Correlation between mental well-being and severity of class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders

Sunita Shrivastav; Abhishek Sanchla

doi:10.12688/f1000research.134158.1

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Correlation between mental well-being and severity of class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders

[version 1; peer review: 1 approved, 1 not approved]

Sunita Shrivastav¹, Abhishek Sanchla ¹

PUBLISHED 09 Oct 2023

Author details Author details

¹ Orthodontics, Sharad Pawar Dental College, Datta Meghe Institute of Higher Education & Research, Wardha, Maharashtra, 442001, India

Sunita Shrivastav
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abhishek Sanchla
Roles: Data Curation, Software, Supervision, Validation, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

Temporomandibular joint disorders (TMDs) are one of the most common ailments encountered in the craniofacial region, with various clinical, radiological and psychological manifestations but often go undiagnosed due to lack of a diagnostic protocol to assess and correlate all these factors in order to create an effective management plan based on early diagnosis. The objectives of this research are to assess, compare and co-relate the severity of clinical and radiological findings with mental well-being in class II (vertical growth pattern) TMD cases as compared to class I non-TMD cases. Grading of skeletal class II cases on the severity of TMD will be done using Diagnostic Criteria for TMDs (DC/TMD). Bilateral sagittal as well as coronal magnetic resonance imaging (MRI) images will be obtained. Evaluation and grading of mental well-being and anxiety will be done using the Warwick-Edinburgh and Hamilton scales, respectively. The expected results are a probable positive correlation between the severity of clinical and radiological symptoms of TMDs and deteriorating mental well-being in the form of stress, anxiety and depression. A cause-effect relationship may be evaluated with the aim of early diagnosis and management of TMDs as improving the quality of life of these cases. This study will aid in identifying the clinical symptoms and articular disc position on MRI as they correlate with the mental well-being status and anxiety levels in TMD cases. Further management and early intervention can be undertaken in such cases to prevent or stall the progression of TMD into severe forms while improving the quality of life (QoL) in such cases.

Keywords

Temporomandibular joint disorders, Anxiety, Depression, Stress, Mental well-being, Magnetic resonance imaging

Corresponding author: Abhishek Sanchla

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Shrivastav S and Sanchla A. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Shrivastav S and Sanchla A. Correlation between mental well-being and severity of class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2023, 12:1293 (https://doi.org/10.12688/f1000research.134158.1) First published: 09 Oct 2023, 12:1293 (https://doi.org/10.12688/f1000research.134158.1) Latest published: 09 Oct 2023, 12:1293 (https://doi.org/10.12688/f1000research.134158.1)

Introduction

Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw and the muscles that control its movement.¹ These disorders can cause pain, discomfort, and limited jaw movement and can impact a person’s mental well-being.²

Evidence suggests that TMJ disorders can cause or contribute to altered mental well-being.³ TMJ disorders can greatly affect an individual’s quality of life, causing chronic pain and discomfort. This often leads to anxiety, depression, and poor sleep quality, worsening the disorder’s symptoms.⁴ Furthermore, the limitations of TMJ disorders can cause social isolation, reduced self-esteem, and decreased functional abilities.⁵ The general population is affected by temporomandibular joint disorder (TMD) at varying rates, according to epidemiological studies ranging from 45% to 75% incidence.⁶ Given the high incidence, it is likely that a sizable fraction of the population is affected with TMD.

According to Ruf and Pancherz’s 1999 paper, those with Class II malocclusion and a vertical growth pattern are more likely to have temporomandibular joint disease (TMD).⁷

The gold standard and most accurate diagnostic tool for temporomandibular joint (TMJ) abnormalities is magnetic resonance imaging (MRI). The TMJ and its encircling components, including the articular disc, muscles, and ligaments, can be seen on an MRI scan. With the help of this imaging method, the joint space, disc location, and bone morphology may all be assessed non-invasively.⁸ Moreover, MRI can detect additional problems like tumours, infections, and fractures that may resemble TMJ disorders. MRI offers higher soft tissue contrast than other imaging methods like computed tomography (CT) and plain radiography and does not subject the patient to ionising radiation. It has been demonstrated that using MRI for TMJ evaluation improves patient outcomes, treatment planning, and diagnosis accuracy.⁹

The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) is an essential tool for determining mental well-being.¹⁰ It is a validated questionnaire that assesses positive facets of mental health, such as joy, self-esteem, and good interpersonal interactions. Higher scores indicate more well-being on the scale, which consists of 14 items rated on a 5-point Likert scale. The WEMWBS has been used in research and clinical settings. It has produced useful data on mental well-being and its relationships to different health outcomes, which can be used to assess it in TMD situations.⁷ A popular measure for measuring anxiety in people is the Hamilton Anxiety Scale (HAM-A).¹¹ The HAM-application A’ s in TMD studies has highlighted the connection between anxiety and TMD. According to one study, those with TMD had considerably higher HAM-A scores than healthy controls, which may indicate that these people had higher anxiety levels.¹²

Hence this study is planned to assess the correlation of these clinical radiologic and psychological parameters to further aid in the effective and timely management of TMDs.

Objectives

1. To evaluate TMD’s clinical and radiological (MRI-based) symptoms in Class II (Vertical) Temporomandibular joint disorder cases and Class I Non-TMD cases.
2. To evaluate the mental well-being of these cases using curated scales and questionnaires.
3. Compare these symptoms and mental well-being status in Class II (Vertical) cases with those without Temporomandibular joint disorder.

