PROF.

MARCIO LIMA GROSSI (Orcid ID : 0000-0003-2896-3231)

Accepted Article
Article type : Review

GENDER DIFFERENCES IN TEMPOROMANDIBULAR DISORDERS IN ADULT POPULATIONAL

STUDIES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Caroline H. Bueno1; Duziene D. Pereira2; Marcos P. Pattussi3; Patrícia K. Grossi4, Márcio L. Grossi5

1
DDS, MS, Post-Graduate Program in Dentistry (Prosthodontics), Faculty of Dentistry, Pontifical

Catholic University of Rio Grande do Sul (PUCRS), Brazil.

2
DDS, MS, PhD student, Post-Graduate Program in Dentistry (Prosthodontics), Faculty of Dentistry,

Pontifical Catholic University of Rio Grande do Sul (PUCRS), Post-Graduate Program in Dentistry

(Prosthodontics), Brazil.
3
DDS, MSc, PhD , Post-Graduate Program in Public Health, Vale do Rio dos Sinos University

(UNISINOS), Brazil.
4
BSW, MSW, PhD, Post-Graduate Program in Social Work, School of Humanities, Pontifical Catholic

University of Rio Grande do Sul (PUCRS), Brazil

5
DDS, MS, PhD, Post-Graduate Program in Dentistry (Prosthodontics), Faculty of Dentistry, Pontifical

Catholic University of Rio Grande do Sul (PUCRS), Brazil.

Corresponding author: Prof. M. L. Grossi. Faculty of Dentistry, Pontifical Catholic University of Rio

Grande do Sul (PUCRS), Brazil. Address: Faculdade de Odontologia – PUCRS, Avenida Ipiranga

6681, Porto Alegre RS, Brazil, 90619-900. E-mail: mlgrossi@pucrs.br

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/joor.12661
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 ABSTRACT
Accepted Article
The objective of this study was to systematically evaluate gender differences in the prevalence of

TMD.A systematic review was performed in PUBMED,EMBASE,WEB OF SCIENCE and LILACS in

duplicate by two independent reviewers. The inclusion criteria were cross-sectional studies that

reported the prevalence of TMD for men and women and that used the RDC/TMD Axis I group

diagnostic criteria:(group I=muscle disorders; group II=disc displacements; group

III=arthralgias/arthritis/arthrosis).To be eligible for inclusion, studies must include adult individuals (>18

years) from a non-clinical population (i.e.,without pre-diagnosis of TMD);in other words, from

population-based studies.There were no restrictions on the year and language of publication. The

quality of the articles was assessed by an adapted version of the Newcastle-Ottawa Scale(NOS), and

the publication bias was assessed by a funnel plot graph. Data were quantitatively analyzed by meta-

analysis using odds ratio (OR) as the measure effect. The electronic search retrieved a total of 6,104

articles, of which 112 articles were selected for full-text reading according to the eligibility criteria. By

means of manual search, one study was retrieved. Five articles were selected for meta-analysis with a

combined sample of 2,518 subjects.Women had higher prevalence of TMD in all RDC/TMD diagnostic

groups. The meta-analysis yielded the following results:a) OR=2.24 for global TMD (groups I, II and III

combined), b) OR=2.09 for group I, c) OR=1.6 for group II,and d) OR=2.08 for group III. The

importance of gender in the development of TMD has been demonstrated,with a two-times greater risk

for women to develop it as compared to men.

Keywords: temporomandibular joint disorders; orofacial pain; gender identity; epidemiology; review;

meta-analysis.

BACKGROUND

Gender serves as an important determinant of health and plays an etiological role in the

pathophysiology of several dental diseases including temporomandibular disorders (TMD)1. Women

tend to show more signs and symptoms of TMD and to seek treatment more frequently as compared

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 to men2,3. Despite pain has also been associated with gender in most studies4, the literature has been

ambiguous regarding the role of gender in TMD.

