The relationship between psychological factors and temporomandibular disorders: a systematic review and meta-analysis

Abstract

Background

Temporomandibular disorders (TMD) are multifactorial conditions that involve pain, dysfunction, and impaired jaw movement, significantly impacting patients' quality of life. Emerging evidence suggests that psychological factors, including anxiety, depression, and stress, play a crucial role in the onset and progression of TMD. However, the exact nature of this relationship remains unclear. This study aims to systematically analyze and quantify the association between psychological factors and TMD, providing clinically relevant insights to improve patient management and therapeutic strategies.

Methods

This study was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY202420084) to ensure methodological transparency and adherence to systematic review standards. The study design and protocol followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The National Institutes of Health (NIH) Quality Assessment Tool was used to assess the methodological quality of the included studies. The data were systematically extracted and analyzed.

Results

The literature search yielded 2392 potential articles, of which 21 were included in this study. A significant correlation was found between TMD and anxiety, depression, stress, and somatization. Statistically significant differences in anxiety and depression scores were observed between patients with TMD and the controls (p < 0.00001). Stress increased TMD development and severity. In addition, subgroup analyses revealed gender differences, with depression significantly correlating with TMD in males. Similarly, students showed significant correlations between TMD and anxiety, while adults demonstrated strong associations with both anxiety and depression. Adolescents showed correlations between TMD development and somatization and obsessive-compulsiveness.

Conclusion

Anxiety, depression, and stress are significant risk factors for the development and progression of TMD. Subgroup analyses demonstrated significant correlations between particular psychological factors and TMD in different sub-populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13005-025-00522-9.

Introduction

Psychological factors influence human experience and behaviour, including emotions, cognition, personality, stress and coping, and psychopathology [1, 2]. Emotions, including extraversion and neuroticism, may impact quality of life. Many psychological factors can influence an individual's physical and mental health. For instance, anxiety and post-traumatic stress disorder can affect the development and course of other physical disorders such as cardiovascular health, pain perception, and recovery from illness [3].

TMDs are characterized by abnormalities in the temporomandibular joint and associated muscles that cause pain, dysfunction, and impaired jaw movements [4]. They could be divided into muscle disorders, including myofascial pain with and without mouth opening limitation; disc displacement with or without reduction and mouth opening limitation; and arthralgia, arthritis, and arthrosis [5]. They negatively affect the oral health and quality of life [6]. They may exhibit overlapping symptoms such as chronic pain conditions, including headaches, fibromyalgia, and neurological disorders. Overlapping symptoms suggest common mechanisms such as central sensitization or comorbidities [7].

TMD is the second most common musculoskeletal disorder that causes pain and disability [8]. Biological, biomechanical, psychological, and environmental factors are potential causes of TMDs [9]. Their severity varies in the origin, level of symptoms, and responsiveness to treatment, all of which are associated with prognosis. These conditions may be magnified by injury to the jaw, tooth grinding, jaw clenching, misaligned bite (malocclusion), arthritis, stress, anxiety, and genetic predisposition [10]. TMDs diagnosis involve medical history evaluation, physical examinations, jaw function assessment, and diagnostic procedures such as electromyography [11–13].

Psychological factors may increase the risk of TMD Symptoms. They may also influence the intensity of patients’ pain and how they respond to treatment [14, 15]. In addition, affective components, such as emotional response and coping heterogeneity, impact pain intensity [16]. Similarly, psychosocial stress may lead to muscle hypertonicity, bruxism, and peripheral/central sensitization, which may predispose to TMD onset [17, 18]. Emotional factors such as anxiety, depression, and somatization have been linked to TMD, with increased levels of psychological stress correlating with increased pain severity and functional impairment [19, 20]. In addition, high levels of catastrophizing are associated with greater pain intensity and disability in patients with TMD [21].

Evidence suggests that elevated levels of psychological distress increase pain severity, frequency of occurrence, and duration in TMD patients [22]. Additionally, psychological factors may cause central sensitization and increase pain severity [23]. Therefore, it is essential to develop practical management approaches by understanding the association between psychological factors and TMD. Although some studies have been conducted to establish psychological factors and their association with TMD [24–26], there is need to conclusively report the impact of psychological factors on TMD. Due to the complexity of TMDs it is vital to broaden the scope of treatment strategies and outcomes [27, 28].

