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Received: 1 September 2019    Revised: 5 October 2019    Accepted: 14 October 2019

DOI: 10.1111/joor.12899

REVIEW

Prevalence of temporomandibular disorders in patients seeking


orthodontic treatment: A systematic review

Ye Choung Lai1  | Adrian Ujin Yap1,2,3  | Jens Christoph Türp4

1
Department of Dentistry, Ng Teng Fong
General Hospital, National University Health Abstract
System, Singapore, Singapore The objective of this systematic review was (a) to establish the prevalence of tem‐
2
Faculty of Dentistry, National University of
poromandibular disorders (TMDs) in patients seeking orthodontic treatment and
Singapore, Singapore, Singapore
3
National Dental Centre Singapore,
(b) to determine the association between the presence of TMD and sex, age and
Singapore, Singapore malocclusion. A systematic literature search was performed according to PRISMA
4
Division of Temporomandibular Disorders guidelines from 1969 to 2019 using the PubMed and LIVIVO databases. Eight study
and Orofacial Pain, Department of Oral
Health & Medicine, University Center of articles met the inclusion and exclusion criteria. An additional three contributions
Dental Medicine Basel, University of Basel, were identified through manual searching of the reference lists of retrieved articles.
Basel, Switzerland
The methodological quality of the 11 articles was assessed with the Joanna Briggs
Correspondence Institute Critical Appraisal Checklist for prevalence studies. TMD prevalence ranged
Ye Choung Lai, Department of Dentistry,
Ng Teng Fong General Hospital, National from 21.1% to 73.3%. The frequency of painful TMD signs/symptoms varied from
University Health System, Ng Teng Fong 3.4% to 65.7%, while non‐painful signs/symptoms ranged from 3.1% to 40.8%. The
General Hospital, 1 Jurong East Street 21,
Singapore 609606, Singapore. percentage of males and females presenting with TMD varied from 10.6% to 68.1%
Email: yechoung@yahoo.com and 21.2 to 72.4%, respectively. In all studies, TMD prevalence was higher among
females. The majority of articles reported more TMD signs/symptoms in individuals
older than 18 years as compared to younger ones (≤18 years). While in four studies no
association between TMD and malocclusion was found, another three investigations
indicated that TMD may be related to certain occlusal traits. The TMD prevalence in
patients seeking orthodontic treatment was high, with many individuals presenting
painful TMD signs/symptoms. Female and older patients appear to have a greater
occurrence of TMD. Although no strong association between TMD and malocclusion
was established, several occlusal traits were implicated.

KEYWORDS
age, malocclusion, orthodontics, sex, temporomandibular disorders

1 | I NTRO D U C TI O N and/or TMJ tenderness upon palpation, restriction or deviation/de‐


flection of mandibular movements, TMJ sounds (clicking, popping,
The term “temporomandibular disorders” (TMDs) relates to a group grating) and/or temporomandibular pain. 2 TMD signs/symptoms
of clinical conditions that are characterised by pain and/or dysfunc‐ can be classified as painful and non‐painful. Painful TMD is the most
tion in the masticatory muscles and/or the temporomandibular common reason for treatment‐seeking.3 Based on the “Orofacial
1
joints (TMJs). TMD signs (objective, examiner‐related evidence) and Pain: Prospective Evaluation and Risk Assessment” (OPPERA) stud‐
symptoms (subjective, patient‐related perception) include muscle ies, the estimated annual incidence rate of first‐onset pain‐related
TMD is 3.9%.4 This value is comparable to the 5% prevalence of jaw/
The peer review history for this article is available at https://publons.com/
publon/10.1111/joor.12899