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In Brazil, a large population-based study (n = 1,643) conducted in the city of Maringá has

revealed that 36.2% of the population had some degree of pain and temporomandibular dysfunction,

and that 5.1% of the individuals presented with severe limitation due to pain. They have also found

that the prevalence of TMD is usually more common in young adults, in low income individuals, and in

women5. Another study has investigated the prevalence of TMD related symptoms in subjects in their

fifties in Sweden6. They have found that the prevalence of TMD pain was almost twice as frequent in

women (12.7%) as in men (6.7%); and they have also identified bruxism, impaired masticatory

efficiency, and gender as the most significant risk factors for the development of TMD6. On the other

hand, the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) prospective cohort

study, which monitored 2,737 men and women aged 18 to 44 years, recruited at four U.S. study sites

during 2.8 years, has found that gender differences played a minor role in the early onset of signs and

symptoms of TMD, increasing the risk of TMD in only 37%7.

The literature so far has presented gender differences as secondary findings or has reported it

only as part of the study population description, using clinically-based samples and non-validated TMD

questionnaires8. Therefore, a more detailed analysis of the distribution of TMD diagnoses by gender is

necessary to better quantify these differences. Thus, the main objective of this study was to evaluate

the existence of gender differences in TMD from population-based studies which used the

internationally validated Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD)

Axes I and/or II, the present TMD examination and diagnosis gold standard. The secondary objectives

were to assess these differences according to the RDC/TMD Axis I group diagnostic criteria: a) muscle

disorders or group I, b) disc displacements or group II, and c) arthralgia/osteoarthritis/osteoarthrosis or

group III. The global TMD assessment was a combination of groups I, II, and III. In addition, our

results would be discussed briefly against the gender distribution in both large sample

clinical/institutional TMD and in population-based adolescent TMD studies.

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 METHODS
Accepted Article
Study Design

This is a systematic literature review followed by a meta-analysis. The protocol of this study

was registered in the PROSPERO database (2016: CRD42016039209). The project was approved by

the Scientific and Ethics Committee at the Pontifical Catholic University of Rio Grande do Sul Faculty

of Dentistry (2016: CCEFO/PUCRS, #7211), City of Porto Alegre, State of Rio Grande do Sul, Brazil.

Research question

The PICOT question format was used, where "P" is the population or problem of interest, "I" is

the intervention under investigation or variable of interest, "C" is the comparison of interest, "O" is

considered the research outcome when evaluating the results, and "T" is the type of study22. The

research question developed is: “Is there a gender difference in the development of

temporomandibular disorders in the adult population?”; where: P = adult population (≥18 years), I =

female gender, C = male gender, O = pain / dysfunction, and T = cross-sectional and observational

studies.9,10

Inclusion and Exclusion Criteria

To be included in this systematic review, studies must have reported the prevalence of TMD

for both men and women and must have used the RDC/TMD as the diagnostic tool. In addition, to be

eligible, studies must have also included adult individuals (> 18 years), from populations of non-clinical

origin without a pre-diagnosis of TMD; that is, they must be population-based studies. There were no

restrictions on the year and language of publication.

Case-studies, literature reviews, case series, letters to the editor, editorials, comments, short

communications, clinical trials, as well as cohort, case-control, and in vitro studies were excluded.

Studies in which the outcome/disease was not TMD (e.g., headaches, neuropathic facial pain, lip and

cleft palate patients, etc.); studies in which patients underwent orthodontic treatment, surgery, and

other treatments for TMD (e.g., oral splints, medications, physiotherapy); studies in which patients had

a history of facial trauma or rheumatic diseases; and studies in which patients originated from specific

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 TMD populations (i.e., specialized TMD clinics) were excluded. Finally, studies which did not use the

RDC/TMD as the diagnostic tool were excluded.

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Search Strategy

A search was conducted using both DeCS (Biochemistry Health Sciences Descriptors) and

MeSH (Medical Subject Heading of MEDLINE) terms as well as the most used descriptors of

published scientific papers related to the subject. Thus, the following terms were used in the

databases: temporomandibular joint disorder(s), craniomandibular disorder(s), temporomandibular

joint dysfunction syndrome, temporomandibular disorder(s), temporomandibular joint, gender, sex, and

epidemiology.