Temporomandibular disorders pose a significant clinical challenge due to their multifaceted etiology, which includes both physiological and psychological components. The presence of anxiety, depression, and stress in TMD patients can exacerbate pain perception, prolong treatment duration, and reduce therapeutic success. However, clinical management often focuses primarily on biomechanical factors, overlooking the substantial role of psychological well-being. By identifying the specific psychological factors that contribute to TMD onset and severity, this study provides clinically relevant insights that can aid in the development of multidisciplinary treatment strategies. Integrating psychological assessments and interventions into routine TMD management may improve patient outcomes, reduce chronic pain progression, and enhance overall quality of life.

Thus, the objective of this systematic review and meta-analysis is to critically appraise and quantify the correlation between psychological factors and TMD. By synthesizing evidence from peer-reviewed studies, we aim to provide an evidence-based foundation for a more holistic, patient-centered approach to TMD treatment.

Methods

This study preparation and reporting adhered to the Preferred Reporting of Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [29]. The protocol used for this systematic review was the registered International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY202420084).

Database search

A comprehensive and updated literature search was conducted across multiple databases to identify peer-reviewed research articles on the correlation between psychological factors and TMD. In addition, a researcher searched the first ten pages of Google Scholar for additional articles. The search strategy was tailored for each database using a combination of controlled vocabulary (e.g., MeSH terms in PubMed) and Boolean operators to refine relevant results.- The search strings are listed in Supplementary Table 1.

Foundational research questions

This systematic review and meta-analysis were guided by the following key research questions:

1. What is the correlation between psychological factors (e.g., anxiety, depression, stress, somatization) and the onset and severity of temporomandibular disorders (TMD)?

2. How do different psychological factors contribute to TMD symptoms across various populations (e.g., students, adolescents, adults, males vs. females)?

3. What are the clinical implications of addressing psychological factors in the management and treatment of TMD?

4. Does the presence of psychological distress affect treatment outcomes and the progression of TMD over time?

Eligibility criteria

This study included peer-reviewed articles investigating the correlation between psychological factors and TMDs. This study used modified PICO criteria for the selection process [30].

• Population- Patients with TMD

• Intervention/Exposure: Psychological factors, including stress, anxiety, depression, and somatization.

• Comparison-Controls without TMD

• Outcome- Correlation between psychological factors and TMD

Inclusion criteria,

• Scholarly articles published in the English language or could be translated into the English language.

• Scholarly articles that focused on the correlation between psychological factors and temporomandibular disorders.

• Scholarly articles conducted on humans.

Exclusion criteria,

• Scholarly research articles that did not directly investigate the correlation between psychological factors and temporomandibular disorders.

• Scholarly research articles that were duplicates or continued work of previous publications, opinion pieces, reviews, abstracts, or editorial articles that did not have precise methods or results.

Methodological quality assessment

To ensure the reliability and validity of the findings, the methodological quality of the included studies was assessed using the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies [31]. This tool provides a standardized approach to evaluating the internal validity of studies by addressing key methodological domains, including sample selection, exposure and outcome measurements, confounding variables, and statistical analyses.

Each study included in the systematic review was assessed based on the following 12 criteria outlined by the NIH tool:

1. Clearly stated research objective

2. Defined study population

3. Adequate sample size justification

4. Selection criteria for study participants

5. Specification of exposure and outcome variables

6. Reliability and validity of exposure measures

7. Reliability and validity of outcome measures

8. Adjustment for potential confounders

9. Blinding of assessors (where applicable)

10. Adequacy of follow-up period (for longitudinal studies)

11. Appropriate statistical analysis

12. Overall risk of bias assessment

Two independent reviewers (RV and MJ) individually scored each included study against these criteria, classifying them as:

• Good Quality (low risk of bias, meeting most criteria)

• Fair Quality (moderate risk of bias, meeting some criteria)

• Poor Quality (high risk of bias, failing key criteria)

Any discrepancies between the two reviewers were resolved through discussion with a third independent reviewer to reach a final consensus. The quality ratings for each study are summarized in Tables 1 and 2, providing an overview of the risk of bias and methodological rigor of the included research.

Table 1.

