Clinical Oral Investigations (2021) 25:441–453

https://doi.org/10.1007/s00784-020-03710-w

REVIEW

Prevalence of temporomandibular joint disorders: a systematic

review and meta-analysis
Lígia Figueiredo Valesan 1 & Cecília Doebber Da-Cas 1 & Jéssica Conti Réus 1 & Ana Cristina Scremin Denardin 1 &
Roberto Ramos Garanhani 2 & Daniel Bonotto 3 & Eduardo Januzzi 4 & Beatriz Dulcineia Mendes de Souza 5

Received: 8 July 2020 / Accepted: 25 November 2020 / Published online: 6 January 2021
# Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objectives The aim of this systematic review was to evaluate the prevalence of temporomandibular joint disorders (TMJD)
among the general population.
Materials and methods Five main electronic databases and three grey literature were searched to identify observational studies in
which TMJD was diagnosed using the research diagnostic criteria (RDC/TMD) or diagnostic criteria (DC/TMD). The studies
were blindly selected by two reviewers based on eligibility criteria. Risk of bias (RoB) was assessed using the Joanna Briggs
Institute Critical Appraisal Checklist, and the “R” Statistics software was used to perform meta-analyses.
Results From 2741 articles, 21 were included. Ten studies were judged at low RoB, seven at moderate, and four at high. The
TMJD investigated were as follows: arthralgia, disk displacement (DDs) with reduction (DDwR), DDwR with intermittent
locking, DDs without reduction (DDwoR) with limited opening, DDwoR without limited opening, degenerative joint disease
(DJD), osteoarthritis, osteoarthrosis, and subluxation. The main results from prevalence overall meta-analyses for adults/elderly
are as follows: TMJD (31.1%), DDs (19.1%), and DJD (9.8%). Furthermore, for children/adolescents are as follows: TMJD
(11.3%), DDs (8.3%), and DJD (0.4%). Considering the individual diagnosis meta-analyses, the most prevalent TMJD is DDwR
for adults/elderly (25.9%) and children/adolescents (7.4%).
Conclusions The overall prevalence of TMJD was approximately 31% for adults/elderly and 11% for children/adolescents, and
the most prevalent TMJD was DDwR.
Clinical relevance Knowledge about the frequency of TMJD can encourage dentists to consider appropriate strategies for early
and correct diagnosis and, if need be, correct management.

Keywords Temporomandibular disorder . Temporomandibular joint . Prevalence . Evidence-based dentistry . Systematic

review . Meta-analysis

* Lígia Figueiredo Valesan Introduction

[email protected]
The American Academy of Orofacial Pain defines temporo-
1
Postgraduate Program in Dentistry, Federal University of Santa mandibular disorders (TMD) as an umbrella term, which
Catarina (UFSC), Av. Delfino Conti, s/n - Trindade, covers a set of musculoskeletal and neuromuscular conditions
Florianópolis, SC 88040-900, Brazil
involving the masticatory musculature, the temporomandibu-
2
Department of Dentistry, University of South Santa Catarina lar joint (TMJ), and/or their associated structures [1].
(UNISUL), Av. Pedra Branca, 25 - Cidade Universitária,
Palhoça, SC 88137-272, Brazil
Temporomandibular disorders (TMD) are a significant public
3
health problem affecting approximately 5 to 12% of the over-
Department of Dentistry, Federal University of Paraná (UFPR), Av.
XV de Novembro, 1299 - Centro, Curitiba, PR 80060-000, Brazil
all population [2] being considered the most common cause of
4
chronic pain of nondental origin in the orofacial area [3].
Orofacial Pain Center, Hospital Mater Dei (HMD), Av. Gonçalves
Dias, 2700 - Santo Agostinho, Belo Horizonte, MG 30190-094,
The disorders can be classified in two subgroups: those of
Brazil articular origin, in which the signs and symptoms are related
5
Department of Dentistry, Federal University of Santa Catarina
to TMJ, and those of muscular origin, when the signs and
(UFSC), Av. Delfino Conti, s/n - Trindade, symptoms are related to the stomatognathic musculature [4].
Florianópolis, SC 88040-900, Brazil In particular, TMD of articular origin embraces several
442 Clin Oral Invest (2021) 25:441–453