Different combinations of these search terms were used according to the formatting of each

database. The Boolean terms "AND" and "OR" were used to cross search terms among each other in

order to enlarge (OR) or to restrict (AND) the search spectrum. The search was carried out by two

reviewers (i.e., a master's and a doctoral student) in a duplicate and independent manner (i.e., same

search was conducted twice by each reviewer). The electronic search strategy was performed as

follows in all searched databases: (“Temporomandibular joint disorders” OR “Temporomandibular joint

disorder” OR “Craniomandibular disorders” OR “Craniomandibular disorder” OR “Temporomandibular

joint dysfunction syndrome” OR “Temporomandibular disorders” OR “Temporomandibular disorder”

OR “Temporomandibular joint”) AND (gender OR sex OR epidemiology). The final number of articles

found in each database was the following: a) PUBMED/MEDLINE = 2,198, b) EMBASE = 2,254, c)

LILACS = 231, and d) WEB OF SCIENCE = 1,421. In an effort to search for the gray literature, the

databases NDLTD / Global EDT Search, BDTD - Bank of Theses and Dissertations of CAPES, Open

Gray and Google Scholar were also searched.

Study Selection and Extraction of Data

The results of the electronic search were exported to the EndNote Web program (Thomson

Reuters®, New York, USA). A database was created in the program, where it was possible to store, to

organize, and to select the articles. Prior to selecting the articles themselves, articles in duplicate were

eliminated by the program as well as manually. The selection of the articles was carried out in two

phases: a) phase I: reading and selection of the relevant articles through titles and abstracts by two

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 independent reviewers, and the article was maintained if selected by at least one reviewer; and b)

phase II: analysis by complete reading of the article by two independent reviewers, with the need for
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agreement of both reviewers to include/exclude the study, and in case of disagreement, consensus

was achieved by a third reviewer.

In the second phase, articles which did not meet the inclusion criteria were excluded, and the

reasons were described in a table. To obtain articles selected for complete reading that were not

available in full text, an attempt was made to contact the authors to request them. After completing the

full-text article analysis, the data obtained from those articles which met the inclusion criteria were

transferred to an Excel worksheet (Microsoft Office®, Microsoft, Redmond, USA). In this worksheet, all

relevant information in each article has been noted. The “Cochrane Handbook for Systematic

Reviews”9 and the “Strobe initiative: guidelines on reporting observational studies”10 were used to build

this worksheet.

The data collected were: a) general information about the study (i.e., title, year and publication

period, first author, and country(ies) of origin); b) information about the study methods (i.e.,

duration/follow-up of the study, place of the study, study design, diagnostic criteria used to define the

condition of interest, and methods of data collection); c) information about the study sample (i.e.,

source and method of sample selection, sample size, sample age, and sample distribution by gender);

d) information about outcome(s) (i.e., prevalence of outcome(s) by gender); and e) additional

information (i.e., statistical methods employed, such as odds ratio and standard error).

Statistics and data analysis

To evaluate the quality of the articles, the Newcastle - Ottawa Scale (NOS) was used. The

questionnaire works by means of a "star system" (i.e., a star is awarded for each quality item, which

serves as a quick visual assessment, with a maximum seven stars) used to classify prevalence

studies. In the study selection questionnaire, a study is graded into three major topics: a) the selection

of the study groups; b) the comparability of groups; and c) the verification of the exposure/outcome of

interest11. The study selection questionnaire was applied to each of the articles selected for full-text

reading analysis, in a duplicate and independent manner by the two reviewers. Afterwards, a

consensus was reached, and the final result of the quality of each article was obtained.

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 The data were also analyzed quantitatively, since the heterogeneity between the studies was

low, by combining the results in a meta-analysis and presenting them in a forest plot chart. The
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measure of effect used was the odds ratio (OR), since the outcome was dichotomous. The effect

model used was the fixed one due to the absence of heterogeneity. The statistical method employed

was the Mantel-Haenszel. The statistical program used for data analysis and graphing was the Review

Manager (RevMan Computer program. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The

Cochrane Collaboration, 2014). The heterogeneity was analyzed by means of the I2 inconsistency test,

also present in the Review Manager program. The I2 assigns a value from 0 to 100%, and this

percentage shows how much of the difference between the studies can be explained by

heterogeneity, and not by chance. It is standardly considered that 0-25% has a low heterogeneity, 25-

75% has an intermediate heterogeneity, and above 75% has a high heterogeneity12. Studies with

positive results are more likely to be published, therefore an analysis is important to verify the

presence or absence of publication biases. For this purpose, a visual analysis with a funnel plot graph

(Software Review Manager) was performed. The presence of asymmetry will lead us to question the

interpretation of the global estimate of effect when the studies are combined in a meta-analysis13.