Protocol

Study design and setting

An observational and analytical study will be conducted at Sharad Pawar Dental College, Sawangi, in collaboration with the Department of Radiology, Acharya Vinobha Bhave Rural Hospital (AVBRH). See Extended data²³ for the STROBE (Strengthening the reporting of observational studies in epidemiology) checklist items relevant to this protocol.

A total of 30 adult cases Class II (vertical growth pattern) will be chosen from the Sharad Pawar Dental College’s outpatient department (OPD) of Orthodontics and Dentofacial Orthopaedics in Sawangi, Wardha. The number of samples was selected based on the prevalence of TMD in Class II (Vertical) cases, using the formula n = N*X/ (X + N – 1), where, X = Zα/22 p(1-p) /MOE2, and Zα/2 is the critical value of the normal distribution at α/2 (e.g., for a confidence level of 95%, α is 0.05 and the critical value is 1.96).

Ethics statement

Ethical approval has been granted on 31/03/2023 by Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha, with reference number DMIHER (DU)/2023/18. Informed and written consent will be obtained from all the cases included in the study for their participation. A separate consent form will be issued to obtain participant consent for publication of the research results and data.

Inclusion criteria

Adults more than 18 years of age with Class I (normal skeletal growth pattern of the maxillo-mandibular complex) or Class II (vertical) malocclusion with permanent dentition would be included in this study. Class I or Class II (vertical) malocclusion would be decided based on the cephalometric criteria listed in Table 1.

Table 1. Cephalometric criteria.

Class I	Class II (vertical)
ANB-2°	ANB-<4°
Wit’s Appraisal-0-1 mm	Wit’s Appraisal-<2 mm
FMA-22-28°	FMA-<20°
Beta angle-27-33°	Beta angle-<25°
MP-32-36°	MP<31°
Overjet-2-4 mm	Overjet-0-2 mm
Overbite-2-4 mm	Overbite>4 mm

Exclusion criteria

Cases with Class III malocclusion, Myofascial pain dysfunction syndrome, or those with a history of temporomandibular joint surgery and skeletal dysplasia would be excluded from this study.

Methods

The methodology of this study involves several steps. Firstly, patients will be diagnosed according to the DC/TMD criteria for clinical signs and symptoms. Secondly, grading of skeletal Class II (vertical growth pattern) cases based on the severity of TMD will be done using the Helkimo index. Bilateral sagittal, as well as coronal MRI images, will then be obtained.

In addition to the above, all cases will be evaluated for mental well-being and anxiety levels using the Warwick-Edinburgh and Hamilton scales, respectively. The evaluation of Articular Disc morphology in the sagittal and coronal plane using MRI will also be conducted.

Furthermore, the study will focus on the correlation of articular disc morphology with clinical symptoms, anxiety, and mental well-being in both groups. Finally, a comparison of articular disc morphology, clinical symptoms, anxiety, and mental well-being will be made among both groups. By following this methodology, the study aims to gain a deeper understanding of the relationship between articular disc morphology and various clinical symptoms in patients with TMD.

Bias

Bias will be minimised by random selection of patients based on inclusion and exclusion criteria.

Study sample

The calculation of sample size was done as follows:

n = N^{*} X / (X + N - 1),

Each group would consist of 15 individuals, with the frequency of severe cases being 0.95 per cent. There will be 15 patients in 2 groups, hence, the total sample size will be 30. The sample will be divided into three groups based on the inclusion and exclusion criteria: Group A will be a control group, with 15 Class I (Non-TMD) cases. Group B will comprise 15 skeletal Class II (vertical growth pattern) cases with TMD.

Statistical analysis

All the demographic outcome data will be presented using descriptive statistics for categorical variables in terms of frequency & percentage for continuous variables in terms of mean, standard deviation and median.

Results will be analysed on SPSS version 27 for statistical analysis. The outcome variable will be tested for normality using the Kolmogorov-Smirnov test for continuous data.

Articular disc variations are categorised according to the range that will be distributed for analysing the data into the normal range and not in the normal range. The chi-square test will be used to find the result of an association of clinical, radiological and psychological symptoms in Class I (Non-TMD cases) and skeletal Class II (Vertical growth pattern) TMD cases.

An Independent t-test will be used to find the result on three groups for the outcome variable if data comes under the normal distribution. A non-parametric test will find a significant difference if data does not fit the normal distribution.

Dissemination

This study will assist in identifying and promptly diagnosing TMD based on clinical symptoms, changes in articular disc position and psychological status. It will aid in the formulation of an effective management protocol.

Study status

The study has yet to start.

Discussion

Stress and anxiety are prevalent in today’s population due to various factors, including work-related stress, financial stress, social media and technology, family and relationship issues, health concerns, political and social unrest, and trauma and past experiences.¹ It is important to seek help if these feelings overwhelm or interfere with daily life.

Several studies¹³^–¹⁵ have found a correlation between mental well-being and temporomandibular disorders (TMD). Individuals with TMD are more likely to experience depression, anxiety, and other mental health issues than those without TMD.¹⁶ Additionally, stress, anxiety, depression or other mental health-related symptoms may deteriorate the existing morbidity due to TMD.¹⁷ Similarly, management of TMD has been shown to reduce the mental health-related symptoms and improve mental well-being.¹⁸ Thus, healthcare professionals must focus on improving psychological status while diagnosing and treating TMD patients, for a better outcome. When Simoen L et al. (2020) examined the prevalence of depression and anxiety in TMD patients, they found that these individuals had much higher anxiety levels than controls of anxiety than controls did.¹⁹ Chisnoiu et al. (2015) carried out a systematic review to investigate the association between psychological factors and TMD in a related study. 24 publications, according to the authors, met the requirements for inclusion. The review shows, there is a direct link between TMD and such psychological characteristics as anxiety, depression, stress, and somatization. The authors came to the conclusion that psychological evaluation and intervention should be a part of patient management in order to enhance treatment outcomes for TMD patients.²⁰

