F1000Research 2022, 11:271 Last updated: 13 NOV 2023

RESEARCH ARTICLE

Temporomandibular joints disorders (TMDs) prevalence

and their relation to anxiety in dental students [version 2;
peer review: 2 approved]
Lujain Homeida, Emtenan Felemban, Wed Kassar, Mazen Ameen,
Salwa Aldahlawi
Basic and Clinical Oral Sciences,, Umm-Al-Qura University, Makkah, 24382, Saudi Arabia

v2 First published: 03 Mar 2022, 11:271 Open Peer Review

https://doi.org/10.12688/f1000research.76178.1
Latest published: 27 Apr 2022, 11:271
https://doi.org/10.12688/f1000research.76178.2 Approval Status

1 2
Abstract
Background: Temporomandibular joint disorders (TMDs) are very version 2
common disorders affecting the population and causing pain. (revision) view view
Researchers have reported a high prevalence of TMDs among 27 Apr 2022
university students due to increased distress. The aims of this study
were to determine the frequency of TMDs in Umm al-Qura University
version 1
(UQU) dental students using the Diagnostic Criteria for
03 Mar 2022 view
Temporomandibular Disorders (DC/TMD), and to examine the
relationship between anxiety, bruxism, and TMDs among those
students. 1. Arwa Farag , Tufts School of Dental
Methods: The DC/TMD pain screener questionnaire was completed by Medicine, Boston, USA
dental students. Students who reported TMD pain or had at least one
positive TMD symptom were invited to the dental clinic for a full TMJ 2. Mahnaz Fatahzadeh, Rutgers School of
evaluation. History of bruxism was documented and an ultra-brief tool Dental Medicine, Newark, USA
for detecting anxiety and depression (Patient Health Questionnaire-4
PHQ) was completed by all students. Any reports and responses or comments on the
Results: A total of 240 students responded to the TMD pain screener
article can be found at the end of the article.
in which 119 reported at least one TMJ symptom. Only 93 dental
students presented to clinical examination in which 64.5% (n=60) of
them had temporomandibular joint disorders. Disc displacement with
reduction and local myalgia (38.7% & 32.25%, respectively) were the
most frequent diagnosis. A total of 29% (n=27) of students had more
than one diagnosis. Overall, 41 participants (44.09%) reported a
positive response to the anxiety scale and (n=38) 40% of participants
reported parafunctional habits. Both the history of bruxism and
anxiety were significantly related to TMDs (P=0.0002) and also
significantly higher in women of higher academic years (P≤0.01).
Conclusions: This study found a high prevalence of TMDs among
UQU dental students. Disc displacement with reduction was the most
prevalent disorder. Bruxism and anxiety were associated with painful
TMDs.

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Keywords
TMD, DENTAL, STUDENTS, PAIN, STRESS , PARAFUNCTIONAL HABITS

Corresponding author: Lujain Homeida ([email protected])

Author roles: Homeida L: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Resources,
Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Felemban E: Investigation, Methodology,
Visualization, Writing – Original Draft Preparation; Kassar W: Investigation, Methodology, Visualization, Writing – Original Draft
Preparation; Ameen M: Formal Analysis, Investigation, Methodology, Software, Visualization, Writing – Original Draft Preparation;
Aldahlawi S: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original
Draft Preparation, Writing – Review & Editing
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright: © 2022 Homeida L et al. This is an open access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite this article: Homeida L, Felemban E, Kassar W et al. Temporomandibular joints disorders (TMDs) prevalence and their
relation to anxiety in dental students [version 2; peer review: 2 approved] F1000Research 2022, 11:271
https://doi.org/10.12688/f1000research.76178.2
First published: 03 Mar 2022, 11:271 https://doi.org/10.12688/f1000research.76178.1

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REVISED Amendments from Version 1

A new paragraph was added to the discussion comparing TMD prevalence between dental students and general
population. New references were used and added to the end of the references list. We amended the inclusion and
exclusion criteria of the subjects participated in the study. No changes to data or figures were made.
Any further responses from the reviewers can be found at the end of the article

