healthcare

Systematic Review
Etiologic Factors of Temporomandibular Disorders: A Systematic
Review of Literature Containing Diagnostic Criteria for
Temporomandibular Disorders (DC/TMD) and Research
Diagnostic Criteria for Temporomandibular Disorders
(RDC/TMD) from 2018 to 2022
Joanna Warzocha 1, *, Joanna Gadomska-Krasny 2 and Joanna Mrowiec 3, *

1 Faculty of Medicine, Lazarski University, Świeradowska 43, 02-662 Warszawa, Poland

2 Ordo-Dent. Gabinet Stomatologiczny, Edmunda Bałuki 22, 70-406 Szczecin, Poland; [email protected]
3 SCS Astermed-Centrum Ortodontyczno-Implantologiczne, Świ˛etego Bonifacego 92, 02-940 Warszawa, Poland
* Correspondence: [email protected] (J.W.); [email protected] (J.M.)

Abstract: This study aims to conduct a systematic analysis of literature published between
1 January 2018 and 1 September 2022, exploring factors influencing the progression or develop-
ment of temporomandibular disorders (TMD), diagnosed using the Diagnostic Criteria for Temporo-
mandibular Disorders (DC/TMD) or Research Diagnostic Criteria for Temporomandibular Disorders
(RDC/TMD). Three electronic databases were reviewed to identify papers that examined TMD factors
using DC/TMD or RDC/TMD. Inclusion criteria encompassed original research published in English
between 1 January 2018 and 1 October 2022, online, and complete DC/TMD or RDC/TMD studies
Citation: Warzocha, J.; on human participants aged 18 or older. Two authors independently assessed the risk of bias using
Gadomska-Krasny, J.; Mrowiec, J. The Joanna Briggs Institute (JBI) Analytical cross-sectional studies’ Critical Appraisal Tool. Of 1478
Etiologic Factors of articles, 11 were included. The studies revealed strong associations between TMD and factors such
Temporomandibular Disorders: A as female, poor sleep quality, depression, oral parafunction, anxiety, somatization, and anatomical
Systematic Review of Literature features. However, variables such as education, living conditions, socioeconomic status, marital
Containing Diagnostic Criteria for
status, chronic pain, and stress did not exhibit statistically significant correlations. Based on the
Temporomandibular Disorders
obtained data, it can be concluded that the causes of TMD are largely related to psychological factors,
(DC/TMD) and Research Diagnostic
which supports the biopsychosocial theory of the disorder.
Criteria for Temporomandibular
Disorders (RDC/TMD) from 2018 to
Keywords: temporomandibular disorders; TMD; diagnostic criteria for temporomandibular disorders;
2022. Healthcare 2024, 12, 575.
https://doi.org/10.3390/ research diagnostic criteria for temporomandibular disorders; etiology; biopsychosocial model
healthcare12050575

Academic Editor: Mieszko

Wiȩckiewicz
1. Introduction
Received: 15 January 2024 Temporomandibular disorder (TMD) includes a range of musculoskeletal disorders
Revised: 17 February 2024 affecting the masticatory muscles, the temporomandibular joints (TMJ), and surrounding
Accepted: 25 February 2024 tissue structures [1]. The pathophysiological causes of this condition may arise from
Published: 29 February 2024 alterations in the structure and function of the TMJ joints themselves, or the surrounding
muscles and/or other tissues.
Rather than a single cause, TMD arises from a multifactorial interplay of various
factors, including biochemical changes, such as structural abnormalities, muscle dysfunc-
Copyright: © 2024 by the authors.
tion, trauma, genetic mutations, hormonal changes, systematic diseases, and other factors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
According to the literature, whiplash injury is considered to be a specific type of trauma
distributed under the terms and
that has been associated with the development of this disorder. The prevalence of TMD
conditions of the Creative Commons among patients with whiplash injury has been reported to range from 14% to 37.5% [2].
Attribution (CC BY) license (https:// Hypertension and insulin resistance are recognized as significant disease factors that are
creativecommons.org/licenses/by/ becoming more prevalent in the population and have an impact on the development of
4.0/). TMD. The literature reports on the effect of raised blood pressure on the impairment of

Healthcare 2024, 12, 575. https://doi.org/10.3390/healthcare12050575 https://www.mdpi.com/journal/healthcare

Healthcare 2024, 12, 575 2 of 31

central pain regulatory systems and its potential contribution to painful TMD. Patients
with temporomandibular disorder (TMD) exhibit heightened sensitivity to aversive stimuli,
implying that the presence of painful TMD may arise, to some extent, from dysfunction
in central pain modulation mechanisms influenced by baseline arterial blood pressure [3].
Helena Martynowicz et al. [4] suggest that hypertension, higher BMI, lower values of mean
SpO2, and higher percentages of SpO2 < 90% constitute independent risk factors for in-
creased bruxism episode index. It has been suggested that autoimmune and inflammatory
disorders could potentially play a role in the development of TMD. According to a study
conducted by Ji Rak Kim et al. [5], a small percentage of subjects (15%) exhibited ANA/RF
positivity. Furthermore, Shinya Kototaki et al. [6] reported a high prevalence of severe TMD
in patients with SAPHO syndrome. According to Alina Grozdinska et al. [7], there appears
to be a statistical relationship between TMD and Hashimoto’s thyroiditis (HT). In their
study, muscle pain and stiffness were present in 86.5% of HT patients, and disc displace-
ment in 63.4%. Additionally, Ehlers–Danlos syndrome is another systemic disorder that
has been linked to TMD. According to Karen Bech et al. [8], there is a significant correlation
between hypermobile Ehlers–Danlos syndrome and symptoms and signs of TMD, as well
as osseous changes in the TMJs. It has also been noted that genetics and TMD have been
associated with congenital coagulation disorders. According to the clinical study conducted
by Selda Yenel et al. [9], it was found that patients with inherited coagulation disorders,
especially hemophilia, may have a higher likelihood of developing temporomandibular
disorders (TMD) compared to healthy individuals.
Symptoms of TMD can include discomfort and pain in the orofacial region, limited
TMJ mobility, difficulty with speech and chewing, stiffness, tinnitus, and clicking or skip-
ping sounds when chewing, opening, or closing the mouth. It is essential to objectively
diagnose TMD to manage them effectively. The persistent and progressive manifestation
of symptoms deteriorates the quality of life and psychological well-being, which poten-
tially impacts existing psychiatric ailments like depression, chronic stress, and anxiety.
Wiackiewicz et al. suggest that Polish patients with TMD have heightened levels of anxiety,
depression, perceived stress, and pain intensity, recommending screening assessments uti-
lizing Patient Health Questionnaire-9, Perceived Stress Scale-10, and Generalized Anxiety
Disorder-7 [10]. Seweryn et al. [11] proved that a large number of TMD patients experienc-
ing poor sleep quality and the associated reduced life satisfaction; these parameters should
be considered as influential factors that modify the management of patients with TMD.
Research suggests that psychological disorders have an impact on TMD development [12].
Considering the multifactorial etiology of TMD, their development is explained by the
biopsychosocial model [13,14].
TMD is an umbrella term, encompassing multifactorial and heterogeneous disorders
that may occur in different genders and ages. According to epidemiological data, this
problem affects from 5–12% [15] of the population, to 21.5–50.5% [16], and is the second most
common musculoskeletal dysfunction, after chronic lower back pain [17]. The systematic
review by Valesan et al. [1] showed that the overall prevalence of temporomandibular joint
disorders was approximately 31% for adults/elderly and 11% for children/adolescents.
Minervini et al. [18] found that TMD prevalence in children and adolescents varies between
20% and 60% and females had a higher prevalence of TMD compared to males. A 2020
study found that the frequency of TMD among the Polish urban adult population was
55.9% [19]. Patients with TMD require multi-specialist management, often extending
beyond dentists’ expertise.
To our knowledge, previous literature reviews on the etiology of TMD have not used
a single consistent tool. In contrast, this study utilized both the DC/TMD and RDC/TMD
questionnaires to standardize the diagnosis of TMD and objectively identify its causal
factors. Additionally, a large study group was used as an inclusion and exclusion criterion,
further enhancing the objectivity of the results. All of these factors have contributed to
a paper that discusses various aspects of the etiology of TMD. This is relevant for both
clinicians and from a scientific perspective. Recognizing the identified links between psy-
Healthcare 2024, 12, 575 3 of 31

chological factors and TMD, it is imperative to enhance the identification of psychological

conditions in at-risk individuals. Effective early intervention programs necessitate develop-
ment, incorporating a comprehensive management approach with collaboration among
diverse professionals.
The objective of this study is to provide a systematic analysis of the literature published
from 1 January 2018 to 1 September 2022 concerning the factors that affect the development
and progression of TMD in patients who received a diagnosis by using the Diagnostic
Criteria for Temporomandibular Disorders (DC/TMD) or Research Diagnostic Criteria for
Temporomandibular Disorders (RDC/TMD) protocol.

2. Materials and Methods

This review was conducted following the Preferred Reporting Items for System-
atic Reviews and Meta-Analysis (PRISMA) guidelines and was registered in PROSPERO
(ID: CRD42024497070, date: 15 January 2024).

2.1. Eligibility Criteria and Information Sources

All selected papers met the criteria. Three online databases were searched: Medline
Complete, PubMed, and MDPI. The databases were last searched on 29 October 2022.
The inclusion criteria were as follows: (I) Original research, (II) Written and published
in English, (III) Published between 1 January 2018 and 1 October 2022, (IV) Online ac-
cess to and download of the work, made possible by the accessibility of the library of
Lazarski University in Warsaw, (V) A complete DC/TMD or RDC/TMD study conducted,
(VI) Subjects aged at least 18 years, (VII) Study conducted on human participants. Works
excluded from this systematic review comprised studies meeting the following exclusion
criteria: (I) Incomplete, absent, or modified version of DC/TMD or RDC/TMD protocol,
(II) Systematic or narrative review, (III) Case reports, (IV) Study group size less than 100
participants, (V) Studies focusing exclusively on individual symptoms such as bruxism or
headaches, which were not diagnosed as TMD, (VI) Absence of data analysis. Inclusion
and exclusion criteria are presented in Table 1.

Table 1. Inclusion and exclusion criteria.

Inclusion Criteria Exclusion Criteria

Incomplete/absent/modified DC/TMD or
Original research
RDC/TMD
Articles in English, published between
Systematic/narrative review
1 January 2018 and 1 October 2022
Full DC/TMD or RDC/TMD Case reports
Participants at least 18 years old Study group < 100 participants
Only human participants Symptoms of TMD, defined as TMD
Full online access granted by the library of
Absence of data analysis
Lazarski University in Warsaw

2.2. Search Strategy

An electronic search was conducted across Medline Complete, PubMed, and MDPI.
The last database review took place on 29 October 2022. Boolean operators (OR and/or
AND) combined with keywords were employed in each database search to achieve optimal
results. The following keywords were used: ‘factors’, ‘causes’, ‘influences’, ‘TMD’, ‘tem-
poromandibular disorder’, ‘temporomandibular disorders’, ‘DC/TMD’, and ‘RDC/TMD’.
The following keywords were dropped in the last phase of the search: “factors”, “causes”,
and “influences”, to obtain as many relevant papers as possible. In each of the searches,
keywords were combined with the Boolean operator (OR and/or AND). A time restriction
was imposed in all databases, limited to papers published between 2018 and October 2022.
Healthcare 2024, 12, 575 4 of 31

In the Medline Complete database, filters such as “find all search terms”, “use equivalent
topics”, “full text”, “English language”, and “adults only” were utilized in the ‘advanced
search’ option. In the ‘clinical questions’, ‘publication type’, and ‘gender’ options, no filters
were applied. In the MDPI and PubMed databases, no additional limitations were applied.
The search strategy is presented according to the PICO (patient/population, intervention,
comparison, and outcomes) strategy in Table 2.

