842577

review-article2019
AORXXX10.1177/0003489419842577Annals of Otology, Rhinology & LaryngologyOmidvar and Jafari

Review Article
Annals of Otology, Rhinology & Laryngology

Association Between Tinnitus and

1­–14
© The Author(s) 2019
Article reuse guidelines:
Temporomandibular Disorders: A sagepub.com/journals-permissions
DOI: 10.1177/0003489419842577
https://doi.org/10.1177/0003489419842577

Systematic Review and Meta-Analysis journals.sagepub.com/home/aor

Shaghayegh Omidvar, PhD1,2 and Zahra Jafari, PhD3

Abstract
Objectives: Tinnitus is one of the most common otological symptoms in patients with temporomandibular disorders.
This study aimed to investigate the possible association between tinnitus and temporomandibular disorders.
Methods: The online databases of PubMed, Ovid, ScienceDirect, and Web of Science were explored for all English articles
published until September 2018 using the combined keywords tinnitus and temporomandibular. Cross-sectional, cohort, or
case-control studies that investigated the association between tinnitus and temporomandibular disorders (TMDs) were
considered. The quality of the included papers was assessed by the Crowe Critical Appraisal Tool.
Results: Twenty-two papers met the eligibility criteria and were included in the systematic review. Meta-analysis was
performed on 8 papers to investigate the possible relationship between tinnitus and TMDs by calculating the odds ratios.
Odds ratios ranged from 1.78 to 7.79 in the studies related to tinnitus frequency in temporomandibular disorders and from
1.80 to 7.79 in the papers linked to temporomandibular disorder frequency in tinnitus, indicating a significant association
between tinnitus and temporomandibular disorders.
Conclusions: There was a strong relationship between tinnitus occurrence and TMDs. The findings implied the significance
of exploring the signs of TMDs in patients with tinnitus as well as tinnitus in those who complain from temporomandibular
disorders.

Keywords
tinnitus, temporomandibular disorder, hearing loss, systematic review, meta-analysis

