Tzvika Greenbaum

Background: Temporomandibular disorders (TMD) exhibit a marked female predominance, suggesting a potential role for estrogen in their pathophysiology. However, the evidence linking estrogen status to TMD risk and symptom severity remains inconsistent across studies. Objective: To systematically review and synthesize the available evidence on the association between estrogen status—including hormonal contraceptive use, menopausal status, menstrual cycle variation, pregnancy, and estrogen receptor gene polymorphisms—and the prevalence and clinical features of TMD in women. Methods: A comprehensive search of PubMed, Embase, Scopus, Web of Science, and Google Scholar was conducted through September 2025. Observational studies involving women diagnosed with TMD using validated diagnostic criteria (RDC/TMD, DC/TMD, or equivalent) and reporting estrogen-related exposures were included. Two independent reviewers conducted study selection, data extraction, and risk-of-bias assessment using the Newcastle-Ottawa Scale (NOS). Due to heterogeneity in exposure definitions and outcome measures, a narrative synthesis was performed. Meta-analysis was not conducted due to insufficient homogeneity across studies. Results: Seven studies met the inclusion criteria, comprising six clinical studies involving 2,735 participants and one mechanistic supportive study involving 18 participants. Two high-quality clinical studies—a prospective cohort and a cross-sectional study—reported quantitative effect estimates: hormonal contraceptive use was associated with an increased risk of first-onset TMD (OR 1.37, 95% CI 1.13–1.66) and concurrent TMD symptoms (OR 1.20, 95% CI 1.06–1.35), while climacteric status was associated with increased odds of TMJ palpation pain (OR 2.64, 95% CI 1.12–6.21), crepitus (OR 2.92, 95% CI 1.13–7.56), and degenerative joint disease (OR 2.27, 95% CI 1.05–4.91). Additional moderate-quality studies provided qualitative evidence supporting associations between menopausal status and TMD prevalence, menstrual cycle–related symptom variation, pregnancy-related symptom modulation, and estrogen receptor gene polymorphisms with TMD susceptibility. According to GRADE criteria, the certainty of evidence was rated as moderate for hormonal contraceptive use and menopausal/climacteric status, and low to very low for the remaining exposure categories due to inconsistency, indirectness, and imprecision. Conclusions: Current evidence suggests that hormonal factors, particularly hormonal contraceptive use and menopausal status, are associated with TMD risk and symptom presentation. However, the limited number of high-quality studies, heterogeneity in exposure definitions, and variability in diagnostic criteria constrain definitive conclusions. Further well-designed prospective cohort studies with standardized diagnostic protocols and biochemically validated hormonal assessments are needed to clarify causal relationships and inform clinical decision-making.

Temporomandibular disorders (TMD) are the most common cause of non-dental orofacial pain, affecting about 1/3 of the population worldwide. The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) Axis I is recognized as the international gold standard for the clinical and research diagnosis of TMD; however, no validated Romanian version has been available to date. The aim of the present study was to translate and culturally adapt the DC/TMD Axis I into Romanian, and to evaluate its criterion validity and interand intra-examiner reliability. This cross-sectional methodological study followed the Beaton et al. and DC/TMD translation guidelines. The process included forward-backward translation, an expert panel review, and pre-testing on 20 patients to ensure semantic and conceptual equivalence. A total of 140 Romanian-speaking adults (mean age: 34.7 ±12.1 years; 70.7% women) were examined by 2 calibrated clinicians. Criterion validity was assessed against an expert-consensus reference diagnosis. Interand intra-examiner reliability for categorical variables was analyzed using Cohen's κ, and for continuous measurements using intraclass correlation coefficients (ICCs). The Bland-Altman plots and demographic analyses further evaluated measurement consistency. The Romanian DC/TMD Axis I showed excellent diagnostic performance, with sensitivity ranging from 85.7% (for disc displacement without reduction) to 91.2% (for myalgia), specificity of 93.5-98.2%, and AUC (the area under the receiver operating characteristic (ROC) curve) ≥ 0.91 for all diagnostic categories. Inter-examiner agreement was substantial to almost perfect (κ = 0.78-0.94), and intra-examiner agreement similarly high (κ = 0.80-0.95). Continuous mandibular measurements demonstrated excellent reproducibility (ICC = 0.89-0.96). Slightly lower sensitivity for disc displacement without reduction indicates an area for further refinement of diagnostic criteria. The Romanian version of the DC/TMD Axis I is a valid, reliable and culturally equivalent tool for diagnosing TMD. Its adoption will standardize clinical assessment, enhance interdisciplinary communication, and enable Romanian participation in multicenter and educational initiatives across Central and Eastern Europe.