Table 2. PICO strategy used in the search strategy.

PICO Elements Keywords Search Items Search Strategies

Temporomandibular disorder OR
P: Patients or Patients diagnosed with TMD temporomandibular disorders OR
Patients suffering from TMD
Population using DC/TMD or RDC/TMD TMD AND DC/TMD OR
RDC/TMD
Factors contributing to the
etiology of TMD, as measured by
I: Intervention Factors impacting TMD Factors OR influences OR causes
standardized questionnaires or
other diagnostic methods
TMD patients and general population; TMD patients and healthy control groups; comparison within TMD
C: Comparison
patients
O: Outcome Factors impacting TMD

2.3. Selection and Data Collection Process

In phase one, two researchers (JM, JKG) independently performed a blind analysis
of papers available in three databases based on titles and abstracts (TiAb screening). The
papers that met the inclusion criteria were printed in full and analyzed manually in more
detail by the first author (JW) (phase two). At this stage, the exclusion criteria were taken
into account. Those papers that qualified in phase two proceeded to phase three, which
consisted of a thorough analysis of the full texts by all reviewers (JM, JW, JGK) and a
discussion of the resulting disagreements.

2.4. Data Items

The first author (JW) collected data from the selected papers, which was later verified
for content validity and integrity by the third author (JM). The extracted information
includes the following: first author’s name, year of publication, title, study group and its
characteristics (gender, age, country of origin, any special features), research tools utilized,
presence of control group, and outcomes associated with TMD etiology.

2.5. Study Risk of Bias Assessment

The risk of bias (RoB) was assessed independently by 2 authors (JW) and (JM) and
discussed in a meeting with the whole team. The Joanna Briggs Institute (JBI) analytical
cross-sectional studies’ Critical Appraisal Tool [20], consisting of 8 categories scored as ‘yes’,
‘no’, ‘unclear’, and ‘not applicable’, was used for the assessment. The categories assessed
were clearly defined criteria for inclusion of the group in the study; study subjects and
the setting described in detail; exposure measured in a valid and realistic way; objective,
standard criteria were used for measurement of the condition; confounding factors were
identified; outcomes were measured in a valid and reliable way; appropriate statistical
analysis was used.
The “low risk of bias” group included papers with more than 85% “yes” responses, i.e.,
a maximum of 1 “no” response or 1 “unclear” response. The ‘moderate risk of bias’ group
included papers with a maximum of 2 “no” answers or 2 unclear answers, i.e., papers with
62.5–75% “yes” answers. The final group, with a high risk of bias, included papers with
less than 62.5% “yes” responses.
 group included papers with a maximum of 2 “no” answers or 2 unclear answers, i.e., pa-
Healthcare 2024, 12, 575
pers with 62.5–75% “yes” answers. The final group, with a high risk of bias, included pa-
5 of 31
pers with less than 62.5% “yes” responses.

3. Results
3. Results
3.1.
3.1. Study
Study Selection
Selection
Electronic
Electronic searches
searches were
were conducted
conducted using MDPI, Medline
using MDPI, Medline Complete,
Complete, and PubMed
and PubMed
databases.
databases. Two methods were used, depending on the selected keywords. Firstly, withwith
Two methods were used, depending on the selected keywords. Firstly, the
the following
following keywords:
keywords: ‘factors’,
‘factors’, ‘causes’,
‘causes’, ‘influences’,
‘influences’, ‘TMD’,‘TMD’, ‘temporomandibular
‘temporomandibular dis-
disorder’,
order’, ‘temporomandibular
‘temporomandibular disorders’,disorders’,
‘DC/TMD’, ‘DC/TMD’,
‘RDC/TMD’, ‘RDC/TMD’,
505 papers505were
papers were Sec-
acquired. ac-
quired. Secondly, the search was narrowed by limiting the keywords
ondly, the search was narrowed by limiting the keywords to ‘TMD’, ‘temporomandibular to ‘TMD’, ‘temporo-
mandibular disorder’, ‘temporomandibular
disorder’, ‘temporomandibular disorders’,
disorders’, ‘DC/TMD’, and‘DC/TMD’,
‘RDC/TMD’, andwhich
‘RDC/TMD’,
received
which received a total of 973 papers. A comprehensive review
a total of 973 papers. A comprehensive review was conducted on 1478 papers. was conducted on After
1478
papers. After eliminating duplicates, 1060 papers were assessed via abstract
eliminating duplicates, 1060 papers were assessed via abstract and title based on inclusion and title
based on inclusion
and exclusion and exclusion
standards. In-depthstandards.
analysis wasIn-depth analysis
performed on was performed
19 papers, with onthe19 pa-8
last
pers,
beingwith the lastEventually,
excluded. 8 being excluded. Eventually,
this literature reviewthis literature
included 11review
papersincluded 11 papers
[21–31]. The study
[21–31].
selectionThe studyisselection
process shown inprocess
Figure is1. shown in Figure 1.

Figure
Figure 1.
1. The
The flow
flow diagram
diagram of
of the
the included
included literature
literature searching strategy.
searching strategy.

3.2. Study
3.2. Study Characteristics
Characteristics
The selected
The selectedpapers
paperscomprise
comprisestudies conducted
studies on adult
conducted patient
on adult populations
patient from diverse
populations from
countries, including Portugal, Finland, Poland, Germany, Italy, Slovenia, Brazil,
diverse countries, including Portugal, Finland, Poland, Germany, Italy, Slovenia, and China. In
Brazil,
11 of the inclusions, the study group was a total of 8585 people (3357 subjects were assessed by
RDC/TMD; 5228 were assessed DC/TMD), (3076 men, 5509 women). Three [21,28,31] of the
papers selected were population-based studies, involving 5188 participants.
In addition to the DC/TMD or RDC/TMD questionnaires, two papers [21,22] used the
Oral Behavior Checklist (OBC) to assess oral parafunctions and habits that can contribute to
Healthcare 2024, 12, 575 6 of 31

various oral health issues [32]. Three papers [21–23] used the Patient Health Questionnaire-
9 (PHQ-9), a widely used questionnaire based on the Diagnostic and Statistical Manual of
Mental Disorders (DSM-4) criteria, to screen and assess the severity of mental disorders [33].
The GAD-7 questionnaire is a tool used to measure the severity of generalized anxiety
disorder [34]. It has been referenced in two papers [22,23]. The SCID (Structured Clinical
Interview for DSM-III-R) is an instrument used to evaluate 33 commonly diagnosed Axis I
DSM-III-R disorders in adults [35]. It has been referenced in two papers [24,25]. The Silness
and Loe Plaque Index is a dental assessment tool that evaluates the presence and extent of
dental plaque, providing insights into oral hygiene [36]. It was used in one paper [24]. The
pericranial tenderness score (PTS), masticatory muscle tenderness score (MTS), and cervical
muscle tenderness score (CTS) are components of an assessment tool for myofascial pain,
specifically in the pericranial, masticatory, and cervical muscles [37,38]. Consecutively,
PTS, MTS, and CTS were used in one paper [24]. The Oral Health Impact Profile (OHIP)
is a questionnaire that assesses the impact of oral health on an individual’s quality of
life [39]. It was used in one paper [22]. The Patient Health Questionnaire-15 (PHQ-15) is
commonly employed as an accessible screening tool for somatization syndromes across
various healthcare environments [40]. The Pittsburgh sleep quality index (PSQI) is a
questionnaire used to assess sleep quality and disturbances over one month [41]. It was
used in two papers [22,26]. These tools were each used in one paper [22]: The visual
analog scale (VAS), graded chronic pain scale (GCPS), and Symptom Checklist-90 (SCL-90).
These are tools to assess the subjective perception of acute and chronic pain [42], categorize
and measure the severity of chronic pain [43], and assess a broad range of psychological
problems and symptoms [44], respectively. The Fonseca Anamnestic Index (FAI) is a
questionnaire used to evaluate the severity of temporomandibular disorders (TMD) based
on the patient’s symptoms [45]. It was utilized in a single study [26]. The characteristics of
the study are shown in Table 3.

3.3. Risk of Bias in Studies

Two papers [27,28] attained a ‘high risk of bias’ rating as they obtained a minimum
of three responses other than yes, whereas one paper [22] received a “moderate risk of
bias” rating. The criteria for which papers most often received a negative response were
“strategies to deal with confounding factors” (which received five negative responses)
and “clearly defined criteria for inclusion in the sample” (which received four negative
responses and one unclear response). In the case of the strategy criterion, such a low score
may have been due to the lack of clear guidelines on how to structure the work. This factor
may also have been an indirect cause of the result for the inclusion criteria, as it should
be noted that it was the exclusion criteria rather than the inclusion criteria that were most
often described in detail.
It is noteworthy that high scores were attained in certain criteria, namely “appropriate
statistical analysis was used”; “outcomes were measured in a valid and reliable way”;
and “objective, standard criteria were used for measurement of the condition”, all of
which achieved 100% positive responses. These scores may have been influenced by the
inclusion and exclusion criteria of the study, which necessitated accurate, comprehensive,
and suitable analysis for the study to be included in this literature review. Risk of bias
(RoB) results are presented in Table 4.
Healthcare 2024, 12, 575 7 of 31

