Temporomandibular joint (TMJ) disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia

Albraa Alolayan; Shayma S. Alsayed; Ruwaa M. Salamah; Khadija M. Ali; Mashael Alsousi; Shadia Elsayed

doi:10.12688/f1000research.104272.2

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Research Article

Revised

Temporomandibular joint (TMJ) disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia

[version 2; peer review: 1 approved with reservations]

Albraa Alolayan¹, Shayma S. Alsayed¹, Ruwaa M. Salamah^1,2, Khadija M. Ali¹, Mashael Alsousi^1,2, Shadia Elsayed ^1,3

Albraa Alolayan¹, Shayma S. Alsayed¹, [...] Ruwaa M. Salamah^1,2, Khadija M. Ali¹, Mashael Alsousi^1,2, Shadia Elsayed ^1,3

PUBLISHED 11 Apr 2022

Author details Author details

¹ Department of Oral and Maxillofacial Surgery, College of Dentistry, Taibah University, Almadinah Almunawwarrah, Madinah, Saudi Arabia
² Dentistry, Ministry of Health, Al Madinah Al Munawwarah, Madianh, Saudi Arabia
³ Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

Albraa Alolayan
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Shayma S. Alsayed
Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing

Ruwaa M. Salamah
Roles: Conceptualization, Data Curation, Methodology, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Khadija M. Ali
Roles: Conceptualization, Formal Analysis, Methodology, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Mashael Alsousi
Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Shadia Elsayed
Roles: Data Curation, Methodology, Software, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Painful temporomandibular joint disorders (TMDs) are of musculoskeletal origin and are considered the most common cause of non-odontogenic pain in the orofacial region. The purpose of this study was to investigate the prevalence and awareness of temporomandibular joint (TMJ) disorders in Almadinah Almunawwarah community.
Methods: An observational cross-sectional study with convenience sampling was conducted. A translated Arabic version of Fonseca's questionnaire was employed. The questionnaire asked about the participant's personal information, if they thought they had TMDs, and who to visit for therapy if necessary. These were followed by 10 items from Fonseca's questionnaire, each with a three-point scale.
Results: The questionnaire was completed by 598 people. Females made up 57.1% of the participants. TMDs were present in 61% of the population, with varying degrees of severity. Males (44.3%) were less affected than females (55.7%). The difference, however, was not statistically significant (P = 0.354). Out of the 61% TMDs Positive patients, 74.1% had mild TMDs symptoms, while 20.8% and 5.1%, respectively, had moderate and severe TMDs symptoms (P = 0.05). The severity of the symptoms was unaffected by demographic data (P > 0.05). Only 40% seek care, with 64.6% selecting for a dentist and 24.6% preferring for an orthopaedic specialist (P= 0.008).
Conclusions: Participants from Al-Madinah had a greater prevalence of mild TMDs. The majority of the participants had no idea who to go to for treatment. The findings of this study highlight the importance of educational activities to enhance public awareness. Fonseca's Anamnestic Index could also be considered as a useful instrument for early identification and measuring the severity of TMDs in the general population.

Keywords

TMJ, prevalence, awareness, severity, Almadinah Almunawwarrah

Corresponding author: Shadia Elsayed

Competing interests: No competing interests were disclosed.

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

Copyright: © 2022 Alolayan A et al. 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: Alolayan A, Alsayed SS, Salamah RM et al. Temporomandibular joint (TMJ) disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia [version 2; peer review: 1 approved with reservations]. F1000Research 2022, 11:395 (https://doi.org/10.12688/f1000research.104272.2) First published: 06 Apr 2022, 11:395 (https://doi.org/10.12688/f1000research.104272.1) Latest published: 12 Apr 2023, 11:395 (https://doi.org/10.12688/f1000research.104272.4)

Revised Amendments from Version 1

We updated the version with the incomplete information based on reviewer suggestions, which included: the study's rationale, inclusion criteria, sample size estimates, and the study's limitations.

See the authors' detailed response to the review by Shakeerah Olaide Gbadebo and Olayinka D. ADEOSUN
See the authors' detailed response to the review by Essam Ahmed Al‐Moraissi

Introduction

Temporomandibular disorders (TMDs) is a term used to describe a set of musculoskeletal and neuromuscular diseases characterized by localized discomfort in the pre-auricular and face regions, as well as deviations or restrictions in mandibular joint movement, in addition to joint noises.¹ TMDs are multifactorial, caused by stress, trauma and malocclusion.² Painful TMDs are of musculoskeletal origin and are considered the most common cause of non-odontogenic pain in the orofacial region.³^–⁵ The most prevalent symptom of TMD is tenderness of the masticatory muscles when palpated.⁶^,⁷

The prevalence of TMDs was twice higher in women compared to men,⁸ also pain intensity was greater in women.⁹ According to a previous report, 75% of the participants exhibited one TMD sign and 33% had one TMD symptom.¹⁰ Another study concluded that 50–75% of the population had TMD signs at some moment in their lives.¹¹ One study showed that only 39% participants had sought treatment for pain related to TMDs.¹² Patients with TMDs symptoms tend to consult first with general medical practitioners due to the availability and financial feasibility in nearly six countries. 27% of children and adolescents in Saudi Arabia were found to have TMDs.