270  |  wileyonlinelibrary.com/journal/joor


© 2019 John Wiley & Sons Ltd J Oral Rehabil. 2020;47:270–280.
LAI et al. |
      271

facial pain reported in large epidemiological studies in Europe and be borne in mind that the risk of adult females developing TMD is
5,6
America. greater than among males. 27 Considering the aforementioned state‐
7
Typical TMD patients are women of childbearing age. TMD prev‐ ments and the elevated TMD prevalence during adolescence, there
alence rises during adolescence, and depending on methodology, it is a high possibility that orthodontists and dentists will encounter
ranges from 7% to 30%.8 The higher TMD occurrence has been as‐ patients with pre‐existing TMD who seek therapy for their maloc‐
sociated with hormonal, physical and psychosocial changes during clusion. Thus, the failure to check for TMD signs or symptoms prior
pubertal development.9,10 The OPPERA studies have confirmed to the commencement of orthodontic therapy may lead to thera‐
the multifactorial aetiology of TMD and their consistency with a peutic complications and even medico‐legal issues. 28 Hence, there is
11
biopsychosocial model of illness. Aetiological factors encompass a pressing need for a systematic review on the presence of TMD in
macro‐trauma, micro‐trauma (eg bruxism and other parafunctions), prospective orthodontic patients. To the authors’ knowledge, such
psychological and somatic distress, and genetic factors.12,13 In con‐ an analysis is still not available in the literature.
trast, the role of malocclusion, which traditionally had been regarded Thus, the objectives of this systematic review were (a) to estab‐
as one of the most important aetiological influences of TMD signs/ lish the TMD prevalence in patients seeking orthodontic treatment
symptoms, has been deemphasised.14,15 The decline of the impor‐ and (b) to determine the association between the presence of TMD
tance of occlusal factors, however, does not imply that the dental and biological sex, age and malocclusion. A further objective was to
occlusion has zero impact on TMD signs/symptoms.16 Angle Class ascertain the occurrence of painful and non‐painful TMDs in pro‐
II, crossbite and maximum intercuspal instability have all been as‐ spective orthodontic patients.
17,18
sociated with higher odds for TMD. Moreover, individuals with
a history of TMD may be at greater risk of developing TMD signs/
2 | M ATE R I A L S A N D M E TH O DS
symptoms in response to occlusal changes.19 The cause‐effect re‐
lationship between TMD and malocclusion is thus multifaceted and
2.1 | Search strategy
as expressed by Storey three decades ago who noted that “the door
is still ajar.”20 The systematic review was conducted in accordance with (a) the
The term “malocclusion” has been defined as “any deviation from Preferred Reporting Items for Systematic Reviews and Meta‐
a physiologically acceptable contact between the opposing dental Analyses (PRISMA) guidelines and (b) the Joanna Briggs Institute
21
arches” or “any deviation from a normal occlusion.” It should be (JBI) systematic review methodology. 29,30 The search strategy was
considered, however, that malocclusion is a widespread phenom‐ divided into the following three steps:
enon. About 70% of North American youths have some form of
malocclusion, mostly crowding of teeth within an Angle Class I occlu‐ 1. Identification of keywords for the search.
22
sion. Nonetheless, in some cases untreated malocclusion may be 2. Literature search of targeted databases using identified keywords.
significantly associated with oral health‐related quality of life, with 3. Review of reference lists of articles retrieved from the electronic
more severe malocclusion ensuing in greater impairment. 23 search.
Orthodontic treatment is often sought by patients to enhance
psychological and social well‐being through improvement in the Electronic searches were conducted in PubMed and LIVIVO,
alignment of the dentition. 24 Other specific reasons for orthodon‐ covering the period between January 1969 and January 2019. The
tic treatment‐seeking may involve dentist's advice, parental interest MeSH terms “temporomandibular joint disorders,” “orthodontics”
and concern, peer influence, dissatisfaction with the appearance of and “prevalence” were used for the searches in PubMed and LIVIVO
teeth and anticipated improvement in life quality, including greater (Table 1). Articles about retrospective, prospective, cross‐sectional,
ease in finding jobs and romantic partners. 25 longitudinal, case‐control and cohort studies were considered. The
Recent data released by the British Orthodontic Society have main outcome measures of interest were (a) prevalence of TMD in
revealed an increasing trend of adults seeking orthodontic therapy, pre‐orthodontic patients, (b) association between TMD and sex,
26
especially among females aged between about 26 and 40 years. (c) association between TMD and age, and (d) association between
This observation may also apply in other countries. Yet, it should TMD and malocclusion.