alterations affecting the hard and the soft tissues of the TMJ. The exclusion criteria encompassed the following: (1) stud-
Among the most common temporomandibular joint disorder ies that did not use RDC/TMD (studies published before
(TMJD), there are the following: disk disorders, joint pain, 1992) or DC/TMD, or studies that modified the tool; (2) stud-
joint disorders, and degenerative joint disease [1, 5]. ies with duplicated data from another included study; (3) stud-
The worldwide-accepted classification tools for the diag- ies focused on the following patients: with full prosthesis,
nosis of TMD are research diagnostic criteria for temporo- orthodontic treatment, athletes, pregnant, obese, musician,
mandibular disorders (RDC/TMD) and diagnostic criteria for postmenopausal women, and full or partial edentulous; (4)
temporomandibular disorders (DC/TMD) [5, 6]. Recently, an studies focused on samples of patients with comorbidities (fi-
International Classification of Orofacial Pain (ICOP) was de- bromyalgia, systemic joint hypermobility, juvenile idiopathic
veloped, which aims to increase compliance among studies, arthritis, tinnitus, post-traumatic stress disorder, systemic os-
allowing the standardization and reproduction of results, both teoarthritis, trigeminal neuralgia, burning mouth syndrome,
clinically and in research [7]. atypical facial pain, migraine, atypical odontalgia, cervical
However, the actual prevalence of TMD in the population pain, neuropathic pain, and dentoskeletal deformities) or frac-
level is a matter of debate, due to the lack of homogeneity in tures and congenital/developmental disorders (aplasia, hypo-
the diagnostic criteria adopted in correlated investigations. plasia, hyperplasia) or any other syndrome associated to
Previous studies have evaluated the prevalence of TMD TMJD; (5) studies reporting only annual incidences of
among the general population; however, to date, no systematic TMD; (6) Studies that did not investigate TMJD or did not
review has been performed evaluating the two available diag- provide separate data of the joint diagnoses; (7) studies with
nostic criteria, RDC/TMD and DC/TMD, among the general sample recruited from orofacial pain centers or studies from a
population. Therefore, the present systematic review has been sample in which all patients had diagnosis, signs, and symp-
performed to answer the following focused question: “What is toms of TMD; (8) studies focused on samples of university
the prevalence of temporomandibular joint disorders among students; (9) studies that report only the signs and symptoms
the general population?” of TMJD; (10) reviews, letters, books, conference abstract,
expert opinion, case reports, technique articles, posters, guide-
lines, pilot studies; (11) full text not available.
Methods
Information sources and search
Protocol and registration
An electronic search strategy was developed for PubMed and
This systematic review was elaborated according to the adapted for each of the following bibliographic databases:
Preferred Reporting Items for Systematic Reviews and EMBASE, Latin American and Caribbean Health Sciences
Meta-Analysis checklist (PRISMA) [8]. The protocol was per- (LILACS), Scopus, and Web of Science. A partial grey liter-
formed according to PRISMA-P [9] and enrolled in the ature search was also performed on Google Scholar, Open
International Prospective Register of Systematic Reviews Grey, and ProQuest. The Google Scholar search was limited
(PROSPERO, Centre for Reviews and Dissemination, to the first 100 most relevant articles published in the last
University of York; and the National Institute for Health 10 years. The search strategy was coordinated by an experi-
Research) [10] under the registry number CRD42020151507. enced librarian. All searches were conducted from the starting
coverage date to January 22, 2020. Moreover, the list of ref-
Eligibility criteria erences of included studies was hand-searched to identify ad-
ditional relevant studies. The expert authors of this review
Inclusion criteria consisted of cross-sectional studies that eval- were consulted by email in order to refine search findings. A
uated the prevalence of TMJD among general population. reference manager (EndNote X7®, Thomson Reuters,
Also, TMJD should be assessed through RDC/TMD [6] or Philadelphia, PA) was used to collect references and remove
DC/TMD [5]. No restrictions regarding participant’s age, duplicates. More information on the search strategies is pro-
sex, and language of publication was applied. Painful and vided in Online resource 1.
non-painful TMD were accepted. The types of TMJD consid-
ered in this study were arthralgia, disk displacements (DD), Study selection
and degenerative joint disease (DJD). All primary studies
should start with patients in the general population, who had In phase 1, two authors (LFV and CDD) blindly assessed titles
no signs or symptoms of orofacial pain or who already had a and abstracts of identified studies, applying eligibility criteria
diagnosis of TMD. Concerning the sample collection site, using a software (Rayyan®, Qatar Computing Research
samples from the general population from basic health units Institute) [11]. If papers were considered eligible for inclusion,
and public and private schools were considered. a full-text reading was blindly performed by the same
Clin Oral Invest (2021) 25:441–453 443

reviewers in phase 2. Disagreements were discussed with third prediction interval. Moreover, the τ2 was calculated through
reviewer (JCR) and resolved in a consensus meeting. the restricted maximum likelihood method. Since a distribu-
tion of true effect sizes was expected across included studies, a
Data collection process and data items random effect model was applied [14].

The data collection process was performed by the first author Risk of bias across studies
(LFV) and cross-checked by the second author (CDD) to en-
sure integrity of contents. Any disagreements were discussed The heterogeneity across studies was assessed by comparing
with third reviewer (JCR). The following data were extracted variability among sample characteristics (such as age and type
for each included study: descriptive study characteristics (au- of TMJD). Methodological and statistical heterogeneity were
thor, year, and country), population characteristics (sample evaluated by comparing the variability in study design and the
size, sex distribution, mean age) were registered, and the prev- risk of bias in individual studies.
alence according the type of TMJD for RDC/TMD and DC/
TMD. In addition to the single diagnosis, for the RDC/TMD,
multiple diagnoses were collected.
Results
Risk of bias in individual studies
Study selection
The risk of bias (RoB) was independently assessed by two
blinded reviewers (LFV and CDD). The Joanna Briggs Following a systematic literature search, a total of 3769 arti-
Institute Critical Appraisal Checklist for Studies Reporting cles were found in main electronic databases and 452 studies
Prevalence Data [12] tool was used, and information was were selected from grey literature and reference list. After
cross-checked in a consensus meeting between the reviewers. duplicates had been removed, 2741 records remained for title
In case of disagreements, a third author was consulted (JCR). and abstracts screening (phase 1). Subsequently, 145 studies
The answers could be “yes,” “unclear,” “no,” or “not were considered eligible to be fully assessed. After full-text
applicable.” reading (phase 2), 124 studies were excluded (Online resource
Decisions about the scoring system and cut-off points were 2) and 21 were finally included for qualitative and quantitative
determined by the authors, according to a previous systematic synthesis. An overview of the selection process is shown in
review [13] and agreed upon by all team members in a collab- Fig. 1.
orative meeting, before critical appraisal commences. The ar- Regarding to excluded articles, two methods were used
ticles were categorized according to the following: Studies when full text is not available. The first was through the search
that reached up to 49% of questions scored as “yes” were service for articles, in the university library, with the help of an
classified as “high RoB”; from 50 to 69% as “moderate experienced librarian. If an article is not found by this method,
RoB”; and more than 70% as “low RoB.” Figures were gen- three attempts of contact, with the corresponding author or
erated using the software RevMan 5.3 (Review Manager 5.3, with some other author of the article, by email or through
The Nordic Cochrane Centre, Copenhagen, Denmark). the website “research gate” were performed, during three con-
secutive weeks. If not successful, the study was excluded jus-
Summary measures and synthesis of results tified by “full-text not available.”