Introduction related structures.7 All of these disorders share a group of

Tinnitus is a phantom auditory experience in the absence of
external auditory stimuli.1 It is estimated that 10% to 15% of
the adult population suffers from tinnitus.2,3 In addition to
the auditory system that is commonly associated with this
phantom auditory perception,4 the somatosensory system
also appears to contribute to tinnitus resulting from the
somatosensory-auditory interactions in the central nervous
system.5 The somatic involvement of the structures outside
of the ear, for example, the temporomandibular joint (TMJ)
and masculatory muscles, may also interfere in tinnitus
(somatic tinnitus) perception.5 Various cranial nerves,
including the trigeminal (V), facial (VII), glossopharyngeal
(IX), vagus (X), and autonomic nerves, innervate the ear.
The TMJ is likewise innervated by cranial nerves V and VII
with communicating branches like the chorda tympani,
which are close to the ear structures. Due to the common
cranial nerves between the ear and TMJ, ear difficulties like
tinnitus, otalgia, and vertigo have been postulated to be con-
nected to temporomandibular disorders (TMDs).6 TMDs is a
collective term used to demonstrate a number of associated
disorders involving the TMJ, masticulatory muscles, and
symptoms, including (a) ear symptoms such as hearing loss,
otalgia, tinnitus, and vertigo8; (b) pain, originated from
either macular or articular conditions,9 in the form of head-
ache about the vertex, occiput, and behind the ears, and a
burning sensation in throat, tongue, and side of the nose8; (c)
miscellaneous symptoms such as dryness of the mouth, her-
pes of the external ear canal, buccal mucosa8; and limited
mouth opening.10
Approximately 60% to 70% of the general population
suffers from at least 1 symptom of TMDs; however, 1 out of
4 of these individuals is aware of the signs and reports them.
1
Department of Audiology, School of Rehabilitation Sciences, Shiraz
University of Medical Sciences, Shiraz, Fars, Iran
2
Rehabilitation Sciences Research Center, Shiraz University of Medical
Sciences, Shiraz, Fars, Iran
3
Department of Neuroscience, Canadian Center for Behavioral
Neuroscience (CCBN), University of Lethbridge, Lethbridge, AB, Canada
Corresponding Author:
Zahra Jafari, PhD, Department of Basic Sciences in Rehabilitation, School of
Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.
Emails: jafari.z@iums.ac.ir, zahra.jafari@uleth.ca
2 Annals of Otology, Rhinology & Laryngology 00(0)
Approximately 5% of individuals with 1 or more TMD
symptoms also seek for treatment.10
Although tinnitus and TMDs are 2 common complaints
in every society, the incidence of each one in patients with
the other complaint does not necessarily suggest a causal
relation. Tinnitus has been shown to be more frequent in
individuals with TMDs (36.6%) compared to the controls
(4.4%).11 Patients with tinnitus also display a significantly
higher frequency of TMDs (85%) compared with the indi-
viduals without tinnitus (55%).12 In 1934, Costen described
the relationship between otologic symptoms and TMDs and
attributed it to a misdisplacement of mandibular condyle,
causing pressure on ear structures.13 Thereafter, diverse
hypotheses were presented to explain the underlying rea-
sons for reporting otologic signs in TMDs,13 for instance,
the similar embryonical origin of the middle ear and chew-
ing muscles; compression of vessels, nerves, and ligaments
of the middle and inner ear regions following the transloca-
tion of articular head of the mandible13,14; middle ear dis-
eases subsequent to an Eustachian tube dysfunction15; and a
neuroanatomical interaction between the neural input from
trigeminal system and dorsal cochlear nucleus (DCN).16,17
A great amount of uncertainty, however, still exists about
the biological origin of the relationship between TMDs and
tinnitus.18
This topic, namely, “exploring the association between
tinnitus and TMDs,” contains major clinical implications
for a diverse spectrum of health care professionals, which
impacts both levels of clinical practice and future research.
It also indicates taking advantage of specific multidisci-
plinary clinical assessments and therapeutic approaches in
the management of patients with tinnitus with underlying
TMJ dysfunction. The present study aimed to systemati-
cally investigate and quantitatively analyze the association
between tinnitus and TMDs.
Methods
Systematic Search Strategy
This systematic review was conducted based on the guide-
lines of the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis (PRISMA).19 A comprehen-
sive systematic search was conducted on January 7, 2018,
updated September 2018, in PubMed, Ovid, ScienceDirect,
and Web of Science databases. The searched terms were tin-
nitus and temporomandibular. They were always combined,
thus papers with both keywords in the title and/or abstract
were extracted regardless of whether they focused on the
association between tinnitus and TMDs.
Inclusion criteria. Cross-sectional, cohort, or case-control
studies in individuals with TMDs or tinnitus and their asso-
ciation were considered for the review. Three inclusion
criteria for TMDs were applied: (1) the research diagnostic
criteria for temporomandibular joint disorder (RDC/
TMD),20 (2) the revised versions of the RDC/TMD,21,22 and
(3) complain of TMJ noise (like clicking), mouth opening
limitation, or both that were evaluated by asking questions
and/or clinical examinations.
RDC/TMD incorporates 2 axes. Axis I demonstrates
the clinical condition, and Axis II includes the psycho-
social status and pain-related disability given the bio-
psychosocial model of chronic pain.20 Axis I diagnoses
are based on the following diagnostic groups: group I
([a] myofascial pain, [b] myofascial pain with limitation
in mouth opening), group II ([a] disk displacement with
reduction, [b] disk displacement without reduction with
limited opening, [c] disk displacement without reduc-
tion without limited opening), and group III ([a] arthral-
gia, [b] osteoarthritis, [c] osteoarthrosis). Axis II
diagnoses are also according to the scores of the follow-
ing instruments: chronic pain grades, based on graded
chronic pain scale (GCPS) (0, no disability; I, low dis-
ability, low intensity; II, low disability, high intensity;
III, high disability, moderately limiting; and IV, high
disability, severely limiting)23; depression levels, based
on the depression scale of the symptoms-checklist-90R
(SCL-90R) (normal, moderate, severe depression)24;
and nonspecific physical symptoms levels based on the
somatization scale (SOM) of the SCL-90R (normal,
moderate, severe somatization). The DC/TM22 and
expanded DC/TMD21 are the revised versions of the
RDC/TMD. The main discrepancy between DC/TMD
and RDC/TMD is that DC/TMD confirms pain and/or
headache locations as it separately examines each side
of the head.22 In the expanded DC/TMD, a set of uncom-
mon nonoverlapping TMDs with realizable criteria are
included to achieve high interexaminer reliability and
diagnostic validity.21
Exclusion criteria. Reviews, letters, case reports, conference
abstracts, books, and studies that did not investigate the
association between TMDs with tinnitus; non-English
papers; and studies without an accessible full text were
excluded.
The duplicates were removed using Endnote software
(Thomson Reuters, Philadelphia, Pennsylvania, USA, ver-
sion X7). The final papers were included through a 3-stage
process: title screening, abstract screening, and full-text
screening. In each section, the papers that did not meet the
inclusion criteria were excluded. In the cases of uncertainty,
first the abstracts and then the full texts were screened. All
3 stages were independently conducted by 2 reviewers
(S.O., Z.A.). If there was any disagreement, the authors dis-
cussed to reach a consensus.25 Overall, there was a com-
plete agreement between the reviewers.
Omidvar and Jafari
Quality Assessment
Because of the heterogeneity of the studies, the Crowe
Critical Appraisal Tool (CCAT)26 was applied as the quality
measurement tool in this systematic review. This instrument
is one of the few instruments that has undergone both reli-
ability and validity evaluations26,27 and is able to appraise
different research study designs. The CCAT permits assess-
ments of the following aspects of each paper using a 6-point
scale (from 0 to 5 for each category): permeable, introduc-
tion, design, sampling, data collection, ethical issues,
results/findings, and discussion, with a total potential score
of 40.
Synthesis of Results
A meta-analysis was carried out to investigate the possible
relationship between tinnitus and TMDs by calculating the
odds ratios (ORs). Therefore, the studies without a convenient
control group were excluded from the analysis. To prevent
confounding bias resulting from low sample sizes, the papers
with a sample size less than 100 subjects were not considered
in the analysis. The papers were first classified into 2 groups,
the first group including papers associated with tinnitus fre-
quency in TMDs and the second group containing papers
linked to TMD frequency in tinnitus. Then the papers of each
group were separated based on the study type (cross-sectional,
cohort, or case-control), and meta-analysis was conducted for
each subgroup. The metan procedure in STATA software (Stata
Corp., College Station, Texas, USA) version 14 was employed
for meta-analysis of ORs. Heterogeneity was assessed by
Q-Cochrane test and I-squared statistic. Whenever heterogene-
ity was confirmed (I2 value >0.75 and P value <0.1 by
Q-Cochrane test), a random-effect meta-analysis with 95%
confidence intervals (CIs) was performed; otherwise, a fixed-
effect meta-analysis was applied. Forest plots were used to
present the pooled estimates of ORs and the 95% CIs.
Results
The database search yielded 620 papers that were screened.
Duplicated papers (n = 396), non-English papers (n = 17),
case report studies (n = 28), animal studies (n = 1), and
titles out of the study scope (n = 60) were removed. This
initial screening resulted in a set of 118 papers. The co-
authors evaluated the 118 abstracts to extract those items
corresponding to the inclusion criteria, allowing the authors
to determine the levels of evidence available. Of the 37
studies extracted for the full review, 22 studies were identi-
fied and selected for final inclusion: 2 cohort and 3 case-
control studies related to tinnitus frequency in individuals
with and without TMDs (Table 1), 7 cross-sectional papers
on tinnitus frequency in TMD patients without a control
group (Table 1), 1 case-control study related to TMDs in
3
individuals with and without tinnitus (Table 2), 4 cross-sec-
tional studies on TMD frequency in tinnitus without a con-
trol group (Table 2), and 6 cross-sectional studies related to
both tinnitus frequency in individuals with TMDs and vice
versa (Table 1 and 2). One paper consisted of 2 parts, a
case-control study and a cross-sectional study.28 The refer-
ence lists for the selected publications were hand-searched;
no additional related article, however, was found. The bias
resulting from only searching databases in the English lan-
guage (language bias) is acknowledged. All steps of the
screening procedure are illustrated in Figure 1.
The strength of the Evidence
The included studies were assessed for methodological
quality using CCAT.26,27 The final CCAT scores (after an
agreement between authors) are reported in Table 3.
According to CCAT recommendations, the scores are
reported as both a total score and a percentage. There was
extreme variability in the quality of the studies, with a rat-
ing of 35% to 80% (mean = 65.57%). Overall, only 5
studies12,29-32 contained scores above 75%. The majority of
studies were deficient in several aspects, including the
unclear definition of the assessment tools and potential bias,
application of invalid and unreliable tools, and little or no
mention of ethnical matters, for example, ethical approvals,
funding sources, or potential conflict(s) of interest. Most
papers provided minimal details regarding sample size cal-
culations, inclusion and exclusion criteria, as well as non-
participation, withdrawal, and other incomplete/lost data.
The external validity of the studies, their particular strengths
and limitations, and suggestions for future investigations
were also less described.
Findings From the Systematic Review
Demographic Characteristics of the Included
Papers
Tables 1 and 2 demonstrate the characteristics of the
included studies such as sample size, age, gender, and
assessment tools used for diagnosing tinnitus and TMDs and
investigating the outcome. Sample size varied between 5933
and 17 01732 in the studies focusing on tinnitus frequency in
individuals with TMDs. In the studies investigating TMDs
in patients with tinnitus, the sample size was from 2034,35 to
17 017.32 Song et al32 investigated both the frequency of tin-
nitus in TMDs and vice versa. Both genders (male and
female) were considered in approximately all papers, except
3 that assessed only females.33,36,37 Different age ranges
were studies in the included papers; the youngest person
was 10 years,7 and the oldest was 84 years old.16
Demographic information of the participants, namely, age
and gender, was not mentioned in 2 papers.18,32
4
Table 1. Summary of Characteristics of the Included Studies Reporting the Frequency of Tinnitus in Individuals With and Without TMDs.
Study Characteristics Population Characteristics Assessment Tool Outcome