For our patients, temporomandibular joint (TMJ) disorders still cause difficulty in diagnosis and conflicts between different specialties. Some individuals seek treatment from different specialized clinics such as ENT (ear, nose and throat) or neurosurgery clinics, and the rationale for the current study was that there is a rise in oral health awareness in Saudi Arabia. However examination and diagnosis of TMJ disorders continue to require emphasis and increased knowledge among dentists, therefore it is critical to focus on epidemiological data to estimate the prevalence of these conditions among our populations, particularly given the increasing in stressful environments that induce TMDs. as a result, the study’s aim was to determine the prevalence and severity of distribution of TMDs among Almadinah Almunawwarah community population and to focus on the population’s awareness towards the appropriate clinical practice of the disorders using the Fonseca questionnaire, which hasn’t been used in our population before.

Methods

Study design and setting

This study was designed to be an observational cross-sectional study with convenience sampling technique. The Taibah University Dental College Ethical Committee approved the study protocol (TUCDREC/20200219/MIAlsousi), and all participants’ identities were kept anonymous. The study followed the Helsinki Declaration on Human Research Studies. The patients were selected from the dental college and the hospital at Taibah University in Al-Madinah, Saudi Arabia. Following an explanation of the study’s aims and objectives, patients who agreed to participate in the study signed an informed consent form.

Inclusion and exclusion criteria

All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study.

All patients with systemic disease associated with TMJ like rheumatoid arthritis, regular use of medication such as anti-anxiety or antidepressants, history of TMJ surgery, wearing removable denture or splints, psychological problems and/or with incomplete questionnaire form were excluded from the study.

Response bias was reduced by keeping the questions simple and short, as in the verified Fonseca questionnaire, which has structured proper length and understandable language, and by limiting the patient experience to the previous three months.

Sample size

Using a sample size calculator with a confidence level of 99% and estimated the entire Madinah population to be above one million, the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598. Patients seeking dental treatment were recruited through the Oral and Maxillofacial Surgery clinics at Taibah University, Almadinah Almunawwarah, in Saudi Arabia.

Instrument for data collection

In order to estimate Fonseca’s Anamnestic Index (FAI), a translated Arabic version of Fonseca’s questionnaire was utilized. The original Fonseca’s questionnaire was proposed by Fonseca et al¹³ in Brazilian Portuguese. Two investigators who collect data conducted face-to-face questionnaire assessments.

The questionnaire included questions about participant’s demographic data, if the participant thought he/she is suffering from TMDs, and whom to seek for a treatment if he/she needed to. These questions were followed by 10 questions of Fonseca’s questionnaire with three points scale, and it was distributed to patients in an Arabic version. For each question, the participants were instructed that just one answer should be marked: “yes” (10 points), “no” (0 points), and “maybe” (5 points). Based on the sum of their points, the individuals were classified as TMD free (0–15), mild TMD (20–40), moderate TMD (45–60), and severe TMD (70–100). The FAI has been usually applied in Brazilian studies to measure the severity of TMDs.⁹^,¹⁴ A copy of the original and translated questionnaire can be found in the Extended data.

Statistical analysis

The data was evaluated using a social science statistical software (SPSS version 25). Means, standard deviation, and percentages were used to show descriptive data. It was followed by Chi-square test for nominal outcomes and Student’s t-test for continuous study variables. Significance level was set at P value of 0.05.

Results

A total of 598 participants answered the questionnaire, based on the above-mentioned exclusion criteria, 80 (13.4 %) participants were removed from the study. Thus, leveeing a total of 518 (86.6%) recruited participants, females made up 57.1% of the participants. The age group distribution of participants and the level of education are presented in Figure 1 and Figure 2, respectively.

Figure 1. Age group distribution.

Figure 2. Level of education.

Based on the participants’ answers on Fonseca’s questionnaire, 61% had TMDs with variable degree of severity. Male group (44.3%) was less than female group (55.7%). The difference, however, was not statistically significant (P = 0.354). On the other hand, there was a significant difference in the positive responses to the questions of whether or not the participants had TMDs (12.5 %), and the participants whom actually suffering from TMDs according to Fonseca’s questionnaire (P < 0.05). The level of TMDs in regard to gender distribution is presented in Figure 3.