TA B L E 1   Search strategy and


Database Search terms Search details Hits
outcomes
PubMed Temporomandibular disorders, “Tempormandibular joint 236
temporomandibular joint, ortho‐ disorders” (MeSH terms) OR
dontics and prevalence “temporomandibular joint” (All
Fields) AND “Orthodontics”
(MESH terms) AND “Prevalence”
(All Fields)
LIVIVO Temporomandibular disorders, ‐ 103
temporomandibular joint, ortho‐
dontics and prevalence
|
272      

TA B L E 2   JBI checklist for prevalence studies

Akeel & Morrant & Olsson & Sasowsky


  Jain et al34 Piao et al35 Conti et al36 Al‐Jasser37 Taylor38 Lindqvist39 Tanne et al40 Hirata et al41 Runge et al42 et al43 Williamson44

Q1 Was the sample frame Y Y Y Y Y Y Y Y Y Y Y


appropriate to address
the target population
Q2 Were the study par‐ Y Y Y Y Y Y Y Y Y Y Y
ticipants sampled in an
appropriate way?
Q3 Was sample size Y Y U U U U U U U U U
adequate?
Q4 Were the study Y Y Y Y Y Y Y Y Y Y Y
subjects and setting
described in detail?
Q5 Was the data analysis Y Y Y Y Y Y Y Y Y Y Y
conducted with suf‐
ficient coverage of the
identified sample?
Q6 Were valid methods Y Y Y Y Y Y Y Y Y Y Y
used for identification of
the condition?
Q7 Was the condition Y U Y Y Y Y Y Y Y Y Y
measured in a stand‐
ard, reliable way for all
participants?
Q8 Was appropriate sta‐ Y Y Y Y Y N Y N Y Y N
tistical analysis used?
Q9 Was the response rate Y Y Y Y Y Y Y Y Y Y Y
adequate, and if not, was
the low response rate
managed appropriately?

Abbreviations: N, no; U, unclear; Y, yes.


LAI et al.
LAI et al.

TA B L E 3   Summary of data extracted from included studies

Type of Total sample TMD preva‐ Sex and TMD Age and TMD preva‐ Malocclusion and TMD
Authors study Diagnostic tools used size lence n (%) prevalence n (%) lence n (%) prevalence n (%) Authors' conclusion
34
Jain et al Cross‐sec‐ Questionnaire 390 88/390 Male: 34/178 12‐18 y: 16/105 (15.23%) Class I: 44/209 (21.1%) 1. More females
tional (Fonseca) (22.6%) (19.1%) 19‐30 y: 72/285 Class II: 38/169 (22.5%) presented with TMD
Female: 54/212 (25.26%) Class III: 6/12 (50%) compared to males in
(25.5%) 19‐30 y of age group
2. As age increases, the
presence of TMD also
increases
Piao et al35 Cross‐sec‐ Clinical examination 7116 1773/7116 N.A <7 y: 1/60 (1.7%) Skeletal Class I: 508/1773 Prevalence of TMD
tional (Helkimo) (24.9%) 7‐12 y: 70/1705 (4.1%) (7.1%) gradually increases up
13‐18 y: 366/1644 Skeletal Class II: 667/1773 to middle age, following
(22.3%) (9.4%) which it decreased
19‐39 y: 1270/3396 Skeletal Class III: 598/1773
(37.4%) (8.4%)
>40 y: 66/311 (21.2%)
Conti et al36 Cross‐sec‐ Questionnaire (modi‐ N.A (40%) N.A N.A Class I: (40%)  
tional fied Helkimo) and Class II: (40%)
clinical examination
(evaluation of jaw
movement, TMJ
sound and pain)
Akeel & Cross‐sec‐ Questionnaire and 191 Females N.A N.A No significant differ‐ N.A 1. No significant associa‐
Al‐Jasser37 tional clinical examination ences between 8‐13 y, tion between IOTN and
(Nassif & Hilsen, 14‐18 y and >18 y TMD
1992) 2. Malocclusion could
not be considered as a
primary aetiology factor
for TMD
Morrant & Cross‐sec‐ Questionnaire and 301 203/301 No significant More joint sounds in No relationship found be‐ 1. No relationship be‐
Taylor38 tional clinical examination (67.4%) differences >20 y*  tween incisor classification tween age and MDI
(modified Helkimo Reduced opening in and TMD 2. Assessment of TMJ
index/MDI) <10 y*  and muscles should be
made during routine or‐
thodontic examination
|
      273