Table 3. PICO.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Painful TMDs were significantly associated with
Univariate associations between categorical
both low- and high-frequency oral parafunctional
variables were tested using chi-square tests.
behaviors. (p < 0.001)
RDC/TMD;
Univariate logistic regression was used to
Other TMDs were associated mainly with the
assess the relationship between individual
high-frequency behavior of clenching or grinding
OBC items and OBC sum score categories
teeth during sleep. (p = 0.03)
with painful TMDs and other TMDs.
The model retained specific behaviors, such as
holding or jutting the jaw forward/to the side,
t-tests were used to compare the OBC sum clenching or grinding teeth during sleep, grinding
Are oral overuse N = 1381 (M: 339, F: score between dichotomous groups (sex teeth when awake, holding the jaw in a rigid
behaviors 1042), range: 18–67, and age). position, leaning the jaw, and sustained talk, as
associated with mean age: 21, Oral Behavior non independent variables associated with painful
painful population: Checklist (OBC); applicable TMDs.
Cláudia temporomandibu- Portuguese
Barbosa, ANOVA followed by Scheffe post hoc test
lar disorders? A University Painful TMDs were more prevalent in females
2021 [21] was used among diagnostic groups
cross-sectional Students (30.7%) than males (19.5%). (Mann–Whitney test, p <
(TMD-free, other TMDs, and painful
study in 0.001)
TMDs).
Portuguese
university students Females, younger adults, and those with painful
TMDs had higher oral behaviors checklist (OBC)
Multivariable binary logistic regression scores. (p = 0.001, p < 0.001, p < 0.001, respectively)
Patient Health models were used to test the association
Questionnaire between individual oral parafunctional High OBC scores were associated with myalgia (p =
(PHQ-9); behaviors, OBC sum score categories, and 0.002), arthralgia (p = 0.001), and combined myalgia
painful TMD subtypes. and arthralgia (p ≤ 0.001).
Low OBC scores were only associated with
combined myalgia and arthralgia (p = 0.001).
Healthcare 2024, 12, 575 8 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Female gender and self-reported poor/fair health
conditions were strongly associated with
pain-related symptoms and clinical signs of
Temporomandibular Disorders (TMD) (p < 0.000).
DC/TMD;
Subjects with poor or fair health conditions had
more pain-related TMD symptoms and pain in the
masticatory muscles and TMJs (p < 0.000).
Subjects not working or retired had a numerically
higher prevalence of pain-related symptoms in the
non temples, TMJs, face, or jaw compared to those
Association of risk Additional Chi-square Test applicable currently working (p > 0.05).
factors with N = 1962, (M: 912, questionnaires
temporomandibu- F: 1050), range: about comorbid Diagnosed depression, migraine, fibromyalgia (FM),
Päivi lar disorders in the born in 1966 (46 rheumatic disease, and general osteoarthritis
factors: gender,
Jussila, Northern y.o), population: showed statistically significant associations with
employment,
2018 [28] Finland Birth Finland pain-related TMD symptoms (p < 0.05).
self-reported
Cohort 1966 health conditions, Migraine, FM, rheumatic disease, and general
depression, osteoarthritis were also associated with pain-related
fibromyalgia, TMD symptoms during maximal mouth opening or
gastrointestinal chewing (p < 0.05).
disease, migraine
Thyroid disease and gastrointestinal disease were
headache,
associated with pain in the masticatory muscles and
osteoarthritis,
pain in the TMJs (p < 0.05).
rheumatic Fisher’s exact test used along with the
disease, thyroid chi-square test Self-reported sleep apnea (diagnosed by a physician)
disease was associated with clicking in the TMJs (p = 0.029).
Current smoking or use of snuff had an association
with clinical TMD signs (p = 0.021).
Healthcare 2024, 12, 575 9 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
General health problems (depression, migraine, FM,
gastrointestinal diseases, rheumatic disease, and
general osteoarthritis) were strongly associated with
TMD pain symptoms (p < 0.05).
Diagnosed depression showed a strong association
with pain on palpation in the masticatory muscles
Päivi Jussila, 2018 [28] non
Statistical significance was determined at p and pain in the TMJs (p < 0.05).
applicable
< 0.05. Perceived stress and personal well-being were
associated with diagnosed depression and pain on
palpation in the masticatory muscles and TMJs (p <
0.05).
Subjects not working or retired had more
pain-related symptoms than those currently working
(p > 0.05).
Odds ratios (OR) were calculated in Patients
COL5A1 RS12722
DC/TMD; relation to the most frequent combination with no
Is Associated with
with 95% confidence intervals. TMD
Temporomandibu-
N = 124, (M: 20, F: problems: The COL5A1 marker rs12722 showed significant
Bartosz lar Joint Pearson’s chi-square test was used to assess
104), mean age: N = 126 (M: p-values, indicating differences in the frequencies of
Dalewski, Anterior Disc the significance of genotype distribution
32.36, population: CBCT/MRI; 30, F: 96), temporomandibular joint disc dislocation.
2021 [29] Displacement differences.
Poland mean age: (p = 0.0119)
without Reduction Logistic regression modelling was
in 43.86,
employed to analyze the influence of population:
Polish Caucasians investigated SNPs on ADDwoR. Poland
Healthcare 2024, 12, 575 10 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
The Student’s
Patients with the rs12722 genotype CT had an almost
t-test was used to
2.4 times higher likelihood of disc dislocation (OR =
determine age
2.41) compared to those with the reference genotype
differences
Patients TT (OR = 1). (0 = 0.0032)
between groups.
with no
Bartosz SWAB TMD Analysis of COL5A1 markers revealed a significant
Dalewski, Genomic problems: association for rs12722. Patients with rs12722
2021 [29] Extraction GPB A chi-square test was used for sex N = 126 (M: genotype CT had a 2.4 times higher likelihood of
Mini Kit distribution analysis. 30, F: 96), disc dislocation compared to TT (OR = 2.413, p =
mean age: 0.003), while rs13946 genotypes showed no
43.86, significant association.
population: Logistic regression confirmed the significant impact
Poland of the rs12722 CT allele on disc dislocation (OR =
Statistical significance was set at p < 0.05. 2.413, p = 0.003). The rs13946 genotypes did not
exhibit a significant effect in the logistic regression
model.
Kolmogorov–Smirnov Test (KS Test) Patients with pain attributed to TMD exhibited
DC/TMD; significantly higher scores on both PHQ-9 and
Chi-square Test
GAD-7 compared to a general population sample. (p
Depression and Generalized < 0.05)
anxiety levels in N = 243 (M: 52, F: Anxiety Disorder N = 5018
patients with tem- Spearman’s rank correlation tests
Louis 191), mean age: 41; Assessment for PHQ-9;
Simoen, poromandibular population: (GAD-7) N2 = 5026
2020 [23] disorders: Germany for GAD-7
comparison with Pearson correlation 19% of the study sample had a PHQ-9 score ≥ 10
the general (moderate depression), while 29% had a GAD-7
Patient Health
population score ≥ 10 (moderate anxiety). In contrast, the
Questionnaire Results were considered statistically reference population had lower percentages (7% and
(PHQ-9) significant at p ≤ 0.05. 6%, respectively).
Healthcare 2024, 12, 575 11 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Gender played a crucial role; women had 90% higher
RDC/TMD; Multivariate logistic regression analysis
odds than men of developing TMD. (p < 0.01)
Structured
Clinical
Interview For
DSM-IV (SCID-I)
Determining Risk Silness and Loe
Factors for the plaque index
Alessandro Development of N = 224 (M: 105, F:
Ugolini, 119), mean age: 28; Angle’s No control
Temporomandibu-
2020 [24] population: Italy classification group
lar Disorders Odds ratios (ORs) were adjusted for age, There is a statistically significant relationship
during Pericranial sex, and the presence of anxiety or mood between the presence of TMD and anxiety,
Orthodontic tenderness score disorders. depression, and somatization (p < 0.01)
Treatment (PTS)
Masticatory
muscle
tenderness score
(MTS)
Cervical muscle
tenderness score
(CTS)
Healthcare 2024, 12, 575 12 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Cohen’s d, a measure of effect size, was
DC/TMD; calculated to demonstrate the standardized Simple logistic regression:
differences between the two groups.
Oral Health
Impact Profile Female gender was significantly associated with
Simple logistic regression analysis
questionnaire Patients TMD patients reporting HATMJD (p = 0.005)
(OHIP) with TMD,
without
Patient Health Depression (p = 0.011), anxiety (p = 0.020), and
headache
Questionnaire Multiple logistic regression analysis physical symptoms (p = 0.001) were significantly
because of
Headache Because (PHQ-9) associated with TMD patients reporting HATMJD.
problems
of Problems with Generalized
Tadej N = 109 (M: 17, F: with teeth,
Teeth, Mouth, Jaws, Anxiety Disorder Oral behaviors (OBC summary score) were
Ostrc, 92), mean age: mouth,
or (GAD-7 Omnibus Test of Model significantly higher in the group with HATMJD
2022 [22] 35.07; population: jaws, or
Dentures in summary (p < 0.001).
Slovenia dentures
Chronic Temporo- score) (HATMJD);
mandibular
Patient Health M = 68 (M:
Disorder Patients: Sleep quality (PSQI summary score) was
Questionnaire-15 Hosmer–Lemeshow test 23, F: 45);
A significantly worse in the HATMJD group (p < 0.001).
(PHQ-15) mean age:
Case–Control
38.9
Study Oral Behavior
Nagelkerke’s R-square Multiple logistic regression:
Checklist (OBC)
Pittsburgh sleep Odds Ratio Calculation
Female gender (p = 0.023), oral behaviors (p = 0.019),
quality index
sleep quality (p = 0.021), and depression (p = 0.549)
(PSQI) Statistical significance was set at p < 0.05
were identified as significant predictors of HATMJD.
Healthcare 2024, 12, 575 13 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
RDC/TMD;
Single-variable logistic regression analyses
were performed to assess the association
between various predictors and the TMD
Visual Analog
group (pain group vs. non-pain group)
Scale (VAS);
Graded Chronic
Variables removed until all retained
Pain Scale
variables showed p < 0.05.
(GCPS);
Magdalena Pain Predictors in a N = 109 (M: 22, F: Symptoms A multiple logistic regression model was
Osiewicz, Population of Tem- 87), mean age: 33.2, Checklist-90 attempted, but only depression (DEP)
2019 [25] poromandibular range: 18–72; (SCL-90); remained a significant variable. No control
Disorders Patients population: Poland group Only gender (p < 0.063) and depression (p < 0.019)
Cervical muscle
showed a significant correlation with TMD.
tenderness score Odds ratios (OR) assessed for each variable.
(CTS);
Somatization
Scale (SOM);
Diagnostic and
Statistical Nagelkerke’s R-square
Manual of
Mental Disorder
(SCID I);
Healthcare 2024, 12, 575 14 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Canine relationship and canine asymmetry were
associated with pain in temples, TMJs, face, or jaw
(p = 0.015, p = 0.039).
In the multivariable model, the association between
Pearson’s chi-square test (χ2 -test) canine asymmetry and pain remained significant
(p = 0.041).
DC/TMD;
Limited mouth opening was more frequent in
subjects with asymmetry in canine relationships
(p = 0.040).
A statistically significant difference in crepitus in
Prevalence of
TMJs was observed between groups of different
sagittal molar and
N = 1845 (M: 857, F: molar relationships, with the half-cusp Class II
canine
988), mean age: 46; group being most affected (p = 0.020).
relationships,
Elisa Ter- asymmetries and range: 46; Fisher’s exact test Non In the multivariable model, half-cusp Class II
vahauta, midline shift in population: applicable remained significantly associated with crepitus in
2022 [31] relation to temporo- Finland TMJs (p = 0.024).
mandibular iTero 3D scanner;
Half-cusp Class II was the most frequent bilateral
disorders (TMD) in molar relationship in females with disc displacement
a Finnish adult with reduction (15.8%, p = 0.043) and degenerative
population joint disease (26.3%, p < 0.001).
The bilateral molar relationship was statistically
significantly associated with disc displacement with
reduction and degenerative joint disease (p = 0.034, p
Logistic regression analyses < 0.001, respectively).
Females with one or more missing canines had
significantly more myalgia and arthralgia compared
to females with no missing canines (p = 0.014, p =
0.022).
Healthcare 2024, 12, 575 15 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Self-reported general health was significantly
associated with pain symptoms, limited mouth
opening, myalgia, and arthralgia (p < 0.001, p = 0.047,
p < 0.001, p < 0.001, respectively).
Elisa Tervahauta, Self-reported Non Mental health was associated with arthralgia
Significance level set at p < 0.05.
2022 [31] general health applicable p (p = 0.049).
questionnaire
Rheumatoid arthritis was associated with crepitus in
TMJs and arthralgia (p = 0.002, p = 0.018).
Gender was associated with TMD symptoms and
signs (p < 0.001, p = 0.004, p = 0.024).
Descriptive statistics, including mean,
Patients with a TMD diagnosis showed significantly
Skeletal standard deviation, minimum, median, and
greater skeletal divergence with a higher SpPGoGn
Divergence and maximum values, were calculated for all
angle (p = 0.00155).
Condylar numerical groups.
DC/TMD; Patients
Maria Asymmetry in N = 100 (M: 34, F: A strong statistically significant difference in the
A linear regression model for TMD was without
Francesca Patients with 66); range: 18–30; condylar symmetry parameter was observed, with
performed, adding age, sex, symmetry, and TMD;
Sfondrini, Temporomandibu- population: Italy the TMD group having a much higher percentage of
divergence as covariates. N = 100 (M:
2021 [30] lar Disorders asymmetric condyles (p < 0.0001).
46, F: 54)
(TMD): A
Regarding gender, a statistically significant
Retrospective
difference was found between the two groups
Study X-ray Analysis; Significance level set at p < 0.05 for all tests.
(p = 0.0444), while no difference in age was detected
(p = 0.297).
Healthcare 2024, 12, 575 16 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Global sleep score, insomnia, nonrestorative sleep,
schedule disorders, daytime sleepiness, sleep apnea,
restlessness were the factors in which mean scores
were significantly higher in TMD subjects compared
to controls (p < 0.001).
RDC/TMD; Student t test
72.1% of TMD subjects had a global sleep disorder
Sleep Disorders in compared to 48.2% of controls (p < 0.001).
Patients with Tem-
37.5% of TMD subjects had insomnia compared to
poromandibular
Daniela D. N = 1643 (M: 561, F: No control 14.7% of controls (p < 0.001).
Disorders (TMD) in
S. Rehm, an Adult 1082), range: 18–65; group 47.2% of TMD subjects had nonrestorative sleep
2019 [27] Population- Based population: Brazil compared to 18.2% of controls (p < 0.001).
Cross-Sectional 60.0% of TMD subjects had sleep schedule disorders
Survey in Southern compared to 52.8% of controls (p < 0.01).
Brazil
Pearson chi-square test 26.6% of TMD subjects had daytime sleepiness
Sleep Assessment compared to 16.2% of controls (p < 0.001).
Questionnaire
(SAQ) 24.7% of TMD subjects had sleep apnea compared to
17.4% of controls (p < 0.001).
TMD subjects showed a higher prevalence of
restlessness (p < 0.001).
Healthcare 2024, 12, 575 17 of 31

Table 3. Cont.