Figure 3. The level of TMDs in regard to gender distribution.

Out of the 61% TMDs positive patients, 74.1% had symptoms of mild TMDs, while the moderate and severe symptoms were 20.8% and 5.1%, respectively (P < 0.05). However, the demographic data showed no effect on the severity of the symptoms (P > 0.05).

In regards whom to seek for treatment, 51.6% of the sample chose a dentist while 41.8% chose an orthopedic specialist (P > 0.05). Based on participants who suffered or suffering from TMDs, only 40% sought out treatment, 64.6% of them chose a dentist while 24.6% chose orthopaedic specialist (P ≤ 0.008).

The symptoms mostly associated with TMDs ranged from behavioral changes and quick fatigue of the mastication muscles, to frequent headache or pain related to the TMJ or the neck, reaching to TMJ stiffness and clicking or even limitation in mouth opening. Table 1 summarizes the frequencies of the most common symptoms.

Table 1. The frequency of the most common symptoms for patient with TMDs.

Symptom	Frequency (n = 518)	Percentage
Limited mouth opening	12	2.3%
Limited side-to-side movement	7	1.4%
Muscles of mastication fatigue	29	5.6%
Frequent headaches	211	40.7%
Neck pain or stiffness	55	10.6%
Pain in the ear or TMJ area	44	8.5%
TMJ clicking	102	19.7%
Temper behavior	151	29.2%

Discussion

The study evaluates the prevalence and awareness of TMD amongst the population of Al-Madinah to produce sufficient data on TMD, helps to find crucial part of planning programs to educate and raise awareness through the population. The study showed that TMDs were present in 61% of the population. Many studies employed the Fonseca questionnaire to diagnose and grade the severity of TMDs. TMD is divided into four categories: minor, moderate, severe, and non-TMD.¹⁵ It has a number of advantages, including quick application, low cost, minimal inconsistency, and self-administration.¹⁶ The Fonseca questionnaire was used in this study to assess the prevalence of TMD symptoms and manifestations in the Almadianh region of Saudi Arabia. It is used to gather data from a wider number of people in a short period. The most significant advantage of employing this questionnaire is that it has no bearing on the investigator and is straightforward.¹⁷

More than half of the participants had some level of TMDs, which has been associated with headache. In regard, frequent headaches were associated with 40% of the participant, patients with TMD are five times more likely to report headaches.⁸ The results are related to a study done in Brazil in 2018 which over two third of the adolescents had headache/migraine and 36 percent of them connected it with TMD.¹⁸

Though TMD is suggested to have a higher frequency and severity in females than in males, and females were reported to have a greater sensitivity to pain¹⁹ which has been connected to hormonal, psychological, and even neurological changes,⁸^,⁹^,²⁰ no conclusive results achieved to the date. In this study TMD male patients (44.3%) were less than female patients (55.7%). However, the difference is not significant, also in a similar study done in Al-Badar Dental College mentioned that men (49.14%) had higher free of TMD symptoms than women (44.78%) but this difference was also not statistically significant.²⁰

Although more than 70% of the TMD positive participants have mild TMD, only 51.6% of the sample knows who to see for TMD therapy, and 40% of TMD patients seek treatment. TMD treatment varies from one physician to another. It ranges from patient education and the development of new habits such as self-massage, hot and cold packs, diet and nutrition instruction, and muscle exercises, which have been shown to have a high level of success and improvement, to the need for invasive and high-technical or invasive surgical treatments.¹^,²¹^,²² According to Reynaldo, 91.7% of patients responded well to conservative treatment. There was no TMD recurrence in the majority of patients who could be examined four to six years after treatment completion.²³ The current study’s findings highlight the importance of public oral health education and assessment of TMDs using Fonseca questionnaire.²⁴ The present survey collected data had limitations in terms of measuring patients’ reporting outcomes and also had limitations in evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, and another limitation was that it was a one-center study, though it is the largest and only university centre in the Al Madinah region, and so other multicenter studies of the health clusters in our community’s population are still needed.

Conclusion

Based on this study, participants from Al-Madinah showed higher prevalence in mild degree of TMDs. Most of the participants were lacking the knowledge of TMDs and whom to seek for a treatment. The results from this study emphasize the need for educating programs to raise awareness through the population, and to consider Fonseca’s anamnestic index as a valuable tool for early identification and severity assessment of TMDs in the general population.