A randomised controlled experiment was undertaken by Manfredini et al. (2014) to assess the efficacy of cognitive behavioural therapy (CBT) and occlusal splint therapy in reducing pain and enhancing function in TMD patients. The authors randomly assigned 90 patients with TMD to three groups: CBT, occlusal splint therapy, or a combination of CBT and occlusal splint therapy. According to the study’s findings, all three treatment groups’ pain and function levels significantly improved compared to baseline. In contrast to the other two groups, the combination group (CBT plus occlusal splint therapy) saw the largest pain intensity reduction and the best improvement in function. The authors concluded that the combination of CBT and occlusal splint therapy is an effective treatment approach for TMD.²¹

Though isolated, few studies are reported in the literature similar to this study. Moreover, Sanchla et al.²² described that Class II (vertical) cases are more prone to TMD’s. Hence, this study would be clinically significant as correlating the skeletal features, radiologic soft tissue findings, and psychologic status would give a comprehensive picture of the TMD status and aetiology. Further, it will help in laying down a problem-oriented treatment protocol. The expected outcome of this study is to establish a positive correlation between the severity of clinical and radiological symptoms of temporomandibular joint disorders (TMDs) and deteriorating mental well-being in the form of stress, anxiety, and depression. The study aims to identify potential predictors of TMDs, particularly psychological factors, to aid in the early diagnosis and management of TMDs, which may ultimately lead to an improved quality of life for individuals with TMDs.

Through a multidisciplinary approach that considers physical and psychological factors, this study aims to provide valuable insights into the complex interplay between TMDs and mental health. By establishing a cause-effect relationship between TMDs and mental health, this study may contribute to developing targeted treatment approaches to improve the quality of life of individuals with TMDs.

Data availability

Underlying data

No underlying data are associated with this article.

Extended data

Zenodo: Correlation between Mental well-being and severity of Class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders’, https://doi.org/10.5281/zenodo.7953756.²³

This project contains the following extended data:

- strobe checklist.docx

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

1. Sanchla AD, Shrivastav S, Kamble RH, et al.: Altered Quality of Life in Patients with Temporomandibular Joint Disorders: A Review. J. Clin. Diagn. Res. 2023 Mar 1; 17(3). Publisher Full Text
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3. Dahlström L, Carlsson GE: Temporomandibular disorders and oral health-related quality of life. A systematic review. Acta Odontol. Scand. 2010 Mar 1; 68(2): 80–85. Publisher Full Text
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8. Sanchla A, Shrivastava S, Kamble R: Comparative evaluation and correlation of neurologic symptoms, otologic symptoms and proximity of TMJ disk with condyle in class ii (vertical) mild, moderate and severe TMD cases as compared to non-TMD cases. Ann. Med. Health Sci. Res. 2021; 11: 103–121.
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13. Minervini G, Franco R, Marrapodi MM, et al.: The Association between COVID-19 Related Anxiety, Stress, Depression, Temporomandibular Disorders, and Headaches from Childhood to Adulthood: A Systematic Review. Brain Sci. 2023 Mar 12; 13(3): 481. PubMed Abstract | Publisher Full Text | Free Full Text
14. De Leeuw JR, Steenks MH, Ros WJ, et al.: Psychosocial aspects of craniomandibular dysfunction. An assessment of clinical and community findings. J. Oral Rehabil. 1994; 21(2): 127–143. PubMed Abstract | Publisher Full Text
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17. Natu VP, Yap AU, Su MH, et al.: Temporomandibular disorder symptoms and their association with quality of life, emotional states and sleep quality in South-East Asian youths. J. Oral Rehabil. 2018; 45(10): 756–763. PubMed Abstract | Publisher Full Text
18. Huhtela OS, Koivisto N, Hägg V, et al.: Effectiveness of applied relaxation method vs splint in treatment of temporomandibular disorders in Finnish students. J. Oral Rehabil. 2020 Feb; 47(2): 123–131. PubMed Abstract | Publisher Full Text
19. Simoen L, Van den Berghe L, Jacquet W, et al.: Depression and anxiety levels in patients with temporomandibular disorders: comparison with the general population. Clin. Oral Investig. 2020 Nov; 24(11): 3939–3945. PubMed Abstract | Publisher Full Text
20. Chisnoiu AM, Picos AM, Popa S, et al.: Factors involved in the etiology of temporomandibular disorders-a literature review. Clujul Med. 2015; 88(4): 473–478. PubMed Abstract | Publisher Full Text
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22. Sanchla AD, Shrivastav S, Bharti L, et al.: Comparative Evaluation and Correlation of Pain Pattern in Neck Musculature Observed in Mild, Moderate, and Severe Temporomandibular Joint Disorder Cases as Compared to Non-temporomandibular Joint Disorder Cases. Cureus. 2022; 14(10). Publisher Full Text
23. Shrivastav S, Dr Sanchla AD : Correlation between Mental well-being and severity of Class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders. [dataset]. 2023. Publisher Full Text

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Version 1

VERSION 1 PUBLISHED 09 Oct 2023

Author details Author details

¹ Orthodontics, Sharad Pawar Dental College, Datta Meghe Institute of Higher Education & Research, Wardha, Maharashtra, 442001, India