The prevalence of TMJD was expressed by means of relative Study characteristics

or absolute frequencies and its 95% confidence intervals (95%
CI). A meta-analysis was performed to assess the overall The 21 studies on general populations accounted for a total of
pooled prevalence of TMJD. Furthermore, additional meta- 11,535 subjects (10,743 to RDC/TMD and 792 to DC/TMD)
analyses were conducted to assess the pooled prevalence of (6099 women; 4078 men, 1358 unspecified gender; female-
TMJD considering individually diagnosis. to-male ratio 1.5) with a mean age ranging between 7 [15] and
A method of proportion meta-analysis was performed by 75 [16] years. The studies were divided between RDC/TMD
using the software R Statistics version 4.0.2 (The R (17 studies) and DC/TMD (4 studies) and also between
Foundation, Vienna, Austria). The metafor package was used children/adolescents (aged 7 to 19 years) and adults/elderlies
for estimation of overall proportions and generation of forest (aged 20 to 75). The studies were conducted in 16 different
plots. The confidence interval of individual studies was esti- countries and sample sizes regarding TMJD ranged from 30
mated using the Clopper-Pearson interval. For analysis of sta- [16] to 1643 participants [17]. A summary of the descriptive
tistical heterogeneity, the following parameters were calculat- characteristics of the studies can be found in Table 1 for RDC/
ed: Cochran Q (χ2), I-squared (I2), Tau-squared (τ2), and the TMD and Table 2 for DC/TMD. There has been a recent
444 Clin Oral Invest (2021) 25:441–453

Fig. 1 Flowchart of the process of

literature search and selection
(adapted from Preferred
Reporting Items for Systematic
Reviews and Meta-Analysis [8]
and generated using the software
Review Manager 5.3, The
Cochrane Collaboration)

ICOP publication; however, there are still no primary studies Results of individual studies
using this diagnostic tool.
The prevalence of individual diagnosis was quite variable
among individuals’ studies. The studies that used RDC/
RoB within and across studies TMD were divided into adults/elderly and children/adoles-
cents, and obtained the following prevalence results:
None of the included studies fulfilled all the methodological
quality criteria. Most studies were judged at low risk [17–26], & Adults/elderly: arthralgia, 5.7 [17] until 17% [35]; disc
seven studies at moderate risk [15, 16, 27–31], and four at displacement with reduction (DDwR), 2.1 [17] until
high risk of bias [32–35]. Further information about the risk 33% [32]; DD without reduction (DDwoR) without limit-
of bias assessment can be found in Fig. 2 and detailed infor- ed opening, 0.0 [32] until 0.74% [35]; osteoarthritis, 1.9
mation about assessment of critical issues are available in [35] until 3.2% [17]; osteoarthrosis, 4.8 [35] until 70%
Online Resource 3. [16]. Two studies [32, 35] investigated DDwoR with lim-
The study with the biggest sample size [17] had low risk ited opening; however, no case was found in the studied
and was conducted on patients from general population. The sample; therefore, the prevalence was 0%.
high RoB was assigned by a negative or unclear response to & Children/adolescents: arthralgia, 0.8 [18] until 3.5% [24];
questions 3 and 5 in studies. These items corresponded to DDwR, 0.4 [33] until 14.4% [15]; DDwoR without limit-
sample size, and sample coverage, respectively. Ideally, the ed opening, 0 [20, 24, 31] until 0.3% [18]; osteoarthritis, 0
authors should have conducted an adequate sample size cal- [24] until 0.6% [31]; osteoarthrosis, 0 [24, 31, 33] until
culation, and, in addition, all subgroups of the identified sam- 2.2% [20]. Four studies [18, 20, 24, 31] investigated the
ple should respond at the same rate. The main methodological prevalence of DDwoR with limited opening; however, no
problem was concerning selection of the reported result. Some case was found in the studied sample; therefore, the prev-
studies did not divide the results into single diagnosis, but only alence was 0%.
in the main group or they mixed in multiple diagnoses of & Some studies reported only group prevalence, without
muscle and joint TMD, limiting some analyses. mentioning the prevalence of each sub diagnosis.
Table 1 Summary of descriptive characteristics of included articles adopting RDC/TMD axis I in temporomandibular joint disorders (n = 17)

Study Population Prevalence of single diagnosis (n/%) Prevalence of multiple diagnosis (n/%)

Author (year); Sample (F) O.S Age (mean Disk displacements (Group II) Arthralgia, osteoarthritis, and osteoarthrosis Group I + Group I + Group II Group I +
country ± SD, range) (Group III) Group II Group III + Group Group II +
III Group III
DDwR DDwoR with DDwoR Arthralgia Osteoarthritis Osteoarthrosis
limited without
opening limited
opening
Clin Oral Invest (2021) 25:441–453