Introduction
Temporomandibular joint disorders (TMDs) are a very common group of musculoskeletal disorders affecting the
temporomandibular joint (TMJ) and the face causing pain. They are considered a significant public health burden in
approximately 5% to 12% of the general population (National Institute of Dental and Craniofacial Research 2018, July).
Painful TMD has a direct impact on the person’s quality of life and daily activity (Schiffman, Ohrbach et al. 2014). The
TMD has a multifactorial pathogenesis in which it involves physiological and/or psychological factors like emotional
distresses. Chronic parafunctional habits can cause repetitive trauma to the masticatory system, which may result in
painful TMD episodes (Schiffman, Ohrbach et al. 2014). Parafunctional habits including but not limited to bruxing and
clenching are known to have a critical role in aggravation and progression of TMD (Chisnoiu, Picos et al. 2015).
Furthermore, psychosocial distress is also considered an important comorbidity contributing to TMD (Schiffman,
Ohrbach et al. 2014). Some individuals, when exposed to stressful situations, tend to activate the stomatognathic system
by clenching or grinding their teeth and increasing masticatory muscle contraction in order to relieve their stress. This
increased masseter activation during stress and decrease in a relaxing situation was highly associated with the presence of
TMD in individuals under more stress (Calixtre, Gruninger et al. 2014).

Many studies have looked into the psychological stress among university students and its impact on student’s academic
achievement and well-being. High prevalence of mental issues between university students was reported (Adlaf, Gliksman
et al. 2001). Stallman et al evaluated mental stress among Australian universities students and found a high prevalence of
mental health problems (19.2 %) and subsyndromal symptoms (67.4%) which were significantly higher than those of the
general population (Stallman 2010). This supports that university student population live under more stress than the
general population. Thus, the prevalence of TMDs is relatively high among university students of different specialties.

Binoleil et al, assessed the prevalence of headaches and painful TMDs and examined the relationship between TMDs,
headaches, and depression rates among dental and medical students. They reported higher depression scores in patients
with painful TMD compared to patients without TMD (Benoliel, Sela et al. 2011). Furthermore, the relationship between
stress level and painful TMD in students of health science was supported in few more studies locally (Alkhudhairy, Al
Ramel et al. 2018) and internationally where stress played an important role in TMD progression (Monteiro, Zuim et al.
2011, Wieckiewicz, Grychowska et al. 2014).

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was first proposed in 1992 and has
been used widely as diagnostic protocol for TMD research (Dworkin and LeResche 1992). However, more research was
done over the years to improve its validity and clinical utility. In 2014, an evidence-based new Diagnostic Criteria for
Temporomandibular Disorders (DC/TMD) was published and was considered a valid and reliable screening tool for use
in clinical and research settings and included important modifications to the original RDC/TMD (Schiffman, Ohrbach
et al. 2014). An acceptable sensitivity and specificity for a definitive diagnosis are considered as sensitivity ≥ 70% and
specificity ≥ 95%. DC/TMD has diagnostic algorithms used to diagnose the most common pain-related TMD and most
common intra-articular disorders (Schiffman, Ohrbach et al. 2014). The Axis I diagnostic algorithm consists of two parts;
a self-report instrument where it is used for pain screening. The second part is used for TMJ clinical examination. The
DC/TMD Axis II protocol included instruments to evaluate pain behavior, psychological status, and psychosocial
functioning (Schiffman, Ohrbach et al. 2014).

To the best of our knowledge, the prevalence of TMDs among Umm al-Qura University (UQU) dental students has not
been evaluated. In this study, we aimed to determine the prevalence of TMDs in UQU dental students using Diagnostic
Criteria for Temporomandibular Disorders (DC/TMD). Also, to examine the relation between anxiety, self-reported
bruxism and TMDs among UQU dental students.

Methods
This cross-sectional study was approved from Umm Al-Qura University (UQU), College of Dentistry Institutional
Review Board (IRB) # (98-18). This study took place at collage of Dental Medicine Umm al Qura University. Data were
collected between July 2019 and December 2019.

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Screening dental students for TMDs

The UQU dental collage program starts at 2nd level and it is involves 5 academic years followed by internship year. All
UQU dental students (year 2 - internship year) were included in this study and were invited by email to fill The Research
Diagnostic Criteria (RDC) three-items pain screener on TMD symptoms (Schiffman, Ohrbach et al. 2014). Non-dental
students from UQU and dental student from other universities were excluded. All participants have given their consent to
participate in the study. Demographic data were collected including age, gender, marital status and year of study.
In addition, history of TMD diagnosis and history of parafunctional habits (bruxism), and the use of chronic medication
was included. The response to each of the three questions was documented.