Sunita Shrivastav
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abhishek Sanchla
Roles: Data Curation, Software, Supervision, Validation, Visualization, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 09 Oct 2023, 12:1293

https://doi.org/10.12688/f1000research.134158.1

Copyright

© 2023 Shrivastav S and Sanchla A. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Shrivastav S and Sanchla A. Correlation between mental well-being and severity of class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2023, 12:1293 (https://doi.org/10.12688/f1000research.134158.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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PUBLISHED 09 Oct 2023

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Reviewer Report 03 Sep 2024

Deepa Jatti Patil, Sumandeep Vidyapeeth Deemed to be University, Gujarat, India

Approved

https://doi.org/10.5256/f1000research.147188.r265368

.The authors plan to correlate the mental well-being of TMD patients with skeletal Class II disorders. The study design is appropriate .But the sample size is small and needs to increased to validate the study and improve the generalisability of ... Continue reading

.The authors plan to correlate the mental well-being of TMD patients with skeletal Class II disorders. The study design is appropriate .But the sample size is small and needs to increased to validate the study and improve the generalisability of data. Will the study include patients with skeletal class II without any symptoms of TMD?
Mention in methodology how will the
MRI images be screened? Are the authors using any classification such as Wilkes classification for classifying internal disc derangement. Kindy elaborate this in detail.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Temporomandibular disorders, Orofacial pain, CBCT ,OPMD

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report 15 Feb 2024

Mohamed Jaber, Ajman University, Ajman, Ajman, United Arab Emirates

Not Approved

https://doi.org/10.5256/f1000research.147188.r237111

1. Abstract
- The abstract outlines a systematic approach to assessing and correlating clinical, radiological, and psychological aspects of temporomandibular joint disorders (TMDs). The use of established diagnostic criteria and scales (DC/TMD, Warwick-Edinburgh, Hamilton) indicates a rigorous ... Continue reading

1. Abstract
   - The abstract outlines a systematic approach to assessing and correlating clinical, radiological, and psychological aspects of temporomandibular joint disorders (TMDs). The use of established diagnostic criteria and scales (DC/TMD, Warwick-Edinburgh, Hamilton) indicates a rigorous methodology.
   - The study's focus on correlating mental well-being with the severity of class II TMDs adds novelty to existing literature, addressing a gap in understanding the holistic impact of TMDs.
   - The study addresses the relevance of TMDs, emphasizing their common occurrence and the lack of a comprehensive diagnostic protocol. The research aims to contribute to effective management plans.
   - The abstract does not include citations, which might be necessary to establish the background and current knowledge on the subject. The absence of references may weaken the context and background of the study.
   - The abstract appears to be logically structured, with clear objectives and methodologies. However, without specific details, it's challenging to assess the correctness of the approach.
   - The abstract discusses various aspects, including clinical, radiological, and psychological dimensions, demonstrating a comprehensive approach and considering the diversity of factors influencing TMDs.
   - As mentioned earlier, there are no citations provided in the abstract. It is crucial to incorporate relevant literature to support the study's rationale and contextualize the research within the existing knowledge.
   - The methodology outlined seems accurate, relying on established diagnostic criteria and scales. However, the actual accuracy depends on the execution of the study, which cannot be fully assessed from the abstract.
   - The language used is clear and professional. However, some sentences could be refined for better clarity and flow.
    - The abstract is generally clear, but some sentences could benefit from simplification for a broader audience. For instance, explaining the significance of Warwick-Edinburgh and Hamilton scales for readers not familiar with them.
    - There is no indication of plagiarism in the provided abstract. However, without the ability to check against external sources, a comprehensive evaluation is not possible.
    - The study appears to be original in its approach, aiming to correlate TMD severity with mental well-being. This contributes to the understanding of TMDs beyond the physical symptoms.
    - The study objectives are clear: to assess, compare, and correlate clinical, radiological, and mental well-being aspects in class II TMD cases compared to class I non-TMD cases.
Suggestions for Improvement:
   - Incorporate relevant citations to establish the context, show awareness of existing literature, and strengthen the background of the study.

   - Refine sentences for better clarity, especially for readers less familiar with the specific scales and terminology used.
   - Include specific details about the research design, sample size, and other methodological aspects to enhance transparency and allow for a more thorough evaluation.
   - Explicitly state how the study's findings could impact clinical practice and patient outcomes, emphasizing the practical implications of the research.
   - The abstract could conclude with a statement on the potential positive impact of the study, engaging the reader and emphasizing the significance of the research.
In summary, the abstract covers the main aspects of the study but would benefit from additional details, citations, and minor refinements to enhance clarity and engagement. If executed well, the study could contribute valuable insights to the field of TMD research.
Keywords: The selected keywords appear to be generally suitable for the topic of the study, which focuses on the correlation between mental well-being and the severity of class II temporomandibular joint disorders (TMDs). These keywords collectively cover the clinical, psychological, and radiological dimensions of the study, reflecting the multidisciplinary nature of the research. However, it's always a good practice to consider potential variations or synonyms of these keywords to ensure comprehensive searchability. Additionally, the inclusion of broader terms related to temporomandibular disorders and mental health might be beneficial for reaching a wider audience and increasing the visibility of the study in relevant literature searches.
3. Introduction
   - The introduction lacks an in-depth analysis of existing literature. It briefly mentions evidence suggesting a connection between TMJ disorders and mental well-being but does not provide a comprehensive review of relevant studies.
   - While the introduction touches on various aspects of TMJ disorders, it lacks detailed exploration, and the information is presented in a relatively surface-level manner.
   - The introduction doesn't explicitly highlight the novelty of the study. Emphasizing the unique aspects of the research could make the study more compelling.
   - Citations are appropriately used to support statements. However, the citations are somewhat dated, and more recent references could strengthen the foundation of the study. Citations are provided for specific statements, but the absence of more recent references might limit the incorporation of the latest knowledge on the subject.
   - The information presented is generally correct, but the lack of recent citations may impact the accuracy and currency of the background information.
   - The introduction encompasses various aspects of TMJ disorders, including their impact on mental well-being, diagnostic tools like MRI, and relevant scales. This reflects a degree of diversity in the information provided.