Obstructive sleep apnea (OSA) is a prevalent chronic condition characterized by recurrent episodes of upper airway narrowing or collapse during sleep. Obstructive sleep apnea is associated with various health issues, including cardiovascular disease and metabolic disorders. The cervico-craniomandibular complex (CCMC) plays a critical role in musculoskeletal functions such as mouth opening and head stabilization; however, its relationship with OSA remains insufficiently explored. The aim of the study was to evaluate the association between cervico-cranio-mandibular musculoskeletal function and OSA severity, based on the hypothesis that dysfunctions within the CCMC are associated with greater OSA severity. A pilot cross-sectional study was conducted involving 32 patients with symptoms of OSA. The participants underwent assessment of cervico-cranio-mandibular musculoskeletal function and an ambulatory sleep study to determine OSA severity. Spearman's tests were used to analyze the relationships between cervico-cranio-mandibular musculoskeletal parameters and OSA severity. Significant negative correlations were observed between cervical range of motion (ROM) (flexion, left rotation, right/left lateral flexion) and OSA severity. The strongest correlation was identified for cervical movement in the frontal plane (r = -0.607, p < 0.001), especially among females (r = -0.772, p < 0.01). A positive relationship was found between mouth-opening muscle endurance and OSA severity in male participants (r = 0.445, p < 0.05). This preliminary study highlights potential associations between specific musculoskeletal characteristics of the CCMC and OSA severity, with notable sex-specific patterns. These findings may contribute to the development of targeted screening approaches and support individualized physiotherapeutic interventions.

Temporomandibular disorders (TMDs) are challenging to manage due to their multifactorial nature. As with other joints, the function of temporomandibular joint (TMJ) is influenced by proprioception, making it an essential factor in TMD management. However, previous studies on the joint position error (JPE) in TMD patients lacked a proper diagnosis and reliability assessment. The aim of the present study was to develop a reliable JPE test in healthy adults as a foundation for future evaluation in TMD patients. Two examiners conducted the JPE assessment, utilizing a methodology encompassing between-days intra-rater and within-day inter-rater reliability assessments. A total of 22 healthy participants (7 men and 15 women) with a mean unassisted mouth opening of 46 ±5 mm were recruited. The evaluation targeted specific distances (10 mm, 20 mm and 30 mm) within the participants' mouth opening range, with proprioceptive accuracy evaluated through the measurement of the absolute error (AE) and the constant error (CE). The CE was consistently lower than AE across all the targeted distances, although with higher standard deviations. Intra-rater reliability varied across the distances, with poor reliability observed for AE at 10 mm, moderate reliability for CE at 10 mm, good reliability for both AE and CE at 20 mm, and moderate reliability for both AE and CE at 30 mm. Inter-rater reliability was moderate at 10 mm and good at 20 mm for both AE and CE, with equally moderate reliability levels at 30 mm. The 20 mm target distance demonstrated good intraand inter-rater reliability, warranting its evaluation in patients with TMDs in the subsequent investigation phase.