Tinnitus
Gender Frequency
Author Year Study Design Subjects (n) Age (y) Female/Male Tinnitus Evaluation TMJ Evaluation (%)

Ciancaglini et al 1994 Cross-sectional Case = 797 37.4 ± 8.3 (15-60) 534/263 Asking questions -Clinical examinations 6.4
-CT
Tuz et al 2003 Case-control 250 *29.6 *165/35 Asking questions RDC/TMD *45.5
(*case = 200, **control = 50) **37.2 ** **26
27/23
Bernhardt et al 2004 Cross-sectional 4228 20-79 NR Asking questions Clinical examinations *5.77
(*case = 745, **control = 3483) **2.76
Bernhardt et al 2011 Cohort 3134 (*case = 191; **control = 20-81 1628/1506 Asking questions Clinical examinations *12.6
2643) **5.8
Calderon et al 2012 Cross-sectional Case = 59 35.25 (17-52) 59 F Asking a question -RDC/TMD 54.24
-VAS
Saldanha et al 2012 Cross-sectional 200 (*case = 140, **control = 60) 36.7 149/51 -Asking a question -RDC/TMD *60.71
-VAS -PPT **25
-VAS
Fernandes et al 2013 Case-control 224 37.7 (18-76) 184/40 A question in RDC/TMD RDC/TMD *70.37
(*case = 162, **control = 62) questionnaire **24.19
Fernandes et al 2014 Cross-sectional 261 37.0 (18-76) 261 F A question in RDC/TMD RDC/TMD *70.37
(*case = 216, **control = 45) questionnaire **24.44
Ferendiuk et al 2014 Cross-sectional Case = 1209 19-50 952/256 Medical interview Clinical examinations 3.72
Buergers et al 2014 Cross-sectional 951 54.1 ± 17.1 478/473 -Asking question RDC/TMD *36.6
(*case = 82, **control = 869) -THI **4.4
Manfredini et al 2014 Cross-sectional Case = 238 49.3 ± 13.5 58/192 Asking questions An executive summary of the 30.4
DC/TMD
Algieri et al 2016 Cross-sectional Case = 200 44.10 (13-79) 168/32 THI -Clinical examinations 60
MRI
-Wilkes classification
Effat 2016 Case-control 214 *35.3 ± 12.1 (10-59) *84/20 Asking questions -History taking *52
(*case = 104, **control = 110) **30.9 ± 8.1 (14-53) **66/44 -The expanded DC/TMD **12
de-Pedro-Herráez et al 2016 Cohort 62 (*case = 31, **control = 31) 24-58 62 F An item in a health RDC/TMD *51.6
questionnaire **9.7
Vasconcelos et al 2016 Cross-sectional Case = 100 13-70 80/20 Asking questions The simplified Fonseca 64
anamnestic questionnaire
Maciejewska-Szaniec et al 2017 Cross-sectional Case = 246 40.08 ± 11.12 147/99 Asking questions RDC/TMD 14.63
Kim et al 2018 Cross-sectional 11 745 NR 5967/5778 Asking questions -A questionnaire *27.38
(*case = 924, **control = 10 821) -Clinical examinations **21.27
Song et al 2018 Cross-sectional 17 017 (*case = 2003, **control = NR NR Asking questions Asking questions *32.65
15 014) **21.39