Data availability

Underlying data

Figshare: Data for TMJ disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia.sav https://doi.org/10.6084/m9.figshare.17215940²⁵

This project contains the following underlying data

- Data for TMJ disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia.sav (raw data in Arabic)

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

Figshare: Data for TMJ disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia.sav. https://doi.org/10.6084/m9.figshare.19086635.v2²⁶

This project contains the following underlying data

- Data for TMJ disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia.sav (raw data in English)

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

Extended data

Figshare: Questionnaire. https://doi.org/10.6084/m9.figshare.19292474²⁷

This project contains the following extended data

A copy of the questionnaire (in Arabic and the English version).

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

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Comments on this article Comments (1)

Version 4

VERSION 4 PUBLISHED 12 Apr 2023

Revised

Comment

Version 1

VERSION 1 PUBLISHED 06 Apr 2022

Discussion is closed on this version, please comment on the latest version above.

Author Response 11 Apr 2022

Shadia Elsayed, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

11 Apr 2022

Author Response
Thank you very much for your time and effort spent on reviewing our manuscript. We greatly appreciate all comments for giving us the opportunity to improve our manuscript further.
... Continue reading
Thank you very much for your time and effort spent on reviewing our manuscript. We greatly appreciate all comments for giving us the opportunity to improve our manuscript further.

Authors completely failed to state the rationale of the study (why it's important to do this study) or show the size of the gap in the literature. Unfortunately, the indexing of this study will not add any new material to the existing literature.

Thank you. The rationale for the current study was that there is a rise in oral health awareness in Saudi Arabia. However examination and diagnosis of TMJ disorders continue to require emphasis and increased knowledge among dentists, therefore it is critical to focus on epidemiological data to estimate the prevalence of these conditions among our populations, particularly given the increasing in stressful environments that induce TMJDs. As a result, the study's aim was to determine the prevalence and severity of distribution of TMJ disorders among the Al Madinah population and to focus on the population's awareness towards the appropriate clinical practice of the disorders using the Fonseca questionnaire, which hasn't been used in our population before. This has been added to the introduction section.

Authors did not state the inclusion criteria completely, only mentioned the exclusion criteria. So authors should state inclusion criteria based on PICOS criteria.

Thank you for your comment. All adult males and females who visited Taibah University's Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study.

Authors did not present adequately information about how they calculated the sample size.

Thank you for your comment. Using a sample size calculator with a confidence level of 99 % and estimated the entire Madinah population to be above one million, the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Authors should explain why they chose a modified version of Fonseca's questionnaire.

Thank you. We used the same Fonseca questionnaire, but we used a newly translated Arabic version that is provided.

Authors should include others predictors variables to be analysed type of TMDs if myogenous or arthrogenous, chronicity, signs and symptoms of TMDs such as clicking, muscles tenderness, headache, limited mouth opening etc.

Thank you. The questionnaire was composed of 10 questions, which include checking for the presence of pain in temporomandibular joint, headache, parafunctional habits, movement limitations, joint clicking, perception of malocclusion, and sensation of emotional stress. The limitation of the study is now reported as it had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, which need future studies.

Authors did not clarify who performed the assessment.

Thank you. Two investigators who collect data conducted face-to-face questionnaire assessments.

This study is based on a survey so its mandatory to clarify the limitations of this study.

Thank you for your comment. The survey data collected had limitations in terms of measuring patients' reporting outcomes and also had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, and another limitation was that it was a one-center study, though it is the largest and only university centre in the Al Madinah region, and more multicenter studies are still needed.
Thank you very much for your time and effort spent on reviewing our manuscript. We greatly appreciate all comments for giving us the opportunity to improve our manuscript further.

Authors completely failed to state the rationale of the study (why it's important to do this study) or show the size of the gap in the literature. Unfortunately, the indexing of this study will not add any new material to the existing literature.

Thank you. The rationale for the current study was that there is a rise in oral health awareness in Saudi Arabia. However examination and diagnosis of TMJ disorders continue to require emphasis and increased knowledge among dentists, therefore it is critical to focus on epidemiological data to estimate the prevalence of these conditions among our populations, particularly given the increasing in stressful environments that induce TMJDs. As a result, the study's aim was to determine the prevalence and severity of distribution of TMJ disorders among the Al Madinah population and to focus on the population's awareness towards the appropriate clinical practice of the disorders using the Fonseca questionnaire, which hasn't been used in our population before. This has been added to the introduction section.

Authors did not state the inclusion criteria completely, only mentioned the exclusion criteria. So authors should state inclusion criteria based on PICOS criteria.

Thank you for your comment. All adult males and females who visited Taibah University's Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study.

Authors did not present adequately information about how they calculated the sample size.