(Continues)
|
274      

TA B L E 3   (Continued)

Type of Total sample TMD preva‐ Sex and TMD Age and TMD preva‐ Malocclusion and TMD
Authors study Diagnostic tools used size lence n (%) prevalence n (%) lence n (%) prevalence n (%) Authors' conclusion

Olsson & Longitudinal Questionnaire and 210 154/210 TMD signs TMD signs TMD signs 1. Higher prevalence of
Lindqvist39 clinical examination (73.3%) Male: 64/94 <13 y: 82/118 (69.5%) Deep bite: 28/60 (46.7%) TMD in older age group
(Olsson & Lindqvist (68.1%) >13 y: 66/92 (71.7%) Anterior open bite: 11/15 than in younger
1992) (Helkimo) Female: 84/116 TMD symptoms (73.3%) 2. Higher prevalence in
(72.4%) <13 y: 18/118 (15.3%) Crossbite: 28/57 (49.1%) females than in males
TMD symptoms >13 y: 17/92 (18.5%) Scissor bite: 8/23 (34.8%) 3. Higher prevalence
Male: 10/94 TMD symptoms of TMD in cases with
(10.6%) Deep bite: 8/60 (12.9%) deep bite, anterior open
Female: 25/116 Anterior open bite: 5/15 bite and transverse
(21.6%) (33.3%) discrepancies
Crossbite: 5/57 (8.8%)
Scissor bite: 3/23 (13.0%)
Tanne et al40 Cross‐sec‐ Questionnaire and 232 49/232 Male: 18/86 N.A Max protrusion: 14/75 1. Prevalence of TMD did
tional clinical examination (21.1%) (20.9%) (18.7%) not differ significantly
(Helkimo) Female: 31/146 Mandprognathism: 23/125 between the sexes
(21.2%) (18.4%) 2. Open bite, deep bite
Posterior crossbite: 31/117 and posterior crossbite
(26.5%) appear to induce TMD
Open bite: 12/27 (44.4%) more frequently than
Deep bite: 12/58 (20.7%) other malocclusions
Crowding: 18/97 (18.6%)
Hirata et al41 Longitudinal Questionnaire and 102 N.A N.A N.A N.A 1. Variability in the signs
clinical examina‐ of TMD
tion (evaluated jaw 2. Possibility that many of
movement and TMJ the prior signs of TMD
sounds) may not have clinical
significance
Runge et al42 Cross‐sec‐ Interview, clinical 226 N.A TMJ sounds TMJ sounds TMJ sound vs molar relation‐ 1. Occlusion and skeletal
tional examination and Male: 31/103 <18 y: 52/184 (28.3%) ship, overjet, overbite and relationships are not
audiovisual examina‐ (30.1%) >18 y: 30/42 (71.4%) posterior crossbite (no significant factors in
tion (Sasowsky et al Female:51/123 (statistically significant) significant association) contributing to TMJ
1985) (41.5%) Joint sound vs interin‐ sounds
(not statistically cisal angle (statistically 2. Larger interincisal
significant) significant) angle may be associated
with TMJ sounds
LAI et al.