Al-Khotani 456(272) 14.0 ± 2.3 TMJ right ** 0(0.0) ** 0(0.0) ** TMJ right ** TMJ right ** TMJ right ** NR NR NR NR
et al. (2016); Saudi Arabia 22✝ (4.8) 15✝ (3.3) 0 (0.0) 10✝ (2.2)
Sweden TMJ left ** TMJ left ** TMJ left ** TMJ left **
23✝ (5) 15✝ (3.3) 1✝ (0.2 7✝ (1.5)
Overall: 39 (8.5✝) ** any type of TMJD
Aravena et al. 186 (91) Chile 15.4 ± 1.25 Overall: 12 Overall: 13 3 (1.61) ** 5 (2.69) ** 2 (1.08) ** NR
(2016); Chile (6.45) ** (6.99) **
Balke et al. 223 (171) Iran 32.07 ± 10.83 Overall: age groups for urban population * Overall: age groups for urban population * NR NR NR NR
(2010); ≤ 24: 1 (4.2) ≤ 24: 1 (3.3)
Germany 25 to 34: 3 (7.3) 25 to 24: 5 (12.2)
35 to 44: 5 (12.5) 35 to 44: 5 (12.5)
45 to 54: 0 (0.0) 45 to 54: 1 (12.5)
55 to 65: 1 (16.7) 55 to 65: 0 (0.0)
Overall: age groups for rural population * Overall: age groups for rural population *
≤ 24: 5 (11.1) ≤ 24: 9 (20.0)
25 to 34: 2 (6.5) 25 to 24: 3 (9.7)
35 to 44: 1 (5.5) 35 to 44: 2 (11.1)
45 to 54: 1 (20.0) 45 to 54: 1 (20.0)
55 to 65: 3 (60.0) 55 to 65: 1 (20.0)
Bertoli et al. 934 (518) Brazil 11.32 ± 1.2 75 (8.0) ** 0 (0.0) ** 0 (0.0) ** 33 (3.5) ** 0 (0.0) ** 0 (0.0) ** NR NR NR NR
(2018); Brazil
De Melo Junior 1342 (922) Brazil Ranged from Overall: 135 Overall: 173 (38.9) ** 9 (2.0) ** 46 (2.3) ** 24 (5.4) ** 7 (1.6) **
et al. (2019); 10 to 17 (30.3) **
Brazil
Guerrero et al. 270(168) F: 42.0 ± 15.7 TMJ right ** 42 0(0.0) ** TMJ right TMJ right ** TMJ right ** TMJ right ** NR NR NR NR
(2017); Chile Chile M: 44.4 ± 17.0 (15.56) ** 1 (0.37) 46 (17.04) 5 (1.85) 13 (4.81)
TMJ left ** 44 TMJ left ** 1 TMJ left ** TMJ left ** TMJ left ** 15
(16.30) (0.74) 49 (18.15) 4 (1.48) (5.56)
Overall: 62✝ (23) ** Total:46✝(17) Total: 5✝ Total: 13✝
** (1.9) ** (4.8)**
Hirsch et al. 893 (506) Germany 40.6 ± 11.7 Overall age group NR NR NR NR NR NR Overall age group NR NR
(2008); Germany 20–60 ** 100 20–60 **
and United (11.2) 25 (2.8)
States of America Age groups for men * Age groups for
20 to 29: 4 (5.0) men *
30 to 39: 3 (3.6) 20 to 29: 1 (1.2)
40 to 49: 9 (8.2) 30 to 39: 1 (1.2)
50 to 60: 8 (7.1) 40 to 49: 1 (0.9)
Age groups for 50 to 60: 3 (2.6)
women * Age groups for
20 to 29: 22 (16.7) women *
30 to 39: 16 (13.6) 20 to 29: 6 (4.5)
40 to 49: 19 (15.3) 30 to 39: 5 (4.2)
445
 446

Table 1 (continued)

Study Population Prevalence of single diagnosis (n/%) Prevalence of multiple diagnosis (n/%)

Author (year); Sample (F) O.S Age (mean Disk displacements (Group II) Arthralgia, osteoarthritis, and osteoarthrosis Group I + Group I + Group II Group I +
country ± SD, range) (Group III) Group II Group III + Group Group II +
III Group III
DDwR DDwoR with DDwoR Arthralgia Osteoarthritis Osteoarthrosis
limited without
opening limited
opening

50 to 60: 19(14.4) 40 to 49: 2 (1.6)

50 to 60: 6 (4.5)
Hirsch et al. (2012); 1011 (525) Germany Ranged from 80 (7.9) ** NR NR Overall: 23 (2.3) ** NR NR NR NR
Germany and 10 to 17
Switzerland
Marpaung et al. 1358 (NR) Indonesia Children Children NR NR NR NR NR NR NR NR NR
(2018); Indonesia (n = 546) 109✝ (7.0) **
and The 9.5 ± 1.7 Adolescents
Netherlands Adolescents 225✝(14.4) **
(n = 812)
15.0 ± 1.5
Paduano et al. 361 (183) Italy 16.17 ± 1.47 47 (13.0) ** 0 (0.0) ** 0 (0.0) ** 7 (1.9) ** 2 (0.6) ** 0 (0.0) ** NR NR NR NR
(2018); Italy
Pereira et al. 558 (330) Brazil All subjects were Boys: 0 (0.0) ** 0 (0.0) ** Boys: 0 Boys: 1(0.1✝) NR NR NR NR NR NR
(2010); Brazil 12 years old Girls: 3 (0.5✝) ** (0.0) ** **
Total: 3✝ (0.5✝) Girls: 2 Girls: 4 (0.7✝) **
(0.3✝)** Total: 5✝ (0.8✝)
Total: 2✝
(0.3✝)
Progiante et al. 1643 (1083) Brazil 32.7 ± 10.3 Right or left TMJ: Overall: disk Right or left Right or left Right or NR NR NR NR
(2015); Brazil 73 (4.4) ** displacement TMJ: TMJ: left TMJ:
Right and left without reduction: 93 (5.7) ** 32 (1.9) ** 85 (5.2) **
TMJ: 34 (2.1) ** Right or left TMJ: Right and left Right and Right and
23 (1.4) ** TMJ: left TMJ: left TMJ:
Right and left TMJ: 263 (16.0) ** 53 (3.2) ** 116 (7.1) **
0 (0.0) **
Wu et al. (2010); 1058 (534) Ranged from Overall: Overall: Overall Overall Overall NR
Germany and Germany and 13 to 18 Germany: Germany: 8 (1.4) ** Germany: 1 Germany: 0 Germany: 2
China China Germany: 60 (10.7) ** China: 26 (5.2) ** (0.2) ** (0.0) ** (0.4) **
14.7 ± 1.1 China: 33 (6.6) ** Total: 34✝ (6.6✝) ** China: 0 China: 9 China: 2
China: 15.7 ± 1.7 Total: 93✝ (0.0) ** (1.8) ** (0.4) **
(17.3✝) **
Loster et al. 260 (192) Poland 17.9 ± 0.57 Right or left NR NR Right or left NR Right or left 7 (2.7) ** 9 (3.5) ** 0 (0.0) ** 1 (0.4) **
(2015); Poland TMJ: 23 TMJ: 6 (2.3) ** TMJ: 0
(8.8) ** Right and left (0.0) **
Right and left TMJ: 5 (1.9) ** Right and left
TMJ: 1 (0.4) ** TMJ: 1
(0.4) **
Overall: 16 (6.2) ** Overall: 2 (0.8) **
Sandoval et al. 100 (67) 67.6 ± 6 33 (33) ** 0 (0.0) ** 0 (0.0) ** 8 (8) ** 0 (0.0) ** 5 (5) ** NR NR NR NR
(2015); Chile Chile
30 (15) Germany Overall: 8 (26.6✝) ** NR NR 21 (70) ** NR NR NR NR
Clin Oral Invest (2021) 25:441–453
Clin Oral Invest (2021) 25:441–453 447

