Temporomandibular Disorders and Fibromyalgia Prevalence: A Systematic Review and Meta-Analysis

Purpose: To evaluate the prevalence of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS) in TMD patients and the prevalence of TMDs in patients with FMS. Method: A systematic search was performed in electronic databases. Studies published in English examining the prevalence of comorbid TMDs and CWP/FMS were included. The Newcastle-Ottawa Scale was used to assess study quality, and meta-analyses using defined diagnostic criteria were conducted to generate pooled prevalence estimates. Results: Nineteen studies of moderate to high quality met the selection criteria. Meta-analyses yielded a pooled prevalence rate (95% CI) for TMDs in FMS patients of 76.8% (69.5% to 83.3%). Myogenous TMDs were more prevalent in FMS patients (63.1%, 47.7% to 77.3%) than disc displacement disorders (24.2%, 19.4% to 39.5%), while a little over 40% of FMS patients had comorbid inflammatory degenerative TMDs (41.8%, 21.9% to 63.2%). Almost a third of individuals (32.7%, 4.5% to 71.0%) with TMDs had comorbid FMS, while estimates of comorbid CWP across studies ranged from 30% to 76%. Conclusions: Despite variable prevalence rates among the included studies, the present review suggests that TMDs and CWP/FMS frequently coexist, especially for individuals with painful myogenous TMDs. The clinical, pathophysiologic, and therapeutic aspects of this association are important for tailoring appropriate treatment strategies.

temporomandibular disorder; chronic widespread pain; fibromyalgia; prevalence; epidemiology; systematic review; meta-analysis

1. de Leeuw R, Klasser Gary D (eds). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management, ed 6. Quintessence, 2018.

2. International Classification of Orofacial Pain, 1st edition (ICOP). Cephalalgia 2020;40:129–221.

3. Gesch D, Bernhardt O, Alte D, et al. Prevalence of signs and symptoms of temporomandibular disorders in an urban and rural German population: Results of a population-based study of health in Pomerania. Quintessence Int 2004;35:143–50.

4. Okeson JP. Management of Temporomandibular Disorders and Occlusion, ed 8. Elsevier, 2019.

5. Progiante PS, Pattussi MP, Lawrence HP, Goya S, Grossi PK, Grossu ML. Prevalence of temporomandibular disorders in an adult Brazilian community population using the research diagnostic criteria (axes I and II) for temporomandibular disorders (the Maringá study). Int J Prosthodont 2015;28:600–609.

6. Salonen L, Helldén L, Carlsson GE. Prevalence of signs and symptoms of dysfunction in the masticatory system: An epide-miologic study in an adult Swedish population. J Craniomandib Disord 1990;4:241–250.

7. Ferreira CLP, Silva MAMR da, Felício CM de. Signs and symptoms of temporomandibular disorders in women and men. Codas 2016;28:17–21.

8. Fricton J. Myogenous temporomandibular disorders: Diagnostic and management considerations. Dent Clin North Am 2007;51:61–83.

9. De Kanter RJ, Truin GJ, Burgersdijk RC, et al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms of temporomandibular disorder. J Dent Res 1993;72:1509–1518.

10. List T, Wahlund K, Wenneberg B, Dworkin SF. TMD in children and adolescents: Prevalence of pain, gender differences, and perceived treatment need. J Orofac Pain 1999;13:9–20.

11. Hoffmann RG, Kotchen JM, Kotchen TA, Cowley T, Dasgupta M, Cowley AW Jr. Temporomandibular disorders and associated clinical comorbidities. Clin J Pain 2011;27:268–274.

12. Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping chronic pain conditions: Implications for diagnosis and classification. J Pain 2016;17(9 suppl):T93–T107.

13. Slade GD, Fillingim RB, Sanders AE, et al. Summary of findings from the OPPERA prospective cohort study of incidence of first-onset temporomandibular disorder: Implications and future directions. J Pain 2013;14(12 suppl):T116–T124.

14. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301–355.

15. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the international RDC/TMD consortium network* and orofacial pain special interest group† J Oral Facial Pain Headache 2014;28:6–27.

16. Treede R-D, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain 2015;156:1003–1007.

17. Borchers AT, Gershwin ME. Fibromyalgia: A critical and comprehensive review. Clin Rev Allergy Immunol 2015;49:100–151.

18. Wolfe F, Smythe HA, Yunus MB, et al. The American college of rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 1990;33:160–172.

19. Häuser W, Perrot S, Sommer C, Shir Y, Fitzcharles M-A. Diagnostic confounders of chronic widespread pain: Not al-ways fibromyalgia. Pain Rep 2017;2:e598.

20. Marques AP, Santo A de S do E, Berssaneti AA, Matsutani LA, Yuan SLK. Prevalence of fibromyalgia: Literature review update. Rev Bras Reumatol Engl Ed 2017;57:356–363.