   - The information about the diagnostic tools and their advantages seems accurate. However, the use of more recent sources could enhance the accuracy of the background information.
    - The language is generally clear, but there are areas where sentence structures could be improved for better flow and comprehension.
    - The introduction is mostly clear, but providing context for the scales used (WEMWBS, HAM-A) may enhance clarity, especially for readers unfamiliar with these tools.
    - There are minor grammatical issues that could be addressed to improve the overall readability.
    - There is no evidence of plagiarism in the provided text.
    - The introduction does not explicitly state the knowledge gap or highlight the original contribution of the study. Identifying a gap in existing knowledge would strengthen the rationale for the research.
    - The study objectives are clearly outlined, specifying the clinical, radiological, and psychological aspects to be evaluated.
Suggestions for Improvement:
   - Expand the literature review to provide a more comprehensive background on the connection between TMJ disorders and mental well-being. Include more recent references to reflect the current state
   - Explicitly state the novelty or unique contribution of the study to engage readers and demonstrate the significance of the research.
   - Use more recent and diverse references to strengthen the credibility and currency of the background information.
   - Refine sentence structures for better clarity and readability. Provide explanations for specialized terms and scales to aid understanding.
   - Clearly identify the knowledge gap or research question that the study aims to address. This helps establish the need for the research.
   - Offer a brief rationale or context for each objective to enhance understanding and emphasize the relevance of each aspect of the study.
   - Address minor grammatical issues for smoother readability.
   - Consider incorporating visuals (charts, graphs) to illustrate the prevalence of TMJ disorders and the potential impact on mental well-being.
By addressing these suggestions, the introduction can be strengthened, providing a more solid foundation for the study and engaging readers more effectively.

4. Material and methods
   - The methodology is outlined in a systematic manner, detailing the study design, setting, sample size calculation, inclusion and exclusion criteria, and data collection methods. However, it lacks depth in explaining certain aspects, such as the rationale behind choosing specific scales and indices.
   - The methodology doesn't explicitly highlight any novel approaches or techniques. Emphasizing the innovative aspects of the study could enhance its appeal.
- Providing references to justify the choice of specific criteria, scales, or statistical methods would strengthen the research design.
   - The language is generally clear, but there are areas where sentence structures could be improved for better flow and comprehension.
   - The methods are generally clear, but some sections, especially those related to the statistical analysis, could benefit from additional explanations for readers unfamiliar with statistical terms and tests.
   - While ethical approval is mentioned, there is no explicit discussion of potential ethical issues or considerations in the methodology. It's important to highlight how ethical concerns will be addressed, especially in a study involving human subjects.
   - The statistical analysis plan is appropriate for the study objectives. However, providing more details on the validity and reliability of the scales and indices used would strengthen the methodological foundation.

Suggestions for Improvement:
   - Offer more detailed explanations and rationale for the selection of specific scales (WEMWBS, HAM-A) and indices (DC/TMD criteria, Helkimo index). This will enhance the reader's understanding of why these tools were chosen.
   - Include more recent references to support the methodology and ensure that the latest knowledge is incorporated into the study design.
   - Provide additional explanations for statistical terms and tests used. This will make the section more accessible to a broader audience.
   - Explicitly discuss ethical considerations, including participant consent, confidentiality, and how potential biases and risks will be addressed.
   - Highlight any unique aspects of the study design or methodology that contribute to its originality.
   - Discuss the validity and reliability of the diagnostic criteria, scales, and indices used. This information is crucial for establishing the trustworthiness of the study findings.
   - Address minor grammatical issues for smoother readability.
   - Consider incorporating visuals (flowcharts, diagrams) to illustrate the study design and data flow, making it more accessible to readers.
By addressing these suggestions, the methodology section can be strengthened, ensuring clarity, transparency, and a solid foundation for the research study.
5. Results

6. Discussion
   - The discussion section lacks an in-depth analysis of the existing literature. While some relevant studies are cited, a more comprehensive review of the literature, including recent findings, would strengthen the discussion.
   - Citations are relevant to the topic, but the lack of recent references is a limitation. Incorporating more recent studies would enhance the currency of the discussion and demonstrate awareness of the latest research.
   - The language is clear and concise. However, there are some grammatical errors that, if addressed, would improve the overall readability.
   - The conclusion is clear and reiterates the expected outcome of the study. However, it could be strengthened by explicitly summarizing how the study addresses the stated objectives and contributes to the existing knowledge.
   - The discussion does not explicitly connect the findings to the stated objectives. A clearer link between the results and the research objectives would enhance the coherence of the discussion.
   - The discussion does not effectively contrast or compare the study's findings with the broader literature. A more detailed examination of how the results align or differ from existing studies would provide a more nuanced understanding.
   - The discussion does not explicitly identify a knowledge gap. A clearer articulation of the gap in the literature that the study aims to fill would strengthen the rationale for the research.
   - The discussion does not raise any explicit ethical concerns related to the study. However, it would be beneficial to discuss potential ethical considerations in research involving mental health and patient data.
    - The references provided are relevant to the study, but more recent literature could be included. A broader range of studies, including those with different perspectives, could provide a more comprehensive discussion.
Suggestions for Improvement:
   - Expand the literature review by incorporating more recent studies and providing a more in-depth analysis of existing literature. Discuss how the current findings align with or diverge from previous research.
   - Clearly articulate how the study's findings address the stated objectives. This will provide a more structured and coherent discussion.
   - Explicitly state the knowledge gap that the study aims to fill. This will provide context for the research and enhance the justification for conducting the study.
   - Compare and contrast the current findings with other relevant studies in the field. This will highlight the study's contributions and limitations in the context of existing literature.
   - Discuss ethical considerations related to the study, especially when dealing with mental health data. Address issues such as patient consent, confidentiality, and potential biases.
   - Review and correct grammatical errors for improved readability.
   - Include more recent references to demonstrate an up-to-date understanding of the topic. This will strengthen the relevance and impact of the study.
By addressing these suggestions, the discussion section can be enhanced to provide a more thorough analysis of the study's findings and their implications in the broader context of research on temporomandibular disorders and mental health.