RESULTS

The literature search resulted in 6,104 articles, which yielded a total of 3,418 initial records

after duplicated items were removed. The first screening excluded 3,306 results leaving 112 articles

for full reading. One additional article was included after manual search in these articles’ references.

After reading the full texts, five articles were selected for inclusion in the study, yielding a total sample

size of 2,518 subjects. The sequence of identification, selection of studies and reasons for exclusion

can be seen in detail in Figure 1, and the detailed description of these selected studies were

presented in Table I.

Most of the studies were published in the last five years, and only one in the last 15 years. The

place of studies was divided between Europe and Latin America. Two used both axes of the

RDC/TMD questionnaire (i.e., Axes I and II) for the patient evaluation, and the other three used only

Axis I. Most of them were performed in young adult patients, and one study14 evaluated the elderly

population (Table I).

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 Women presented higher prevalence of TMD in the majority of the RDC/TMD Axis I diagnostic

groups. Men presented higher prevalence of TMD in group I only in Martínez et al. (2013)15, and in

group II in Martínez et al. (2013)15 and Sandoval et al. (2015)14. Group III had higher prevalence rates
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for women in all studies. In the global prevalence of TMD (i.e., groups I, II, and III combined), all

studies have shown higher TMD prevalence for women (Table II).

Meta-analysis

The meta-analysis was performed for each diagnostic group (i.e., groups I, II and III) of the

RDC/TMD Axis I and also for the global results of the TMD prevalence (i.e., all groups combined).

Figure 2a shows the global prevalence of TMD among genders, and there was a highly statistically

significant difference in the prevalence of TMD between men and women (P < 0.00001). The odds for

presenting TMD was 2.2 times higher in women as compared to men. There was no heterogeneity

among the studies.

The meta-analysis performed individually for groups I, II and III of the RDC/TMD is presented

in Figures 2b, 2c and 2d; respectively. There was a statistically significant difference for all TMD

diagnostic groups. The OR has shown us that women are 2.08 times more likely to present muscle

disorders; 1.6 times more likely to have disc displacements; and 2.09 times more likely to have

arthralgia/arthritis/osteoarthrosis than men. The heterogeneity was moderate (i.e., 45%) among the

studies for group I; and low (i.e., 12% and 0%) for groups II and III, respectively.

Publication Bias

The search for publication bias was performed with a Funnel Plot graph. In Figure 3, it can be

observed that the graph found in this study, due to its symmetry, suggests that there is no publication

bias regarding positive results.

Quality of studies

The qualitative analysis of the included studies can be observed in Table III. Overall, all the

studies have presented good quality assessment, having 2 articles with a maximum star evaluation

(i.e., 7 stars), two with six stars, and only one with 5 stars.

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 DISCUSSION
Accepted Article
This systematic review and meta-analysis has found twice the risk of women to develop TMD

than men, an important factor when planning treatment and prevention programs16; although it is

possible to notice that the difference was relatively smaller in group II (disc displacements) than in

both groups I (muscular disorders) and III (arthralgia/arthritis/osteoarthrosis). However, the OPPERA

study, which was not included in this study for not using the RDC/TMD, has confirmed the growing

gender difference with time, as the incidence of TMD observed was 3.9% per year (i.e., 3.6% for

women and 2.8% for men) for 2.8 years with 2,737 participants, producing mild to moderate levels of

pain and disability in all cases17. The difference between the relative risk in the OPPERA study (RR =

1.37) and ours (OR = 2.2) might be attributed to the fact that RR is calculated based on TMD

incidence, while the OR is based on TMD prevalence16, which is higher according the RDC/TMD

graded chronic pain grade classification levels I to IV (36,2%)5.