Group I, muscle disorders; Group II, disk displacements; Group III, arthralgia, osteoarthritis, and osteoarthrosis; DDwR, disk displacement with reduction; DDwoR, disk displacement without reduction; F,
Group II +
Group I +

female; O.S, origin of the sample; TMJD, temporomandibular joint disorder; NR, not reported; TMJ, temporomandibular joint; RDC/TMD, research diagnostic criteria for temporomandibular disorders
Group III
Aravena’s article [22] reported the general prevalence of
the DD group (6.45%) and the arthralgia, osteoarthritis,

NR
and osteoarthrosis (A + O + O) group (6.99%). De Melo
Prevalence of multiple diagnosis (n/%)

Group II Junior [25] obtained 30.3% for (DD) and 38.9% for (A +
+ Group
O + O). Wu [19] obtained 17.3% for (DD) and 6.6% for

NR
III
(A + O + O). Hirsch [30] obtained 2.3% for (A + O + O).
Schmitter [16] obtained 26.6% for (DD) and Nilsson [27]
obtained 10% for (DD).
Group I + Group I +
Group II Group III

The eligible studies that adopted DC/TMD as diagnostic

NR
criteria presented data, mainly, for adults and elderlies, be-
cause only one study covered children/adolescents. Below
are the following prevalence values:
NR
Osteoarthritis Osteoarthrosis

&
Arthralgia, osteoarthritis, and osteoarthrosis

Adults/elderly: arthralgia, 1.2 [16] until 21.1% [25];

DDwR, 20.8 [17] until 47.9% [25]; DDwoR without lim-
ited opening, 0.4 [25] until 3.3% [17]; DDwoR with lim-
NR

ited opening, 0 [25] until 1.9% [17]; DJD, 1.3 [17] until
34.9% [16]. Only one study [25] investigated DDwR with
intermittent locking and subluxation; however, no case
was found in the studied sample; therefore, the prevalence
NR

was 0%.
& Children/adolescents: Only one study [21] investigated
(Group III)

Arthralgia

this population. Arthralgia, 1.2%; DDwR, 5.4%; DDwR

0 (0.0) **

with intermittent locking, 0.6%. The diagnoses of

DDwoR without limited opening, DDwoR with limited
opening, DJD, and subluxation were not investigated in
DDwoR with DDwoR

opening
without

this study.
limited

& Some studies reported only group prevalence, without

Prevalence of single diagnosis (n/%)

mentioning the prevalence of each sub diagnosis.

Nguyen’s article [23] reported only the general prevalence
Disk displacements (Group II)

opening

of DD (37.6%).
limited

Synthesis of results
Overall: 6 (10) **

There was a high heterogeneity between the studies in the

DDwR

meta-analyses because of the variability between the charac-

teristics of the sample, methodological heterogeneity and risk
of bias, therefore, a random effect was considered. The results
± SD, range)
Age (mean

Ranged from

of the meta-analyses were divided by age group (adults/ el-

73 to 75
16.2 ± 2.2

derlies) and (children/adolescents), and by each diagnostic

Calculated by systematic review authors

criterion (RDC/TMD) and (DC/TMD), as well as with the

Percentage regarding TMD subgroup

grouped criteria (RDC + DC). The results of all meta-analy-

Percentage regarding total sample
Sample (F) O.S

ses, as well as the parameters obtained, I-squared (I2), Tau-

60 (43) Sweden
Population

squared (τ2), and prediction interval, are available in Table 3.

Table 1 (continued)

Overall diagnoses
(2010); Germany

(2006); Sweden
Author (year);

The overall prevalence of TMJD for adults/elderlies was

Schmitter et al.

Nilsson et al.

29.3% for RDC/TMD, 38.8% for DC/TMD, and 31.1% for

country

the grouped criteria (RDC + DC). While for children/

Study

adolescents was obtained 11% for the RDC/TMD and only

**
*

✝
448 Clin Oral Invest (2021) 25:441–453

Disc displacement Degenerative Subluxation

one study used DC/TMD in children/adolescents, so it was not
possible to do a meta-analysis with this group.