TMJ clinical examination and diagnosis

The respondents who reported TMD pain or had at least one positive answer to one of the 3-items questionnaire were
invited to have a full TMJ clinical examination in the specialty clinic at UQU teaching hospital. Detailed medical history
was obtained and subjects with underlying rheumatoid conditions, generalized pain symptoms, connective tissue
disorders were excluded from the study. The TMJ clinical examination included detailed assessment of the TMJ position
and structure, range of motion measurements, and palpation of muscle of mastication following DC/TMD protocol. The
clinical examination provided to all students was performed by one oral medicine/TMD specialist. Written informed
consent was obtained from all participants prior to clinical examination.

The DC/TMD diagnostic criteria algorithms were followed to reach a TMD diagnosis. This included pain-related
temporomandibular disorders (local myalgia, myofascial pain, myofascial pain with referral, arthralgia, and headache
attributed to TMD) and intra-articular disorders (disc displacement with reduction, disc displacement with reduction with
intermittent locking, disc displacement without reduction with limited opening, disc displacement without reduction
without limited opening). History of bruxism was obtained and those who had painful TMD were referred to an oral
medicine specialist clinic for further treatment.

Anxiety and depression scale

During the clinical examination, a valid and ultra-brief tool for detecting anxiety and depression (Patient Health
Questionnaire-4 PHQ) was completed by all participants (Kroenke, Spitzer et al. 2009). This four-items questionnaire
(PHQ-4) consisted of two core anxiety and two core depression items. The total score of this scale ranges from 0-12 and
categorized as normal (0 –2), mild (3–5), moderate (6 – 8), and severe (9–12). This instrument is not diagnostic, however,
is indicator for further assessment of possible clinical disorder warranting treatment.

Data analysis
The data analysis was performed using Statistical Package for the Social Sciences version 22 (SPSS Inc., Chicago, IL,
USA, RRID:SCR_019096). Student T-test and chi-square analysis were used to relate the existence of TMD problem to
age, gender, academic year, history of bruxism and anxiety level. Also, to compare the anxiety scores among male and
female groups. Statistical significance was set at P ≤ 0.05.

Results
A total of 304 electronic questionnaires were sent via email to all dental students at Umm al-Qura university who were
between 2nd year to the internship with a total of 6 academic years. A total of 240 questionnaires were completed and
returned with a compliance rate of 78.9% (Homeida 2022). The demographics of respondents from the pain screening
questionnaire can be found in Table 1.

Temporomandibular joint disorder pain screener results

Out of the 240 responders, 49.5% (n=119) reported either TMD pain or other TMD symptoms in the past 30 days. And
20.4% (n=49) reported TMJ pain that comes and goes. The majority of students 30% (n=72) reported jaw habits with 25%
(n=60) had pain on opening, 16% (n=40) reported pain on chewing hard or tough food and 14% (n=35) had pain with jaw
activities such as talking and yawning (Table 2).

Prevalence of TMDs among dental students

All the responders who reported TMD pain or symptoms (n=119) were invited for a TMJ examination. A total of
93 (78%) subjects presented for clinical assessment. The demographics of the subjects received the clinical examination
are presented in Table 1. During TMJ clinical examination, more than half of the subjects 64.5% (n=60) had
temporomandibular disorders (TMDs), while only 35.4% (n=33) students had normal TMJ findings at the time of the
examination.

Disc displacement with reduction was the most frequent diagnosis 38.7%(n=36) followed by local myalgia 32.25%
(n=30) and arthralgia 16.1% (n=15) (Figure 1). Interestingly, 29% (n=27) students had more than one diagnosis and
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Table 1. Demographic data of participants who responded positive to the pain screener and who presented
for the temporomandibular joint (TMJ) clinical examination.

Respondents to pain screener (n=240) Participants in TMJ clinical examination (n=93)

Age 22.38  1.2 year 22.3  1.25 year
Gender
Male 131 (54%) 45 (48.4%)
Female 109 (46%) 48 (51.6%)
Academic Year
2nd year 11 (4.5%) 3 (3.2%)
3rd year 46 (19.1%) 12 (12.9%)
th
4 year 42 (17.5%) 14 (15.1%)
th
5 year 56 (23.3%) 25 (26.9%)
6th year 55 (22.9%) 27 (28%)
Internship year 30 (12.5%) 12 (14%)

Table 2. Results of temporomandibular joint disorder pain screener (n=240).