7. Overall assessment
The study investigates the correlation between temporomandibular joint disorders (TMDs), particularly in Class II (vertical growth pattern) cases, and mental well-being using a multidisciplinary approach. The study design involves an observational and analytical study with a sample size calculated based on the prevalence of TMD in Class II cases. The methodology includes the use of validated diagnostic criteria, imaging techniques, and psychological assessment scales.

Strengths:
1. The study addresses an important and clinically relevant topic, exploring the interplay between TMDs and mental well-being, which has implications for patient management.
2. The methodology is well-structured, detailing the study design, inclusion and exclusion criteria, and data collection methods.
3. The use of established diagnostic criteria and scales enhances the reliability of the study's findings.
Concerns and Areas for Improvement:
1. Literature Review
   - The literature review in the introduction and discussion sections is limited and could benefit from a more comprehensive review of relevant studies. Including recent literature would strengthen the background and discussion.
2. Linking Findings to Objectives:
   - The discussion does not clearly link the study's findings to the stated objectives. Strengthening this connection would enhance the coherence of the discussion.
3. Identification of Knowledge Gap
   - The study does not explicitly identify a knowledge gap, making it less clear why the research was conducted. A more explicit articulation of the gap in the literature would strengthen the rationale for the study.
4. Ethical Considerations
   - While an ethical approval statement is provided, the discussion does not explicitly discuss potential ethical concerns related to the study. A brief discussion of ethical considerations, especially in research involving mental health and patient data, would be beneficial.
5. Recent Literature
   - The references used in the study are somewhat dated. Including more recent literature would enhance the currency of the study and demonstrate awareness of the latest research in the field.

In summary, the study addresses a valuable research question, and the methodology is well-structured. However, there are areas for improvement, including enhancing the literature review, clearly linking findings to objectives, addressing ethical considerations, and incorporating more recent literature.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Oral surgery, Oral Medicine, Oral Pathology, Maxillofacial Radiology, Dental Education

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Version 1 09 Oct 23	read	read

Mohamed Jaber, Ajman University, Ajman, United Arab Emirates
Deepa Jatti Patil, Sumandeep Vidyapeeth Deemed to be University, Gujarat, India

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03 Sep 2024 | for Version 1

Deepa Jatti Patil, Sumandeep Vidyapeeth Deemed to be University, Gujarat, India

1 Views Cite this report Responses(0)

Approved

.The authors plan to correlate the mental well-being of TMD patients with skeletal Class II disorders. The study design is appropriate .But the sample size is small and needs to increased to validate the study and improve the generalisability of data. Will the study include patients with skeletal class II without any symptoms of TMD?
Mention in methodology how will the
MRI images be screened? Are the authors using any classification such as Wilkes classification for classifying internal disc derangement. Kindy elaborate this in detail.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Temporomandibular disorders, Orofacial pain, CBCT ,OPMD

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

10 Views

15 Feb 2024 | for Version 1

Mohamed Jaber, Ajman University, Ajman, Ajman, United Arab Emirates

10 Views Cite this report Responses(0)

Not Approved

1. Abstract
   - The abstract outlines a systematic approach to assessing and correlating clinical, radiological, and psychological aspects of temporomandibular joint disorders (TMDs). The use of established diagnostic criteria and scales (DC/TMD, Warwick-Edinburgh, Hamilton) indicates a rigorous methodology.
   - The study's focus on correlating mental well-being with the severity of class II TMDs adds novelty to existing literature, addressing a gap in understanding the holistic impact of TMDs.
   - The study addresses the relevance of TMDs, emphasizing their common occurrence and the lack of a comprehensive diagnostic protocol. The research aims to contribute to effective management plans.
   - The abstract does not include citations, which might be necessary to establish the background and current knowledge on the subject. The absence of references may weaken the context and background of the study.
   - The abstract appears to be logically structured, with clear objectives and methodologies. However, without specific details, it's challenging to assess the correctness of the approach.
   - The abstract discusses various aspects, including clinical, radiological, and psychological dimensions, demonstrating a comprehensive approach and considering the diversity of factors influencing TMDs.
   - As mentioned earlier, there are no citations provided in the abstract. It is crucial to incorporate relevant literature to support the study's rationale and contextualize the research within the existing knowledge.
   - The methodology outlined seems accurate, relying on established diagnostic criteria and scales. However, the actual accuracy depends on the execution of the study, which cannot be fully assessed from the abstract.
   - The language used is clear and professional. However, some sentences could be refined for better clarity and flow.
    - The abstract is generally clear, but some sentences could benefit from simplification for a broader audience. For instance, explaining the significance of Warwick-Edinburgh and Hamilton scales for readers not familiar with them.
    - There is no indication of plagiarism in the provided abstract. However, without the ability to check against external sources, a comprehensive evaluation is not possible.
    - The study appears to be original in its approach, aiming to correlate TMD severity with mental well-being. This contributes to the understanding of TMDs beyond the physical symptoms.
    - The study objectives are clear: to assess, compare, and correlate clinical, radiological, and mental well-being aspects in class II TMD cases compared to class I non-TMD cases.
Suggestions for Improvement:
   - Incorporate relevant citations to establish the context, show awareness of existing literature, and strengthen the background of the study.