NR

NR

NR
The overall prevalence for the DD group, in adults/el-

0
derlies, was 12.9% for RDC/TMD, 37.1% for DC/TMD,

88 (34.9) **
without reduction joint disease

2✝ (1.3) **

3 (1.4✝) **

F, female; SD, standard deviation; O.S, origin of the sample; TMJD, temporomandibular joint disorder; NR, not reported; DC/TMD, diagnostic criteria for temporomandibular disorders
and 19.1% for the grouped criteria (RDC + DC). For chil-
dren/adolescents, a prevalence of 8.3% was obtained for the

NR
RDC/TMD.
Finally, the overall prevalence for the DJD group, in adults/
elderlies, was 17.4% for RDC/TMD, 5.2% for DC/TMD, and
without limited

9.8% for the grouped criteria (RDC + DC). For children/

5✝ (3.3) **

1 (0.4✝) ** adolescents was obtained 0.4% for RDC/TMD.

opening

NR Individual diagnoses
Disc displacement Disc displacement with Disc displacement
without reduction

Additional meta-analyses were performed for individual diag-

with limited

3✝ (1.9) **

noses, divided by diagnostic criteria and age, as presented in

opening
Summary of descriptive characteristics of included articles adopting DC/TMD axis I in temporomandibular joint disorders (n = 4)

Table 3. The most prevalent individual diagnosis was DDwR,

NR

for adult/elderly, both in the RDC/TMD (19.8%) and in the

0

DC/TMD (33.2%). Likewise, DDwR was also the most prev-

Overall: 104 (49✝) ** any type of TMJD
Overall: 97 (37.6) ** disk displacements

alent diagnosis in children/adolescents assessed by the RDC/

intermittent locking

TMD (7.4%).
reduction with

1 (0.6) **

Discussion
NR

0
Prevalence of single diagnosis (n/%)

This systematic review investigated the prevalence of TMJD

with reduction

45✝ (21.1) ** 102 (47.9) **

among the general population, using diagnostic criteria recog-

32✝ (20.8) **

9 (5.4) **

nized worldwide such as RDC/TMD and DC/TMD, in order

to summarize the data collected over the years for epidemio-
logical purposes. The development of RDC/TMD in 1992 had
the intention of be used only by research. Later, in 2014, the
3✝ (1.9) **

DC/TMD expanded its use to clinical scope. These diagnostic

Age (mean ± SD, Arthralgia

3 (1.2) **

2 (1.2) **

tools are intended to establish a reliable, standardized, and

validated criteria to diagnose TMD subtypes, since one of
the biggest methodological problems in correlated research
is the accurate definition of the criteria applied [6, 36–38].
258 (128) Vietnam Ranged from

Ranged from

The most common types of TMJD are arthralgia, as well as

65 to 74

12 to 19
At least 60

213 (149) Poland 37 ± 15.8

disorders associated with the TMJ, such as DD (e.g., DDwR)

range)

and DJD (e.g., osteoarthritis, osteoarthrosis) [5].

Patients with TMD symptoms are present over a large age
154 (116) Mexico

Graue et al. (2016); Norway 167 (86) Norway

range, appearing to be quite common among children and

Sample (F) O.S

adolescents. Yet, a higher prevalence is seen in young and

Calculated by systematic review authors
Population

middle-aged adults, with a peak of occurrence between 20

Percentage regarding total sample

and 40 years of age [3, 39, 40], corroborating our findings that
adults/elderlies have a higher prevalence of TMJD (31.1%)
than children/adolescents (11.3%).
Wieckiewicz et al. (2019);

It should be noted that the number of articles that adopted

Estonia and Vietnam
Author (year); country

Murrieta et al. (2016);

Nguyen et al. (2017);

the DC/TMD [21, 23, 26, 34] and that met the eligibility
criteria were low; moreover, there was only one study [21]
in children using this criterion. The smaller number of articles
Mexico

that used DC/TMD may be justified due to the fact that it is a

Poland
Table 2

relatively new tool and has not yet been translated into many
Study

languages, as the RDC/TMD. Thus, to disseminate the use of

**

✝
Clin Oral Invest (2021) 25:441–453 449

Fig. 2 Risk of bias summary, assessed by Joanna Briggs Institute Critical Appraisal Checklist for Analytical for Studies Reporting Prevalence Data:
author’s judgments for each included study (generated using the software Review Manager 5.3, The Cochrane Collaboration)

new diagnostic criteria, such as DC/TMD and ICOP, peer- In DC/TMD, the sensitivity and specificity are considered
reviewed journals should encourage its use in future primary good, for arthralgia, subluxation, and DDwoR with limited
studies. opening, based only on clinical history and physical examina-
The results for overall arthralgia in this systematic review tion, without imaging. But for DDwR, DDwR with intermit-
were 7%, a higher prevalence when compared to the 2.6% tent locking, DDwoR without limited opening, and DJD, the
prevalence found in a previous systematic review [40]. This sensitivity and specificity are bad, demanding a standard im-
prevalence increased, possibly, due to the fact that more stud- age exam [5]. Another systematic review also reported that
ies were included evaluating this condition; moreover, this only clinical examination protocols have poor validity to di-
increase in prevalence was already expected and suggested agnose DDwR and DDwoR, as compared with magnetic res-
in previous systematic reviews [40], due to the creation of onance imaging (MRI) [46].
new diagnostic criteria. New instruments have been added to However, an accurate diagnosis, with the aid of MRI,
the DC/TMD, such as the diagnostic algorithms for arthralgia, should be reserved for those few cases with diagnostic diffi-
which include criteria for modification of pain by function, culties or when the results of imaging may influence treatment
movement, or parafunction [5]. Additionally, the clinical ex- and prognosis for the patient [46]. Unfortunately, only one
amination for arthralgia includes provocation tests of pain article adopted MRI in their diagnoses. Thus, it is believed
with any jaw movement and new sites for TMJ palpation [5]. that the use of images may increase the prevalence rate in
According to the included studies, the prevalence of TMJD these cases.
in adults/elderly shows that DDwR is the most prevalent Regarding to prevalence of TMJD, considering individual
(25.9%) individual diagnosis, regardless of the diagnostic diagnoses, it was observed the lowest rates for DDwoR, re-
criteria, in agreement with results of previous studies [41, gardless diagnostic criteria. In addition, in the RDC/TMD for
42]. Nevertheless, in a previous systematic review [40], which children/adolescents, there were more categories with low
was used only RDC/TMD, a lower prevalence was found prevalence, such as osteoarthritis and osteoarthrosis. The dis-
(11.4%) due to the smaller number of articles and patients tribution pattern of these diagnoses seems to suggest that these
affected by the condition. disorders are more unusual than other conditions in the gen-
It is worth mentioning that in the studies included in the eral population. Furthermore, the DD is commonly false-
present review, only one [16] used imaging exams to diagno- negative diagnosis, since this clinical sign many times has to
sis of DD and DJD. Therefore, this prevalence may be even be confirmed by imaging tests [6, 47].
higher, as many patients with DDwR or DJD did not present No case of subluxation was found, possibly because one of
any signs or symptoms; hence, dental surgeons should be the exclusion criteria was patients with systemic joint hyper-
aware of diagnosis of false negative cases [43–45]. Also, there mobility. Another possibility is that in primary studies, a mis-
are some changes in the diagnostic process for some catego- understanding could have happened between the diagnosis of
ries in DC/TMD; for instance, for DD and DJD, it is now hypermobility and DD [48]. Patients might have difficulties to
considered: any joint noise present in the last 30 days and understand questions regarding the position of the luxated
the patient’s report for the presence of any type of joint jaw, or closing problems, so mix-ups may occur between sub-
crepitus (thin or thick) [5]. These details may be one of the luxation and opening problems with a closed mouth position.
explanations for the increased prevalence found in some cat- However, reported closing problems of the jaw could also be
egories of this review. attributed to DD. In a clinical context, this problem may be
450 Clin Oral Invest (2021) 25:441–453