National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies [31]

Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Quality Rating
Bonjardim et al. (2009) [32]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Chinthakanan et al. (2018) [33]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Chung et al. (2020) [34]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Deshpande et al. (2023) [35]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Diniz et al. (2012) [36]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Eisenlohr-Moul et al. (2013) [37]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Fillingim et al. (2013) [38]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Yes	Good
Fillingim et al. (2011) [39]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Hekmati et al. (2022) [40]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Heo et al. (2018) [41]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Yes	Good
Jivnani et al. (2017) [42]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Good
Lee et al. (2019) [43]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Good
Liu et al. (2022) [44]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Yes	Good
Omezli et al. (2023) [45]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Yes	Good
Paulino et al. (2018) [46]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Pereira et al. (2009) [47]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Staniszewski et al. (2018) [48]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Wu et al. (2021) [49]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Yang et al. (2014) [50]	Yes	Yes	Yes	Cannot determine	Yes	Yes	Cannot determine	Yes	Cannot determine	Cannot determine	Some concerns
Yap and Natu (2020) [51]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Cannot determine	Good
Ye et al. (2022) [52]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Cannot determine	Yes	Good

Q1: Was the research objective clearly stated? Q2: Was the study population specified and defined? Q3: Was the participation rate of eligible persons at least 50%? Q4: Were all the subjects selected or recruited from the same or similar populations? Q5: Were effect estimates provided? Q6: Was the exposure of interest measured before the outcome was measured? Q7: Did the study examine different levels of exposure as related to the outcome? Q8: Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Q9: Were the outcome assessors blinded to the exposure status of participants? Q10: Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposures and outcomes?

Table 2.