Abbreviations: Case, subjects with temporomandibular joint disorders; control, subjects without temporomandibular joint disorders; CT, computed tomography; F, female; MRI, magnetic resonance imaging; NR, not reported;
PPT, pain pressure threshold; RDC/TMD, research diagnostic criteria for temporomandibular joint disorder; THI, tinnitus handicap inventory; TMD, temporomandibular disorders; TMJ, temporomandibular joint; VAS, visual
analog scale
 Table 2. Summary of Characteristics of the Included Studies Reporting TMD Frequency in Individuals With and Without Tinnitus.

Study Characteristics Population Characteristics Assessment Tool Outcome

Gender TMD
Author Year Study Design Subjects (n) Age (y) Female/Male Tinnitus Evaluation TMJ Evaluation Frequency (%)
Morgan 1992 Cross-sectional Case = 20 55.3 (22-74) 4/16 NR -*Clinical examinations *95
-**Mandibular scan and EMG **20
Lam et al 2001 Cross-sectional Case = 192 NR NR Asking questions RDC/TMD 64.1
Rubinstein 1993 Cross-sectional Case = 102 56 (15-84) 40/62 NR -*Clinical examinations *84
et al. -**A questionnaire **46
Bernhardt et 2004 Cross-sectional 4228 (*case = 139, **control = 20-79 *67/72 Asking questions Clinical examinations *30.93
al (Phase I) 4089) **2092/1997 **17.17
Bernhardt et 2004 Case-control 1937 *18-71 *13/17 Asking questions Clinical examinations *60
al (Phase II) (*case = 30; **20-79 **992/915 **36.5
**control = 1907)
Morais and Gil 2012 Cross-sectional Case = 20 32.1 (20-55) 14/6 -Asking question Asking questions 90
-THI
Saldanha et al 2012 Cross-sectional 200 (*case = 100, **control = *39.16 ± 12.01 *84/16 -Asking a question -RDC/TMD * 85
100) **34.33 ± 10.72 **65/35 -VAS -PPT **55
-VAS
Buergers et al 2014 Cross-sectional 951 54.1 ± 17.1 478/473 -Asking question RDC/TMD *44.12
(*case = 68, **control = 883) -THI **5.89
Fernandes 2014 Cross-sectional 261 37.0 (18-76) 261 F A question in RDC/TMD *93.25
et al (*case = 163, **control = 98) RDC/TMD **65.31
questionnaire
Kim et al 2018 Cross-sectional 11 745 (*case = 2555, **control *49.1 ± 0.6 *1436/1119 Asking questions -Asking questions *9.9
= 9190) **44.5 ± 0.3 **4531/4659 -Clinical examination **7.3
Song et al 2018 Cross-sectional 17 017 NR NR Asking questions Asking questions *16.92
(*case = 3866, **10.26
**control = 13 151)

Abbreviations: Case, subjects with tinnitus; control, subjects without tinnitus; EMG, electromypgraphy; F, female; NR, not reported; PPT, pain pressure threshold; RDC/TMD, research diagnostic
criteria for temporomandibular joint disorder; THI, tinnitus handicap inventory; TMD, temporomandibular disorders; TMJ, temporomandibular joint; VAS, visual analog scale