Study
First Comparison
Title Population (P) Intervention (I) Statistical Analysis (SA) Outcomes (O)
Author, (C)
Year
Sleep component scores showed significant
A general/health differences across severity levels, indicating a
The significance level was set at 0.05.
questionnaire; worsening trend in sleep quality with increasing
TMD severity (p < 0.001).
Fonseca Subjects with any DC/TMD diagnoses (PT, IT, or CT)
Anamnestic Shapiro–Wilks test had significantly higher global PSQI scores
Temporomandibular Patients
Index (FAI); compared to those with no TMDs (p < 0.001).
disorder severity without
Adrian and diagnostic N = 845 (M: 157, F: Diagnostic TMD;
Ujin Yap, groups: Their 688), mean age: Criteria for Tem- N = 116 (F: Significant age differences were found between
2021 [26] associations with 31.66; population: poromandibular Chi-square test 73, M: 43); subjects with moderate and severe TMDs (p = 0.031)
sleep quality and China disorders mean age: and those with PT, IT, and CT (p < 0.001).
impairments (DC/TMD) 31.66)
Symptom Kruskal–Wallis and Mann–Whitney U
Women were significantly more prevalent than men
Questionnaire; post-hoc test
in all TMD severity and diagnostic groups (p < 0.001).
Pittsburgh sleep
Results were presented as odds ratios (ORs)
quality index
with 95% confidence intervals (95% CI).
(PSQI)
Healthcare 2024, 12, 575 18 of 31

Table 4. Risk of bias assessed by The Joanna Briggs Institute (JBI) analytical cross-sectional studies’ Critical Appraisal Tool. (Y—Yes, N—No, U—Unclear, L—Low
RoB, M—Moderate RoB, H—High RoB).

Objective and
Criteria for Study Standard Strategies to Outcomes
Exposure Appropriate
First Author, Year of Inclusion in Subjects and Criteria Were Confounding Deal with Were
Measured in a Statistical Risk of
Publication/Risk of Bias the Sample the Setting Used for the Factors Were Confounding Measured in a
Valid and Analysis Was Bias
Assessment Criteria Are Clearly Described in Measurement Identified Factors Were Valid and
Reliable Way Used
Defined Detail of the Stated Reliable Way
Condition
Cláudia Barbosa, 2021 [21] Y Y Y Y Y N Y Y L
Päivi Jussila, 2018 [28] N Y Y Y N N Y Y H
Bartosz Dalewski, 2021 [29] Y Y Y Y Y Y Y Y L
Louis Simoen, 2020 [23] Y Y Y Y Y N Y Y L
Alessandro Ugolini, 2020 [24] N Y Y Y Y Y Y Y L
Tadej Ostrc, 2022 [22] N Y Y Y Y N Y Y M
Magdalena Osiewicz, 2019 [25] Y Y Y Y Y Y Y Y L
Elisa Tervahauta, 2022 [31] N Y Y Y Y Y Y Y L
Maria Francesca Sfondrini, 2021 [30] Y Y Y Y Y Y Y Y L
Daniela D. S. Rehm, 2019 [27] U Y Y Y N N Y Y H
Adrian Ujin Yap, 2021 [26] Y Y Y Y Y Y Y Y L
Healthcare 2024, 12, 575 19 of 31

3.4. Results of Individual Studies

The selected papers examined the following factors:
• Biological: sex, age, self-reported health condition, genetic mutations, oral parafunc-
tion, occlusion, condylar symmetry, skeletal divergence, extraction of teeth, orthodon-
tic treatment, bruxism, fibromyalgia, migraine/headache, gastrointestinal disease,
rheumatic disease, thyroid disease,
• Sociological: education, employment status, marital status, living conditions, socioeco-
nomic status,
• Psychological: somatization, sleep quality, anxiety, depression, stress, chronic pain.
The data collected on the factors are presented in Table 5.

Table 5. Analyzed etiologic factors of TMD.

No. of
Outcome Sum of
Primary Outcome Trials Participants
Significance Participants
(Studies)
Cláudia Barbosa, 2021 [21] 1381
Päivi Jussila, 2018 [28] 1962
Significant Louis Simoen, 2020 [23] 243 3058
correlation
Alessandro Ugolini, 2020 [24] 224
Sex
Tadej Ostrc, 2022 [22] 109
Maria Francesca Sfondrini, 2021 [30] 100
Adrian Ujin Yap, 2021 [26] 961
Insignificant Bartosz Dalewski, 2021 [29] 124
233
correlation Magdalena Osiewicz, 2019 [25] 109
Significant Bartosz Dalewski, 2021 [29] 124
1085
correlation Adrian Ujin Yap, 2021 [26] 961
Cláudia Barbosa, 2021 [21] 1381
Biological Age
Insignificant Alessandro Ugolini, 2020 [24] 224
1923
correlation Tadej Ostrc, 2022 [22] 109
Magdalena Osiewicz, 2019 [25] 109
Maria Francesca Sfondrini, 2021 [30] 100
Self-reported Significant
Päivi Jussila, 2018 [28] 1962 1962
health condition correlation
Significant
Genetic mutations Bartosz Dalewski, 2021 [29] 124 124
correlation
Significant Cláudia Barbosa, 2021 [21] 1381
1490
Oral parafunction correlation Tadej Ostrc, 2022 [22] 109
Insignificant Alessandro Ugolini, 2020 [24] 224
333
correlation Magdalena Osiewicz, 2019 [25] 109
Significant Elisa Tervahauta, 2022 [31] 1845
Anatomical 1945
correlation Maria Francesca Sfondrini, 2021 [30] 100
features
Insignificant
Alessandro Ugolini, 2020 [24] 224 224
correlation
Significant
Fibromyalgia Päivi Jussila, 2018 [28] 1962 1962
correlation
Healthcare 2024, 12, 575 20 of 31

Table 5. Cont.

No. of
Outcome Sum of
Primary Outcome Trials Participants
Significance Participants
(Studies)
Migraine, Significant
Päivi Jussila, 2018 [28] 1962 1962
headache correlation
Gastrointestinal Significant
Päivi Jussila, 2018 [28] 1962 1962
disease correlation
Biological Significant
Rheumatic disease Päivi Jussila, 2018 [28] 1962 1962
correlation
Significant
Osteoarthritis Päivi Jussila, 2018 [28] 1962 1962
correlation
Significant
Thyroid disease Päivi Jussila, 2018 [28] 1962 1962
correlation
Insignificant Tadej Ostrc, 2022 [22] 109
Education 2071
correlation Päivi Jussila, 2018 [28] 1962
Employment Significant
Päivi Jussila, 2018 [28] 1962 1962
status correlation
Sociological Insignificant
Living conditions Päivi Jussila, 2018 [28] 1962 1962
correlation
Socioeconomic Insignificant
Päivi Jussila, 2018 [28] 1962 1962
status correlation
Insignificant Tadej Ostrc, 2022 [22] 109
Marital Status 2071
correlation Päivi Jussila, 2018 [28] 1962
Significant Alessandro Ugolini, 2020 [24] 224
333
correlation Tadej Ostrc, 2022 [22] 109
Somatization
Insignificant
Magdalena Osiewicz, 2019 [25] 109 109
correlation
Tadej Ostrc, 2022 [22] 109
Significant
Sleep quality Daniela D. S. Rehm, 2019 [27] 1643 2713
correlation
Adrian Ujin Yap, 2021 [26] 961
Louis Simoen, 2020 [23] 243
Significant
Anxiety Alessandro Ugolini, 2020 [24] 224 576
correlation
Psychological
Tadej Ostrc, 2022 [22] 109
Päivi Jussila, 2018 [28] 1962
Significant Louis Simoen, 2020 [23] 243
2647
Depression correlation Alessandro Ugolini, 2020 [24] 224
Tadej Ostrc, 2022 [22] 109
Magdalena Osiewicz, 2019 [25] 109
Insignificant
Stress Magdalena Osiewicz, 2019 [25] 109 109
correlation
Insignificant
Chronic pain Magdalena Osiewicz, 2019 [25] 109 109
correlation

3.4.1. Gender
The relationship between gender and the prevalence of TMD was examined in nine
papers [21–26,28–30]. Seven papers [21–24,26,28,30] (total study group n = 3058) demon-
strated a statistically significant association between the prevalence of TMD and female
Healthcare 2024, 12, 575 21 of 31

gender, while statistical significance was not established in two papers [25,29] (total study
group n = 233).

3.4.2. Age
Seven [21,22,24–26,29,30] studies analyzed a group of 3008 individuals to assess the
correlation between age and TMD. Two studies [26,29] demonstrated a significant statistical
association between TMD and increasing age (study group n = 1085), while in the remaining
five studies [21,22,24,25,30], this factor was deemed statistically insignificant (study group
n = 1923).

3.4.3. Depression
Depression’s role as an etiological factor in TMD was analyzed in five papers
[22–25,28], which collectively studied 2647 patients. All of these studies confirmed a
statistically significant relationship between the two conditions.
To evaluate depression, the questionnaires utilized included the author’s question-
naire, GAD 7, PHQ-9, PHQ-15, and SCID I.

3.4.4. Oral Parafunction

Oral parafunction as a risk factor of TMD, was studied in four papers [21,22,24,25],
reaching a total of 1823 patients studied. The correlation proved statistically significant in
two papers [21,22], a total of 1490 subjects. Two papers [24,25] showed no such correlation
(n = 333 subjects). Given the data, the connection between oral parafunction and TMD was
evidenced in 81% of the participants.

3.4.5. Anxiety
An examination of anxiety as a contributing factor to TMD was conducted across three
studies [22–24] involving a total of 578 patients. In all three studies, there was a statistically
significant correlation found between the presence of TMD and anxiety.
The GAD-7 and SCID-1 were utilized to assess anxiety in patients.

3.4.6. Somatization
Three papers [22,24,25] analyzed the correlation between TMD and somatization
within a sample size of 442 participants. Out of these, two papers [22,24] verified a
significant statistical correlation after studying 333 subjects, while one paper [25] did not
report similar findings.
The SCID-1, PHQ-15, and SOM tools were employed to examine the occurrence of
somatization among patients.

3.4.7. Sleep Quality

Sleep quality was assessed in three papers [22,26,27] featuring 2713 subjects. All three
papers confirmed a statistically significant relationship.
The PSQ1 and SAC were utilized to investigate sleep quality.