Thank you for your comment. Using a sample size calculator with a confidence level of 99 % and estimated the entire Madinah population to be above one million, the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Authors should explain why they chose a modified version of Fonseca's questionnaire.

Thank you. We used the same Fonseca questionnaire, but we used a newly translated Arabic version that is provided.

Authors should include others predictors variables to be analysed type of TMDs if myogenous or arthrogenous, chronicity, signs and symptoms of TMDs such as clicking, muscles tenderness, headache, limited mouth opening etc.

Thank you. The questionnaire was composed of 10 questions, which include checking for the presence of pain in temporomandibular joint, headache, parafunctional habits, movement limitations, joint clicking, perception of malocclusion, and sensation of emotional stress. The limitation of the study is now reported as it had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, which need future studies.

Authors did not clarify who performed the assessment.

Thank you. Two investigators who collect data conducted face-to-face questionnaire assessments.

This study is based on a survey so its mandatory to clarify the limitations of this study.

Thank you for your comment. The survey data collected had limitations in terms of measuring patients' reporting outcomes and also had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, and another limitation was that it was a one-center study, though it is the largest and only university centre in the Al Madinah region, and more multicenter studies are still needed.
Competing Interests: No conflict of interest. Close
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Author details Author details

Albraa Alolayan
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Shayma S. Alsayed
Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing

Ruwaa M. Salamah
Roles: Conceptualization, Data Curation, Methodology, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Khadija M. Ali
Roles: Conceptualization, Formal Analysis, Methodology, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Mashael Alsousi
Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Shadia Elsayed
Roles: Data Curation, Methodology, Software, Writing – Original Draft Preparation, 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 (4)

version 4

Revised

Published: 12 Apr 2023, 11:395

https://doi.org/10.12688/f1000research.104272.4

version 3

Revised

Published: 04 Jul 2022, 11:395

https://doi.org/10.12688/f1000research.104272.3

version 2

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Published: 11 Apr 2022, 11:395

https://doi.org/10.12688/f1000research.104272.2

version 1

Published: 06 Apr 2022, 11:395

https://doi.org/10.12688/f1000research.104272.1

© 2022 Alolayan A et al. 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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Alolayan A, Alsayed SS, Salamah RM et al. Temporomandibular joint (TMJ) disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia [version 2; peer review: 1 approved with reservations] F1000Research 2022, 11:395 (https://doi.org/10.12688/f1000research.104272.2)

NOTE: 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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Version 2

VERSION 2

PUBLISHED 11 Apr 2022

Revised

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Reviewer Report 13 Apr 2022

Essam Ahmed Al‐Moraissi, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Dhamar, Yemen

Approved with Reservations

https://doi.org/10.5256/f1000research.126287.r134580

Update 07/07/2022 – We have added a conflict of interest statement that was not disclosed before this report was published. This statement can be found below this report under the heading ‘Competing Interests’.

Thank you for your ... Continue reading

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study."

My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?
Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.
It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study."

So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.
Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.
In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)
The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation
Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.
Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Competing Interests: I don't have any financial conflict of interest. I know only Dr. Shayma S. Alsayed (via social media) for 2 years from the ResearchGate. We have been contacted intermittently (from time to time) for an independent scientific discussion before and during and after reviewing process. Our communications have never had an effect on the transparency, confidentiality, and impartiality of the reviewing process.

Reviewer Expertise: Oral and Maxillofacial Surgery

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, however I have significant reservations, as outlined above.

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Author Response 04 Jul 2022

Shadia Elsayed, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

04 Jul 2022

Author Response
Thank you for your feedback, which provided us with another opportunity to edit the article.
1. Authors stated in the inclusion criteria that "All adult males and females who
... Continue reading
Thank you for your feedback, which provided us with another opportunity to edit the article.

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?

Answer: Thank you for your input. The study included individuals who came to the TUDC for routine dental screening, with the goal of determining the prevalence of TMJ problems in this specific demographic.

Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.

Answer: Thank you for your input. The study was conducted as a prospective observational study, and this is now addressed in the methodology and abstract.

It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Answer: I appreciate your input. The study sample calculation was determined using the OpenEpi tool kit application with a confidence level of 99 percent and estimated the entire Madinah population to be above one million and estimated prevalence indicator of 27% (Al-Khotani, A., Naimi-Akbar, A., Albadawi, E. et al. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain 17, 41 (2016). https://doi.org/10.1186/s10194-016-0642-9) and the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.

Answer: Thank you for your comment. The study was conducted during the last two years, and the sample was drawn from clinic visitors on a daily basis.

Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.