   - Refine sentences for better clarity, especially for readers less familiar with the specific scales and terminology used.
   - Include specific details about the research design, sample size, and other methodological aspects to enhance transparency and allow for a more thorough evaluation.
   - Explicitly state how the study's findings could impact clinical practice and patient outcomes, emphasizing the practical implications of the research.
   - The abstract could conclude with a statement on the potential positive impact of the study, engaging the reader and emphasizing the significance of the research.
In summary, the abstract covers the main aspects of the study but would benefit from additional details, citations, and minor refinements to enhance clarity and engagement. If executed well, the study could contribute valuable insights to the field of TMD research.
Keywords: The selected keywords appear to be generally suitable for the topic of the study, which focuses on the correlation between mental well-being and the severity of class II temporomandibular joint disorders (TMDs). These keywords collectively cover the clinical, psychological, and radiological dimensions of the study, reflecting the multidisciplinary nature of the research. However, it's always a good practice to consider potential variations or synonyms of these keywords to ensure comprehensive searchability. Additionally, the inclusion of broader terms related to temporomandibular disorders and mental health might be beneficial for reaching a wider audience and increasing the visibility of the study in relevant literature searches.
3. Introduction
   - The introduction lacks an in-depth analysis of existing literature. It briefly mentions evidence suggesting a connection between TMJ disorders and mental well-being but does not provide a comprehensive review of relevant studies.
   - While the introduction touches on various aspects of TMJ disorders, it lacks detailed exploration, and the information is presented in a relatively surface-level manner.
   - The introduction doesn't explicitly highlight the novelty of the study. Emphasizing the unique aspects of the research could make the study more compelling.
   - Citations are appropriately used to support statements. However, the citations are somewhat dated, and more recent references could strengthen the foundation of the study. Citations are provided for specific statements, but the absence of more recent references might limit the incorporation of the latest knowledge on the subject.
   - The information presented is generally correct, but the lack of recent citations may impact the accuracy and currency of the background information.
   - The introduction encompasses various aspects of TMJ disorders, including their impact on mental well-being, diagnostic tools like MRI, and relevant scales. This reflects a degree of diversity in the information provided.

   - The information about the diagnostic tools and their advantages seems accurate. However, the use of more recent sources could enhance the accuracy of the background information.
    - The language is generally clear, but there are areas where sentence structures could be improved for better flow and comprehension.
    - The introduction is mostly clear, but providing context for the scales used (WEMWBS, HAM-A) may enhance clarity, especially for readers unfamiliar with these tools.
    - There are minor grammatical issues that could be addressed to improve the overall readability.
    - There is no evidence of plagiarism in the provided text.
    - The introduction does not explicitly state the knowledge gap or highlight the original contribution of the study. Identifying a gap in existing knowledge would strengthen the rationale for the research.
    - The study objectives are clearly outlined, specifying the clinical, radiological, and psychological aspects to be evaluated.
Suggestions for Improvement:
   - Expand the literature review to provide a more comprehensive background on the connection between TMJ disorders and mental well-being. Include more recent references to reflect the current state
   - Explicitly state the novelty or unique contribution of the study to engage readers and demonstrate the significance of the research.
   - Use more recent and diverse references to strengthen the credibility and currency of the background information.
   - Refine sentence structures for better clarity and readability. Provide explanations for specialized terms and scales to aid understanding.
   - Clearly identify the knowledge gap or research question that the study aims to address. This helps establish the need for the research.
   - Offer a brief rationale or context for each objective to enhance understanding and emphasize the relevance of each aspect of the study.
   - Address minor grammatical issues for smoother readability.
   - Consider incorporating visuals (charts, graphs) to illustrate the prevalence of TMJ disorders and the potential impact on mental well-being.
By addressing these suggestions, the introduction can be strengthened, providing a more solid foundation for the study and engaging readers more effectively.

4. Material and methods
   - The methodology is outlined in a systematic manner, detailing the study design, setting, sample size calculation, inclusion and exclusion criteria, and data collection methods. However, it lacks depth in explaining certain aspects, such as the rationale behind choosing specific scales and indices.
   - The methodology doesn't explicitly highlight any novel approaches or techniques. Emphasizing the innovative aspects of the study could enhance its appeal.
- Providing references to justify the choice of specific criteria, scales, or statistical methods would strengthen the research design.
   - The language is generally clear, but there are areas where sentence structures could be improved for better flow and comprehension.
   - The methods are generally clear, but some sections, especially those related to the statistical analysis, could benefit from additional explanations for readers unfamiliar with statistical terms and tests.
   - While ethical approval is mentioned, there is no explicit discussion of potential ethical issues or considerations in the methodology. It's important to highlight how ethical concerns will be addressed, especially in a study involving human subjects.
   - The statistical analysis plan is appropriate for the study objectives. However, providing more details on the validity and reliability of the scales and indices used would strengthen the methodological foundation.