21. Wolfe F, Clauw DJ, Fitzcharles M-A, et al. The American college of rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010;62:600–610.

22. Fraga BP, Santos EB, Farias Neto JP, et al. Signs and symptoms of temporomandibular dysfunction in fibromyalgic patients. J Craniofac Surg 2012;23:615–618.

23. da Silva LA, Kazyiama HH, de Siqueira JTT, Teixeira MJ, de Siqueira SRDT. High prevalence of orofacial complaints in pa-tients with fibromyalgia: A case-control study. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:e29–34.

24. Pimentel MJ, Gui MS, Martins de Aquino LM, Rizzatti-Barbosa CM. Features of temporomandibular disorders in fibromyalgia syndrome. Cranio 2013;31:40–5.

25. Salvetti G, Manfredini D, Bazzichi L, Bosco M. Clinical features of the stomatognathic involvement in fibromyalgia syndrome: A comparison with temporomandibular disorders patients. Cranio 2007;25:127–133.

26. Fillingim R, Ohrbach R, Greenspan J, et al. Associations of psychologic factors with multiple chronic overlapping pain conditions. J Oral Facial Pain Headache 2020;34:s85–s100.

27. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 2011;152(3 suppl):S2–S15.

28. Yunus MB. The prevalence of fibromyalgia in other chronic pain conditions. Pain Res Treat 2012;2012:584573.

29. Gui MS, Pimentel MJ, Rizzatti-Barbosa CM. Temporomandibular disorders in fibromyalgia syndrome: A short-communication. Rev Bras Reumatol 2015;55:189–194.

30. Ayouni I, Chebbi R, Hela Z, Dhidah M. Comorbidity between fibromyalgia and temporomandibular disorders: A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2019;128:33–42.

31. De Stefano R, Bruno A, Muscatello MRA, et al. Oral health and fibromyalgia syndrome: A systemic review. J Funct Morphol Kinesiol 2020;5:7.

32. Nascimento LP do, Taveira KVM, Berretta F, et al. Prevalence of temporomandibular disorder in patients with fibromyalgia: A systematic review. Brazilian J Dev 2020;6:80261–80285.

33. Kleykamp BA, Ferguson MC, McNicol E, et al. The prevalence of psychiatric and chronic pain comorbidities in fibromyal-gia: An ACTTION systematic review. Semin Arthritis Rheum 2021;51:166–174.

34. Kleykamp BA, Ferguson MC, McNicol E, et al. The prevalence of comorbid chronic pain conditions among patients with tem-poromandibular disorders: A systematic review. J Am Dent Assoc 2022;153:241–250.e10.

35. Yakkaphan P, Tara R. Systematic review of temporomandibular disorders with comorbid headache. PROSPERO 2020. Accessed August 21, 2023. https://www.crd.york.ac.uk/pros-pero/display_record.php?ID=CRD42020177509

36. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak 2007;7:16.

37. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Med 2009;6:e1000100.

38. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177–188.

39. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557–560.

40. Wells GA, Shea B.; O’Connell D, et al. The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Accessed August 21, 2023. http://www. ohri.ca/programs/clinical_epidemiology/oxford.asp

41. Gough D. Weight of evidence: A framework for the apprais-al of the quality and relevance of evidence. Res Pap Educ 2007;22:213–228.

42. Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000;160:221–227.

43. de Siqueira SRDT, Teixeira MJ, de Siqueira JTT. Orofacial pain and sensory characteristics of chronic patients compared with controls. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:e37–e45.

44. Wright EF, Des Rosier KF, Clark MK, Bifano SL. Identifying undiagnosed rheumatic disorders among patients with TMD. J Am Dent Assoc 1997;128:738–744.

45. Raphael KG, Marbach JJ, Klausner J. Myofascial face pain. Clinical characteristics of those with regional vs. widespread pain. J Am Dent Assoc 2000;131:161–171.

46. Leblebici B, Pekta¸s ZO, Ortancil O, Hürcan EC, Bagis S, Akman MN. Coexistence of fibromyalgia, temporomandibular disorder, and masticatory myofascial pain syndromes. Rheumatol Int 2007;27:541–544

47. John MT, Miglioretti DL, LeResche L, Von Korff M, Critchlow CW. Widespread pain as a risk factor for dysfunctional temporomandibular disorder pain. Pain 2003;102:257–263.

48. Velly AM, Look JO, Schiffman E, et al. The effect of fibromyalgia and widespread pain on the clinically significant temporomandibular muscle and joint pain disorders—A prospective 18- month cohort study. J Pain 2010;11:1155–1164.

49. Losert-Bruggner B, Hülse M, Hülse R. Fibromyalgia in patients with chronic CCD and CMD—A retrospective study of 555 patients. Cranio 2017;36:318–326.

50. Rhodus NL, Fricton J, Carlson P, Messner R. Oral symptoms associated with fibromyalgia syndrome. J Rheumatol 2003;30:1841–1845.