Answer: Thank you for your comment. The study included A total of 598 participants answered the questionnaire, based on the mentioned exclusion criteria, 80 (13.4 %) participants were removed from the study. Thus, leveeing a total of 518 (86.6%) recruited participants

In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)

Answer: Thank you for your comment. Conclusion section has been updated in accordance with your thoughtful advice.

The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation.

Answer: In order to assess the actual prevalence among the population that did not get prosthodontic devices like splints, we eliminated patients receiving splint therapy and removable prosthodontics, which could be a contributing confounding cause of TMJ adaptive modifications.

Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.

Answer: thank you for your comment. The questionnaires were filled out by well-trained two investigators who collect data from patients and contribute to the current study's authorship.

Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Answer: Thank you for your comment. The title has been updated in response to your helpful suggestion.
Thank you for your feedback, which provided us with another opportunity to edit the article.

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?

Answer: Thank you for your input. The study included individuals who came to the TUDC for routine dental screening, with the goal of determining the prevalence of TMJ problems in this specific demographic.

Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.

Answer: Thank you for your input. The study was conducted as a prospective observational study, and this is now addressed in the methodology and abstract.

It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Answer: I appreciate your input. The study sample calculation was determined using the OpenEpi tool kit application with a confidence level of 99 percent and estimated the entire Madinah population to be above one million and estimated prevalence indicator of 27% (Al-Khotani, A., Naimi-Akbar, A., Albadawi, E. et al. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain 17, 41 (2016). https://doi.org/10.1186/s10194-016-0642-9) and the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.

Answer: Thank you for your comment. The study was conducted during the last two years, and the sample was drawn from clinic visitors on a daily basis.

Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.

Answer: Thank you for your comment. The study included A total of 598 participants answered the questionnaire, based on the mentioned exclusion criteria, 80 (13.4 %) participants were removed from the study. Thus, leveeing a total of 518 (86.6%) recruited participants

In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)

Answer: Thank you for your comment. Conclusion section has been updated in accordance with your thoughtful advice.

The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation.

Answer: In order to assess the actual prevalence among the population that did not get prosthodontic devices like splints, we eliminated patients receiving splint therapy and removable prosthodontics, which could be a contributing confounding cause of TMJ adaptive modifications.

Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.

Answer: thank you for your comment. The questionnaires were filled out by well-trained two investigators who collect data from patients and contribute to the current study's authorship.

Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Answer: Thank you for your comment. The title has been updated in response to your helpful suggestion.
Competing Interests: I declare no conflict of interest. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 04 Jul 2022

Shadia Elsayed, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

04 Jul 2022

Author Response
Thank you for your feedback, which provided us with another opportunity to edit the article.
1. Authors stated in the inclusion criteria that "All adult males and females who
... Continue reading
Thank you for your feedback, which provided us with another opportunity to edit the article.

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?

Answer: Thank you for your input. The study included individuals who came to the TUDC for routine dental screening, with the goal of determining the prevalence of TMJ problems in this specific demographic.

Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.

Answer: Thank you for your input. The study was conducted as a prospective observational study, and this is now addressed in the methodology and abstract.

It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Answer: I appreciate your input. The study sample calculation was determined using the OpenEpi tool kit application with a confidence level of 99 percent and estimated the entire Madinah population to be above one million and estimated prevalence indicator of 27% (Al-Khotani, A., Naimi-Akbar, A., Albadawi, E. et al. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain 17, 41 (2016). https://doi.org/10.1186/s10194-016-0642-9) and the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.

Answer: Thank you for your comment. The study was conducted during the last two years, and the sample was drawn from clinic visitors on a daily basis.

Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.

Answer: Thank you for your comment. The study included A total of 598 participants answered the questionnaire, based on the mentioned exclusion criteria, 80 (13.4 %) participants were removed from the study. Thus, leveeing a total of 518 (86.6%) recruited participants

In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)

Answer: Thank you for your comment. Conclusion section has been updated in accordance with your thoughtful advice.

The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation.

Answer: In order to assess the actual prevalence among the population that did not get prosthodontic devices like splints, we eliminated patients receiving splint therapy and removable prosthodontics, which could be a contributing confounding cause of TMJ adaptive modifications.

Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.

Answer: thank you for your comment. The questionnaires were filled out by well-trained two investigators who collect data from patients and contribute to the current study's authorship.

Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Answer: Thank you for your comment. The title has been updated in response to your helpful suggestion.
Thank you for your feedback, which provided us with another opportunity to edit the article.

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?

Answer: Thank you for your input. The study included individuals who came to the TUDC for routine dental screening, with the goal of determining the prevalence of TMJ problems in this specific demographic.

Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.

Answer: Thank you for your input. The study was conducted as a prospective observational study, and this is now addressed in the methodology and abstract.