5
6 Annals of Otology, Rhinology & Laryngology 00(0)
Figure 1. Flow diagram of literature search and selection criteria corresponding with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement 2009.
Tinnitus Frequency in Individuals With TMDs
Table 1 presents the frequency of tinnitus in individuals
with TMDs in 18 included publications. Tinnitus frequency
varied between 3.72%38 and 70.37%36,39 in the patients with
TMDs (total sample = 7647) and 2.76%28 and 26%40 in the
controls (total sample = 33 188).
TMD Frequency in Individuals With Tinnitus
Among the included studies, 11 papers investigated TMD
frequency in patients with tinnitus (Table 2). TMD fre-
quency was reported between 9.9%30 and 95%35 in the tin-
nitus group (total sample = 7255) and 5.89%11 and 65.31%36
in the subjects without tinnitus (total sample = 29 418).
The Relationship Between the Type of TMDs
and Tinnitus
Among the included papers, 8 studies reported the effect of
TMD type on the prevalence of tinnitus,12,28,29,31,33-35,40 In 2
studies, patients with tinnitus and TMDs perceived tender-
ness of the masticatory muscles and TMJ significantly more
often than subjects with dysfunctions but without tinni-
tus.12,28 In another study, tenderness or pain in the TMJ was
a stronger predictor for the development of tinnitus than
tenderness or pain in the masticatory muscles.29 There was
no significant difference between the prevalence of tinnitus
in different TMD subgroups in 2 studies.31,40 In Calderon
et al’s33 (2012) study, approximately 68% of patients with
tinnitus suffered both muscular and articular TMDs. In
another study, 75% of patients with tinnitus complained of
some soreness or pain to palpation in the TMJ.35 The asym-
metrical opening movement was the most frequent TMD
sign reported by individuals with tinnitus in 1 study.34
Tinnitus Characteristics in TMDs
In a population with both tinnitus and TMDs (n = 30), all
patients with unilateral TMDs and simultaneous unilateral
tinnitus demonstrated both symptoms on the same side
(8/8), and participants with bilateral TMDs complained
from either bilateral (14/17) or unilateral (3/17) tinnitus.11
In another study, unilateral tinnitus (n = 26) was more fre-
quent than bilateral tinnitus (n = 19) in participants with
both TMDs and tinnitus (n = 45).38 The frequency of bilat-
eral tinnitus (n = 83/200) in TMD patients was higher than
unilateral tinnitus (n = 37/200) in 1 study.41 In 2 later stud-
ies, the laterality of TMDs was not reported.38,41 Other
characteristics of tinnitus (eg, its pitch, loudness, duration,
 Table 3. Quality Assessment of the Included Papers With CCAT Ratings.

Data Ethical
Author Year Preamble Introduction Design Sampling Collection Matters Results Discussion Total/40 Total (%)
Rubinstein et al 1990 5 4 2 3 3 0 3 3 23 57.5
Morgan 1992 3 3 1 1 2 0 3 1 14 35
Ciancaglini et al 1994 5 3 4 4 3 0 4 4 27 67.5
Tuz et al 2003 4 5 3 3 3 0 3 2 23 57.5
Bernhardt et al 2004 4 5 4 4 3 1 3 3 27 67.5
Bernhardt et al 2011 4 5 4 4 3 3 4 4 31 77.5
Lam et al 2011 5 5 4 2 3 1 3 5 28 70
Calderon et al 2012 5 5 1 1 4 3 3 4 26 65
Morais and Gil 2012 3 3 2 1 2 3 2 1 17 42.5
Saldanha et al 2012 5 5 4 3 4 3 4 3 31 77.5
Fernandes et al 2013 5 5 4 3 3 2 3 4 29 72.5
Buergers et al 2014 5 5 4 2 5 1 3 4 29 72.5
Fernandes et al 2014 5 5 3 2 3 3 3 4 28 70
Ferendiuk et al 2014 4 5 3 3 3 3 3 2 26 65
Manfredini et al 2014 5 5 3 3 4 3 4 4 31 77.5
de-Pedro-Herráez et al 2016 2 5 1 1 2 3 2 3 19 47.5
Effat 2016 3 5 3 4 4 2 3 3 27 67.5
Vasconcelos et al 2016 5 5 2 2 2 1 4 3 24 60
Algieri et al 2017 5 5 3 3 3 0 4 2 25 62.5
Maciejewska-Szaniec et al 2017 4 5 4 3 4 4 3 2 29 72.5
Song et al 2018 5 5 3 5 3 3 3 5 32 80
Kim et al 2018 5 5 2 5 3 3 4 4 31 77.5

Abbreviation: CCAT, Crowe critical appraisal tool.

