Is there a higher prevalence of tinnitus in patients with temporomandibular disorders? A systematic review and meta‐analysis

The aim of this study was to determine whether there exists a higher prevalence of tinnitus in patients with temporomandibular disorders (TMDs) than in patients without TMDs. A systematic review was conducted in PubMed/MEDLINE for articles published between January 1992 and April 2018 in accordance with the PRISMA statement. Studies were included in this review only if they assessed TMDs using the research diagnostic criteria (RDC)/TMD or DC/TMD. A total of five studies were included in the systematic review, and a random‐effects meta‐analysis of three of the studies was conducted. In all of the selected studies, the prevalence of tinnitus was higher in patients with TMDs (35.8% to 60.7%) than in patients without TMDs (9.7% to 26.0%). The odds ratio of suffering from tinnitus among patients with TMDs was 4.45 (95% CI 1.64‐12.11. P = 0.003). Thus, despite the limitations of the included studies, this review demonstrates that the prevalence of tinnitus in TMD patients is significantly higher than that in patients without TMD.     

Tinnitus as a comorbidity to temporomandibular disorders—A systematic review

The aim of this systematic review was to evaluate the prevalence of tinnitus in patients with temporomandibular disorders (TMD) and the possible effects of TMD treatment on tinnitus symptoms. A search of the PubMed, Web of Science and Cochrane databases from inception of each database up to January 2017 found 222 articles. After independent screening of abstracts by two of the authors, we assessed 46 articles in full text. The inclusion and exclusion criteria reduced these to 25 articles of which 22 studies reported prevalence based on 13 358 patients and 33 876 controls, and eight studies reported effect of TMD treatment on tinnitus based on 536 patients and 18 controls. The prevalence of tinnitus in patients with TMD varied from 3.7% to 70% (median 42.3%) whereas the prevalence in control groups without TMD varied between 1.7% and 26% (median 12%). The eight treatment studies indicated that treatment of TMD symptoms may have a beneficial effect on severity of tinnitus. However, only one treatment study included a control group, meaning that the overall level of evidence is low. The finding that tinnitus is more common in patients with TMD means that it can be regarded as a comorbidity to TMD. However, in view of the lack of evidence currently available, further well‐designed and randomised studies with control groups are needed to investigate whether possible mechanisms common to tinnitus and TMD do exist and whether TMD treatment can be justified to try to alleviate tinnitus in patients with TMD and comorbidity of tinnitus.     

Prevalence of otologic complaints in patients with temporomandibular disorder

The prevalence and rank of order of 4 otologic complaints in 200 temporomandibular disorder (TMD) patients, as well as the relationship between the complaints and TMD subgroups, were investigated and compared with an asymptomatic control group. No subjective otologic complaints were reported by 45 (22.5%) TMD patients; the remaining 155 (77.5%) patients had at least 1 otologic complaint. Otalgia, tinnitus, vertigo, and hearing loss were reported by 63.6%, 59.1%, 50%, and 36.4%, respectively, of the subjects with myofascial pain and dysfunction; by 46.1%, 44.2%, 32.5%, and 22% of the patients with internal derangement; and by 62.5%, 45.8%, 41.6%, and 20.8% of the patients with both myofascial pain and dysfunction and internal derangement. However, the incidence of otalgia (8%), tinnitus (26%), vertigo (14%), and hearing loss (14%) was found to be lower for the control group. Statistically, the control group had fewer otologic complaints. Patients in the TMD groups had high incidences of otologic complaints compared with the control subjects without TMD signs or symptoms. Aural symptoms in patients with internal derangement or myofascial pain and dysfunction, or their combination, were nonspecific.     

Temporomandibular disorders, otologic symptoms and depression levels in tinnitus patients

The aim of this study was to determine the prevalence of signs and symptoms of temporomandibular disorders (TMD) and otologic symptoms in patients with and without tinnitus. The influence of the level of depression was also addressed. The tinnitus group was comprised of 100 patients with tinnitus, and control group was comprised of 100 individuals without tinnitus. All subjects were evaluated using the research diagnostic criteria for temporomandibular disorders (RDC/TMD) to determine the presence of TMD and depression level. Chi-square, Spearman Correlation and Mann-Whitney tests were used in statistical analysis, with a 5% significance level. TMD signs and symptoms were detected in 85% of patients with tinnitus and in 55% of controls (P≤0·001). The severity of pain and higher depression levels were positively associated with tinnitus (P≤0·001). It was concluded that tinnitus is associated with TMD and with otalgia, dizziness/vertigo, stuffy sensations, hypoacusis sensation and hyperacusis, as well as with higher depression levels.     