(Continues)
LAI et al. |
      275

2.2 | Identification of relevant articles

be common in patients
2.TMJ sounds appear to

TMD prior to the start


cantly associated with

thorough diagnosis of
1. TMJ sounds signifi‐

There is a need for a


before orthodontic
Authors' conclusion The electronic literature search was carried out by two authors (LYC
and YAU). Titles and abstracts of the articles were screened for rele‐

of treatment
vance to the review. Publications that were not written in English, or re‐

treatment
ported TMD prevalence in the general population, or involved ongoing
orthodontic therapy, or did not consider TMD signs and/or symptoms
age

(eg only radiographs), or were published in journals no longer in circula‐


tion were excluded. All relevant articles were independently evaluated
was found between joint
No significant association

by the two authors (LYC and YAU) to ensure they fulfilled the inclusion

Class II: 39/121 (32.2%)


Malocclusion and TMD

sounds and functional

Class I: 62/165 (39.4%)

Class III: 6/18 (33.3%)


and exclusion criteria. The reference lists of the retrieved articles were
scrutinised to identify possible additional relevant publications.
prevalence n (%)

occlusion

2.3 | Assessment of methodological quality


The retrieved articles were assessed using the JBI Critical Appraisal
Checklist for prevalence studies (Table 2).31 The study articles were
evaluated in their entirety by the two authors (LYC and YAU), and
Age and TMD preva‐

any discrepancies were mediated by the third author (TJC) to reach


a common consensus.
lence n (%)

2.4 | Data synthesis
N.A

N.A

Qualitative and quantitative data extracted from the articles included


prevalence n (%)

study type, tool/method for diagnosing TMD, sample size, TMD preva‐
Female: 64/175
Sex and TMD

Male: 43/129

lence, painful and non‐painful TMD signs/symptoms, sex distribution,


(33.3%)

(36.6%)

age distribution, type of skeletal pattern and/or malocclusion.


N.A

3 | R E S U LT S
TMD preva‐
lence n (%)

3.1 | Yield of search
N.A

N.A

The electronic searches yielded a total of 236 articles (PubMed 236;


LIVIVO 103) after the elimination of duplicates. After screening the
Total sample

titles and abstracts, 10 full articles were relevant. Two articles were
subsequently omitted: one publication examined the TMD preva‐
304
size

98

lence in the general population,32 while the other included patients


who were undergoing orthodontic treatment.33 In addition to the
determine the occur‐
pain) and audiovisual
Diagnostic tools used

ated jaw movement,


examination (evalu‐

rence and timing of

Clinical examination
examination (using

remaining 8 publications, 3 supplementary contributions were iden‐


video recorder to

muscles and joint


microphones and
TMJ sounds and
Interview, clinical

(evaluated TMJ,

tified by handsearching of the reference lists of the 8 full‐text arti‐


TMJ sounds)

cles. Thus, 11 articles were included in this systematic review.34-44


sounds)

The data extracted from these publications are summarised in Tables


3 and 4. The PRISMA flow diagram describing the process of article
selection, full‐text retrieval, appraisal, extraction and data synthesis
is presented in Figure 1.
*Denotes statistically significant.
Abbreviation: N.A, not available.
Cross‐sec‐

Cross‐sec‐
Type of

tional

tional
TA B L E 3   (Continued)

study

3.2 | Prevalence of TMD
Most studies made use of both questionnaires and clinical exami‐
Williamson44

nation to determine the presence of TMD.36-43 Jain et al34 utilised


Sasowsky et

only a questionnaire, while Piao et al35 relied on record‐based demo‐


Authors

graphic, clinical and radiological information. Williamson44 made use


al43

of only clinical examination to determine TMD presence. Prevalence


|
276      

TA B L E 4   Occurrence of painful and non‐painful TMD signs/symptoms from included studies

Total sample Occurrence of non‐painful TMD signs/


Authors Type of study Diagnostic tools used size Occurrence of painful TMD signs/symptoms n (%) symptoms n (%)