Data extraction table

Study	Study Design	Sample Size	Mean Age	Study Purpose	Psychological factors	TMD Symptoms	Severity of Symptoms	Findings
Bonjardim et al. (2009) [32]	Cross-sectional Study	196	18–25	To explore the prevalence of TMD and the correlation with psychological factors, sex, and occlusion.,	Anxiety and depression	Difficulty in opening mouth and moving the jaw, muscular pain when chewing, frequent headache and neck aches, shoulder pain and morning facial pain	9.18% of patients had moderate to severe TMD	TMD had a statistically significant correlation with anxiety
Chinthakanan et al. (2018) [33]	Cross-sectional Study	44	20–40	To assess the association between pain intensity, heart rate variability, psychological factors, and salivary cortisol level by comparing TMD patients and a control group	Anxiety and depression	Orofacial pain, masticatory muscle pain	Pain intensity was significantly higher in TMD group	Pain intensity and psychological distress were more significant in the TMD group
Chung et al. (2020) [34]	Retrospective study	328	41.1 ± 15.4	To assess the correlations between various risk factors for TMD	Emotional stress,	TMD pain, TMD dysfunction, tooth pain, neck/shoulder pain, headache, sharp pain in the face	Not specified	There were different associations between TMD and physical, psychological, and demographic risk factors
Deshpande et al. (2023) [35]	A Case–control Study	100	31.22	To compare risk factors and clinical manifestations in TMD patients	Parafunctional habits, Self-perceived stress	Joint sound, mandibular deviation, myofascial pain (MFP), disc displacement with reduction, arthralgia, disc displacement without reduction	Not specified	TMD had a statistically significant correlation with parafunction and psychological stress
Diniz et al. (2012) [36]	Longitudinal study	55	18–25	To explore the influence of stress and anxiety in TMDs	Stress and anxiety	Joint sounds, headache, neck pain	Not specified	Stress and anxiety are risk factors for TMDs
Eisenlohr-Moul et al. (2013) [37]	Cross-sectional Study	135	41.67 ± 14.05	To investigate the correlation between pain acceptance, psychological distress, and self-regulatory fatigue in TMD patients	Self-regulatory fatigue, psychological distress and well-being, and pain Acceptance	TMD Pain	Not specified	Pain acceptance may minimize psychological symptoms
Fillingim et al. (2013) [38]	Prospective cohort study	2737	27.1 ± 7.8	To investigate TMDs risk factors	Psychological adjustment and personality, affective distress, psychosocial stress, somatic symptoms, and pain coping and catastrophizing	Not specified	Not specified	Psychological factors can predict TMD onset
Fillingim et al. (2011) [39]	Case–Control Study	1818	20–40	To investigate TMDs risk factors	Somatization, sleep quality, and perceived stress	Pain in cheeks, jaw muscles, temples, or jaw joints; myalgia; arthralgia	Not specified	Psychological factors can predict TMD onset
Hekmati et al. (2022) [40]	Case–control study	258	28.98 ± 7.01	To investigate the correlation between TMDs and personality	Anxiety and depression	Joint sound, pain, fatigue, limited mouth opening, locked mandibles, jaw deviation	18.21% of patients had moderate symptoms while 22.09% patients had severe symptoms of TMD	Personality traits were predominant in TMD patients
Heo et al. (2018) [41]	Cross-sectional survey	1337	15.13	To explore the correlation between psychological factors and TMDs	Depression and suicidal ideation	Tenderness on palpation of the TMJ and masticatory muscles, joint noise, limited jaw mobility	Not specified	There was an association between depression, suicidal ideation, and TMDs
Jivnani et al. (2017) [42]	Observational study	200	21.81 ± 1.99	To investigate the correlation between TMDs and psychological factors and to evaluate the prevalence of TMDs	Anxiety and depression	Not specified	Not specified	There was a significant correlation between TMDs and psychological factors
Lee et al. (2019) [43]	Case–control study	70	16.46 ± 2.36	To assess the clinical and psychological aspects of magnetic resonance imaging among adolescent TMD patients	Somatization, anxiety, obsessive-compulsivity, hostility, psychosis, and phobic ideation	Temporomandibular joint (TMJ) pain and dysfunction	High severity in muscle pain among young adults than older people	Psychological factors positively correlated with TMDs
Liu et al. (2022) [44]	Cross-Sectional Study	531	21.86	To assess the correlation between orthodontic history, psychological factors, and TMDs	Depression and anxiety	Pain in the temporomandibular joint, Pain while chewing, Pain in the head or neck, Difficulty in opening the mouth, Jaw locking	Not specified	Orthodontic history is a risk factor for TMD but is not correlated with psychological distress
Omezli et al. (2023) [45]	Cross-sectional study	2580	35.29 ± 12.70	To assess the correlation between anxiety and depression, sociodemographic aspects, parafunctional habits, and TMDs	Anxiety and depression	Pain while chewing, difficulty in opening mouth, joint sounds	Mild, moderate, and severe (in depressed and anxious people)	Bruxism, parafunctional habits, and anxiety and depression are correlated with TMDs
Paulino et al. (2018) [46]	Non-probability cross-sectional study	303	15–19	To assess the correlation between depression, anxiety, emotional distress, parafunctional habits, and TMD prevalence	Anxiety and depression	Pain in temporomandibular joint (TMJ) region, earache, joint noises, limited mouth opening, tiredness, headache, tooth wear	Mild (50.2%), Moderate (33%), Severe (6.6%)	TMDs are associated with female gender and psychological factors
Pereira et al. (2009) [47]	cross-sectional observational study	558	12	To evaluate the correlation between psychological factors and clinical manifestation of TMDs	Depression and somatization	TMD Pain	Not specified	The female gender and psychological factors are risk factors for TMDs
Staniszewski et al. (2018) [48]	Clinical cross-sectional study	88	45	To investigate if TMD patients'hypothalamic–pituitary–adrenal (HPA) axis is upregulated	Anxiety and depression	Not specified	Severe	TMDs are correlated with anxiety, depression, and catastrophizing scores
Wu et al. (2021) [49]	Cross-sectional study	754	19	To assess the prevalence of TMDs and the correlation with psychological factors	Anxiety and depression	Orofacial pain,joint nose,headache and jaw locking	Not specified	TMDs are associated with psychological factors
Yang et al. (2014) [50]	Case–control study	200	Unspecified	To assess the correlation between psychological factors and TMDs	Anxiety and depression	Not specified	Not specified	Anxiety and depression are a significant risk factor for TMDs
Yap and Natu (2020) [51]	Cross-sectional, observational study	400	18.77	To investigate the correlation between TMDs and psychological factors	Depression, anxiety, and Stress	Jaw and temple pain	Not specified	Painful TMDs were associated with somatic and psychological factors
Ye et al. (2022) [52]	Cross-sectional study	570	24.44 ± 8.29	To explore the correlation between TMDs and psychological factors	Anxiety and depression	Jaw pain, ear pain, temple pain, headaches	Severe	Anxiety, depression, and pain catastrophizing are risk factors for TMDs

By applying this rigorous quality assessment framework, the study ensures that only high-quality, reliable evidence informs the systematic review and meta-analysis.

Data extraction

Data extraction was performed systematically to ensure consistency and accuracy. Two independent reviewers (RV and MJ) assessed the full text of all eligible studies, extracting relevant data, including study characteristics, population details, psychological factors examined, TMD outcomes, and statistical findings. Discrepancies between reviewers were discussed and resolved through consensus, with a third reviewer acting as an arbitrator when necessary. Extracted data were organized in a structured Excel workbook to facilitate synthesis and analysis.