Association between dental pain and depression in Korean adults using the Korean National Health and Nutrition Examination Survey

The purpose of this study was to evaluate the relationships between the prevalence of depression and dental pain using a well characterised, nationally representative, population‐based study. This study analysed data from the 2012 Korea National Health and Nutrition Examination Survey (n = 4886). Oral health status was assessed using the oral health questionnaire, and oral examination was performed by trained dentists. Depression was defined as the participant having been diagnosed as depression during the previous year. Logistic regression was applied to estimate adjusted odds ratios (AOR) and 95% confidence intervals (CI), controlling for a range of covariates. Results demonstrated that participants included in ‘root canal treatment is necessary’ showed higher prevalence of self‐reported dental pain; in particular, participants with depression presented more dental pain than those without depression. After adjusting for sociodemographic factors, self‐reported dental pain increased in participants with depression. The AOR (95% CI) for having self‐reported dental pain was 1·58 (1·08–2·33) in dentists' diagnosis of no dental pain/depression group, 1·62 (1·32–1·98) in dentists' diagnosis of dental pain/no depression group and 2·84 (1·10–7·37) in dentists' diagnosis of dental pain/depression group. It was concluded that depression was associated with dental pain after adjustment for potential confounders in Korean adults. Thus, dentists should consider the possible presence of psychopathology when treating patients with dental pain.     

Signs and symptoms of temporomandibular disorders and the incidence of tinnitus

In a cross-sectional analysis of data from the Study of Health in Pomerania (SHIP 0), temporomandibular disorders (TMD) were the strongest predictors for tinnitus beside headache. The aim of this study was to investigate whether signs and symptoms of TMD can be identified as risk factors for developing tinnitus. The SHIP 1 is a population-based 5-year longitudinal study intended to systematically describe the prevalence of and risk factors for diseases common in the population of Pomerania in northern Germany. A total of 3300 subjects (76% response) were reevaluated after 5 years for tinnitus and signs and symptoms of TMD using the same questionnaires and examination tools as baseline. To estimate the relative risk (RR) appropriately, a modified Poisson regression was used. After exclusion of prevalent cases with diagnosed tinnitus, 3134 subjects were analysed. Among the 191 exposed subjects with palpation pain in the temporomandibular joint (TMJ), 24 subjects (12·6%) received diagnosed tinnitus after 5 years, whereas among the 2643 unexposed subjects 142 subjects (5·8%) received tinnitus yielding a risk difference of 7·7% (95% confidence interval [CI]: 3·0%-12·5%) and a risk ratio of 2·60 (95% CI: 1·7-3·9). The risk ratio was 2·4 (95% CI: 1·6-3·7) after adjustment for gender, age, school education and frequent headache. Pain on palpation of the TMJ, however, did not worsen the prognosis for tinnitus in prevalent tinnitus cases (RR = 0·8, P = 0·288). Signs of TMD are a risk factor for the development of tinnitus.     

Signs and symptoms related to temporomandibular disorders--Follow-up of subjects with shortened and complete dental arches

OBJECTIVE: To assess prevalence of cardinal signs and symptoms related to temporomandibular disorders (TMD) in subjects with shortened dental arches and to clarify the individual course of these signs and symptoms. METHODS: In this 9-year follow-up study, subjects with shortened dental arches (n=74) were compared with subjects with complete dental arches (n=72). Of three reported symptoms (pain, noises/clicking and restricted mobility of the lower jaw), and of two clinical signs (palpated clicking of the temporomandibular joint and restricted maximal mouth opening) estimates of mean scores were calculated by a mixed model. Suggested determinants for TMD (gender, time, bruxism, chewing side preference) were investigated by covariate analyses. Subjects with complete 9-year follow-up (shortened dental arches: n=42; complete dental arches: n=41) were described more detailed by frequency distributions, Pearson correlations of signs and symptoms, and fluctuation of the symptoms. RESULTS: Covariate analyses using the mixed model revealed no significant differences between the shortened and the complete dental arch groups (p>0.05) with respect to symptoms and signs. Most prevailing effect was gender: females reported more frequently pain (p=0.05) and noises/clicking (p=0.03). Restricted mobility was significantly related with chewing side preference and bruxism habits (both: p=0.01). In both groups, subjects with complete 9-year follow-up had low prevalence of serious symptoms and signs and symptoms fluctuated without demonstrable correlation. CONCLUSION: In this 9-year follow-up, subjects with shortened dental arches had similar prevalence, severity, and fluctuation of signs and symptoms related to TMD compared to subjects with complete dental arches.     