Conti et al36 Cross‐sectional Questionnaire (modified Helkimo) and N.A N.A 1. Joint sounds: (9%)
clinical examination (evaluation of jaw
movement, TMJ sound and pain)
Akeel & Cross‐sectional Questionnaire and clinical examination 191 Females 1. Pain on TMJ palpation: 22/191 (12%) 1. Joint sounds: 32/191 and 60/191 (17%
Al‐Jasser37 (Nassif & Hilsen, 1992) 2. Pain on muscle palpation: 17/191 (9%) and 32%)
3. Difficult/painful mouth opening: 21/191 (11%) 2. Limited jaw movement: 35/191 (18%)
4. Pain in jaw/ear region: 29/191 (15%)
5. Headache > 1 per week: 23/191 (12%)
Morrant & Cross‐sectional Questionnaire and clinical examination 301 1. Pain on TMJ palpation: 38/301 (13%) 1. Joint sounds: 42/301 and 68/301 (14%
Taylor38 (modified Helkimo index/ MDI) 2. Tenderness of masseter: 54/301 (18%) and 23%)
3. Tenderness of temporalis: 14/301 (5%)
4. Tenderness of lateral pterygoid: 14/301 (5%)
5. TMJ pain: 36/301 (12%)
6. Muscle pain: 48/301 (16%)
7. Headaches > 1 per week: 31/301 (10%)
Olsson & Longitudinal Questionnaire and clinical examination 210 1. Pain on TMJ palpation: 41/210 (19.5%) 1. Joint sounds: 22/210 (10.5%)
Lindqvist39 (Olsson & Lindqvist 1992) (Helkimo) 2. Pain on TMJ movement: 53/210 (25.2%) 2. Impaired function: (joint sounds + move‐
3. Pain on muscle palpation: 138/210 (65.7%) ments) 38/210 (18.1%)
Tanne et al40 Cross‐sectional Questionnaire and clinical examination 232 1. Muscle pain: 8/232 (3.4%) 1. TMJ sounds: 30/232 (12.9%)
(Helkimo) 2. TMJ pain: 18/232 (7.8%) 2. Difficulty of jaw movement: 23/232 (9.6%)
Hirata et al41 Longitudinal Questionnaire and clinical examination 102 N.A 1. Joint sounds: 23/102 (22.5%)
(evaluated jaw movement and TMJ sounds) 2. Deviation of opening: 34/102 (33.3%)
Runge et al42 Cross‐sectional Interview, clinical examination and audio‐ 226 1. Pain on TMJ movement: 21/226 (9.3%) 1. Joint sounds: 82/226 (36.3%)
visual examination (Sasowsky et al 1985) 2. Limited jaw movement: 7/226 (3.1%)
3. Jaw locking: 12/226 (5.3%)
Sasowsky et Cross‐sectional Interview, clinical examination (evaluated 98 N.A 1. Joint sounds: 27/98 & 40/98 (27.5% &
al43 jaw movement, TMJ sounds and pain) and 40.8%)
audiovisual examination (using micro‐
phones and video recorder to determine
occurrence and timing of TMJ sounds)
Williamson44 Cross‐sectional Clinical examination (evaluated TMJ, mus‐ 304 1. Pain on muscle palpation: 85/304 (30.0%) 1. Joint sounds: 46/304 (15.1%)
cles and joint sounds)

Abbreviation: N.A, not available.


LAI et al.
LAI et al. |
      277

F I G U R E 1   The PRISMA flow


diagram [Colour figure can be viewed at

Identification
Records identified through PubMed Records identified through LIVIVO
wileyonlinelibrary.com]
(n = 236) (n = 103)

Records after duplicates removed


(n = 236)

Screening
Records screened Records excluded
(n = 236) (n = 226)

Eligibility

Full-text articles assessed Full-text articles excluded,


for eligibility with reasons
(n = 10) (n = 2)