Frequency
n (%)
In the last 30 days, how long did any pain last in your jaw or temple area on either side?
No pain 189 (78.7)
Pain comes and goes 49 (20.4)
Pain is always present 2 (0.8)
In the last 30 days, have you had pain or stiffness in your jaw on awakening?
Yes 45 (18.7)
No 195 (81.2)
last 30 days, did the following activities change any pain (that is, make it better or it worse) in
your jaw or temple area on either side? Chewing hard or tough food
Yes 40 (16)
No 200 (83)
Opening your mouth or moving your jaw forward or to the side
Yes 60 (25)
No 180 (75)
Jaw habits such as holding teeth together, clenching, grinding, or chewing gum
Yes 72 (30)
No 168 (70)
Other jaw activities such as talking, kissing, or yawning
Yes 35(14)
No 205 (86)

coexistence of disc displacement with reduction and local myalgia was found to be the most frequent combination
in 19.3% (n=18) students (Table 3). Overall, the diagnosis of TMD was significantly higher in the female students
compared to the male students (P≤0.022). Both, pain-related disorders and intra-articular disorders were significantly
higher in females with (P=0.027) and (P=0.024), respectively. Also, disc displacement with reduction showed a
significant increase with the higher academic year (P≤0.01).

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45
Percentage of dental students % 40
35
30
25
20
15
10
5
0
Normal TMJ Disc Local Myalgia Arthralgia Myofascial Headache Disc Myofascial Disc
findings displacement pain aributed to displacement pain with displacement
with TMJ with referral without
reducon reducon reducon
with with limited
intermient opening
Tempromandibular joint disorders locking

Figure 1. Percentage of dental students presenting with DC/TMD Diagnosis. DC/TMD: Diagnostic Criteria for
Temporomandibular Disorders.

Table 3. Gender based distribution of TMDs, Anxiety scale and history of bruxism.

Female N (%) Male N (%) Total N (%)

Total number of participants 45 (48.3) 48 (51.6) 93 (100)
Bruxism 28 (30) 10 (10.7) 38 (40.8)
TMDs
Normal TMJ findings 12 (12.9) 21 (22.5) 33 (35.4)
Disc displacement with reduction 22 (23.6) 14 (15) 38.7 (36)
Local myalgia 16 (17) 14 (15) 32.2 (30)
Myofascial pain 11 (11.8) 1 (1) 12.9 (12)
Arthralgia 5 (5.3) 10 (10.7) 16.1 (15)
Headache attributed to TMD 4 (4) 0 4.3 (4)
Disc displacement with reduction with intermittent locking 3 (3) 0 3 (3)
Myofascial pain with referral 1 (1) 0 1 (1)
Disc displacement without reduction with limited opening 1 (1) 0 1 (1)
PHQ-4
Mild 16 (17) 4 (4) 20 (21.5)
Moderate to severe 20 (21.5) 1 (1) 21 (22.5)
TMD: Temporomandibular disorders. PHQ-4: Patient Health Questionnaire-4.

Anxiety and depression scale and history of parafunctional habits

In total, 41 participants (44.09%) reported a positive response to the anxiety and depression scale. In which, 48.7% (n=20)
had a mild score and 51% (n=21) had moderate to severe anxiety score (Table 3). Of the 41 subjects with a positive
response to PHQ-4, 31 (73%) had been diagnosed with a painful TMDs. Moderate to severe anxiety was significantly
associated with TMDs (P=0.006).

Overall, 40% of the participants (n=38) reported a parafunctional habit. Out of 38 (71%) with a history of bruxism, 27 had
TMDs. Self-reported history of bruxism was significantly associated with TMDs in all students (P≤0.01).

Both the history of bruxism and the level of anxiety were significantly related (P=0.0002) and also significantly higher in
females than males (P≤0.01). Besides, the anxiety level and history of bruxism significantly increased with higher
academic years (P≤0.05). Those high scores of anxieties and bruxism were reversed in the internship year (Figure 2).

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14

12

10
Number of students

0
2nd 3rd 4th 5th 6th Internship year

Mild anxiety Moderate- severe anxiety Bruxism

Figure 2. History of bruxism and anxiety levels significantly increased with higher academic years and
declined in internship year.

Discussion
The present study found that half of UQU dental students reported at least one TMD symptom. Moreover, the clinical
examination found that 64% were diagnosed with at least one TMJ disorder and about 30% (one- third) had multiple
diagnoses. Bruxism and high anxiety levels were related to TMDs in this student population.