3.4.8. Anatomy and Factors Affecting Anatomy (Orthodontic Treatment)

Three papers [24,30,31] on this topic were identified, with a total of 2169 subjects.
One study [31] analyzed sagittal molar and canine relationships, asymmetries, and
midline shifts in TMD patients. The study found statistically significant relationships
between TMD and several occlusal abnormalities, which included cusp-to-cusp class II
molar relationships, midline shift, canine asymmetry, and missing first molars or canines
(study group n = 1845).
The second study [24] aimed to examine the impact of orthodontic treatment on TMD
development (n = 224). Although the study found no significant relationship between
orthodontic treatment and TMD, pain scores for myofascial pain syndrome appeared to
Healthcare 2024, 12, 575 22 of 31

worsen during the treatment. Nevertheless, after completing the treatment, pain showed
an improvement.
The third study [30] investigated the correlation between TMD and condylar asym-
metry and the growth’s divergence pattern (n = 100). This study demonstrated a strong
correlation between condylar asymmetry and hyperdivergence facial growth patterns.

3.4.9. Social Factors

This literature review examines the social factors of education, employment status,
marital status, living conditions, and socioeconomic status. The review analyses two papers,
one on employment [28] and the second [22] on other factors.
The results indicate a significant statistical relationship only for employment status,
which was examined in one paper [28] with a sample size of 1962.
There was no significant correlation found between education (two papers [22,28],
n = 2071), living conditions (one paper [28], n = 1962), socioeconomic status (one paper [28],
n = 1962), and marital status (two papers [22,28], n = 2071).

3.4.10. Other Factors

Other factors were explored individually in single papers, and they revealed a sig-
nificant statistical association with self-reported health conditions [28] (n = 1962), fibromyal-
gia [28] (n = 1962), gastrointestinal disease [28] (n = 1962), migraine/headache [28] (n = 1962),
osteoarthritis [28] (n = 1962), rheumatic disease [28] (n = 1962), thyroid disease [28] (n = 1962),
and genetic mutation [29] (n = 142).
There was no statistical correlation observed among variables including chronic
pain [22] (n = 109), and stress [25] (n = 109).

3.5. Results of Synthesis

Due to the diverse nature of the papers and the various methods implemented to study
the factors, a high degree of heterogeneity is exhibited among the papers, rendering com-
parisons challenging. Of the eleven papers chosen for appraisal, three are population-based
studies, with successive observations conducted on cohorts of n = 1381 [21], n = 1845 [31],
and n = 1962 [28]. The systematic review identified a significant correlation between female
gender and temporomandibular disorders (TMD) in seven out of nine studies. TMD was
linked to increasing age in two out of seven studies. Psychological factors, such as depres-
sion and anxiety, exhibited consistent statistically significant associations with TMD, as
documented in five and three research papers, respectively. Oral parafunction displayed
varied correlations, with specific parafunctions like clenching or grinding teeth exhibiting
significance in two out of four studies. Sleep quality showed a consistent association
with TMD in three studies. Occlusal abnormalities, orthodontic treatment, and condylar
asymmetry were linked to TMD in the context of papers that explored anatomical features.
Other individual factors, such as employment status, health conditions, and genetic muta-
tions, demonstrated noteworthy associations with TMD in individual studies. Nevertheless,
statistical correlations were not observed for variables such as marital status, education, chronic
pain, bruxism, and stress, which were also examined as factors in the individual studies. Table 5
includes data on the analyzed factors.

4. Discussion
The factors influencing TMD can be classified into three main groups: organic, psycho-
logical, and social factors. Organic factors can be further divided into central and peripheral
factors [46]. Peripheral factors are caused by disorders associated with abnormalities of
the peripheral nervous system and other tissues. These include ongoing inflammatory
processes, autoimmune diseases, organ abnormalities, and past trauma. Central factors
include abnormalities related to the central nervous system, such as psychological impair-
ment, neuropathic pain, or selected sleep disorders. Other organic factors include gender,
age, and genetic disorders. Social factors consist of occupation, economic status, and social
Healthcare 2024, 12, 575 23 of 31

conditions, among others [47]. In 1977, George Engel proposed the biopsychosocial model
as a multidimensional approach to disorders [48]. This model considers various factors that
can influence the development of TMD, which is a major diagnostic challenge to investigate
thoroughly. The DC/TMD protocol is currently the most versatile and comprehensive
tool for a multi-specialist approach to diagnosing TMD incorporating the biopsychosocial
model. Its use is a crucial inclusion criterion for this work.
The DC/TMD protocol is currently the most widely used by clinicians worldwide. It
enables standardization of diagnosis and provides a basis for objective data comparison.
The DC/TMD provides a practical classification of TMD, which distinguishes various
disorders, including myalgia, local myalgia, myofascial pain with spreading, myofascial
pain with referral, arthralgia, headache attributed to TMD, disc displacement with re-
duction, disc displacement with reduction and limited opening, disc displacement with
reduction and without limited opening, degenerative joint disease, and subluxation [49].
This analysis also utilizes RDC/TMD (Research Diagnostic Criteria for Temporomandibu-
lar Disorders), the prototype of DC/TMD, as a keyword. RDC/TMD was introduced in
1992 to standardize the classification of a group of patients affected by TMD. It underwent
refinement until 2014, when the current version, DC/TMD, was introduced. A study
by Samuel F. Dworkin et al. examined the reliability, validity, and clinical utility of the
Research Diagnostic Criteria for Temporomandibular Disorders Axis II Scales [50]. The
study found that the psychometric properties of the RDC/TMD are well-suited for the
thorough evaluation and treatment of individuals presenting with Temporomandibular
Disorders (TMD) [50].
This literature review aims to identify factors that may impact the development of TMD.

4.1. Gender
Research suggests that TMD may occur up to two to three times more frequently
in women than in men [51]. There are several theories to explain this gender imbalance
in TMD prevalence. One theory is that women tend to be more attentive to distressing
symptoms and seek medical help more frequently than men [52], which may result in more
frequent TMD diagnoses in this group. Another theory is the estrogen theory. Endogenous
estrogens and their cyclical fluctuations can influence several factors that may eventually
lead to TMD, such as gingivitis, periodontal disease, condylar fibrocartilage, protease activ-
ity, and estrogen signaling [53]. In a 1997 study, LaResche et al. [54] found an association
between taking exogenous estrogens in hormone replacement therapy and an increased
incidence of TMD symptoms, compared to women who did not receive such therapy.
Seven [21–24,26,28,30] out of nine papers that were examined found a statistically signifi-
cant correlation in this analysis. The remaining two papers [25,29] also showed a correlation,
but it was not statistically significant. The authors themselves reported that the lack of
statistical significance may be due to the selection of specific patient groups.

4.2. Age
Among the etiological factors of TMD, age is often cited as a potential risk factor.
However, a comparison of the papers studied does not provide sufficient evidence to
draw a similar conclusion. Out of the seven papers reviewed, only two [26,29] confirmed
this relationship. Proportionally, the total study group in which such a relationship was
confirmed, compared to the group in which no statistical significance was demonstrated, is
1:1.77 (n = 1085, n = 1923). Such a result is in contrast to the study of Gary D. Slade et al. [47],
which showed that the site-adjusted incidence rate of first-onset Temporomandibular
Disorder (TMD) increased with age across the entire cohort of 2737 individuals. The
incidence rate rose from 2.5% per annum in the 18 to 24-year-old group to 4.5% per annum
in the 35 to 44-year-old group [47].
Healthcare 2024, 12, 575 24 of 31

4.3. Depression
Depression and anxiety were the only factors that were statistically significant in all
of the papers studied. V. Aggarwal et al. [55] demonstrated that anxiety contributes to
the development of chronic orofacial pain, while L. Simoen et al. [23] recommended that
questionnaires assessing anxiety in patients be included in the diagnosis of orofacial pain
associated with TMD. It is important to note that in numerous research papers, anxiety
is often associated with depression, and the findings are frequently reported together.
However, this review presents separate results for depression and anxiety, enabling accurate
conclusions to be drawn for each factor. According to S. Kindler et al. [56], “depressive
symptoms were more strongly associated with joint pain compared to muscle pain, while
anxiety symptoms were more strongly associated with muscle pain compared to joint
pain”. Research suggests that anxiety can cause muscle hyperactivity, resulting in muscle
fatigue and compensatory behavior [57]. This can lead to degenerative arthritis, chewing
disorders, and disharmonious occlusion, all of which contribute to the development of
TMD. The relationship between TMD and depression and anxiety has been debated for
years, but is now considered to be two independent disorders: C. Stavrakaki et al. [58]
state that, “anxiety and depression are classified as separate disorders—clinically through
DMS-III and statistically through discriminant function analysis”. Several main streams
explain the relationship between depression and TMD. The three main explanations are
that depression is the result of a pain disorder; TMD is the result of depression (also known
as ‘masked depression’); and depression and pain result from a more central disorder [59].
Gallagher et al. [60] conducted a study on 106 women and found that 41% of patients
diagnosed with TMD had a history of major depression. A study conducted on a cohort of
students found that both depression and perceived stress and mood are risk factors in the
development of TMD [61].

4.4. Oral Parafunction

Oral parafunctions are abnormal activities that involve the oral structures, such as
the jaw, teeth, and surrounding tissues, but are not part of typical functional movements,
such as talking or chewing. These behaviors can adversely affect oral health and may
lead to various dental problems. Typical oral parafunctions include onychophagia (nail
biting), cheek biting, lip biting, tongue thrusting, tongue chewing, and mouth breathing.
Previously, the parafunction groups also included bruxism, which is now considered a
behavioral activity. With a prevalence of up to 90% in the general population, bruxism and
clenching are the most common oral activities [62]. Two studies [21,22] have demonstrated
a statistically significant association between oral parafunctions and TMD. Both studies
employed the Oral Behavior Checklist (OBC), and one of them also used the Oral Health
Impact Profile Questionnaire (OHIP) [22]. The OBC is a questionnaire that patients complete
to evaluate oral and orofacial parafunctional disorders. The OHIP questionnaire is utilized
to assess the effect of oral conditions on an individual’s quality of life, encompassing
physical, psychological, and social well-being [63]. In contrast, the two papers that failed to
confirm the correlation between oral habits and quality of life employed questions from
the RDC/TMD questionnaire and their questionnaires, which relied on YES/NO responses. It
is important to note the relationship between the use of tools specifically designed to assess
parafunctions and their association with TMD. The lack of a statistically significant correlation
between the two may be related to the use of non-specific tools to assess oral habits.

4.5. Somatization
Somatization was found to have a significant statistical relationship in two [22,24]
out of the three papers in which it was studied. This mental disorder involves expressing
emotional distress through physical symptoms. Increased pain sensation is a common
symptom of somatization, as supported by the literature. Wilson et al. [64] demonstrated a
correlation between elevated levels of somatization and TMD pain. Rehm et al. [65] also
reached similar conclusions. The study found that individuals with Temporomandibular
Healthcare 2024, 12, 575 25 of 31

Disorder (TMD) who experience muscle pain and arthralgia/osteoarthritis have higher
pain intensity compared to those with disc displacement and lower pain intensity. This
higher pain intensity is directly associated with secondary depression and nonspecific
symptoms/somatization induced by TMD. According to Canales et al. [66], individuals
with Temporomandibular Disorder (TMD) typically display an emotional profile that is
characterized by low levels of disability, significant impairment related to pain intensity,
and moderate to elevated levels of somatization and depression. Dworkin et al. [67]
emphasized the importance of distinguishing between somatization as a mental disorder
and somatization as a character trait.

4.6. Sleep Quality

Sleep quality was found to be consistently associated with pain in all reviewed pa-
pers [22,26,27]. P.H. Finan et al. [68] hypothesized that sleep is a reliable predictor of pain
and can contribute to the development of chronic pain in joints, which may also be relevant
to the development of TMD. The impact of sleep quality on pain may be associated with
the pathways of serotonergic and dopaminergic neurotransmission. Furthermore, sleep
deprivation can cause elevated cortisol and stress levels, leading to significant daytime
sympathetic nervous system stimulation and increased muscle activity. A separate study
conducted on a group of adolescents revealed a high incidence of sleep deprivation among
college students, which increased the risk of TMD symptoms [69]. Although sleep showed a
statistical relationship in each of the papers in which it was studied, it should be noted that
only three such papers were included in this review. Despite the rather large group in which
this factor was examined (n = 2713), the potential risk of bias must be taken into account.