7
8 Annals of Otology, Rhinology & Laryngology 00(0)
and continuity) in TMDs were not reported in the included
papers.
Instrumentation
The method of classifying individuals as those with and
without tinnitus and with and without TMDs was quite dif-
ferent. To diagnose patients with TMDs, 1 papers used
RDC/TMD11,12,18,33,36,37,39,40,42 or its revised versions,7,31 6
papers did clinical examinations,28,29,35,38,41,43 3 asked
some questions,32,34,44 and 2 used both clinical examina-
tions and asking questions.16,30 The method of labeling
patients as those suffering from TMDs was summarized in
Tables 1 and 2.
To evaluate the presence or absence of tinnitus, various
methods were used in the included papers. Two publica-
tions used a question in RDC/TMD questionnaire.36,39 Other
studies asked 1 or more questions,7,11,12,18,28-34,37,38,40,42-44 but
the applied questions were only mentioned in 4.28-30,33 The
tinnitus handicap inventory (THI) questionnaire was used
in 3 papers.11,34,41
Results of the Meta-Analysis
Eleven papers including a control group for comparison
were considered for the analysis. One of the papers was
excluded given a sample size of less than 100.37 Fernandes
et al36,39 investigated tinnitus frequency in the individuals
with and without TMDs in 2 papers. One study was excluded
from the analysis as all subjects displayed a chief complain
of orofacial pain leading to a high frequency of TMDs both
in the individuals with tinnitus and the control group.36
Bernhardt et al also published 2 papers. The later one was a
cohort study on tinnitus frequency in TMD study,29 and the
former paper contained 2 studies consisting of a case-con-
trol study on TMD frequency in subjects with and without
tinnitus and a cross-sectional study investigating TMD fre-
quency in tinnitus and vice versa.28 The main population
had overlap among these 3 studies. The cohort study29 (the
later one) therefore was considered to investigate tinnitus
frequency in TMDs, and the second part of the former
study,28 with a higher sample size relative to the first part,
was analyzed for exploring TMD frequency in tinnitus.
Song et al32 (2018) and Kim et al30 (2018) also published 2
papers on the same population. The paper with a larger sam-
ple size32 was included for the analysis. Thus, eventually 8
papers were included for the meta-analysis: 3 case-
control7,39,40 and 1 cohort29 papers on tinnitus frequency in
subjects with and without TMDs, 1 cross-sectional study on
TMD frequency in individuals with and without tinnitus,28
and 3 cross-sectional papers (1 on public population32 and 2
on individuals seeking dental care11,12) both on tinnitus fre-
quency in subjects with and without tinnitus as well as
TMD frequency in individuals with and without tinnitus.
The Relationship Between Tinnitus and TMDs
Table 4 indicates the results of the meta-analysis for the
association between tinnitus and TMDs in the included
case-control, cohort, and cross-sectional studies. ORs
(95% CI) ranged from 1.78 (1.61-1.97) to 7.80 (2.93-
20.78) in the studies related to tinnitus frequency in TMDs
and from 1.81 (1.64-1.99) to 7.80 (2.93-20.78) in the
papers related to TMD frequency in tinnitus, all implying
that tinnitus was significantly related to TMDs. The papers
were classified into 2 groups, namely, those with samples
derived from health studies (public population) and those
with samples selected from people seeking dental care
(specific population). The connection between tinnitus
and TMDs was significantly stronger in the papers linked
to specific populations compared to the papers associated
with public populations. The results of the meta-analysis
are also summarized in the forest plots (Figures 2A-2C).
Forest plots provide a simple visual representation of the
amount of variation across studies as well as an estimate
of the overall result of all studies together.45 In the current
study, the forest plots were demonstrated when there was
more than 1 study in each investigated category, namely,
tinnitus occurrence in TMDs and vice versa in cross-sec-
tional studies among people seeking dental care (Figure
2A), TMD occurrence in tinnitus in cross-sectional popu-
lation-based studies (Figure 2B), and tinnitus occurrence
in TMDs in case-control studies among people seeking
dental care (Figure 2C). In each forest plot, the horizontal
axis represents the odds ratios, and the vertical line (dis-
played at the value of 1) is known as the “line of null
effect,” where no association is expected between tinnitus
and TMDs. Each horizontal line put onto a forest plot
demonstrates a separate study being analyzed. Each study
“result” has 2 components comprising: (1) a black box
indicating both a point estimate of the study result and the
size of the stud 45,46 (the largest sample size in Song et al,32
2018) and (2) a horizontal line representing the 95% con-
fidence intervals of the study result.45,46 For example, the
point estimate of Buergers et al11 study was 12.62, and its
confidence interval was 7.25 to 21.97. Since none of the
study lines crossed the line of null effect, they all indi-
cated a statistically significant result.46 The weight (%)
exhibits the impact of each individual study on the pooled
result. Among all included studies for drawing forest
plots, the Song et al32 study had the highest weight (92.99)
and Bernhardt et al28 had the lowest one (7.01). A dia-
mond in each figure presents the overall point estimate
from the meta-analysis and its confidence interval. The
center of the diamond displays the pooled point estimate,
and its horizontal tips represent the 95% confidence
interval.45 Because the diamonds did not cross the line of
null effect, the combined result was potentially statisti-
cally significant.
Omidvar and Jafari 9

Table 4. Summary ORs Estimates and 95% CIs for Case-Control, Cross-Sectional, and Cohort Studies of the Association Between
Tinnitus and TMDs.

Within Hetro

Groups Author Type of Studies Study Design No. ORs 95% CI I2 (%) P
Tinnitus Buergers et al, 2014 Specific population Cross-sectional 2 7.798 2.926-20.782 80.1 .025
occurrence Saldanha et al, 2012 Specific population Cross-sectional
in individuals Effat, 2016 Specific population Case-control 3 5.229 2.422-11.291 73.5 .023
with TMDs Fernandes et al, 2013 Specific population Case-control
Tuz et al, 2003 Specific population Case-control
Song et al, 2018 Public population Cross-sectional 1 1.7813 1.6099-1.9711 — —
Bernhardt et al, 2011 Public population Cohort 1 2.5312 1.5978-4.0098 — —
TMD Buergers et a, 2014 Specific population Cross-sectional 2 7.798 2.926-20.782 80.1 .025
occurrence Saldanha et al, 2012 Specific population Cross-sectional
in individuals Song et al, 2018 Public population Cross-sectional 2 1.806 1.638-1.991 0.0 .322
with tinnitus Bernhardt et al, 2004 Public population Cross-sectional

Abbreviations: CI, confidence interval; hetero, heterogeneity; I2, inconsistency index; No., number of studies; ORs, odds ratios; TMDs,
temporomandibular joint disorders; —, indicates that it was incalculable.