Evidence suggests that TMD is a common complain among students. The prevalence of TMD reported by this study is
higher than what has been reported by other studies in Saudi universities which ranged between 25-39% (Alkhudhairy,
Al Ramel et al. 2018, Srivastava, Shrivastava et al. 2021). Studies that addressed general university Saudi students also
reported TMD prevalence of 20 to 50% (Zulqarnain, Khan et al. 1998, Habib, Al Rifaiy et al. 2015, Zwiri and Al-Omiri
2016, Srivastava, Shrivastava et al. 2021). All the above-mentioned studies with the exception of Srivastava et al. relied
on self-administered questioners to identify subjects with TMDs and did not include TMJ clinical examination to confirm
the diagnosis as the present study which may explain the difference in prevalence. When RDC/TMD algorithm was used
to estimate the prevalence of TMD, 30 to 36% of dental students were found to have TMD (Fernandes Azevedo, Camara-
Souza et al. 2018, Lövgren, Österlund et al. 2018). The present study used RDC/TMD pain screener to identify the
subject with possible TMJ symptoms first, then, only those with positive responses to the pain screener were examined
clinically for TMD diagnosis and that may explain the higher prevalence of TMDs.

Disc displacement with reduction was the most prevalent TMD disorder followed by myalgia. This finding concurs with a
systematic review in which disc displacement of TMJ was highly prevalent TMD in the general population with
prevalence ranging from 18 to 35% (Naeije, Te Veldhuis et al. 2013). Also, the finding of the increasing prevalence
of disc displacement with age in this study is in alignment with other studies were disc displacement with reduction
develops during childhood and adolescence and it’s prevalence levels off towards adulthood (Marpaung, van Selms et al.
2019, Sankuratri, Verma et al. 2021). Although myalgia was the reported as the commonest diagnosed condition in some
studies (Srivastava, Shrivastava et al. 2021), it was the second most prevalence condition in this study. On the other hand,
females had a higher prevalence of TMDs compared to males. This findings was in alignment with other studies (Bagis,
Ayaz et al. 2012, Naeije, Te Veldhuis et al. 2013, Wieckiewicz, Grychowska et al. 2014, de Melo Junior, Aroucha et al.
2019, Xie, Lin et al. 2019, Sankuratri, Verma et al. 2021, Srivastava, Shrivastava et al. 2021). Interestingly, 30% of the
subjects had more than one TMDs diagnosis. Similar finding were reported by Azevedo 2018 et al (Fernandes Azevedo,
Camara-Souza et al. 2018) which highlights the importance of diagnosis and early management of TMDs.

Previous cross-sectional studies reported a significant increase in anxiety and depression scores among medical and
dental students in different Saudi universities (Inam 2007, Aboalshamat, Hou et al. 2015, Basudan, Binanzan et al. 2017).
In this study, 44% of the students with TMD symptoms reported a positive response to the PHQ-4 with half of them
classified as having moderate to severe anxiety. Female dental students had a higher PHQ-4 mean score than male
students which was in agreement with similar studies done on Saudi dental students (Inam 2007, Al-Saleh, Al-Madi et al.
2010, Benoliel, Sela et al. 2011, Al-Sowygh 2013). Overall, the rate of anxiety in women has been reported to be higher
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than men (Kessler, Sonnega et al. 1995, Steel, Marnane et al. 2014, Xie, Lin et al. 2019). This could be explained by the
slower processing in neurotransmitter serotonin which has a critical role in anxiety and depression. Besides, women are
more sensitive to specific hormone such as corticotropin-releasing factor which has an important role in stress response
(Bangasser, Curtis et al. 2010).

The majority of those students who showed moderate to severe levels of anxiety and depression were diagnosed with
painful TMDs on clinical examination and therefore, anxiety was found to be related to TMDs. Other studies have
conflicting results. stress and anxiety were positively associated with TMD in university students in general and dental
students in particular (Ton, Mota et al. 2020, Jaiswal and Deshpande 2021). While Azevedo et al found no association
between anxiety and TMD (Fernandes Azevedo, Camara-Souza et al. 2018). Anxiety and stress in dental students can be
caused by many external factors like exams, clinical requirements and academic assignments. This study was conducted
during the academic year which could contribute to the higher prevalence of anxiety and TMDs.