4.7. Anatomy and Factors Affecting Anatomy (Orthodontic Treatment)

This group included occlusal relations, skeletal relations, and changes in occlusal con-
tacts associated with orthodontic treatment. The relationship between TMD and occlusion
is still a matter of debate. Occlusion, in the context of dentistry, denotes the dynamic rela-
tionship between the maxillary and mandibular teeth during functional and parafunctional
activities, encompassing biting, chewing, and other masticatory functions. Robert J.A.M.
de Kanter et al. [70] discuss occlusion in four aspects. Firstly, it refers to the anatomic
or ‘orthodontic’ jaw relation, including the Angle classification. Secondly, it refers to the
static contact between the upper and lower teeth. Thirdly, it involves dynamic contact
during functional activities, such as cuspid guidance versus group function, articulation,
and identification of occlusal interferences. Finally, occlusion also applies to prosthetic
classifications, which distinguish between complete and incomplete dentition, as well as
fixed or removable prosthetics.
Three papers were found that addressed this issue [22,30,31], each examining a dif-
ferent aspect of the anatomical features. The most relevant paper seems to be that of
the Finnish authors [31], due to the large study population, confirming the relationship
between the occurrence of TMD and such occlusal disorders as sagittal molar class II
cusp-to-cusp relationships, asymmetries, midline shift, and missing teeth. Also, work
investigating skeletal divergence and condylar asymmetry [30], confirms the statistical
relationship between hyperdivergent skeletal pattern and condylar asymmetry as a risk
of TMD. The results of this study provide a field for discussion. Manfredini et al. state
that there is insufficient basis to hypothesize a significant role for dental occlusion in the
pathophysiology of Temporomandibular Disorders (TMDs) [71].
In the past, it was commonly believed that occlusal disorders affecting the position
of the condylar process in the TMJ were the main cause of TMD complaints [72]. This
led to TMD therapy being primarily based on occlusal adjustment. However, there is no
evidence to support the effectiveness of this therapy compared to a placebo in treating
TMD [73]. On the other hand, there is evidence to suggest a correlation between vertical
growth patterns and TMD, as confirmed by several studies [71,74]. The third study [24]
investigated the impact of orthodontic treatment on TMD. The authors observed that
Healthcare 2024, 12, 575 26 of 31

during active tooth shifting, TMD worsened in 13.3% of patients, primarily in the form of
myofascial pain. However, this was significantly associated with factors such as gender,
anxiety, or depression. Furthermore, there was a higher frequency of these complaints
among Angle’s class II patients, although the correlation was not statistically significant.
The study results confirm the dominant role of psychosocial factors over occlusal factors in
TMD. However, there is a lack of research on the relationship between malocclusion and
TMD based on DC/TMD diagnosis. This paper only pertains to a group of orthodontic
patients, and there is no comparison to the development of TMD symptoms in a control
group with similar parameters related to gender, age, and orthodontic needs, and without
orthodontic therapy.

4.8. Stress
Stress is believed to be a contributing factor in the development of TMD. This may be
due to increased cortisol levels [75], which can lead to heightened muscle activity. Such
activity can negatively impact proper muscle function, resulting in altered joint mechanics.
Furthermore, increased muscle activity may contribute to the development of arthritis,
which can cause joint damage [56]. Abnormalities in the muscles and joints in the temporal
region can disrupt homeostasis in the trigeminal nerve. These abnormalities affect the
balance of neurotransmitter secretion, such as serotonin and catecholamines [76]. In this
literature review, there was only one paper referring to a study of the correlation between
stress and TMD, and it showed the absence of such a correlation [25]. According to
other sources, however, such a correlation does occur. K. Staniszewski et al. [77], found
significantly higher levels of stress in the TMD group than in the control group, and Gui
Maísa Soares et al. [78] advocate that chronic TMD is associated with psychological distress
and pain amplification characteristics. In recent years, one factor that may have influenced
stress levels in the population, and thus TMD, has been the coronavirus pandemic. Also,
such a thesis finds support in the literature: Sabina Saccomanno et al. [79] conducted an
online survey of patients during the last phase of the lockdown in Italy (April–May 2020);
in patients who reported experiencing orofacial pain, 51.4% indicated a deterioration of
symptoms in the preceding month. Notably, a substantial 94.7% of these individuals (35
subjects) attributed the escalation of pain to the stressful conditions during the lockdown
and its associated consequences. However, the relationship between TMD and stress as a
factor is still debatable. R. Ohrbach et al. [80], proposed a hypothesis in which stress and
awake oral parafunction admittedly influence the occurrence of myofascial pain, but must
still coexist with other factors.

4.9. Social Factors

This literature review examines the biopsychosocial factors contributing to TMD.
The social factors analyzed include education, marital status, employment status, living
conditions, and socioeconomic status. The statistical analysis revealed that individuals
who were unemployed or retired exhibited a higher prevalence of pain-related symptoms
compared to those who were currently employed [28]. The study found no correlation
between other factors. However, the authors themselves suggest that this may be due
to the homogeneity of the study group, where the standard of living is at a similar level.
Gary D. Slade [47] conducted a study on the indicators and manifestations of initial onset
temporomandibular disorder and the sociodemographic factors that influence its onset.
The study found that the incidence of Temporomandibular Disorder (TMD) was associated
with a subjective measure of material satisfaction, but not with objective indicators of
socioeconomic status such as education and income. It is worth emphasizing that the
assessment of social factors is difficult, due to the differences in the study groups resulting
from the standard of living in each country and the level of public awareness that this
entails, as well as the lack of uniform tools that would assess the factors in question as
objectively as possible.
Healthcare 2024, 12, 575 27 of 31

5. Limitations
The present study has limitations. One of these limitations is the lack of a meta-
analysis performed on the results obtained. This is due to the heterogeneity and the
design of the papers that were studied. The selected papers investigated the correlation
or lack of correlation between TMD and a given etiologic factor. Despite consulting with
master statisticians, it was not possible to perform a meta-analysis. In the future, it may be
worthwhile to consider the feasibility of conducting studies that would enable a proper
meta-analysis. Additionally, the number of papers that examined individual factors was
relatively small, with some factors being studied by only one paper. This limitation is
due to the inclusion and exclusion criteria of this review, which required a minimum of
n = 100 study subjects. To improve the search for factors that may influence TMD, it is
recommended to expand the scope of the search by including more databases.
One of the main limitations of the study, partially self-imposed, is the inclusion criteria
of at least 100 participants. The authors aimed to select papers examining large groups of
people to reduce the risk of statistical error, as the paper is not based on a statistical study.
However, this approach resulted in the rejection of many papers that could potentially
describe real TMD factors. To further investigate this topic, it may be beneficial to consider
reducing the size of the study groups and conducting statistical analyses on the literature
review that was performed.
One of the potential limitations is that the search was conducted in a relatively small
number of databases, and using primarily university library resources. In the future, it may
be beneficial to conduct searches in a wider range of databases. To ensure comprehensive
research, it may be beneficial to explore a wider range of databases in the future.
Another limitation due to the inclusion and exclusion criteria of this work is language.
Only papers published in English were included in this review, which could potentially
exclude relevant studies conducted in other languages. Future studies would also need to
review papers published in other languages. The choice of the DC/TMD and RDC/TMD
surveys should also be considered as a potential risk of bias of this work, due to the
focus of these questionnaires on psycho-sociological disorders. The review’s findings are
primarily limited to Europe, Brazil, and China, which may impact the outcome due to
ethnic differences between populations. It is possible that this limitation was caused by the
inclusion of papers in English only.

6. Conclusions
The study group size and the number of papers confirming the statistical significance
of a given factor suggest that the most significant factors influencing the development
of TMD are female gender, poor sleep quality, depression, occlusion, oral parafunction,
anxiety, somatization, self-reported health condition, fibromyalgia, migraine/headache,
gastrointestinal disease, thyroid disease, osteoarthritis, rheumatoid disease, and employ-
ment status.
Given the findings that demonstrate the influence of psychological factors on TMD, it is
essential to comprehend how psychological dysfunctions can be identified more effectively
in patients at risk of TMD development. Efficient early intervention programs necessitate
development, and a comprehensive management approach involving the collaboration of
various professionals should be implemented.
The DC/TMD and RDC/TMD questionnaires, as diagnostic tools, not only allow the
diagnosis of the disease but also allow the analysis of the factors involved. Therefore, this
questionnaire can be a useful tool not only for researchers but also for clinicians in their
daily practice.

Author Contributions: Conceptualization, J.W., J.M. and J.G.-K.; methodology, J.M. and J.W.; val-
idation, J.M. and J.W.; formal analysis, J.W., J.M. and J.G.-K.; investigation, J.W., J.M. and J.G.-K.;
resources, J.W., J.M. and J.G.-K.; data curation, J.W. and J.M.; writing—original draft preparation, J.W.;
writing—review and editing, J.M. and J.W.; visualization, J.W.; supervision, J.M. and J.W.; project
Healthcare 2024, 12, 575 28 of 31

administration, J.W.; funding acquisition, J.M. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data supporting the reported results can be obtained from the first author.
Conflicts of Interest: Author Joanna Krasny-Gadomska was employed by the company Ordo-Dent.
Gabinet Stomatologiczny. Author Joanna Mrowiec was employed by the company SCS Astermed-
Centrum Ortodontyczno-Implantologiczne. The remaining authors declare that the research was
conducted in the absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.