Suggestions for Improvement:
   - Offer more detailed explanations and rationale for the selection of specific scales (WEMWBS, HAM-A) and indices (DC/TMD criteria, Helkimo index). This will enhance the reader's understanding of why these tools were chosen.
   - Include more recent references to support the methodology and ensure that the latest knowledge is incorporated into the study design.
   - Provide additional explanations for statistical terms and tests used. This will make the section more accessible to a broader audience.
   - Explicitly discuss ethical considerations, including participant consent, confidentiality, and how potential biases and risks will be addressed.
   - Highlight any unique aspects of the study design or methodology that contribute to its originality.
   - Discuss the validity and reliability of the diagnostic criteria, scales, and indices used. This information is crucial for establishing the trustworthiness of the study findings.
   - Address minor grammatical issues for smoother readability.
   - Consider incorporating visuals (flowcharts, diagrams) to illustrate the study design and data flow, making it more accessible to readers.
By addressing these suggestions, the methodology section can be strengthened, ensuring clarity, transparency, and a solid foundation for the research study.
5. Results

6. Discussion
   - The discussion section lacks an in-depth analysis of the existing literature. While some relevant studies are cited, a more comprehensive review of the literature, including recent findings, would strengthen the discussion.
   - Citations are relevant to the topic, but the lack of recent references is a limitation. Incorporating more recent studies would enhance the currency of the discussion and demonstrate awareness of the latest research.
   - The language is clear and concise. However, there are some grammatical errors that, if addressed, would improve the overall readability.
   - The conclusion is clear and reiterates the expected outcome of the study. However, it could be strengthened by explicitly summarizing how the study addresses the stated objectives and contributes to the existing knowledge.
   - The discussion does not explicitly connect the findings to the stated objectives. A clearer link between the results and the research objectives would enhance the coherence of the discussion.
   - The discussion does not effectively contrast or compare the study's findings with the broader literature. A more detailed examination of how the results align or differ from existing studies would provide a more nuanced understanding.
   - The discussion does not explicitly identify a knowledge gap. A clearer articulation of the gap in the literature that the study aims to fill would strengthen the rationale for the research.
   - The discussion does not raise any explicit ethical concerns related to the study. However, it would be beneficial to discuss potential ethical considerations in research involving mental health and patient data.
    - The references provided are relevant to the study, but more recent literature could be included. A broader range of studies, including those with different perspectives, could provide a more comprehensive discussion.
Suggestions for Improvement:
   - Expand the literature review by incorporating more recent studies and providing a more in-depth analysis of existing literature. Discuss how the current findings align with or diverge from previous research.
   - Clearly articulate how the study's findings address the stated objectives. This will provide a more structured and coherent discussion.
   - Explicitly state the knowledge gap that the study aims to fill. This will provide context for the research and enhance the justification for conducting the study.
   - Compare and contrast the current findings with other relevant studies in the field. This will highlight the study's contributions and limitations in the context of existing literature.
   - Discuss ethical considerations related to the study, especially when dealing with mental health data. Address issues such as patient consent, confidentiality, and potential biases.
   - Review and correct grammatical errors for improved readability.
   - Include more recent references to demonstrate an up-to-date understanding of the topic. This will strengthen the relevance and impact of the study.
By addressing these suggestions, the discussion section can be enhanced to provide a more thorough analysis of the study's findings and their implications in the broader context of research on temporomandibular disorders and mental health.

7. Overall assessment
The study investigates the correlation between temporomandibular joint disorders (TMDs), particularly in Class II (vertical growth pattern) cases, and mental well-being using a multidisciplinary approach. The study design involves an observational and analytical study with a sample size calculated based on the prevalence of TMD in Class II cases. The methodology includes the use of validated diagnostic criteria, imaging techniques, and psychological assessment scales.

Strengths:
1. The study addresses an important and clinically relevant topic, exploring the interplay between TMDs and mental well-being, which has implications for patient management.
2. The methodology is well-structured, detailing the study design, inclusion and exclusion criteria, and data collection methods.
3. The use of established diagnostic criteria and scales enhances the reliability of the study's findings.
Concerns and Areas for Improvement:
1. Literature Review
   - The literature review in the introduction and discussion sections is limited and could benefit from a more comprehensive review of relevant studies. Including recent literature would strengthen the background and discussion.
2. Linking Findings to Objectives:
   - The discussion does not clearly link the study's findings to the stated objectives. Strengthening this connection would enhance the coherence of the discussion.
3. Identification of Knowledge Gap
   - The study does not explicitly identify a knowledge gap, making it less clear why the research was conducted. A more explicit articulation of the gap in the literature would strengthen the rationale for the study.
4. Ethical Considerations
   - While an ethical approval statement is provided, the discussion does not explicitly discuss potential ethical concerns related to the study. A brief discussion of ethical considerations, especially in research involving mental health and patient data, would be beneficial.
5. Recent Literature
   - The references used in the study are somewhat dated. Including more recent literature would enhance the currency of the study and demonstrate awareness of the latest research in the field.

In summary, the study addresses a valuable research question, and the methodology is well-structured. However, there are areas for improvement, including enhancing the literature review, clearly linking findings to objectives, addressing ethical considerations, and incorporating more recent literature.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Oral surgery, Oral Medicine, Oral Pathology, Maxillofacial Radiology, Dental Education

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Correlation between mental well-being and severity of class II temporomandibular joint disorders, compared to non-temporomandibular joint disorders

Abstract

Keywords

Introduction

Objectives

Protocol

Study design and setting

Ethics statement

Inclusion criteria

Table 1. Cephalometric criteria.

Exclusion criteria

Methods

Bias

Study sample

Statistical analysis

Dissemination

Study status

Discussion

Data availability

Underlying data

Extended data

References

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