Discussion or constant contraction of the masticatory muscles might

Our study on the relationship between tinnitus and TMDs
demonstrated that (1) TMDs led to ORs of 1.78 to 7.79 for
diagnosed tinnitus and tinnitus perception resulted in ORs
of 1.80 to 7.79 for TMDs, suggesting that (2) the signs of
TMDs can enhance the development of tinnitus and percep-
tion of tinnitus can be considered as a risk for presenting
TMDs. (3) The link between tinnitus and TMDs was stron-
ger in the population with dental complaints.
The ORs of 1.78 to 7.79 for diagnosed tinnitus in patients
with TMDs revealed their higher risk of developing tinnitus
rather than those without TMDs. A few studies determined
the ORs for tinnitus prevalence in TMD patients.30,37 In a
study on a low number of patients with (n = 31) and with-
out (n = 31) TMDs, the ORs of tinnitus prevalence was
9.96.37 A health study on a large population reported that
subjects with TMDs suffered tinnitus 1.6 times more than
subjects without TMDs.30
In our study, tinnitus perception also caused ORs of 1.80
to 7.79 in patients with TMDs, which means tinnitus func-
tions as a risk for TMDs. This finding was consistent with a
few previous studies.28,32 The study of health in Pomerania
on a large population (n = 4228) reported the ORs of 2.99
for TMD prevalence in tinnitus.28 In the other health study,
participants with tinnitus showed ORs of 1.97 for TMD
prevalence.32 This relationship demonstrates an important
clinical implication for diverse health care professionals,
especially in patients requiring dental cares.
One common explanation for tinnitus perception in
TMDs is attributed to an anatomical connection (eg, the
tensor veli palatini, the eustachian tube, or several liga-
ments) between a TMJ or the masticatory muscles and mid-
dle ear muscles. A disorder in TMJ (eg, disc displacement)
affect middle ear muscle tension or ventilation. This can
generate afferent signals that influence the auditory path-
ways via cochlear nerve.6 It, however, cannot be the only
explanation because tinnitus and its somatosensory modula-
tion can persist even after the 8 nerve excision.47 Recently,
neuroanatomical and experimental studies imply anatomic
and topographic associations between the trigeminal nerve
and TMJ capsule and between the trigeminal ganglion and
cochlear nucleus (CN).48,49 As indicated in Figure 3, sen-
sory inputs from the face via the trigeminal (V) nerve in the
spinal trigeminal tract, the neck via the C2 dorsal spinal
root, and the external and middle ears via the common spi-
nal tract of the facial (VII), glossopharyngeal (IX), and
vagus (X) cranial nerves converge to a common region in
the lower part of the medulla (the medullary somatosensory
nucleus). These fibers then project to the ipsilateral dorsal
cochlear nucleus (DCN). The modulation of activity in the
medullary somatosensory nucleus to the DCN pathway dis-
inhibits the DCN. Projections from the DCN to the higher
centers lead to hyperactivity of the central auditory system
and finally, tinnitus perception.5,17 The interaction between
the auditory and somatosensory systems might explain why
tinnitus sufferers can modulate the loudness and pitch of
their tinnitus.50,51
The prevalence of tinnitus in patients with TMDs was
significantly higher than those without TMDs. Similarly,
the prevalence of TMDs was higher in patients with tinnitus
compared with those without tinnitus. Reports of tinnitus
and TMD frequencies, however, widely differed among the
included studies. This can be attributed to differences in
their methodology, including the methods of dividing indi-
viduals into the case and control groups, sample sizes,
demographic data, and differences in the study design and
10 Annals of Otology, Rhinology & Laryngology 00(0)

Figure 2. Forest plots for the relationship between tinnitus and temporomandibular disorders (TMDs) with the use of fixed- and
random-effects models. (A) Tinnitus occurrence in TMDs as well as TMD occurrence in tinnitus in cross-sectional studies on people
seeking dental cares. (B) TMD occurrence in tinnitus in cross-sectional population-based studies. (C) Tinnitus occurrence in TMDs in
case-control studies on people seeking dental cares. CI, confidence interval; OR, odds ratio; square, study-specific OR estimate (size
of square indicates the study specific statistical weight, ie, the inverse of the variance); horizontal line, 95% CI; diamond, summarize
OR estimate and its corresponding 95% CI. All statistical tests were 2-sided. Statistical heterogeneity between studies was assessed
with the I-squared test.