References
1. Valesan, L.F.; Da-Cas, C.D.; Réus, J.C.; Denardin, A.C.S.; Garanhani, R.R.; Bonotto, D.; Januzzi, E.; de Souza, B.D.M. Prevalence of
Temporomandibular Joint Disorders: A Systematic Review and Meta-Analysis. Clin. Oral Investig. 2021, 25, 441–453. [CrossRef]
[PubMed]
2. Lee, Y.-H.; Lee, K.M.; Auh, Q.-S. MRI-Based Assessment of Masticatory Muscle Changes in TMD Patients after Whiplash Injury.
J. Clin. Med. 2021, 10, 1404. [CrossRef] [PubMed]
3. Maixner, W.; Fillingim, R.; Kincaid, S.; Sigurdsson, A.; Harris, M.B. Relationship between Pain Sensitivity and Resting Arterial
Blood Pressure in Patients with Painful Temporomandibular Disorders. Psychosom. Med. 1997, 59, 503–511. [CrossRef] [PubMed]
4. Martynowicz, H.; Dymczyk, P.; Dominiak, M.; Kazubowska, K.; Skomro, R.; Poreba, R.; Gac, P.; Wojakowska, A.; Mazur, G.;
Wieckiewicz, M. Evaluation of Intensity of Sleep Bruxism in Arterial Hypertension. J. Clin. Med. 2018, 7, 327. [CrossRef] [PubMed]
5. Kim, J.R.; Jo, J.H.; Chung, J.W.; Park, J.W. Antinuclear Antibody and Rheumatoid Factor Positivity in Temporomandibular
Disorders. Head Face Med. 2018, 14, 26. [CrossRef] [PubMed]
6. Kotaki, S.; Yoshida, H.; Noma, T.; Tsuji, K.; Akiyama, H.; Yotsui, Y.; Iseki, T.; Shimizutani, K. SAPHO Syndrome of the
Temporomandibular Joint Associated with Trismus: A Case Report and Review of the Literature. Oral Radiol. 2020, 36, 197–202.
[CrossRef]
7. Grozdinska, A.; Hofmann, E.; Schmid, M.; Hirschfelder, U. Prevalence of Temporomandibular Disorders in Patients with
Hashimoto Thyroiditis. J. Orofac. Orthop. Fortschritte Kieferorthopädie 2018, 79, 277–288. [CrossRef] [PubMed]
8. Bech, K.; Fogh, F.M.; Lauridsen, E.F.; Sonnesen, L. Temporomandibular Disorders, Bite Force and Osseous Changes of the
Temporomandibular Joints in Patients with Hypermobile Ehlers-Danlos Syndrome Compared to a Healthy Control Group. J.
Oral Rehabil. 2022, 49, 872–883. [CrossRef]
9. Yenel, S.; Çankal, D.A.; Kayali, S.K.; Akarslan, Z.; Çulha, V.; Kaya, Z. Temporomandibular Disorders in Patients with Inherited
Coagulation Disorders: A Clinical Study. J. Stomatol. Oral Maxillofac. Surg. 2021, 123, 473–477. [CrossRef]
10. Wieckiewicz, M.; Jenca, A.; Seweryn, P.; Orzeszek, S.; Petrasova, A.; Grychowska, N.; Winocur-Arias, O.; Emodi-Perlman, A.;
Kujawa, K. Determination of Pain Intensity, Pain-Related Disability, Anxiety, Depression, and Perceived Stress in Polish Adults
with Temporomandibular Disorders: A Prospective Cohort Study. Front. Integr. Neurosci. 2022, 16, 1026781. [CrossRef]
11. Seweryn, P.; Orzeszek, S.; Waliszewska-Prosół, M.; Jenča, A.; Osiewicz, M.; Paradowska-Stolarz, A.; Winocur-Arias, O.; Zi˛etek,
M.; Bombała, W.; Wi˛eckiewicz, M. Relationship between Pain Severity, Satisfaction with Life and the Quality of Sleep in Polish
Adults with Temporomandibular Disorders. Dent. Med. Probl. 2023, 60, 609–617. [CrossRef] [PubMed]
12. Zwiri, A.; Al-Hatamleh, M.A.I.; Ahmad, W.M.A.W.; Ahmed Asif, J.; Khoo, S.P.; Husein, A.; Ab-Ghani, Z.; Kassim, N.K. Biomarkers
for Temporomandibular Disorders: Current Status and Future Directions. Diagnostics 2020, 10, 303. [CrossRef]
13. Slade, G.D.; Ohrbach, R.; Greenspan, J.D.; Fillingim, R.B.; Bair, E.; Sanders, A.E.; Dubner, R.; Diatchenko, L.; Meloto, C.B.; Smith,
S.; et al. Painful Temporomandibular Disorder. J. Dent. Res. 2016, 95, 1084–1092. [CrossRef] [PubMed]
14. Fillingim, R.B.; Slade, G.D.; Greenspan, J.D.; Dubner, R.; Maixner, W.; Bair, E.; Ohrbach, R. Long-Term Changes in Biopsychosocial
Characteristics Related to Temporomandibular Disorder. Pain 2018, 159, 2403–2413. [CrossRef] [PubMed]
15. Prevalence of TMJD and Its Signs and Symptoms. Prevalence of TMJD and Its Signs and Symptoms|National Institute of Dental
and Craniofacial Research. 1 July 2018. Available online: https://www.nidcr.nih.gov/research/data-statistics/facial-pain/
prevalence (accessed on 21 November 2022).
16. Xu, G.-Z.; Jia, J.; Jin, L.; Li, J.-H.; Wang, Z.-Y.; Cao, D.-Y. Low-Level Laser Therapy for Temporomandibular Disorders: A
Systematic Review with Meta-Analysis. Pain Res. Manag. 2018, 2018, 4230583. [CrossRef]
17. Schiffman, E.; Ohrbach, R.; Truelove, E.; Look, J.; Anderson, G.; Goulet, J.-P.; List, T.; Svensson, P.; Gonzalez, Y.; Lobbezoo, F.; et al.
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of
the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group. J. Oral Facial Pain Headache 2014,
28, 6–27. [CrossRef] [PubMed]
Healthcare 2024, 12, 575 29 of 31

18. Minervini, G.; Franco, R.; Marrapodi, M.M.; Fiorillo, L.; Cervino, G.; Cicciù, M. Prevalence of Temporomandibular Disorders in
Children and Adolescents Evaluated with Diagnostic Criteria for Temporomandibular Disorders: A Systematic Review with
Meta-Analysis. J. Oral Rehabil. 2023, 50, 522–530. [CrossRef]
19. Wieckiewicz, M.; Grychowska, N.; Nahajowski, M.; Hnitecka, S.; Kempiak, K.; Charemska, K.; Balicz, A.; Chirkowska, A.; Zietek,
M.; Winocur, E. Prevalence and Overlaps of Headaches and Pain-Related Temporomandibular Disorders among the Polish Urban
Population. J. Oral Facial Pain Headache 2020, 34, 31–39. [CrossRef]
20. Moola, S.; Munn, Z.; Tufanaru, C.; Aromataris, E.; Sears, K.; Sfetcu, R.; Currie, M.; Lisy, K.; Qureshi, R.; Mattis, P.; et al. Chapter 7:
Systematic reviews of etiology and risk. In JBI Manual for Evidence Synthesis; Aromataris, E., Munn, Z., Eds.; JBI: Miami, FL, USA, 2020.
[CrossRef]
21. Barbosa, C.; Manso, M.C.; Reis, T.; Soares, T.; Gavinha, S.; Ohrbach, R. Are Oral Overuse Behaviours Associated with Painful
Temporomandibular Disorders? A Cross-Sectional Study in Portuguese University Students. J. Oral Rehabil. 2021, 48, 1099–1108.
[CrossRef]
22. Ostrc, T.; Frankovič, S.; Pirtošek, Z.; Rener-Sitar, K. Headache because of Problems with Teeth, Mouth, Jaws, or Dentures in
Chronic Temporomandibular Disorder Patients: A Case–Control Study. Int. J. Environ. Res. Public Health 2022, 19, 3052. [CrossRef]
23. Simoen, L.; Van den Berghe, L.; Jacquet, W.; Marks, L. Depression and Anxiety Levels in Patients with Temporomandibular
Disorders: Comparison with the General Population. Clin. Oral Investig. 2020, 24, 3939–3945. [CrossRef]
24. Ugolini, A.; Garbarino, F.; Di Vece, L.; Silvestrini-Biavati, F.; Lanteri, V. Determining Risk Factors for the Development of
Temporomandibular Disorders during Orthodontic Treatment. Appl. Sci. 2020, 10, 8216. [CrossRef]
25. Osiewicz, M.; Lobbezoo, F.; Ciapała, B.; Pytko-Polończyk, J.; Manfredini, D. Pain Predictors in a Population of Temporomandibular
Disorders Patients. J. Clin. Med. 2020, 9, 452. [CrossRef]
26. Yap, A.U.J.; Cao, Y.; Zhang, M.-J.; Lei, J.; Fu, K.-Y. Temporomandibular Disorder Severity and Diagnostic Groups: Their
Associations with Sleep Quality and Impairments. Sleep Med. 2021, 80, 218–225. [CrossRef]
27. Rehm, D.; Progiante, P.; Pattussi, M.; Pellizzer, E.; Grossi, P.; Grossi, M. Sleep Disorders in Patients with Temporomandibular
Disorders (TMD) in an Adult Population–Based Cross-Sectional Survey in Southern Brazil. Int. J. Prosthodont. 2020, 33, 9–13.
[CrossRef] [PubMed]
28. Jussila, P.; Knuutila, J.; Salmela, S.; Näpänkangas, R.; Päkkilä, J.; Pirttiniemi, P.; Raustia, A. Association of Risk Factors with
Temporomandibular Disorders in the Northern Finland Birth Cohort 1966. Acta Odontol. Scand. 2018, 76, 525–529. [CrossRef]
[PubMed]
29. Dalewski, B.; Białkowska, K.; Pałka, Ł.; Jakubowska, A.; Kiczmer, P.; Sobolewska, E. COL5A1 RS12722 Is Associated with
Temporomandibular Joint Anterior Disc Displacement without Reduction in Polish Caucasians. Cells 2021, 10, 2423. [CrossRef]
[PubMed]
30. Sfondrini, M.F.; Bolognesi, L.; Bosco, M.; Gandini, P.; Scribante, A. Skeletal Divergence and Condylar Asymmetry in Patients with
Temporomandibular Disorders (TMD): A Retrospective Study. BioMed Res. Int. 2021, 2021, 1–6. [CrossRef] [PubMed]
31. Tervahauta, E.; Närhi, L.; Pirttiniemi, P.; Sipilä, K.; Näpänkangas, R.; Tolvanen, M.; Vuollo, V.; Silvola, A.-S. Prevalence of Sagittal
Molar and Canine Relationships, Asymmetries and Midline Shift in Relation to Temporomandibular Disorders (TMD) in a
Finnish Adult Population. Acta Odontol. Scand. 2022, 80, 470–480. [CrossRef] [PubMed]
32. Markiewicz, M.R.; Ohrbach, R.; McCall, W.D. Oral Behaviors Checklist: Reliability of Performance in Targeted Waking-State
Behaviors. J. Orofac. Pain 2006, 20, 306–316. [PubMed]
33. Kroenke, K.; Spitzer, R.L.; Williams, J.B.W. The PHQ-9: Validity of a Brief Depression Severity Measure. J. Gen. Intern. Med. 2001,
16, 606–613. [CrossRef]
34. Löwe, B.; Decker, O.; Müller, S.; Brähler, E.; Schellberg, D.; Herzog, W.; Herzberg, P.Y. Validation and Standardization of the
Generalized Anxiety Disorder Screener (GAD-7) in the General Population. Med. Care 2008, 46, 266–274. [CrossRef]
35. Spitzer, R.L.; Williams, J.B.; Gibbon, M.; First, M.B. The Structured Clinical Interview for DSM-III-R (SCID). I: History, Rationale,
and Description. Arch. Gen. Psychiatry 1992, 49, 624–629. [CrossRef]
36. Fischman, S.L. Current Status of Indices of Plaque. J. Clin. Periodontol. 1986, 13, 371–374. [CrossRef]
37. Almoznino, G.; Zini, A.; Zakuto, A.; Zlutzky, H.; Bekker, S.; Shay, B.; Haviv, Y.; Sharav, Y.; Benoliel, R. Muscle Tenderness Score in
Temporomandibular Disorders Patients: A Case-Control Study. J. Oral Rehabil. 2018, 46, 209–218. [CrossRef] [PubMed]
38. Mongini, F.; Ciccone, G.; Ceccarelli, M.; Baldi, I.; Ferrero, L. Muscle Tenderness in Different Types of Facial Pain and Its Relation
to Anxiety and Depression: A Cross-Sectional Study on 649 Patients. Pain 2007, 131, 106–111. [CrossRef] [PubMed]
39. John, M.; Omara, M.; Su, N.; List, T.; Sekulic, S.; Häggman-Henrikson, B.; Visscher, C.; Bekes, K.; Reissmann, D.; Baba, K.;
et al. Recommendations for Use and Scoring of Oral Health Impact Profile Versions. J. Evid.-Based Dent. Pract. 2022, 22, 101619.
[CrossRef] [PubMed]
40. Kocalevent, R.-D.; Hinz, A.; Brähler, E. Standardization of a Screening Instrument (PHQ-15) for Somatization Syndromes in the
General Population. BMC Psychiatry 2013, 13, 91. [CrossRef] [PubMed]
41. Buysse, D.J.; Reynolds, C.F.; Monk, T.H.; Berman, S.R.; Kupfer, D.J. The Pittsburgh Sleep Quality Index: A New Instrument for
Psychiatric Practice and Research. Psychiatry Res. 1989, 28, 193–213. [CrossRef] [PubMed]
42. Delgado, D.A.; Lambert, B.S.; Boutris, N.; McCulloch, P.C.; Robbins, A.B.; Moreno, M.R.; Harris, J.D. Validation of Digital Visual
Analog Scale Pain Scoring with a Traditional Paper-Based Visual Analog Scale in Adults. JAAOS Glob. Res. Rev. 2018, 2, e088.
[CrossRef]
Healthcare 2024, 12, 575 30 of 31