Table 3 Summary of prevalence of temporomandibular joint disorders from meta-analyses

Meta-analyses RDC/TMD DC/TMD RDC/TMD and DC/TMD

Prevalence (%) (95% CI) (I2) Prevalence (%) (95% CI) (I2) Prevalence (%) (95% CI) (I2)
(τ2) (p.i.) (n) (τ2) (p.i.) (n) (τ2) (p.i.) (n)

Adults and elderlies

Overall - any joint diagnosis 29.3% (6.1–72.3) (99) (5.1) 38.8% (21.9–58.9) (93) (0.3) 31.1% (10.6–63.3) (99) (3.6)
(0.0–99.7) (6) (NE) (2) (0.3–98.4) (8)
• Arthralgia 12.8% (6.2–24.4) (77) (0.2) 4.4%(0.7–23.0) (95) (2.4) 7.0% (2.3–19.0) (92) (1.5)
(NE) (2) (0.0–100) (3) (0.1–85.5) (5)
Overall - disk displacements 12.9% (5.0–29.5) (97) (1.6) 37.1%(25.5–50.4) (89) (0.2) 19.1%(9.4–34.9) (98) (1.5)
(0.3–87.1) (6) (0.0–99.8) (3) (1.0–83.8) (9)
• Disk displacement with reduction 19.8% (6.1–48.5) (97) (0.9) 33.2% (12.8–62.7) (96) (0.7) 25.9% (13.0–44.9) (98) (0.7)
(NE) (2) (NE) (2) (0.5–95.4) (4)
• Disk displacement without reduction without - 1.8% (0.3–8.4) (68) (0.9) (NE) -
limited opening (2)
• Disk displacement without reduction with 0.3% (0.0–2.1) (0) (0) (NE) (2) 1.0% (0.1–8.1) (56) (1.4) (NE) 0.7% (0.1–2.9) (39) (0.9)
limited opening (2) (0.0–57.4) (4)
Overall - degenerative joint disease (osteoarthritis 17.4% (2.0–68.1) (97) (4.0) 5.2% (0.5–35.8) (97) (3.9) 9.8% (2.2–34.3) (96) (3.6)
and osteoarthrosis) (0.0–100) (3) (0.0–100) (3) (0.0–97.1) (6)
• Osteoarthritis 1.8% (0.8–3.9) (0) (0) (NE) (2) - -
• Osteoarthrosis 15.9% (1.6–68.1) (97) (4.4) - -
(0.0–100) (3)
Children and adolescents
Overall - any joint diagnosis 11.3% (7.6–16.4) (96) (0.4) - -
(2.3–40.4) (11)
• Arthralgia 1.9% (0.9–3.9) (69) (0.3) - -
(0.1–26.7) (4)
Overall - disk displacements 8.3% (5.2–13.0) (97) (0.5) - -
(1.3–37.1) (10)
• Disk displacement with reduction 7.4% (2.3–21.2) (98) (1.8) - -
(0.0–90.5) (5)
• Disk displacement without reduction without 0.2% (0.0–0.6) (0) (0.2) - -
limited opening (0.0–5.1) (4)
• Disk displacement without reduction with 0.0% (0.0–0.3) (0) (0) (0.0–1.9) - -
limited opening (4)
Overall - degenerative joint disease (osteoarthritis 0.4% (0.2–0.9) (0) (0) (0.0–2.5) - -
and osteoarthrosis) (4)
• Osteoarthritis 0.3% (0.1–1.0) (30) (0.1) - -
(0.0–93.5) (3)
• Osteoarthrosis 0.2% (0.0–1.0) (17) (0.4) - -
(0.0–99.9) (3)

RDC/TMD, research diagnostic criteria for temporomandibular disorders; DC/TMD, diagnostic criteria for temporomandibular disorders; CI, confidence
interval; I2 , I-squared; T2 , tau-squared; p.i., prediction interval; n, number of articles; NE, not estimable (a minimum of 3 studies per meta-analysis is
required); -, not reported or without enough studies to group into a meta-analysis

solved by observing clicks due to hypermobility that can be 84%, and in another study, it was 30% [40]. However, both of
distinguished from those due to DD by their timing during them only investigated the group of patients with TMD.
opening/closing and through imaging exams [48]. Furthermore, cases of arthralgia are counted along with those
In the DC/TMD, the terms osteoarthritis and osteoarthrosis of osteoarthritis and osteoarthrosis, which may justify this
no longer exist because these diagnoses are considered as high percentage.
subclasses of DJD, but without differentiating them [5]. For The most common individual diagnosis, in children and
this reason, in summary table of the results of the meta-anal- adolescents, was DDwR (7.4%); according to preliminary
yses, osteoarthritis and osteoarthrosis are in the same place of studies, the prevalence of DDwR increases with age: the prev-
the DJD. The prevalence of DJD, in adults/elderly, was 9.8%, alence of symptomatic DD is about 6%, increasing in the
slightly below the value found in previous studies [49] who population between 16 and 19 years old, until it reaches the
reported that the prevalence varied between ranged from 18 to same prevalence observed in adults [31, 50, 51].
Clin Oral Invest (2021) 25:441–453 451