the procedures for diagnosis of tinnitus and TMDs. For
instance, the TMD frequency in the individuals with and with-
out tinnitus was reported 93.25% and 65.31%, respectively.36
These high percentages might be created by selecting both
case and control groups from the subjects with the chief com-
plain of orofacial pain.36 If samples were selected without
any bias, TMD prevalence was likely lower in these sub-
jects. Further studies thus are required to draw a more pre-
cise conclusion in this area.
Effect of the TMD type on the prevalence of tinnitus had
been examined in a few studies.12,28,29,31,33-35,40 Most studies
suggested a higher prevalence of muscular and/or articular
TMDs in patients with tinnitus,12,28,29,33,35 and some reported
no significant difference.31,40 It appears that tinnitus is a
chronic stressor that increases masticatory muscle and TMJ
activities leading to pain. It is, however, not clear whether
the relationship between TMDs and tinnitus might consist
of a response to emotional stress yet.28,29,52 Alteration in the
neuromuscular coordination of the craniomandibular, which
can be considered as one of the possible causes of otogenic
symptoms including tinnitus, might also result in a higher
tenderness of masticatory muscles.53 In a longitudinal study,
the prevalence of tinnitus in patients with palpation pain in
the TMJs was higher than those with tenderness or pain in
the masticatory muscles. The authors, however, argued that
as the small sample of subjects with palpation pain in the
Omidvar and Jafari
Figure 3. Disinhibition of the dorsal cochlear nucleus (DCN) as a possible hypothesis for somatic tinnitus.
Adapted with permission from Levine et al (2007).
TMJs, it was not possible to infer that TMJ palpation pain
could be a prognostic factor for tinnitus.29 Due to inconsis-
tencies and lack of information in the literature, further
investigations are suggested to clarify the effects of the
types of TMDs on tinnitus.
Among the included papers, just 1 reported the relation-
ship between the laterality of tinnitus and the laterality of
TMDs. In this study,11 all subjects with simultaneous unilat-
eral TMDs and unilateral tinnitus had both symptoms on the
same side, and almost all individuals with bilateral TMDs
(except 3 subjects) had tinnitus on both sides. This finding
also was reported in other investigations,16,54 which may be
associated with the DCN as a possible site of hyperactivity
in somatic tinnitus. As the projections from the somatosen-
sory nuclei (nucleus cuneatus/medullary somatosensory
nucleus) to the DCN are only ipsilateral, somatic tinnitus is
perceived ipsilaterally.5 Other characteristics of tinnitus like
its continuity, pitch, and loudness were not explained in any
of the included papers, suggesting further studies to define
the attributes of tinnitus in subjects with TMDs clearly.
There are different methods for TMD diagnosis. In the
current review, almost half of the papers used RDC/
TMD11,12,18,33,36,37,39,40,42 or the revised versions of this
criteria7,31 for diagnosing TMDs. RDC/TMD is a reliable
and valid protocol for diagnosing and grouping the prevalent
forms of TMDs using a questionnaire and clinical examina-
tions.55 It is more likely that individuals classified into the
TMD groups in these studies truly suffered from it. The
other half, however, asked some questions and/or applied
different methods of clinical examinations without reporting
their validity or reliability.16,28-30,32,34,35,38,41,43,44 This
approach might lead to underestimating or overestimating
the presence of TMDs. Applying reliable and valid tools can
11
diminish the likelihood of false positive or false negative
patient selection and increase the accuracy of the results.
Tinnitus is often imperceptible or inaudible to others, and
it is objectively hard to confirm patients’ statements about
tinnitus.56 In almost all included papers, except 3,11,34,41
tinnitus was only examined by asking 1 or more questions,
and no detailed information was given regarding other char-
acteristics of tinnitus, even clinical specifications like tinni-
tus quality and continuity.7,11,12,18,28-34,36-40,43,44 The THI
questionnaire was the validated tool used in 3 papers.11,34,41
The THI, however, was applied to evaluate the severity of
handicap resulting from the tinnitus than to identify tinnitus
appearance.57-61 In future studies, applying well-defined,
detailed questionnaires as well as psychoacoustic measure-
ments of tinnitus are suggested to obtain accurate findings
regarding the tinnitus characteristics in TMD patients.
The study design of almost 80% of included papers was
cross-sectional,11,12,16,18,28,30-36,38,41-44 and the others con-
tained a case-control7,28,39,40 or a cohort design.29,37 Cross-
sectional studies are primarily used to determine the
prevalence and identify associations. This type of study
cannot distinguish between cause and effect. Case-
controlled studies compare people with the outcome of
interest and a control group who do not. They are retrospec-
tive and cannot be applied to calculate the relative risk.
Nevertheless, they can be used to calculate ORs. Cohort
studies are the best way to discriminate between cause and
effect due to evaluating events in chronological order.62 A
few cohort studies had evaluated the risk of tinnitus occur-
rence in patients with TMDs and reported that signs of
TMDs were a risk factor for the development of tinni-
tus.29,37,63 No cohort study, however, investigated the risk of
TMDs occurrence in individuals with tinnitus. Given a low
12
number of cohort studies, future researches with a cohort
design are suggested to identify a likely cause-and-effect
relationship between tinnitus and TMDs.
Due to the large variability across the findings of the
included papers, further studies on homogeneous popula-
tions with sufficient sample sizes and applying convenient
assessment tools are suggested. Most included papers for
the meta-analysis also included a cross-sectional or case-
control study design, implying that the results should be
interpreted with caution. To prove the association between
tinnitus and TMDs, blind cohort studies with random sam-
pling are recommended. Applying the subjective reports as
the only outcome measure for tinnitus in most included
papers also did not provide valid, detailed information
about the pathophysiology of ear structures involved.
Conclusions
Our findings indicated that tinnitus and TMDs are associated.
Namely, the signs of TMDs may augment the likelihood of
developing tinnitus, and the perception of tinnitus may also
promote the sign of TMDs. This association was also stron-
ger in the population with dental complaints. Therefore,
screening TMD symptoms in patients with tinnitus and sug-
gesting an appropriate treatment over current clinical
approaches might lead to a reduction in tinnitus perception.
Longitudinal studies with adequate sample sizes and random
sampling, however, are suggested for more accurate conclu-
sions. Finally, because the etiology of TMDs is multifacto-
rial, diverse health specialists and multidisciplinary and
interdisciplinary approaches are required to alleviate tinnitus
and other otologic symptoms associated with TMDs.
Authors’ Note
Zahra Jafari is currently affiliated to Department of Basic
Sciences in Rehabilitation, School of Rehabilitation Sciences,
Iran University of Medical Sciences (IUMS), Tehran, Iran.
Acknowledgments
We also would like to acknowledge the Research Consultation
Center (RCC) at Shiraz University of Medical Sciences (SUMS)
for their assistance in data analysis.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by Iran University of Medical Sciences
(IUMS) (Grant No. 94-05-32-26129 [Z.J.]).
Annals of Otology, Rhinology & Laryngology 00(0)
ORCID iD
Zahra Jafari https://orcid.org/0000-0002-0485-2003
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