Risk factors associated with symptoms of temporomandibular disorders in a population of 50- and 60-year-old subjects

summary The aims of this study were first to investigate, by means of a mail questionnaire, variables from three domains: (i) socio‐economic attributes; (ii) general and oral health; and (iii) dental attitudes and behaviours in a large sample of 50‐ and 60‐year‐old subjects, and second to compare subjects with or without reported temporomandibular joint (TMJ) pain with respect to these variables. In 2002, a questionnaire was mailed to all 50‐ and 60‐year‐old subjects in two Swedish counties, Örebro and Östergötland (n = 17 138; n₅₀ = 8878; n₆₀ = 8260). Individuals not responding within 2 weeks were given a reminder. If still not answering, a new questionnaire was sent. The final response rate was 72·8% (n = 12 468). The reported responses to questions regarding ‘pain in the TMJ region’ and ‘difficulty to open the mouth wide’ were dichotomized into two groups: (i) no temporomandibular disorders (TMD) symptoms; and (ii) some, rather great or severe TMD symptoms. Striking differences in demographic, occupational, general and oral health conditions were found between the groups with and without TMD symptoms. The strongest risk indicator for both pain and dysfunction was reported bruxism. Women, younger subjects (50 years old) and blue‐collar workers were significantly more prevalent in the TMD symptom groups. Variables related to impaired general and oral health were more common in the groups with reported TMD problems, whereas satisfaction with received dental care and with teeth was lower. Individuals with reported TMD symptoms differed significantly from those without TMD symptoms in socio‐economic attributes, general and oral health symptoms, dental conditions and satisfaction with their teeth.     

Validity of three screening questions (3Q/TMD) in relation to the DC/TMD

Temporomandibular disorders (TMD) are common but seem to be largely undetected within general dental care. To improve dentists’ awareness of these symptoms, three screening questions (3Q/TMD) have been introduced. Our aim was to validate 3Q/TMD in relation to the diagnostic criteria for TMD (DC/TMD), while taking into account the severity level of the symptoms. The study population consisted of 7831 individuals 20–69 years old, who had their routine dental check‐up at the Public Dental Health Service in Västerbotten, Sweden. All patients answered a health declaration, including the 3Q/TMD regarding frequent temporomandibular pain, pain on movement and catching/locking of the jaw. All 3Q‐positives (at least one affirmative) were invited for examination in randomised order. For each 3Q‐positive, a matched 3Q‐negative was invited. In total, 152 3Q‐positives and 148 3Q‐negatives participated. At examination, participants answered 3Q/TMD a second time, before they were examined and diagnosed according to DC/TMD. To determine symptom's severity, the Graded Chronic Pain Scale and Jaw Functional Limitation Scale‐20 (JFLS‐20) were used. In total, 74% of 3Q‐positives and 16% of 3Q‐negatives met the criteria for DC/TMD pain or dysfunction (disc displacements with reduction and degenerative joint disorder were excluded). Fifty‐five per cent of 3Q‐positives had a TMD diagnosis and CPI score ≥3 or a JFLS‐20 score ≥5, compared to 4% of 3Q‐negatives. The results show that the 3Q/TMD is an applicable, cost‐effective and valid tool for screening a general adult population to recognise patients in need of further TMD examination and management.     