In comparison to the general population, TMD prevalence ranges between 5–35% (Nadershah 2019, Schiffman et al.
2014). However, none of those studies reported on the association of TMD with stress, anxiety or phycological factors in
general population. In general, anxiety disordered have been reported in 35% of chronic pain patients compared to only
18% of the general population (Poleshuck et al. 2009). In addition, Reissmann et al. compared patients diagnosed with
TMD and general population without TMD related pain and reported that Trait anxiety is significantly associated with
diagnoses of TMD pain. One point increase in the State-Trait Anxiety Inventory score related to an increase of the odds
for pain-related TMD by the factor 1.04 (Reissmann et al. 2014). A similar finding reported by kmeid et al. were TMDs
was significantly associated with depression, anxiety, and stress among Lebanese population (Kmeid et al. 2020).

In general, oral parafunctional habits are known as a major contributor to TMDs and play an important role in its
progression (Chisnoiu, Picos et al. 2015). In the present study, self-reported bruxism was significantly associated with
TMDs. This finding concurs similar findings in Swedish dental students in which participants with TMD reported
significantly higher oral parafunctional habits (Lövgren, Österlund et al. 2018). Moreover, the results of this study are in
accordance with Jaiswal et al, where they reported significant relationship between TMDs and parafunctional habits in
Indian dental students (Jaiswal and Deshpande 2021).

History of bruxism and anxiety levels were found to be higher among the senior dental students at UQU. Similar findings
were reported by other studies in which a statistical significant relationship between anxiety and the para-functional habit
was revealed (Paterson, Lamb et al. 1995, Ahlberg, Lobbezoo et al. 2013). Most individuals who have anxiety disorders
tend to relieve their stress by clenching and/or grinding their teeth and contracting masticatory muscle which leads to
activation of the stomatognathic system (Calixtre, Gruninger et al. 2014). This increase in stress levels among final-years
students can be due to more participants from those two academic years. However, it can be also explained by the higher
clinical demands and more workload during these final clinical years. Declining of both bruxism and anxiety parameters
was noted in participants from the internship year where there is a significant decrease in academic load and clinical
requirements. Similar findings were reported by Ahuja (Ahuja, Ranjan et al. 2018).

Limitation of the study

This is a cross-sectional study in which only association between variables is detected. Longitudinal studies are needed to
prove causation. The absence of a control group for anxiety screening was regarded as a limitation for this study, as no
clinical examination nor depression score was done for the participants who denied TMD pain or symptoms. Also, a
comparison of TMDs prevalence with age-matched general population (non-dental students) was not considered in this
study and it is recommended for future research projects.

Conclusions
TMDs is highly prevalent among dental students. Disc displacement with reduction was the most predominant one.
Greater prevalence was observed among females and higher academic years. Bruxism and anxiety were associated with
painful TMDs.

Data availability
Underlying data
Dryad: Temporomandibular Joints Disorders TMDs Prevalence and Its Relation to Anxiety in Dental Students. https://
doi.org/10.5061/dryad.kkwh70s62 (Homeida 2022).

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This project contains the following underlying data:

- Pain screener results for 240 participants.xlsx

- TMD diagnosis results of 93 participants.xlsx

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public
domain dedication).

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Open Peer Review

Current Peer Review Status:

Version 2

Reviewer Report 13 November 2023

https://doi.org/10.5256/f1000research.133454.r176706

© 2023 Fatahzadeh M. This is an open access peer review report distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

Mahnaz Fatahzadeh
Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ, USA

This study is interesting and pertinent. Authors provide a concise background and explain the
reason for performing this study, describe their scientific approach and adequately define
inclusion and exclusion criteria. Data analysis seems reasonable. Although the study or its findings
are not novel, the results are interesting and generally in line with previous reports. Authors
explain their findings in a focused and clear manner in the discussion section.

Here are a few points to consider:

Title: The study population were dental students in UQU but it is not stated in the title.

In the results section of abstract, line 7: state what is meant by participants (students completing
the initial survey or those who were examined).

Page 4, 1st paragraph: Since this study specifically investigates the prevalence of TMD in dental
students in UQU, there is no need to mention dental students from other universities were
excluded.

Please rephrase legend for clarity. For example, Table 1: Demographic of participants with
positive response to the pain screener and those receiving temporomandibular joint (TMJ) clinical
examination.

Please rephrase legend for figure 2 for clarity. For example, Figure 2; Distribution of self-reported
history of bruxism and anxiety levels according to academic year of dental training among study
participants

There are minor grammatical issues which could be easily addressed by editing and proof reading.