However, it is not yet clear what aspects of women's biology, psychology, or social roles

predispose them of having more TMD than men. The differences between the genders might be

related to hormonal factors18-20, cultural and social factors21,22, higher levels of work stress for

women2,23, differences in pain sensitivity24-26, as well as health-seeking behaviors1. Although rates of

psychiatric disorders are similar between men and women, the kind of disorders differ. Depression and

anxiety affect women almost twice as often as men2. Since patients with depression are at high risk of

developing TMD27,28, this could be one explanation for the differences found between the genders in

TMD. Using the conclusions from the OPPERA study, self-rated general health conditions (i.e.,

endocrine, cardiovascular, hematologic, somatosensory, and respiratory conditions; as well as sleep

apnea, cigarette smoking, and previous surgeries and hospitalizations), general chronic pain disorders

(i.e., low back and genital pain, irritable bowel syndrome, migraine and tension-type headaches), age,

study site, ethnicity (i.e., African or Asian descendants), and psychosocial and genetic factors seem to

play an equal or more important role than gender. The study has concluded that TMD is a complex

biopsychosocial condition and can no longer be considered a localized orofacial pain condition17. That

said, it seems urgent and relevant to study and investigate why women are more affected by TMD,

since such clarification might bring a more complete clinical approach to these treatments.

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 The choice to include only populational studies that assessed TMD only with the standard

RDC/TMD questionnaire29 was to allow the standardization and unification of TMD diagnoses and a
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better comparison among the study results, considering that only the RDC/TMD has been translated

and validated in many different languages30. Therefore, it is suggested in future studies, the

development of population-based or non-clinical studies which characterize TMD patients using

reliable diagnostic methods, such as the RDC/TMD questionnaire.

In a meta-analysis, it was found that the prevalence of treatment need for TMD in adults was

16.2% and that the study location strongly influenced the summary estimates of the treatment need31.

Indeed, this result contrasts with another Brazilian study by Progiante et al, 2015; which found that

only 5% of the population were in need of TMD treatment.5 Our meta-analysis selected studies from

Latin-America as well as from Eastern and Western Europe; and here too, the study location might

have influenced the different prevalences for men and women found among the selected studies in

our systematic review (Table II) and meta-analysis (Figures 2a, 2b, 2c, and 2d). Therefore, as a

limitation of our study, we should consider the confounding factors specific to the studies that were

selected, such as: the country of study and the methodology applied by single or multiple examiners

which were not considered in our final analysis. The lack of reported data regarding the RDC/TMD

sub-groups in TMD gender prevalence in the literature (i.e., groups Ia, Ib, IIa, IIb, IIc, IIIa, IIIb and IIIc)

for our data collection and meta-analysis was also a limitation. Another issue is the very few studies

selected (only five) which reported primary non-clinical TMD population (i.e., without a prior TMD

diagnosis) and that used the RDC/TMD, which was our main inclusion criteria. The analysis ended

with no study reporting the TMD prevalence in Asia, Africa and North America; only in Europe and

Latin America. However, another study not included in our analysis for not using the RDC/TMD,

reported the prevalence of facial pain and TMD in people from urban and rural areas in Iran. It

evaluated, by means of logistic regression analysis, the influence of potential TMD risk factors such

as: education, gender, health, and the environment. Their results, similar to our global TMD OR = 2.2,

have shown that gender was also an important risk factor with OR = 2.28.32

Another limitation of our study was the fact that we have included a predominantly young adult

population (i.e., 4 out of 5 studies selected) with a mean age ranging from 22 to 46 years. The only

study with an older population was from Sandoval et al, with a mean age of 67 years old, but with a

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 weight of only 4.6% in the overall TMD results (i.e., groups I, II and III combined).14 Therefore, our

results are valid predominantly for the young adult age group; and conclusions for other age groups,
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such as adolescents and the elderly population, should be performed in specific systematic reviews.

However, a brief discussion of the adolescent age group only will be detailed below, considering that

the elderly group comprises a small portion of patients seeking TMD treatment.5

Regarding adolescence, TMD is more prevalent in adolescents. There has been some recent

TMD prevalence studies in adolescents with large samples (n = 934 – 1,307) from the general

population.34,35,36,37 The methodology has been heterogenous, but most of them recruit subjects from

public schools, between the ages of 10 up to 18, and they use the RDC/TMD Axis I for the clinical

examination with a combination of a simple screening questionnaire (i.e., the American Academy

Orofacial Pain - AAOP or the Helkimo Index modified by Fonseca); the Axis II is hardly ever used, or

used partially with few questions.34,35,36,37,38 Using this methodology, the prevalence of TMD symptoms

has been high and varied (25.2% - 34.9%), but with a predominance of myofascial pain diagnosis