Signs of temporomandibular disorders in tinnitus patients and in a population-based group of volunteers: results of the Study of Health in Pomerania

The literature has documented a controversial discussion on the possible relationship of otogenous symptoms and craniomandibular dysfunction since the 1920s. Therefore, an investigation was conducted which consisted of two parts: a case study with population-based controls and a cross-sectional study. The aim of the first study was to screen a group of patients suffering from acute or chronic tinnitus for temporomandibular disorders (TMD) in comparison with a population-based group of volunteers without tinnitus. To this end, 30 patients (13 females and 17 males, age 18-71 years) suffering from acute hearing loss associated with tinnitus, isolated acute tinnitus, and chronically transient tinnitus were examined for symptoms of craniomandibular dysfunction. The results were compared with those of clinical functional analysis from 1907 subjects selected representatively and according to age distribution from the epidemiological 'Study of Health in Pomerania' (SHIP); the occurrence of tinnitus was ruled out in these control subjects. Statistical analysis was performed with Chi-square and Mann-Whitney U-tests. Sixty per cent of the tinnitus patients and 36.5% of the control subjects exhibited more than two symptoms of TMD (P = 0.004). Tinnitus patients had significantly more muscle palpation pain (P < 0.001), temporomandibular joint (TMJ) palpation pain (P < 0.001), and pain upon mouth opening (P < 0.001) than the general population group. No statistical differences were found in TMJ sounds, limitation of mandibular movement, or hypermobility of the TMJ. Furthermore, 4228 subjects of the population group examined in the epidemiological study were screened for co-factors of tinnitus with the help of a multivariate logistic regression model which was adjusted for gender, age, and a variety of anamnestic and examined data. Increased odds ratios (OR) were found for tenderness of the masticatory muscles (OR = 1.6 for one to three painful muscles and OR = 2.53 for four or more painful muscles), TMJ tenderness to dorsal cranial compression (OR = 2.99), listlessness (OR = 2.0) and frequent headache (OR = 1.84) A relationship between tinnitus and TMD was established in both examinations. Tinnitus patients seem to suffer especially from myofascial and TMJ pain. A screening for TMD should be included in the diagnostic survey for tinnitus patients.     

Temporomandibular disorder symptoms and their association with quality of life,emotional states and sleep quality in South‐East Asian youths

Population studies on the prevalence of temporomandibular disorders (TMD) and their associations with quality of life (QoL), emotional states and sleep quality in South‐East Asian youths are not available. This cross‐sectional study assessed the presence of TMD and their relationships to QoL, depression, anxiety, stress and sleep quality in a cohort of South‐East Asian adolescents/young adults. Three hundred and sixty‐two students from a polytechnic were enrolled in the study and completed an online questionnaire consisting of the Fonesca's Anamnestic Index (FAI), Oral Health Impact Profile for TMD (OHIP‐TMD), Depression, Anxiety and Stress Scales‐21 (DASS‐21) and Pittsburgh Sleep Quality Index. The FAI appraises TMD severity while OHIP‐TMD determines the effect of TMD on oral health‐related QoL. Statistical analysis was performed using chi‐square test for categorical data whilst one‐way ANOVA/post hoc Bonferroni's tests were employed for numerical scores (P < 0.05). Of the 244 participants who completed the questionnaires in their entirety (37 males; 207 females, mean age 20.1 ± 3.2 years), 32.4% had mild TMD, 9.4% had moderate TMD and 58.2% were TMD free. The total prevalence of TMD was 41.8% (n = 102) and most OHIP‐TMD domains including functional limitation (P = 0.000), physical pain (P = 0.000), handicapped (P = 0.000) and psychological discomfort (P = 0.001) showed significant differences in mean scores depending on TMD severity. A similar trend was observed for DASS‐21. The majority of participants with TMD (69.6%; n = 71) had poor sleep quality (P = 0.004). TMD appear to be prevalent in South‐East Asian youths with varying severity. Severity of TMD had some bearing on QoL, emotional states as well as sleep quality.     