Data analysis

Extracted data were analyzed using both qualitative and quantitative approaches. Thematic analysis was conducted to identify key psychological factors associated with TMD, including anxiety, depression, stress, and emotional distress. For quantitative analysis, data were processed using RevMan version 5.4.1, applying a random-effects model to account for variability across studies. The standard mean difference (SMD) was used as the effect measure, with 95% confidence intervals (CI) to estimate the strength of associations. Subgroup analyses were performed to explore potential differences across demographic groups, such as age and gender.

Results

Article search and selection

The literature search yielded 2392 potential articles, of which three were retracted, 194 duplicates were excluded, and 2195 records were screened. Twenty-one articles met the eligibility criteria and were included in this study. The results of the article selection process are shown in Fig. 1.

Fig. 1.

PRISMA Flow diagram of the study selection process [29]

Data analysis

The results of the thematic analysis were presented according to anxiety, depression, emotional distress, and somatization.

Anxiety

The relationship between anxiety and TMD has been consistently demonstrated across multiple studies. Several individual studies further support this association, for instance study [27] involving university students revealed a significant relationship between TMDs and anxiety (p = 0.0001), though 65.81% of patients showed no evidence of anxiety according to the Hospital Anxiety and Depression Scale (HADS). Among student populations, research [31] found that 41.8% of 55 students exhibited anxiety symptoms, with 86.95% showing mild anxiety and 13.05% showing moderate anxiety. While study [28] identified a positive correlation between pain intensity and anxiety scores among adult TMD patients, this correlation did not reach statistical significance (p = 0.604). Additional research [38] among adolescents with TMD revealed that the palpation index positively correlates with obsessive compulsiveness and anxiety in TMD following micro trauma.

The study [44] reported a statistically insignificant difference between anxiety and depression assessment scores among university students with and without orthodontic history, and there was no correlation between orthodontic history and anxiety or depression. According to study [45] there was significantly more TMD in adult patients with anxiety than in those without anxiety (p < 0.05). Similarly, [46] clinical signs of TMD among students exhibited a statistically significant correlation with anxiety (p < 0.001). In another study, [50] there were significantly higher anxiety scores in patients with TMD than in controls (p < 0.05). Notably, study [43] found that adult patients with anxiety exhibited a higher prevalence of intra-articular TMDs (p < 0.01).

Quantitative data from three studies analyzed using meta-analysis (Fig. 2) [28, 37, 43] provided strong evidence showing significantly higher anxiety scores in TMD patients compared to controls (p < 0.00001). The meta-analysis employed a random-effects model to account for potential variability across the included studies, yielding a pooled standardized mean difference (SMD) of 1.17 (95% CI: 0.84 to 1.50). This indicates a large and statistically significant effect size, highlighting the increased anxiety levels in TMD patients.

Fig. 2.

Forest plot comparing anxiety scores between TMD patients and controls [33, 42, 48]

Heterogeneity among the studies was minimal, as evidenced by an I² statistic of 3%, suggesting low variability attributable to between-study differences. Additionally, Cochran's Q-test (Chi² = 2.06, df = 2, p = 0.36) confirmed the lack of significant heterogeneity. Confidence intervals were calculated using the inverse-variance method, ensuring precise weighting of studies based on their variance.

Depression

The relationship between depression and TMD presents a complex picture across various studies. According to a study [32], involving university students while 95.39% of patients had no evidence of anxiety, according to the HADS and TMDs had an insignificant correlation with depression (p = 0.0935), there was a positive correlation between pain intensity and depression scores, though this was not statistically significant (p = 0.592).

Gender differences emerged in the findings, with one study [41], revealing that depression had a statistically significant correlation with TMD in males (p = 0.0006), whereas suicidal ideation was insignificantly correlated with TMD (p = 0.0223). Conversely, no psychological factor was significantly correlated with TMD in females.

The palpation index demonstrated positive correlations with depression and psychosis in adolescents TMD patients without trauma [43]. Significant findings emerged from study [45] involving adult TMD patients which reported significantly higher TMD in subjects with depression than in those without depression (p < 0.05). Similarly, a study [50] highlighted that patients with coexistent TMD had a significantly higher prevalence of depression, particularly those with combined migraine and tension-type headache, as well as the importance of assessing psychosocial factors in TMD patients, revealing a clear link between TMD pain and psychological symptoms such as depression, somatization, and anxiety. It also reported significantly higher depression scores in patients with TMD than in controls (p < 0.05).