51. Balasubramaniam R, de Leeuw R, Zhu H, Nickerson RB, Okeson JP. Prevalence of temporomandibular disorders in fibromyalgia and failed back syndrome patients: A blinded prospective comparison study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:204–216.

52. García-Moya E-J, Montiel-Company J-M, Almerich-Silla J-M. Case-control study of craniomandibular disorders in patients with fibromyalgia. J Clin Exp Dent 2015;7:e293–298.

53. Zwir L, Fraga M, Sanches M, Hoyuela C, Len C, Terreri MT. A case-control study about bite force, symptoms and signs of temporomandibular disorders in patients with idiopathic musculoskeletal pain syndromes. Adv Rheumatol 2018;58:7.

54. Gui MS, Pedroni CR, Aquino LMM, et al. Facial pain associated with fibromyalgia can be marked by abnormal neuromuscular control: A cross-sectional study. Phys Ther 2013;93:1092–1101.

55. Di Venere D, Corsalini M, Stefanachi G, et al. Quality of life in fibromyalgia patients with craniomandibular disorders. Open Dent J 2015;9:9–14.

56. Nguyen TT, Vanichanon P, Bhalang K, Vongthongsri S. Pain duration and intensity are related to coexisting pain and comorbidities present in temporomandibular disorder pain patients. J Oral Facial Pain Headache. 2019;33:205–212.

57. Domin M, Grimm NK, Klepzig K, Schmidt CO, Kordass B, Lotze M. Gray matter brain alterations in temporomandibular disorder tested in a population cohort and three clinical samples. J Pain 2021;22:739–747.

58. Häuser W, Perrot S, Sommer C, Shir Y, Fitzcharles M-A. Diagnostic confounders of chronic widespread pain: Not always fibromyalgia. Pain Rep 2017;2:e598.

59. Jo JH, Son C, Chung JW, Park JW. Presence of widespread pain predicts comorbidities and treatment response in temporo-mandibular disorders patients. Oral Dis 2022;28:1682–1696.

60. Dao TT, Reynolds WJ, Tenenbaum HC. Comorbidity between myofascial pain of the masticatory muscles and fibromyalgia. J Orofac Pain 1997;11:232–241.

61. Fricton JR. The relationship of temporomandibular disorders and fibromyalgia: Implications for diagnosis and treatment. Curr Pain Headache Rep 2004;8:355–363.

62. Plesh O, Wolfe F, Lane N. The relationship between fibromyalgia and temporomandibular disorders: Prevalence and symptom severity. J Rheumatol 1996;23:1948–1952.

63. Manfredini D, Tognini F, Montagnani G, Bazzichi L, Bombardieri S, Bosco M. Comparison of masticatory dysfunction in temporomandibular disorders and fibromyalgia. Minerva Stomatol;53:641–50.

64. Pfau DB, Rolke R, Nickel R, Treede R-D, Daublaender M. Somatosensory profiles in subgroups of patients with myogenic temporomandibular disorders and fibromyalgia syndrome. Pain 2009;147:72–83.

65. Campi LB, Visscher CM, Ongaro PCJ, Braido GVV, Fernandes G, Gonçalves DAG. Widespread pain and central sensitization in adolescents with signs of painful temporomandibular disorders. J Oral Facial Pain Headache 2020;34:83–91.

66. Von Korff M, Resche L Le, Dworkin SF. First onset of common pain symptoms: A prospective study of depression as a risk factor. Pain 1993;55:251–258.

67. LeResche L, Mancl LA, Drangsholt MT, Huang G, Von Korff M. Predictors of onset of facial pain and temporomandibular disorders in early adolescence. Pain 2007;129:269–278.

68. Hedenberg-Magnusson B, Ernberg M, Kopp S. Presence of orofacial pain and temporomandibular disorder in fibromyalgia. A study by questionnaire. Swed Dent J 1999;23:185–192.

69. Harper DE, Sayre K, Schrepf A, Clauw DJ, Aronovich S. Impact of fibromyalgia phenotype in temporomandibular disorders. Pain Med 2021;22:2050–2056.

70. Chandola HC, Chakraborty A. Fibromyalgia and myofascial pain syndrome—A dilemma. Indian J Anaesth 2009;53:575–581.

71. Questions & Answers About Fibromyalgia. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Public Health Service, 2004. Accessed August 21, 2023. https://baylor.primo.exlibrisgroup.com/discover y/fulldisplay/alma991016805519705576/01BUL_INST:BAYLOR

72. Barjandi G, Kosek E, Hedenberg-Magnusson B, Velly AM, Ernberg M. Comorbid conditions in temporomandibular disorders myalgia and myofascial pain compared to fibromyalgia. J Clin Med 2021;10:3138.

73. Lövgren A, Visscher CM, Lobbezoo F, et al. The association between myofascial orofacial pain with and without referral and widespread pain. Acta Odontol Scand 2022;80:481–486.