It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Answer: I appreciate your input. The study sample calculation was determined using the OpenEpi tool kit application with a confidence level of 99 percent and estimated the entire Madinah population to be above one million and estimated prevalence indicator of 27% (Al-Khotani, A., Naimi-Akbar, A., Albadawi, E. et al. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain 17, 41 (2016). https://doi.org/10.1186/s10194-016-0642-9) and the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.

Answer: Thank you for your comment. The study was conducted during the last two years, and the sample was drawn from clinic visitors on a daily basis.

Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.

Answer: Thank you for your comment. The study included A total of 598 participants answered the questionnaire, based on the mentioned exclusion criteria, 80 (13.4 %) participants were removed from the study. Thus, leveeing a total of 518 (86.6%) recruited participants

In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)

Answer: Thank you for your comment. Conclusion section has been updated in accordance with your thoughtful advice.

The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation.

Answer: In order to assess the actual prevalence among the population that did not get prosthodontic devices like splints, we eliminated patients receiving splint therapy and removable prosthodontics, which could be a contributing confounding cause of TMJ adaptive modifications.

Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.

Answer: thank you for your comment. The questionnaires were filled out by well-trained two investigators who collect data from patients and contribute to the current study's authorship.

Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Answer: Thank you for your comment. The title has been updated in response to your helpful suggestion.
Competing Interests: I declare no conflict of interest. Close
Report a concern

Version 1

VERSION 1

PUBLISHED 06 Apr 2022

Views

Reviewer Report 06 Apr 2022

Essam Ahmed Al‐Moraissi, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Dhamar, Yemen

Not Approved

https://doi.org/10.5256/f1000research.114358.r129949

Update 07/07/2022 - We have added a conflict of interest statement that was not disclosed before this report was published. This statement can be found below this report under the heading ‘Competing Interests’.

Thank you for giving ... Continue reading

Authors completely failed to state the rationale of the study (why it's important to do this study) or show the size of the gap in the literature. Unfortunately, the indexing of this study will not add any new material to the existing literature.
Authors did not state the inclusion criteria completely, only mentioned the exclusion criteria. So authors should state inclusion criteria based on PICOS criteria.
Authors did not present adequately information about how they calculated the sample size.
Authors should explain why they chose a modified version of Fonseca's questionnaire.
The generalizability of this study is not applicable.
Authors should include others predictors variables to be analysed type of TMDs if myogenous or arthrogenous, chronicity, signs and symptoms of TMDs such as clicking, muscles tenderness, headache, limited mouth opening etc.
Authors did not clarify who performed the assessment.
This study is based on a survey so its mandatory to clarify the limitations of this study.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

Reviewer Expertise: Oral and Maxillofacial Surgery

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.

CITE

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Comments on this article Comments (1)

Version 4

VERSION 4 PUBLISHED 12 Apr 2023

Revised

Comment

Version 1

VERSION 1 PUBLISHED 06 Apr 2022

Discussion is closed on this version, please comment on the latest version above.

Author Response 11 Apr 2022

Shadia Elsayed, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

11 Apr 2022

Author Response
Thank you very much for your time and effort spent on reviewing our manuscript. We greatly appreciate all comments for giving us the opportunity to improve our manuscript further.
... Continue reading
Thank you very much for your time and effort spent on reviewing our manuscript. We greatly appreciate all comments for giving us the opportunity to improve our manuscript further.

Authors completely failed to state the rationale of the study (why it's important to do this study) or show the size of the gap in the literature. Unfortunately, the indexing of this study will not add any new material to the existing literature.

Thank you. The rationale for the current study was that there is a rise in oral health awareness in Saudi Arabia. However examination and diagnosis of TMJ disorders continue to require emphasis and increased knowledge among dentists, therefore it is critical to focus on epidemiological data to estimate the prevalence of these conditions among our populations, particularly given the increasing in stressful environments that induce TMJDs. As a result, the study's aim was to determine the prevalence and severity of distribution of TMJ disorders among the Al Madinah population and to focus on the population's awareness towards the appropriate clinical practice of the disorders using the Fonseca questionnaire, which hasn't been used in our population before. This has been added to the introduction section.

Authors did not state the inclusion criteria completely, only mentioned the exclusion criteria. So authors should state inclusion criteria based on PICOS criteria.

Thank you for your comment. All adult males and females who visited Taibah University's Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study.

Authors did not present adequately information about how they calculated the sample size.

Thank you for your comment. Using a sample size calculator with a confidence level of 99 % and estimated the entire Madinah population to be above one million, the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Authors should explain why they chose a modified version of Fonseca's questionnaire.