Quantitative data from three studies analyzed exhibited a statistically significant difference in depression scores between TMD patients and controls (p < 0.00001) [28, 37, 43]. The TMD group had significantly higher depression scores than the control group, as illustrated in Fig. 3. The meta-analysis employed a random-effects model to account for variability across studies, resulting in a pooled standardized mean difference (SMD) of 1.20 (95% CI: 0.88 to 1.53). This substantial effect size underscores the heightened levels of depression in TMD patients compared to controls.

Fig. 3.

Forest plot comparing depression scores between TMD patients and controls [33, 42, 48]

Heterogeneity was negligible, with an I2 statistic of 0%, indicating that almost all observed variation in effect sizes was due to chance rather than between-study differences. Additionally, Cochran’s Q-test (Chi2 = 1.66, df = 2, p = 0.44) confirmed the absence of significant heterogeneity. Confidence intervals were calculated using the inverse-variance method, which ensures that studies with greater precision contributed more to the overall pooled estimate.

Emotional dysfunction and stress

Stress has emerged as a crucial factor in both the development and exacerbation of TMD. Research [34], established that higher stress levels correlate with increased TMD severity, as measured by indices such as the Pittsburgh Sleep Quality Index (PSQI) and Fonseca Anamnestic Index (FAI).

The relationship between psychological well-being and TMD was further illuminated by study [37], which reported significant correlations between pain acceptance and various psychological factors; negative correlations with both psychological distress and self-regulatory fatigue (p = 0.01), and a positive correlation with psychological well-being (p = 0.01). Study [34] reported a significantly greater incidence of TMD among subjects with post-traumatic stress disorder, neuroticism, negative affect, and perceived stress. Conversely, extraversion showed a statistically insignificant correlation with the incidence of TMD.

The literature emphasizes the complex relationship between stress and TMD, highlighting the significant roles of psychological stress, physical stress, and oxidative imbalances in the development and exacerbation of TMD symptoms. Understanding these interactions is crucial for the development of effective prevention and treatment strategies for individuals with TMD.

Somatization

Research has revealed significant correlations between somatization and various aspects of TMD. According to study [43], the palpation index was positively correlated with somatization in adolescents patients with TMD, emphasizing the importance of considering psychosocial factors in TMD assessment. Additionally, the study found that the palpation index significantly correlated with hostility, while the dysfunction index showed positive correlations with multiple psychological factors. Moreover, the craniomandibular index was positively correlated with obsessive compulsiveness.

Sub-group analysis

Gender differences

Gender differences emerged in the findings, with one study reporting a significant correlation between depression in males and TMD (p = 0.0006), while suicidal ideation was insignificantly correlated [41]. In females, no significant correlation between psychological factors and TMD was identified.

Different populations

Students

The relationship between TMD and anxiety was significant among students, as exhibited by studies involving students. Study by Bonjardim et al. [32] reported a strong correlation between TMD and anxiety (p = 0.0001), and another study revealed that most of half of the students with TMD exhibited anxiety symptoms [36]. Additionally, the clinical signs of TMD among students showed a significant correlation with anxiety, as reported in another study involving students [46]. In contrast, a different study involving students reported an insignificant difference between anxiety and depression in students with and without orthodontic history [44]. In separate research, even though there was an insignificant correlation between TMD and depression among university students, depression scores and pain intensity correlated positively [32].

Adolescents

In adolescents, somatization and obsessive-compulsiveness were particularly notable psychological factors associated with TMD. One study identified positive correlations between the palpation index and somatization, anxiety, and hostility [43]. Additionally, in adolescents TMD patients without trauma the palpation index demonstrated positive correlations with depression and psychosis.

Adults

Among adults, anxiety and depression were the most strongly associated psychological factors with TMD. One study by Chinthakanan et al. [33] exhibited a positive correlation between pain intensity and anxiety scores among adult TMD patients and in a similar manner adult patients with TMD exhibited higher anxiety scores [50]. Another study exhibited a higher prevalence of intra-articular TMDs among adult patients with anxiety [48].

With regards to depression, adult patients reported higher TMD in patients with depression [45]. Similarly, in a separate research by Yang et al. [50] patients with coexistent TMD exhibited a higher prevalence of depression. These findings reinforce the importance of considering psychological profiles—particularly anxiety and depression—in adult TMD patients. [34].

