risk of death, pressure and responsibility in-
would improve their quality of life. herent to the work, to those linked to the corpo-
ration’s infrastructure, such as overloading and
Stress as a risk factor for the development accumulation of tasks due to insufficient staffing
of temporomandibular joint dysfunction and work organization, as well as inadequate fa-
syndrome in police workers cilities, equipment and systems made available
for the implementation of the service.
Parafunctional habits such as bruxism (teeth This study could observe that stress exerts in-
grinding or tightening)24,26 and nail gnawing25, fluence both in the development of TMD and in
whose contributing factor to their etiology is the aggravation of its symptoms, but that stress
stress, are risk factors for the development of alone is not enough to generate alterations in the
TMD, as shown in studies with police officers con- health of individuals. The onset of the syndrome
ducted by Carvalho et al.33 and Cavalcanti et al.32. depends on the association with other factors
Research by Graciola and Silveira34 found such as the individual’s emotional capacity to
that the military police profession is related to deal with stressors, the accumulation of stressors
the higher prevalence of TMD and a higher level or the inclination to develop specific pathologies.
of stress, and that there is a positive correlation Since there is a relationship between stress
between these events. A study by Faria31 found a and development of TMD, and also the pres-
high incidence of TMD in the group of partic- ence of several stressors in the police work, we
ipating military police, especially in women. In can suppose that there is a relationship between
Turkey, police were part of a study on the prev- stress in these activities and the risk of police
alence of TMD symptoms, in which the stress of workers developing TMD.
the profession was cited as responsible for the The TMD theme in police workers does not
high frequency of symptoms evidenced by this have scientific literature that can contribute sig-
professional category53. nificantly to the mitigation of the problem. Thus,
Caria et al.23 pointed out that, because they we suggest developing specific studies on the
are exposed to very high levels of stress, police subject, favoring the triangulation of methods
workers are part of the professional category (qualitative and quantitative approaches)55, and
most likely to develop chronic diseases and dis- the use of different techniques for data collection
orders such as TMD. and analysis, including diagnostic data (physical
Oliveira and Bardagi1 highlighted the im- and imaging tests).
portance of attention and emotional control in In the quantitative approach, we consider
the performance of police activity, requirements that research on the relationship between occu-
corroborated by Minayo et al.22 when pointing pational stress (organizational and individual
out the police officer’s concern to be always alert. stressors) and TMD in police workers can use,
Hilgenberg6 mentions the incidence of dizziness/ for example, a control group, and should exclude
vertigo in patients with TMD, a condition that, from their study population individuals who
according to Hueb and Feliciano54, destabilizes may have orthognathic problems or are submit-
the posture and position of the individual affect- ted to orthodontic treatment, among others. As
ed by the problem. Therefore, it is possible to as- an example of qualitative approach techniques,
sume that TMD patients may have difficulty con- we suggest the (coupled or not) use of individual
centrating and making decisions, as well as suf- interviews and mutual interactions (focus group
fering from physical balance and spatial disori- technique) to understand the contexts and the
entation disorders, conditions that would pose a apprehension of feelings towards a specific phe-
significant danger to the life of the police workers nomenon, theme or environment.
during the exercise of their profession and to the Based on the review, the compromised qual-
population to whom they must protect. ity of life and general health status of individu-
 1763

Ciência & Saúde Coletiva, 24(5):1753-1765, 2019

als with TMD are underscored. We argue that
studies on the subject, even if they do not allow
a cause-and-effect relationship between the vari-
ables studied, may contribute to the non-frag-
mentation of health actions directed at this pa-
thology, particularly concerning the anatomical
and functional complexity and possible emo-
tional damage involved.

Collaborations

G Urbani was responsible for researching and

writing the article, LF Jesus was responsible for
the methodology and writing of the article, EM
Cozendey-Silva was responsible for the method-
ology and final review.

Acknowledgments

The present work was carried out with the sup-

port of the Coordination of Improvement of
Higher Education Personnel - Brazil (CAPES) -
Financing Code 001.
1764
Urbani G et al.

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