Articles identified through


handsearch
(n = 3)
Included

Articles included in
qualitative synthesis
(n = 11)

of TMD ranged from 21.1% to 73.3%. Occurrence of painful TMD Orthodontic Treatment Need (IOTN),37 and occlusal features were
signs/symptoms varied from 3.4% to 65.7%, while non‐painful signs/ selected in the other investigations.39,40,42,43 Authors of 2 studies
symptoms varied between 3.1% and 40.8%. concluded that there was no relationship between dental classifica‐
tion and TMD.34,38 Akeel and Al‐Jasser37 found no significant asso‐
ciation between IOTN and TMD signs or symptoms. Nonetheless,
3.3 | Association between TMD and sex
most authors investigating occlusal features reported that open
TMD prevalence in males ranged from 10.6% to 68.1%. As for fe‐ bite, deep bite and posterior crossbite appeared to be associated
males, it varied from 21.2% to 72.4%. Authors of all investigations with TMD.39,40 Runge et al42 concluded that a larger interincisal
reported a higher occurrence of TMD in females when compared angle as well as increased overbite was associated with TMJ sounds.
to males. In three studies, no statistically significant differences in Conversely, Sadowsky et al43 found no significant connection be‐
38,40,42
prevalence between the sexes were found. tween joint sounds and functional occlusion.

3.4 | Association between TMD and age


4 | D I S CU S S I O N
Akeel and Al‐Jasser37 did not find any significant difference in
TMD prevalence among young females aged 8, 14 and 18 years. This systematic review determined the prevalence of TMD in patients
Conversely, in 4 other studies a higher TMD prevalence was ob‐ seeking orthodontic treatment, and it examined the possible associa‐
served in adult patients when compared to younger ones (18 years tion between the presence of TMD and sex, age and malocclusion. The
old and below).34,39,42,43 Morrant and Taylor recorded significantly JBI approach was adopted due to its ease of use and robust method of
more TMJ sounds in patients older than 20 years.38 Finally, Piao et systematic analysis of prevalence studies. We found that most stud‐
35
al reported that TMD prevalence gradually decreased after the age ies used both questionnaire and clinical examination to establish the
of 40. presence of TMD. Unfortunately, the questionnaires and methodol‐
ogy of clinical examination were not standardised. This, coupled with
the inconsistent description of malocclusion traits, made comparisons
3.5 | Association between TMD and malocclusion
among the results reported in the study articles challenging and infer‐
To determine malocclusion, a dental classification was used in ences somewhat weak. Standardised methods to evaluate and diag‐
4 studies,34,36,38,44 while skeletal relationship,35 the Index of nose TMD were missing until the Research Diagnostic Criteria (RDC/
|
278       LAI et al.