Discussion

This study systematically reviewed the studies on the correlation between psychological variables and TMD and assessed the extent to which they influence the symptoms and management of TMD and how these psychological factors affect the treatment results and quality of life of patients [53]. These psychological factors include anxiety (feeling of unease), depression (feeling of low mood and loss of interest), stress (psychological strain in responding to challenging situations), and somatization, which often involve the expression of psychological distress through physical symptoms [54]. Various instruments, such as the HADS and self-reported assessments, have been used to evaluate these psychological factors [55].

The association between psychological factors and TMD can be explained through several interrelated neurobiological mechanisms [56]. Chronic psychological stress can activate the hypothalamic–pituitary–adrenal (HPA) axis, resulting in sustained muscle hyperactivity and altered cortisol levels, which may contribute to TMD onset and persistence [57]. Additionally, psychological distress is known to influence pain perception through changes in the limbic system, which governs emotional processing and shares pathways with nociceptive signals. Neuroplastic adaptations in the central nervous system, driven by prolonged emotional strain, can enhance pain sensitivity and reduce pain thresholds, a process known as central sensitization [58]. Disruption of descending pain inhibitory pathways may also heighten pain experiences in TMD patients [59]. Finally, psychological models such as the fear-avoidance model suggest that anxiety-related behaviors (e.g., jaw guarding, avoidance of jaw movement) may perpetuate muscle tension and chronic pain. Together, these mechanisms support a biopsychosocial framework for understanding TMD pathophysiology [60].

The results demonstrated a statistically significant correlation between anxiety and TMD, as shown by the forest plot of the meta-analysis demonstrated in Fig. 2. Furthermore, the included studies used different screening tools to assess anxiety, such as the HADS and self-reported assessments. Despite these findings, some of the included studies showed that the differences did not reach statistical significance, which may be related to the different study settings. These discrepancies still imply the need to further explore the nuanced relationships between these variables.

Moreover, this study investigated the link between emotional dysfunction, stress, and TMD and found that TMD correlates strongly with stress. Subjects with high-stress levels are likely to develop TMD symptoms; likewise, somatization, which is the expression of psychological distress in physical symptoms, correlates with TMD and shows higher scores in patients with TMD than in non-TMD controls. Furthermore, somatization also relates to other psychological characteristics, including anxiety and hostility, and supports the relationship between psychological and somatic symptoms observed in TMD. The extensive body of research reviewed underscores the strong correlation between depression and temporomandibular disorders. Psychological factors such as depression, somatization, anxiety, and stress play a crucial role in the onset, progression, and outcomes of TMD. Understanding and addressing these psychological aspects are essential in the comprehensive management of TMD patients, highlighting the importance of a holistic approach that considers both physical and mental health factors in treating temporomandibular disorders.

On the other hand, the fear-avoidance model offers insights into how psychological factors maintain and exacerbate TMD. Anxiety about pain can lead to protective behaviors and muscle guarding, creating a cycle of increased tension and pain.

Study strengths and limitations

The included studies demonstrated favorable methodological quality. Most studies were rated as good quality, with only Yang et al. [50] showing some concerns due to uncertainties about population selection and exposure levels. This high methodological quality strengthens the reliability of this study's findings. However, the studies did not report the blinding status of outcome assessors critical to bias detection especially in psychological assessments. In addition, adjustment for confounding variables was not reported by most studies necessitating careful consideration in interpreting these results since variables like age, socioeconomic status, and concurrent medical conditions could influence both psychological status and TMD severity.

Clinical significance

Several psychological variables can influence the success and compliance of individuals with TMD to therapy, such as elevated levels of psychosocial stress and anxiety, which may counteract the positive effects of treating the physical component of TMD (e.g., occlusal splint and physiotherapy) and medicines for TMD pain [53] and psychological issues that can influence patient compliance with psychological approaches and treatment regimens, thus reducing the effectiveness of treatment techniques. Understanding the relationship between psychological aspects and TMD is essential for optimizing therapeutic approaches to TMD because, although psychological investigations of TMD are scarce, there are sufficient indications of their importance in TMD development and TMD treatment. Therefore, practitioners should adopt a multimodal and comprehensive approach that addresses the psychological component of the patient in parallel to their physical treatment, including cognitive-behavioral therapy and other stress-management approaches, to help treat patients with TMD to have a better treatment outcome and a higher-quality life.

Clinical implications

Using different instruments to evaluate psychological factors across the selected studies has significant implications for the results. Variability in measurements, which arises from the use of various tools like the HADS, leads to inconsistencies in how psychological factors such as anxiety and depression can be defined across multiple studies. Due to this variability, drawing definitive conclusions on the relationship between psychological factors and TMD might be difficult, necessitating the need for careful interpretation of the findings of this study. Practitioners should adopt targeted psychological screening tools specific to TMD populations and develop risk assessment protocols that consider both physical and psychological factors to optimize management outcomes. In addition, it is essential to regularly monitor psychological status throughout treatment.