The relationship between headache and symptoms of temporomandibular disorder in the general population

OBJECTIVES: To describe the relationship between headache and symptoms of temporomandibular disorder (TMD) in a general population, and to assess whether there are specific symptoms associated with headache. METHODS: A personal interview survey conducted in 1995 on 483 adult subjects from the metropolitan community of Segrate, northern Italy. RESULTS: The overall prevalence of headache in the past year was 21.2%. The prevalence of temporomandibular symptoms was 54.3%. Headache occurred significantly more in females than males (26.5 vs 15.4%), and in subjects with, rather than without, symptoms of TMD (27.4 vs 15.2%). Among symptoms, temporomandibular pain, temporomandibular joint sounds, and pain on movements of the jaw were associated with headache using a univariate analysis. After adjustment for confounding variables, a multiple logistic regression confirmed a significant relationship of headache with temporomandibular pain (OR 1.83, 95% CI, 1.07-3.15). CONCLUSIONS: In the general adult population there is an association between headache and symptoms of TMD. A functional evaluation of the stomatognathic system should be therefore considered in subjects with unexplained headache, even if chronic conditions and mechanical symptoms of temporomandibular disorder are absent.     

Association between temporomandibular disorders and pain in other regions of the body

The pain from temporomandibular disorder (TMD) is often associated with physical symptoms of other chronic pain disorders and comorbidities, such as generalised muscle and joint pain. However, this association is not widely studied. To evaluate the prevalence of comorbid pain in joints, specifically in the knees, hips, ankles, shoulders, wrists and elbows, in individuals with and without TMD. We evaluated 337 patients from a public hospital in the city of Rio de Janeiro, Brazil. The Research Diagnostic Criteria for TMD questionnaire were used for the diagnosis of TMD. To assess the presence of other joint pain, the patients were asked to answer questions considering: the presence of pain in the knee, hip, ankle, shoulder, wrist and elbow joints and time duration of pain. Individuals with TMD are 5·5 times more likely to present with other joint pain compared with those without the disorder. TMD muscle disorders were most associated with a higher number of pain at the other locations. There was a significant association between the presence of pain at the other locations, muscle (P < 0·001) and joint disorders (P = <0·001), as well as age advance, in TMD participants, showed to be a covariate factor for pain at the other locations. Individuals with TMD showed a high prevalence of pain in other joints of the body when compared with individuals without the disorder, and knee pain was the most prevalent pain complaint.     

Otological findings and other symptoms related to temporomandibular disorders in young people

In a prospective, observational study between April and November 2017 we evaluated the correlation between temporomandibular disorder (TMD), and otological signs and other symptoms in a sample of 251 patients. First, a simplified anamnestic questionnaire was applied for the diagnosis of TMD and the following symptoms were recorded: otalgia, tinnitus, vertigo, pruritus of the ear, feeling of hearing loss, fullness in the ear, headache, pain in the eye, neck pain, back pain, and dizziness. Some degree of TMD was detected in 177 of the participants (70.5%). Among the otological symptoms studied, significant associations were found with tinnitus (<0.001), ear pain (<0.001), feeling of hearing loss (<0.001), and vertigo (<0.001). There were also significant associations with non-otological symptoms, the most common being back pain (<0.001), headache (<0.001), neck pain (<0.001), pain in the eye (<0.001), and dizziness (0.001). Our findings show that the higher incidence of both otological and non-otological symptoms was associated with a progressive increase in the severity of TMD.     

TMD in class III patients referred for orthognathic surgery: Psychological and dentition-related aspects

ObjectiveTo investigate temporomandibular disorders (TMD), psychosocial, and occlusal variables in class III orthognathic surgery patients with respect to the control subjects, and to compare psychosocial and occlusal features in class III patients with different Research Diagnostic Criteria for TMD (RDC/TMD) diagnoses.Materials and methodsThe study enrolled 44 class III patients referred for orthognathic surgery and 44 individuals without a malocclusion. TMD, depression and somatization were assessed by RDC/TMD. Occlusal analysis included Helkimo's Occlusal Index items, overjet and overbite.ResultsIn the controls, patients with class III deformities had higher prevalence of myogenic TMD, increased grade of chronic pain, and more occlusal deviations. Within the study group, TMD patients reported higher depression score (P < 0.01), myofascial pain was related to higher depression and somatization grades (P < 0.01, P < 0.05 respectively), and disc displacement showed relation with RCP-ICP slide interferences (P < 0.05).ConclusionWith respect to subjects without a malocclusion, TMD in class III dentofacial deformities is similar in prevalence, but differs in clinical appearance. Occlusal, but not psychosocial features deviate from those in the controls. While psychosocial variables accompanied TMD and myofascial pain, increased RCP-ICP slide was related to disc displacement in class III patients.     