TMD)45 and Diagnostic Criteria for TMD (DC/TMD)46 were introduced reported age peaks for TMD.7,54 Some cross‐sectional general
in 1992 and 2014, respectively. Although it had been extensively used population studies, however, appear to suggest a higher preva‐
for TMD‐related research, none of the identified studies had made lence of TMD signs/symptoms amongst children and adolescents
use of the RDC/TMD. The DC/TMD improved upon the reliability and than in adults (7.3% to 30.4% vs 15.6% to 16.2%). 8,55 The differ‐
validity of the RDC/TMD, and provides a comprehensive assessment ences may be attributed to the substantial fluctuation of TMD
of common pain‐related TMD and intra‐articular disorders based on signs and symptoms and the self‐limiting nature of most TMD. 56
the biopsychosocial model. The use of the DC/TMD and other har‐ More longitudinal epidemiological TMD studies are therefore
monised instruments would facilitate further inter‐study compari‐ highly desirable.
sons. Nonetheless, due to the heterogeneity of the study designs and As there was no standardisation of the age grouping across the
data collection, a quantitative analysis could not be performed in our studies, a peak age group for TMD could not be identified in patients
analysis. seeking orthodontic treatment. Piao et al35 noted that prevalence of
TMD among orthodontic patients gradually decreased after age of
40. This was in accordance with current evidence indicating higher
4.1 | TMD prevalence
TMD therapy needs in younger non‐patients adults (19‐45 years)
The prevalence of TMD in prospective orthodontic patients ranged than in older ones (above 46 years). 55 As adolescents and young
from 21.1% to 73.3%, which was much higher than that observed in adults form the majority of patients seeking orthodontic treatment,
the general population.8,47 In a meta‐analysis encompassing data from there could be a possible age bias due to the larger number of ado‐
2,461 individuals from the general population, it was reported that in lescent/young adults investigated in the studies compared with chil‐
adults the overall prevalence of masticatory muscle pain, TMJ arthral‐ dren and mature adults. As a recent systematic review has shown
gia and disc displacement with reduction was 9.7, 2.6 and 11.4%, re‐ that TMD prevalence increases during puberty,10 a developmental
47
spectively. The occurrence of painful TMD signs/symptoms (3.4% to stage where orthodontic treatment is often performed, the impor‐
65.7%) was found to be higher than non‐painful TMD signs/symptoms tance of TMD‐related diagnostic screening and monitoring cannot
(3.1% to 40.8%). These findings suggest a high possibility of orthodon‐ be overemphasised.
tists/dentists encountering patients with pre‐existing TMD. As a con‐
sequence, a routine TMD‐related examination to assess the presence
4.4 | Association between TMD and malocclusion
of TMD signs/symptoms prior to the commencement of orthodontic
therapy appears to be crucial. Simple instruments, such as the DC‐ In 4 studies,34,37,38,43 no connection between TMD and malocclusion
48,49
TMD pain screener and 3Q/TMD, may be used for this purpose. was found. Conversely, the authors of 3 articles39,40,42 stated that
open bite, deep bite, posterior crossbite and large interincisal angle
appeared to be associated with TMD signs and symptoms. A recent
4.2 | Association between TMD and sex
systematic review on this subject concluded a lack of association be‐
All of the identified studies reported a higher prevalence of TMD tween TMD and dental occlusion.15 Out of the 40 occlusal features
in females when compared to males. This finding is not surprising being evaluated, only 2 (centric relation‐maximum intercuspation
because past TMD research in the general population has presented slide; mediotrusive interferences) were related to TMD. A causal
similar findings: females were twice as likely to develop TMD as com‐ relationship could not be implied as the interferences might be the
pared to males. 27 Hormonal differences between females and males result of TMD rather than the cause. The relationship between TMD
have been assumed to be responsible.50,51 Testosterone was found and malocclusion may largely depend on patients’ ability to cope
to have a protective role in the development of TMJ pain, while oes‐ with the occlusal discrepancy present.
trogen did not.52 In addition, Barsky et al53 showed that women tend
to report higher frequency and intensity of bodily symptoms when
4.5 | Limitations and future recommendations
compared to men. The authors concluded that this discrepancy
could be due to the sex differences in perception, symptom descrip‐ This systematic review offered a “status quo” on the prevalence of
tion and readiness in disclosure of discomfort. The OPPERA studies TMD in prospective orthodontic patients. Hence, it may serve as a
found that the rate of TMD symptoms development (incidence) was reference for future work when more specific and high‐quality stud‐
similar for females and males. Likewise, the rate of clinically verified ies will have been carried out and published. A high prevalence of
13
TMD was only slightly greater in women compared with men. This TMD and painful TMD signs/symptoms was observed in patients
contrasts with the findings of this systematic review and epidemio‐ seeking orthodontic treatment. This has important implications in
logical data from other sources. clinical practice especially with regard to informed consent. In the
light of our modern litigious society, it is prudent for clinicians to
examine and to document the condition of the masticatory system
4.3 | Association between TMD and age
prior to the start of orthodontic therapy. Patients should also be in‐
In most investigations, a higher TMD prevalence was observed formed of the risk of developing TMD signs and symptoms during
in patients older than 18 years. This finding is consistent with the course of their treatment.
LAI et al. |
      279

The study articles reviewed here have several limitations. Most 7. Yap AU, Dworkin SF, Chua EK, et al. Prevalence of temporoman‐
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5 | CO N C LU S I O N
Rehabil. 2018;45(12):1007‐1015.
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J Pain. 2013;14(Suppl 2):T116‐124.
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1. There is a high prevalence of painful TMD in patients seeking
jury is strongly associated with subsequent incident temporo‐
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2. Prospective female orthodontic patients have higher TMD preva‐ 2019;160(7):1551‐1561.
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Res. 2016;95(10):1084‐1092.
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