The hyoid bone exhibits potential sex-based variations and is implicated in the severity of obstructive sleep apnea (OSA). Sex-specific comparisons are lacking. The present meta-analysis aimed to address this gap.The Embase, MEDLINE and Web of Science databases were searched. The inclusion criteria were as follows: studies that reported the measurements of the hyoid bone-mandibular plane distance (HMP), demonstrated in cephalometric imaging (CEPH) in patients with OSA of both sexes, involving a polysomnography (PSG) examination with the apnea-hypopnea index (AHI), as well as information on the body mass index (BMI) and age. The exclusion criteria comprised reviews, meta-analyses and case reports. The risk of bias was assessed with the use of the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Statistical analysis was conducted using Comprehensive Meta-Analysis software (CMA) and IBM SPSS Statistics for Windows.Seven observational studies with 718 adult patients (515 males and 203 females) met the inclusion criteria. The mean HMP value was 20.5 ±3.8 mm, with a significant difference observed between males (21.6 ±3.3 mm) and females (17.8 ±3.7 mm) (p < 0.00001). The correlation between HMP and AHI was significantly stronger in females - 2.5 times higher than in males (r = 0.423 vs. r = 0.167, respectively).Although a standard range of the hyoid bone position for healthy adults and elderly individuals is currently lacking, sex significantly affects the anatomical variation of the hyoid mandibular position in patients with OSA. It is crucial to identify distinct OSA endotypes by sex to ensure accurate diagnosis and treatment planning, which could lead to sex-specific therapeutic strategies.

Introduction: Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.Purpose: The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.Implications: Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Background: The mouth‐opening muscular performance in patients with temporomandibular disorders (TMDs) is unclear. Understanding the impairments of this muscle group within specific TMDs is important to develop proper management strategies.Objective: To characterise the mouth‐opening muscular performance in adults with and without TMDs.Methods: PubMed, EMBASE, CINAHL, Scopus, Web of Science and Cochrane databases were searched from inception to 12 November 2020. Bibliographies were searched for additional articles, including grey literature. Case‐control, cross‐sectional and interventional studies reporting mouth‐opening muscular strength and/or endurance were included. Risk of bias was assessed by the SIGN checklist for case‐control studies and by the NIH quality assessment tool for cross‐sectional studies. Results were pooled with a random‐effects model. Confidence in cumulative evidence was determined by means of the GRADE guidelines.Results: Fourteen studies were included; most were rated as having a moderate risk of bias. Only three studies assessed patients with TMDs and the other 11 assessed healthy adults. Significant sex differences in muscular performance were found for healthy adults in the review (strength deficit for females versus males). There was a significant reduction in maximal mouth opening performance (strength and endurance) in the three studies that assessed patients with temporomandibular disorders.Conclusion: Sex plays a significant role in maximal mouth opening strength. There is a lack of reliable data on the normal mouth‐opening strength and endurance of healthy adults as well as for patients with TMDs.Implications: Lack of reliable TMDs patient data and comparable healthy adult data highlight future direction for research.

Upper neck impairments are more prevalent in patients with temporomandibular disorders (TMDs) but the differences between specific types of TMDs are unclear. This study evaluated the distribution of such impairments among different forms of TMD. In total, 116 participants (86 women and 30 men, age range 21–75 yr) were investigated. Forty‐two individuals had no TMDs and were assigned to the control group. The remaining 74 patients were assigned to one of three groups based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) findings: pain‐related (n = 37); intra‐articular (n = 17); or mixed (combined pain‐related and intra‐articular) (n = 20). Analyses of impairments included between‐group comparisons of key parameters of upper neck performance (active/passive mobility and muscular capabilities) and pain (subjective neck disability and pain sensitivity). Patients in the pain‐related and mixed TMD groups were found to have decreased upper neck mobility in the cervical flexion‐rotation test compared with patients in intra‐articular and control groups, as well as poorer capabilities of the deep neck flexor muscles in the cranio‐cervical flexion test compared to the control group. It was concluded that patients with pain‐related TMD diagnoses are more likely to experience significant upper‐neck hypomobility and poor muscular capabilities than patients with intra‐articular diagnoses of TMD.