The prevalence estimates in most of the included studies difficulty in research investigating large populations, both
were obtained from populations of different schools, public due to the high cost and the difficulty of access and also due
and private, based in different locations, which were randomly to exposure to radiation, although minimal in exams like cone
selected, as well as their participants. The second place of beam.
greatest sample collection was from people registered in the For DC/TMD, no sufficient data were available to perform
health system of the city. It is important that these data are the meta-analysis for subluxation and DDwR with intermittent
emphasized so that the results may reflect the reality of the locking, possibly, because they are recent diagnoses, present
population in general and not only a specific group of people. only in this assessment tool. Also, only one study used DC/
Additionally, the participants were not originated from TMD, in children/adolescents, so it was not possible to do a
orofacial pain treatment clinics, or from any venues special- meta-analysis with this group. Finally, in the diagnosis of
ized in the treatment of people with TMJD, in order to avoid DDwoR without opening limitation, for RDC/TMD, there
overestimating the data. were not enough studies to perform the meta-analysis.
One of the exclusion criteria was articles that focused only One study [23] was not added to adult/elderly overall meta-
on university students. Since psychosocial factors are associ- analysis because the muscle disorders were mixed with TMJD
ated with TMD, these individuals are included in a context diagnoses. Therefore, these studies were only included on the
controlled by a curriculum and they are at risk of developing individual diagnosis meta-analysis. These limitations should
symptoms related to psychosocial distress [52–54]. For this be highlighted, because the actual prevalence may have been
reason, we removed this population from Marpaung’s study underestimated and may act as a confounding factor, making
[15], leaving only children and adolescents. it difficult to have a clear judgment about the general preva-
Therefore, dental surgeons must be aware of the relatively lence rates.
high rates of some specific types of TMJD that can affect the
general population, especially in adults. When discussing this
with the patients, appropriate strategies for early and correct Conclusions
diagnosis and, if need be, accurate management should be
considered [55]. The overall prevalence of TMJD was approximately 31% on
“It is important highlight that most cases are asymptomatic adults/elderly and 11% for children/adolescents. Furthermore,
and patients commonly report only an uncomfortable noise. the most prevalent TMJD is DDwR, approximately 26% in
The literature indicates that only a small percentage of affected adults/elderly and 7.5% in children/adolescents.
individuals seek or are in need of treatment [56]. In the few
cases where pain is present, it has a mild and fluctuating char- Supplementary Information The online version contains supplementary
acteristic, being commonly aggravated by chewing or other material available at https://doi.org/10.1007/s00784-020-03710-w.
jaw functions. In these cases, the symptoms will certainly be
resolved over time, due to the natural innocuous progression Acknowledgments The authors thank the librarian MSc Maria Gorete
Monteguti Savi for the instructions regarding the search strategy of this
of the disk disorders. In the few symptomatic cases, the pri- review and the researchers.
mary option is conservative non-surgical treatment. This type
of treatment seems to be sufficient to have a favorable out- Author contributions The idea for the article was performed by Dr.
come with pain relief and improvement of jaw movements [1, Beatriz Dulcineia Mendes de Souza, and the design was performed by
56].” Dr. Beatriz Dulcineia Mendes de Souza and Lígia Figueiredo Valesan.
Material preparation, literature search, data collection, and analysis were
performed by Lígia Figueiredo Valesan, Cecília Doebber Da-Cas, Jéssica
Conti Réus, and Ana Cristina Scremin Denardin. The first draft of the
Limitations manuscript was written by Lígia Figueiredo Valesan, and all authors
critically reviewed the manuscript. All authors read and approved the
final manuscript as submitted.
Some limitations could be pointed out in this systematic re-
view. It was detected statistic heterogeneity among studies. Funding The authors of this study Lígia Figueiredo Valesan [grant num-
The studies differ mostly in sample characteristics and meth- ber 88882.437769], Cecília Doebber Da-Cas [grant number
odological heterogeneity by comparing variability in study 88882.437764] and Ana Cristina Scremin Denardin [grant number
design (differences in the measures of the outcome). In addi- 88882.437761] are funded by Coordination for the Improvement of
Higher Education Personnel (CAPES), Brasília, DF,Brazil - Finance
tion, it was not possible to investigate the prevalence by gen- Code 001.
der, as most studies did not categorize each diagnosis accord-
ing to sex. Therefore, any conclusions about the potential role
Compliance with ethical standards
of gender as risk factor could not be drawn.
Only one article used imaging tests to perform certain Conflict of interest The authors declare that they have no conflict of
TMJD diagnoses. However, it is important to mention the interest.
452 Clin Oral Invest (2021) 25:441–453

Research involving human participants and/or animals This article 14. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR (2010) A
does not contain any studies with human participants or animals per- basic introduction to fixed-effect and random-effects models for
formed by any of the authors. meta-analysis. Res Synth Methods 1(2):97–111. https://doi.org/
10.1002/jrsm.12
Informed consent For this type of study, formal consent is not required. 15 . Marpa un g C, v an Sel m s MKA, Lo bb ezoo F (20 18 )
Temporomandibular joint anterior disc displacement with reduc-
tion in a young population: prevalence and risk indicators. Int J
Paediatr Dent 29(1):66–73. https://doi.org/10.1111/ipd.12426
16. Schmitter M, Essig M, Seneadza V, Balke Z, Schroder J,
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