Sex‐related differences in symptoms of temporomandibular disorders and structural changes in the lateral pterygoid muscle after whiplash injury

Whiplash injury is an initiating or aggravating factor of temporomandibular disorder (TMD). Although there are sex‐related differences in the mechanism of pain perception and pain control, there is a lack of research on differences in TMD after whiplash injury. We aimed to evaluate sex‐related differences in the clinical symptoms and magnetic resonance imaging (MRI) findings of patients with TMD attributed to whiplash injury. This retrospective, cross‐sectional study included 100 patients (50 women; 50 men; mean age, 37.60 years) who visited our oro‐facial pain clinic with symptoms of TMD after whiplash injury. All patients underwent detailed evaluations for history of trauma, and their clinical and MRI findings were comprehensively assessed. Women with TMD after whiplash injury perceived more pain and presented more tenderness upon palpation than did men with TMD. In addition, women showed higher volume (58% vs 26%) and signal changes (54% vs 20%) in the lateral pterygoid muscle (LPM) and more anterior disc displacement without reduction (ADDWoR) (40% vs 20%) than did men. The presence of ADDWoR (odds ratio, 10.58; P = 0.007) and condylar degeneration (odds ratio, 9.30; P = 0.015) predicted LPM volume; stressful conditions (beta = 1.34; P = 0.011) correlated with increased visual analogue scale scores, and sleep problem was associated with an increased palpation index (PI) (beta = 0.42; P < 0.001) and neck PI (beta = 0.49; P < 0.001) scores only in women. Our results showed sex‐specific differences in pain intensity, distribution of clinical and abnormal MRI findings, and their relationships, and these differences should be considered when treating patients with TMD.     

Prevalence of temporomandibular pain and subsequent dental treatment in Swedish adolescents

AIMS: To assess the prevalence of temporomandibular disorder (TMD) pain in Swedish adolescents, to evaluate whether there are differences in TMD pain in regard to age, gender, and place of residence (urban or rural), and to evaluate treatment for TMD pain and compare it with documented treatment for teeth with caries. METHODS: All youths aged 12 to 19 years in Osterg?tland County were eligible to participate in the investigation, which took place at public dental clinics during annual examinations in 2000. The subjects were asked 2 questions: (1) "Do you have pain in your temples, face, jaw joint, or jaws once a week or more?" and (2) "Do you have pain when you open your mouth wide or chew once a week or more?" Two hundred dental records of patients with TMD pain and 100 records of patients with documented caries were randomly selected from the population. These records were used to compare the treatment of TMD pain to the treatment of caries. RESULTS: Among the 28,899 youths participating, 4.2% reported TMD pain. The prevalence increased with age, and a significant difference was seen between boys (2.7%) and girls (6.0%) (P < .001). In 43% of the patients with TMD pain, the TMD condition was noted in the record. TMD-related treatment was given to 34% of patients with TMD pain in dental clinics, whereas 100% of the patients with caries received restorative treatment. The most common treatment modalities for the TMD group were occlusal splints and information about TMD. CONCLUSION: The prevalence of self-reported TMD pain was relatively low, increased with age, and was higher among girls than boys. One third of the patients with TMD pain received some form of TMD treatment in the dental clinics.     

Are temporomandibular disorders and tinnitus associated?

The current study aimed to research the prevalence of temporomandibular disorders (TMD) in patients with subjective tinnitus, as compared to controls, and the association between symptoms of TMD, tinnitus, and chronic pain. Two hundred patients were divided into two groups, according to the presence (experimental) or not (control) of subjective tinnitus. The subgroups were determined according to the RDC/TMD criteria. The Pain Pressure Threshold (PPT) values of the masseter and temporalis muscles were recorded bilaterally, and a Visual Analog Scale (VAS) was used to address subjective pain. The most prevalent TMD subgroups in the tinnitus patients (p < 0.05) were myofascial pain with limited opening (39.0%), disc displacement with reduction (44.33%), and arthralgia (53.54%). The severity of tinnitus was significantly associated with the severity of chronic pain (p = .000). The PPT values were lower (p > 0.05), while the Visual Analog Scale (VAS) was statistically higher (p = .000) for the tinnitus patients. These results suggest that an association exists between TMD and subjective tinnitus.