The present study highlights the significance of early psychological interventions based on identified psychological profiles. In addition, a multidisciplinary approach to care through collaboration between dental practitioners, pain specialists, and mental health professionals should be adopted to enhance accuracy in diagnosis and the use of appropriate interventions for optimal outcomes. Moreover, self-management strategies are critical to enhancing psychological care among patients to minimize their impact on TMD development, necessitating professional education and healthcare delivery systems to support effective multidisciplinary care.

Study contribution & novelty

While the relationship between psychological factors and temporomandibular disorders (TMD) has been widely explored, this study makes several unique contributions by addressing research gaps that have been underexamined. Unlike previous research that broadly examines psychological factors in TMD, this study provides a demographic-specific analysis, identifying key differences across age groups and gender. The findings reveal that depression is more strongly associated with TMD in males, while somatization and obsessive-compulsiveness are prominent in adolescents. Additionally, anxiety is a significant predictor of TMD among students, whereas adults exhibit stronger associations with both anxiety and depression.

From a clinical perspective, these insights emphasize the importance of early intervention, particularly for adolescents, to prevent chronic pain development linked to somatization. The study highlights the need for targeted psychological screening protocols specific to TMD patients, ensuring that assessment tools are appropriately tailored to different demographic groups. Furthermore, the findings support a multidisciplinary approach to TMD treatment, advocating for the integration of cognitive-behavioral therapy (CBT), stress management techniques, and gender-sensitive interventions alongside conventional treatment strategies.

Beyond clinical practice, this study contributes to future research directions by emphasizing the need for population-specific psychosocial interventions and a biopsychosocial framework in TMD management. Unlike previous studies that focus on broad psychological factors, this research underscores the role of demographic variations in treatment response, paving the way for more personalized TMD management strategies. Future investigations should explore how socioeconomic and cultural contexts influence the psychological-TMD relationship and further refine screening tools that integrate psychological, biological, and behavioral markers. By addressing these overlooked aspects, this study enhances our understanding of TMD and provides actionable insights for both research and clinical applications.

Recommendations for future research

Longitudinal studies are necessary to verify the assumed temporal direction of the relationship between psychological factors and TMD and to investigate the effectiveness of psychosocial interventions in reducing TMD symptoms and fostering well-being. Furthermore, specific psychological factors such as personality traits or coping mechanisms could provide a better understanding of the mechanisms underlying the relationship between psychological factors and TMD.

Conclusion

This study provides valuable insights into the association between psychological profiles across populations and gender and TMDs onset, development, and severity. The results highlight significant associations between stress and negative emotions on accelerating TMD onset. In addition, anxiety, depression, emotional dysfunction, and somatization are associated with TMD development and progression. In addition, there were gender differences in psychological manifestations like depression in male patients. Moreover, the relationship between somatization and TMD in adolescents emphasizes the importance of early intervention strategies to minimize chronic pain patterns. A targeted psychological assessment strategy should be considered an essential part of comprehensive TMD care. In addition, it is essential to integrate targeted interventions like cognitive behavioral therapy and stress management techniques tailored to specific demographic groups, given the distinct psychological presentations observed among students, adolescents, and adults. Future research should explore potential biomarkers that could link psychological aspects to TMD pathophysiology. In addition, population-specific psychological intervention efficacy should be tested through trials to optimize TMD management. These targeted research directions will shape evidence-based strategy development of more effective, personalized treatment approaches for TMD patients.

Authors’ contributions

Conceptualization: R.S.S and S.A.Q; Methodology: R.S.S and S.A.Q; Software: S.A.M; Validation: A.H; Formal analysis: R.S.S and S.A.Q; Investigation: R.S.S and S.A.Q; Resources: R.S.S and A.H; Data Curation: R.S.S and S.A.Q; Writing - Original Draft: R.S.S and S.A.Q; Writing - Review & Editing: S.A.M and A.H; Visualization: S.A.M; Supervision: A.H; Project administration: A.H; Funding Acquisition: R.S.S. All authors have read and approved the published version of the manuscript.

Funding

The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through Large Research Project under grant number RGP2/545/46.

Data availability

The data presented in this study will be made available on request from the corresponding author.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.