(10.3% - 15.4%).34,35,36,37 Disc displacement with reduction (4.8% - 8.0%) was also frequent; while

arthralgia was rarely diagnosed (3.3% - 3.5%), similar to osteoarthritis (0.0% - 0.2%) and

osteoarthrosis (1.5% - 2.2%).34,35 Despite the variation observed among studies, most of them have

reported that the majority of the sample with TMD symptoms studied were women (61.2%-63.1%),

keeping the odds in approximately 2:1; similarly to what has been reported in adult populational

studies and in this meta-analysis.5,35,37 However, few studies have actually measured gender as a risk

factor for TMD in this age group; in one study, the authors have found a 37% increase in prevalence

ratio in women for developing TMD symptoms, 76% increase for developing myofascial pain, and

106% increase for developing disc displacement with reduction.35 In another study, the authors have

found a 30% increase in odds ratio for developing TMD symptoms, 50% increase for myofascial pain,

20% increase for disc displacement with reduction, but no difference for arthralgia or osteoarthrosis.34

These results are similar to what was reported in this meta-analysis. As explained before, screening

questionnaires (i.e.; AAOP and the Helkimo index modified by Fonseca) have been used frequently in

the literature in this age group; however, a study has found low sensitivity in both questionnaires for

the detection of TMD symptoms, despite showing a high specificity in children and adolescents. In

addition, the authors have also found low levels of agreement in both screening questionnaires

against the TMD clinical exam.39 Therefore, the results from these screening questionnaires must be

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 interpreted with caution. Studies with the RDC/TMD Axis II Graded Chronic Pain Scale (i.e., GCPS for

TMD pain intensity and disability assessment) are rare, and it is unknown if these adolescents with
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signs and symptoms of TMD are in fact in need of treatment. These two measurements, pain intensity

versus disability (i.e., GCPS=I,II,III,IV versus GCPS=III,IV), have been shown to give very different

prevalences in the adult population (i.e., 36.2% versus 5.1%).5 As an example, only one study that

used the GCPS has shown that only 6.5% of the adolescents with TMD symptoms were included in

Grades=III,IV and were in fact in need of treatment, but 27.2% of them had TMD symptoms.34 It is

important to emphasize that both the RDC/TMD Axis I and the modified Axis II have already been

tested for reliability in this age group, with results ranging from acceptable to excellent in Axis I, and

from good to excellent in the modified Axis II.40 It is not known also if these signs and symptoms are

self-limiting once the growth spurt finishes, or if in fact they will increase after puberty. One single

three-year longitudinal study, which used the GCPS, reported an incidence of TMD symptoms of 4.5%

for girls and 1.3% for boys. They also compared teenagers with 12-15 against those with 13-19 years

of age. They have found significant differences in all TMD pain and psychosocial measures and have

concluded that TMD pain increases with age; and that TMD pain seems to have a greater impact on

girls rather than boys, particularly between 16 to 19 years of age.41 Therefore, more longitudinal

studies with the validated RDC/TMD Axis I and II, or with the newly developed DC/TMD, are still

needed in different age groups during adolescence.42

Regarding large sample studies (N ≥ 300) in TMD seeking-treatment (i.e., institutional or

clinical) patients which have also used the RDC/TMD Axis I or II within the last 10 years, we have

found interesting results. The sample among the reviewed studies have ranged from 308 to 3,263

TMD patients, the mean age has varied from 19 to 44 years, and the proportion of women has varied

from 57.3% 88%.43-52 This yields odds ranging approximately from 3:1 to 9:1, which is substantially

larger than what we have found among non-TMD population-based sample in this study; i.e., odds of

2:1. This can be explained due to the fact that patients seeking treatment have usually higher TMD

pain and disability levels than what has been found in the non-clinical population; and the increase in

pain levels seems to affect women more than men, not only in the adult, but also in adolescent

population.1-4,41

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 CONCLUSIONS
Accepted Article
This systematic review and meta-analysis has shown that female gender increases in more

than two times the risk of developing TMD. However, other equally important factors reported in the

recent literature must be also taken into account, such as: self-rated general health conditions, general

chronic pain disorders, age, study site, ethnicity, and psychosocial and genetic factors.