Is the work clearly and accurately presented and does it cite the current literature?

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Yes

Is the study design appropriate and is the work technically sound?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?
Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?
Yes

Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Oral Medicine

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard.

Reviewer Report 04 May 2022

https://doi.org/10.5256/f1000research.133454.r136082

© 2022 Farag A. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

Arwa Farag
Division of Oral Medicine, Department of Diagnostic Sciences, Tufts School of Dental Medicine,
Boston, MD, USA

The suggestions I provided in my previous review were addressed precisely.

Is the work clearly and accurately presented and does it cite the current literature?
Yes

Is the study design appropriate and is the work technically sound?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?
Yes

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 F1000Research 2022, 11:271 Last updated: 13 NOV 2023

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?
Yes

Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard.

Version 1

Reviewer Report 07 April 2022

https://doi.org/10.5256/f1000research.80143.r126222

© 2022 Farag A. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

Arwa Farag
Division of Oral Medicine, Department of Diagnostic Sciences, Tufts School of Dental Medicine,
Boston, MD, USA

Dear author,

Thank you for conducting this investigation. The study aimed to estimate the prevalence of TMDs
among dental student and characterize the most common TMD diagnoses along with associated
symptoms/conditions. The methodology followed was optimal, starting from screening to
comprehensive clinical assessment and self-reported questionnaires. Recruitment and inclusion of
the study participants were done using the gold standard diagnostic criteria (RDC-TMD). All the
utilized tools of assessment were reliable and previously validated for TMD population.

Below, I’m including minor points/comments, that I hope will further optimize this well-put-
together manuscript.

Methodology:

In the exclusion criteria, author should specify that health history was obtained and those with
underlying rheumatoid conditions, generalized pain symptoms, connective tissue disorders were
excluded from the study.

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 F1000Research 2022, 11:271 Last updated: 13 NOV 2023

Discussion:

It would great if the author can provide some statistics/citations for prevalence of TMD (disc
displacement/myalgia) along with stress and anxiety in the general population and compare them
to this special population (dental students). This will provide insight, and clearly highlight, the
increased prevalence of these conditions among dental students.

Thank you once again for allowing me the opportunity to review this work.

Is the work clearly and accurately presented and does it cite the current literature?
Yes

Is the study design appropriate and is the work technically sound?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?
Yes

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?
Yes

Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: OFP and OM

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard, however I have
significant reservations, as outlined above.

Author Response 21 Apr 2022

Lujain Homeida

Response to TMD reviewer comments

Thank you for the comments and the review, below are our responses

1 - in the exclusion criteria, author should specify that health history was obtained
and those with underlying rheumatoid conditions, generalized pain symptoms,
connective tissue disorders were excluded from the study.

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 F1000Research 2022, 11:271 Last updated: 13 NOV 2023

Thank you for the comment, the material and method section was amended as follows:
under TMJ clinical examination and diagnosis the following sentence was added:

“Detailed medical history was obtained and subjects with underlying rheumatoid conditions,
generalized pain symptoms, connective tissue disorders were excluded from the study”.

2- It would great if the author can provide some statistics/citations for prevalence of
TMD (disc displacement/myalgia) along with stress and anxiety in the general
population and compare them to this special population (dental students). This will
provide insight, and clearly highlight, the increased prevalence of these conditions
among dental students.

Thank you for this point. Most of the literature on TMD addressed specific population
(patients, medical or dental students, or university students) very few literature addressed
general population or included non TMD general population as a comparison group.

The following paragraph was added to the discussion.

'In comparison to the general population, TMD prevalence ranges between 5 – 35 %

(Schiffman, Ohrbach et al. 2014, Nadershah 2019). However, none of those studies reported
on the association of TMD with stress, anxiety or phycological factors in general population.
In general, anxiety disordered have been reported in 35 % of chronic pain patients
compared to only 18 % of the general population (Poleshuck, Bair et al. 2009). in addition,
Reissmann et al. compared patients diagnosed with TMD and general population without
TMD related pain and reported that Trait anxiety is significantly associated with diagnoses
of TMD pain. One point increase in the State-Trait Anxiety Inventory score related to an
increase of the odds for pain-related TMD by the factor 1.04 (Reissmann, John et al. 2014).
A similar finding reported by kmeid et al. were TMDs was significantly associated with
depression, anxiety, and stress among Lebanese population (Kmeid, Nacouzi et al. 2020)'

Competing Interests: N/A

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