43. Von Korff, M.; DeBar, L.L.; Krebs, E.E.; Kerns, R.D.; Deyo, R.A.; Keefe, F.J. Graded Chronic Pain Scale Revised. Pain 2019, 161,
651–661. [CrossRef]
44. Derogatis, L.R.; Savitz, K.L. The SCL-90-R, Brief Symptom Inventory, and Matching Clinical Rating Scales. In The Use of
Psychological Testing for Treatment Planning and Outcomes Assessment; Maruish, M.E., Ed.; Lawrence Erlbaum Associates Publishers:
Mahwah, NJ, USA, 1999; pp. 679–724.
45. Yap, A.U.; Zhang, M.J.; Lei, J.; Fu, K.-Y. Accuracy of the Fonseca Anamnestic Index for Identifying Pain-Related And/or
Intra-Articular Temporomandibular Disorders. Cranio J. Craniomandib. Pract. 2021, 1–8. [CrossRef]
46. Lee, Y.-H.; Auh, Q.-S.; An, J.-S.; Kim, T. Poorer Sleep Quality in Patients with Chronic Temporomandibular Disorders Compared
to Healthy Controls. BMC Musculoskelet. Disord. 2022, 23, 246. [CrossRef]
47. Slade, G.D.; Bair, E.; Greenspan, J.D.; Dubner, R.; Fillingim, R.B.; Diatchenko, L.; Maixner, W.; Knott, C.; Ohrbach, R. Signs and
Symptoms of First-Onset TMD and Sociodemographic Predictors of Its Development: The OPPERA Prospective Cohort Study. J.
Pain 2013, 14, T20–T32.e3. [CrossRef]
48. Gatchel, R.J.; Peng, Y.B.; Peters, M.L.; Fuchs, P.N.; Turk, D.C. The Biopsychosocial Approach to Chronic Pain: Scientific Advances
and Future Directions. Psychol. Bull. 2007, 133, 581–624. [CrossRef] [PubMed]
49. Peck, C.C.; Goulet, J.-P.; Lobbezoo, F.; Schiffman, E.L.; Alstergren, P.; Anderson, G.C.; de Leeuw, R.; Jensen, R.; Michelotti, A.;
Ohrbach, R.; et al. Expanding the Taxonomy of the Diagnostic Criteria for Temporomandibular Disorders. J. Oral Rehabil. 2014, 41,
2–23. [CrossRef]
50. Dworkin, S.F.; Sherman, J.; Mancl, L.; Ohrbach, R.; LeResche, L.; Truelove, E. Reliability, Validity, and Clinical Utility of the
Research Diagnostic Criteria for Temporomandibular Disorders Axis II Scales: Depression, Non-Specific Physical Symptoms, and
Graded Chronic Pain. J. Orofac. Pain 2002, 16, 207–220.
51. LeResche, L. Epidemiology of Temporomandibular Disorders: Implications for the Investigation of Etiologic Factors. Crit. Rev.
Oral Biol. Med. 1997, 8, 291–305. [CrossRef] [PubMed]
52. Bertakis, K.D.; Azari, R.; Helms, L.J.; Callahan, E.J.; Robbins, J.A. Gender Differences in the Utilization of Health Care Services. J.
Fam. Pract. 2000, 49, 147–152. [PubMed]
53. Robinson, J.L.; Johnson, P.M.; Kister, K.; Yin, M.T.; Chen, J.; Wadhwa, S. Estrogen Signaling Impacts Temporomandibular Joint
and Periodontal Disease Pathology. Odontology 2019, 108, 153–165. [CrossRef]
54. LeResche, L.; Saunders, K.; Von Korff, M.R.; Barlow, W.; Dworkin, S.F. Use of Exogenous Hormones and Risk of Temporomandibu-
lar Disorder Pain. Pain 1997, 69, 153–160. [CrossRef] [PubMed]
55. Aggarwal, V.R.; Macfarlane, G.J.; Farragher, T.M.; McBeth, J. Risk Factors for Onset of Chronic Oro-Facial Pain—Results of the
North Cheshire Oro-Facial Pain Prospective Population Study. Pain 2010, 149, 354–359. [CrossRef] [PubMed]
56. Kindler, S.; Samietz, S.; Houshmand, M.; Grabe, H.J.; Bernhardt, O.; Biffar, R.; Kocher, T.; Meyer, G.; Völzke, H.; Metelmann, H.-R.;
et al. Depressive and Anxiety Symptoms as Risk Factors for Temporomandibular Joint Pain: A Prospective Cohort Study in the
General Population. J. Pain 2012, 13, 1188–1197. [CrossRef] [PubMed]
57. Chisnoiu, A.M.; Picos, A.M.; Popa, S.; Chisnoiu, P.D.; Lascu, L.; Picos, A.; Chisnoiu, R. Factors Involved in the Etiology of
Temporomandibular Disorders—A Literature Review. Med. Pharm. Rep. 2015, 88, 473–478. [CrossRef] [PubMed]
58. Stavrakaki, C.; Vargo, B. The Relationship of Anxiety and Depression: A Review of the Literature. Br. J. Psychiatry 1986, 149, 7–16.
[CrossRef]
59. Rollman, G.B.; Gillespie, J.M. The Role of Psychosocial Factors in Temporomandibular Disorders. Curr. Rev. Pain 2000, 4, 71–81.
[CrossRef] [PubMed]
60. Gallagher, R.M.; Marbach, J.J.; Raphael, K.G.; Dohrenwend, B.P.; Cloitre, M. Is Major Depression Comorbid with Temporo-
mandibular Pain and Dysfunction Syndrome? A Pilot Study. Clin. J. Pain 1991, 7, 219–225. [CrossRef] [PubMed]
61. LeResche, L.; Mancl, L.A.; Drangsholt, M.T.; Huang, G.; Von Korff, M. Predictors of Onset of Facial Pain and Temporomandibular
Disorders in Early Adolescence. Pain 2007, 129, 269–278. [CrossRef]
62. Mehta, N.R.; Scrivani, S.J.; Spierings, E.L.H. Dental and Facial Pain. In Practical Management of Pain; Elsevier: Amsterdam, The
Netherlands, 2014; pp. 424–440.e3. [CrossRef]
63. Eraslan, R.; Ozturk, T. Comparison of the Relationship between Temporomandibular Disorder and Oral Habits or Quality of Life
in Dentistry Students in Different Years of Education. Chin. J. Dent. Res. 2022, 25, 223–232. [CrossRef]
64. Wilson, L.; Dworkin, S.F.; Whitney, C.; LeResche, L. Somatization and Pain Dispersion in Chronic Temporomandibular Disorder
Pain. Pain 1994, 57, 55–61. [CrossRef]
65. Rehm, D.; Progiante, P.; Pattussi, M.; Pellizzer, E.; Grossi, P.; Grossi, M. Depression and Somatization in Patients with Temporo-
mandibular Disorders in a Population-Based Cross-Sectional Study in Southern Brazil. Int. J. Prosthodont. 2019, 32, 248–250.
[CrossRef]
66. Canales, G.D.L.T.; Guarda-Nardini, L.; Rizzatti-Barbosa, C.M.; Conti, P.C.R.; Manfredini, D. Distribution of Depression, Somatiza-
tion and Pain-Related Impairment in Patients with Chronic Temporomandibular Disorders. J. Appl. Oral Sci. 2019, 27, e20180210.
[CrossRef]
67. Dworkin, S.F. Somatization, Distress and Chronic Pain. Qual. Life Res. 1994, 3, S77–S83. [CrossRef] [PubMed]
68. Finan, P.H.; Goodin, B.R.; Smith, M.T. The Association of Sleep and Pain: An Update and a Path Forward. J. Pain 2013, 14,
1539–1552. [CrossRef] [PubMed]
Healthcare 2024, 12, 575 31 of 31

69. Lei, J.; Fu, J.; Yap, A.U.J.; Fu, K.-Y. Temporomandibular Disorders Symptoms in Asian Adolescents and Their Association with
Sleep Quality and Psychological Distress. CRANIO® 2016, 34, 242–249. [CrossRef]
70. de Kanter, R.J.A.M.; Battistuzzi, P.G.F.C.M.; Truin, G.-J. Temporomandibular Disorders: “Occlusion” Matters! Pain Res. Manag.
2018, 2018, 8746858. [CrossRef] [PubMed]
71. Manfredini, D.; Lombardo, L.; Siciliani, G. Temporomandibular Disorders and Dental Occlusion. A Systematic Review of
Association Studies: End of an Era? J. Oral Rehabil. 2017, 44, 908–923. [CrossRef] [PubMed]
72. Boever, J.A.; Adriaens, P.A. Occlusal Relationship in Patients with Pain-Dysfunction Symptoms in the Temporomandibular Joints.
J. Oral Rehabil. 1983, 10, 1–7. [CrossRef]
73. Manfredini, D. Occlusal Equilibration for the Management of Temporomandibular Disorders. Oral Maxillofac. Surg. Clin. N. Am.
2018, 30, 257–264. [CrossRef]
74. Colonna, A.; Manfredini, D.; Lombardo, L.; Muscatello, L.; Marchese-Ragona, R.; Arveda, N.; Siciliani, G. Comparative Analysis
of Jaw Morphology and Temporomandibular Disorders: A Three-Dimension Imaging Study. CRANIO® 2018, 38, 158–167.
[CrossRef]
75. Tosato, J.d.P.; Caria, P.H.F.; Gomes, C.A.F.d.P.; Berzin, F.; Politti, F.; Gonzalez, T.d.O.; Biasotto-Gonzalez, D.A. Correlation of Stress
and Muscle Activity of Patients with Different Degrees of Temporomandibular Disorder. J. Phys. Ther. Sci. 2015, 27, 1227–1231.
[CrossRef]
76. Pihut, M.; Szuta, M.; Ferendiuk, E.; Zeńczak-Wi˛eckiewicz, D. Differential Diagnostics of Pain in the Course of Trigeminal
Neuralgia and Temporomandibular Joint Dysfunction. BioMed Res. Int. 2014, 2014, 563786. [CrossRef]
77. Staniszewski, K.; Lygre, H.; Bifulco, E.; Kvinnsland, S.R.; Celine, L.; Helgeland, E.; Berge, T.I.; Rosén, A. Temporomandibular
Disorders Related to Stress and HPA-Axis Regulation. Pain Res. Manag. 2018, 2018, 7020751. [CrossRef]
78. Gui, M.S.; Rizzatti-Barbosa, C.M. Chronicity Factors of Temporomandibular Disorders: A Critical Review of the Literature. Braz.
Oral Res. 2015, 29, 1–6. [CrossRef] [PubMed]
79. Saccomanno, S.; Bernabei, M.; Scoppa, F.; Pirino, A.; Mastrapasqua, R.F.; Visco, M.A. Coronavirus Lockdown as a Major Life
Stressor: Does It Affect TMD Symptoms? Int. J. Environ. Res. Public Health 2020, 17, 8907. [CrossRef] [PubMed]
80. Ohrbach, R.; Michelotti, A. The Role of Stress in the Etiology of Oral Parafunction and Myofascial Pain. Oral Maxillofac. Surg. Clin.
N. Am. 2018, 30, 369–379. [CrossRef] [PubMed]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.