ACKNOWLEDGMENTS

This project was approved by PUCRS Faculty of Dentistry (Project #7211) Ethics Committee,

Brazil. This research received no specific grant from any funding agency in the public, commercial, or

not-for-profit sectors. The authors declare that they have no conflicts of interest.

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 Table I. Description of population-based studies which used the RDC/TMD Axis I to assess the
prevalence of TMD in women versus men.

Diagnostic Sampl Proportio Mean

Accepted Article
Countr Method of data Method of selecting the
Author Year Journal criteria e n of ♀ e age
y collection participants
used size (n) ♂ (%) (years)
Rev
79.5
Colombiana RDC/TMD Patients attended at the
15 201 women
Martínez et al. Investigació Mexico Axes I and Not reported dental clinic but who did not 78 38.2
3 and 20.5
n II receive treatment for TMD.
men
Odontología
Individuals were randomly
Interview + clinical 65.9
RDC/TMD selected by a computer
201
5 Int J examination, women
Progiante et al. Brazil Axes I and program from a list of 1,643 32.7
5 Prosthodont single trained and 34.1
II individuals from the Health
examiner men
Department of Maringá.
Interview + clinical
Individuals randomly 52 women
Rantala 200 J Orofac RDC/TMD examination,
Finland selected from the Finnish 241 and 48 46
et al.33 3 Pain Axis I single trained
Broadcasting Company men
examiner
Selected subjects from the
Interview + clinical universe of patients with
Int J 67 women
Sandoval et 201 RDC/TMD examination, active dental treatment of
Odontostom Chile 100 and 33 67.6
al.14 5 Axis I multiple trained the Clinics of Partial
at men
examiners Removable Prosthesis and
Integrated Clinic of the Adult.
Interview + clinical
BioMed 58 women
Wieckiewicz et 201 RDC/TMD examination, University students from 4
Research Poland 456 and 42 22.01
al.30 4 Axis I multiple trained Polish universities
International men
examiners

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 Table II. Outcomes of the selected studies: prevalence (%) of temporomandibular disorders (TMD) by

gender using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I by
Accepted Article
diagnostic group individually and by all diagnostic groups combined.

n N GI GI GII GII GIII GIII Global Global

Studies
♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ TMD ♂ TMD ♀
Martínez et al.15 16 62 71.4 69.4 85.7 55.5 28.5 38.8 8.9 46.2
Progiante et al.5 561 1082 20.7 34 4.5 7.6 15.3 25 25 42.1
Rantala et al.33 116 125 6 20 6 12.1 6 15.3 16 38
Sandoval et al.14 33 67 6 9 36.5 31.3 0 11.9 36.4 52.2
Wieckiewicz et al.30 192 264 4 14 15 29 4 14 18 36

* GI or group I = muscle disorders; GII or group II = disc displacements; GIII or group III =

arthralgias/arthritis and arthrosis; Global TMD = GI+GII+GIII.

Table III. Result of the quality evaluation of the five selected studies which used the Research

Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I (groups I, II and III) to assess

the prevalence of TMD in women versus men

Studies Selection Comparability Outcome Score

Martínez et al.15 6

Progiante et al.5 7

Rantala et al.33 7

Sandoval et al.14 5

Wieckiewicz et al.30 6

Instrument: The Newcastle - Ottawa Scale (NOS). Maximum of 7 stars can be awarded to a study.

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 < Insert Figure 1>
Accepted Article
Figure 1. Flowchart of the identification and selection of the studies.

<Insert Figure 2>

Figure: 2a. Forest plot of the odds ratios for global prevalence of temporomandibular disorders

(RDC/TMD Axis I: groups I, II and III) in women versus men. 2b. Forest plot of odds ratios (OR) for

muscle disorders (RDC/TMD, Axis I, group I) in women versus men. 2c. Forest plot of the odds ratios

for disk displacements (RDC/TMD, Axis I, group II) in women versus men. 2d. Forest plot of the odds

ratios for arthralgia/arthritis/arthrosis (RDC/TMD, Axis I, group III) in women versus men.

<Insert Figure 3>

Figure 3. Funnel Plot of selected studies which used the Research Diagnostic Criteria for

Temporomandibular Disorders (RDC/TMD) Axis I (groups I, II and III) to assess the prevalence of

TMD in women versus men.

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Accepted Article

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Accepted Article

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Accepted Article

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