Thank you. We used the same Fonseca questionnaire, but we used a newly translated Arabic version that is provided.

Authors should include others predictors variables to be analysed type of TMDs if myogenous or arthrogenous, chronicity, signs and symptoms of TMDs such as clicking, muscles tenderness, headache, limited mouth opening etc.

Thank you. The questionnaire was composed of 10 questions, which include checking for the presence of pain in temporomandibular joint, headache, parafunctional habits, movement limitations, joint clicking, perception of malocclusion, and sensation of emotional stress. The limitation of the study is now reported as it had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, which need future studies.

Authors did not clarify who performed the assessment.

Thank you. Two investigators who collect data conducted face-to-face questionnaire assessments.

This study is based on a survey so its mandatory to clarify the limitations of this study.

Thank you for your comment. The survey data collected had limitations in terms of measuring patients' reporting outcomes and also had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, and another limitation was that it was a one-center study, though it is the largest and only university centre in the Al Madinah region, and more multicenter studies are still needed.
Thank you very much for your time and effort spent on reviewing our manuscript. We greatly appreciate all comments for giving us the opportunity to improve our manuscript further.

Authors completely failed to state the rationale of the study (why it's important to do this study) or show the size of the gap in the literature. Unfortunately, the indexing of this study will not add any new material to the existing literature.

Thank you. The rationale for the current study was that there is a rise in oral health awareness in Saudi Arabia. However examination and diagnosis of TMJ disorders continue to require emphasis and increased knowledge among dentists, therefore it is critical to focus on epidemiological data to estimate the prevalence of these conditions among our populations, particularly given the increasing in stressful environments that induce TMJDs. As a result, the study's aim was to determine the prevalence and severity of distribution of TMJ disorders among the Al Madinah population and to focus on the population's awareness towards the appropriate clinical practice of the disorders using the Fonseca questionnaire, which hasn't been used in our population before. This has been added to the introduction section.

Authors did not state the inclusion criteria completely, only mentioned the exclusion criteria. So authors should state inclusion criteria based on PICOS criteria.

Thank you for your comment. All adult males and females who visited Taibah University's Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study.

Authors did not present adequately information about how they calculated the sample size.

Thank you for your comment. Using a sample size calculator with a confidence level of 99 % and estimated the entire Madinah population to be above one million, the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Authors should explain why they chose a modified version of Fonseca's questionnaire.

Thank you. We used the same Fonseca questionnaire, but we used a newly translated Arabic version that is provided.

Authors should include others predictors variables to be analysed type of TMDs if myogenous or arthrogenous, chronicity, signs and symptoms of TMDs such as clicking, muscles tenderness, headache, limited mouth opening etc.

Thank you. The questionnaire was composed of 10 questions, which include checking for the presence of pain in temporomandibular joint, headache, parafunctional habits, movement limitations, joint clicking, perception of malocclusion, and sensation of emotional stress. The limitation of the study is now reported as it had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, which need future studies.

Authors did not clarify who performed the assessment.

Thank you. Two investigators who collect data conducted face-to-face questionnaire assessments.

This study is based on a survey so its mandatory to clarify the limitations of this study.

Thank you for your comment. The survey data collected had limitations in terms of measuring patients' reporting outcomes and also had limitations in terms of evaluating specific differential diagnostic criteria in the analysis of the type of TMDs, whether myogenous or arthrogenous, and another limitation was that it was a one-center study, though it is the largest and only university centre in the Al Madinah region, and more multicenter studies are still needed.
Competing Interests: No conflict of interest. Close
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Version 4 (revision) 12 Apr 23	read	read
Version 3 (revision) 04 Jul 22	read	read
Version 2 (revision) 11 Apr 22	read
Version 1 06 Apr 22	read

Essam Ahmed Al‐Moraissi, Thamar University, Dhamar, Yemen
Shakeerah Olaide Gbadebo, University of Ibadan, Ibadan, Nigeria

Olayinka D. ADEOSUN, University of Ibadan, Ibadan, Nigeria

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03 May 2023 | for Version 4

Shakeerah Olaide Gbadebo, Department of Restorative Dentistry, Faculty of Dentistry, College of Medicine, University of Ibadan, Ibadan, Oyo, Nigeria

Olayinka D. ADEOSUN, University College Hospital, University of Ibadan, Ibadan, Oyo, Nigeria

4 Views Cite this report Responses(0)

Approved

Improved. All the queries were answered. However, the manuscript should be further reviewed for English and misspelled words.

Introduction

Last paragraph, line 4: "...However, …"
Last paragraph, starting from line 6, should read:
"As a result, the study aimed to determine the prevalence and severity of distribution of TMDs among the Almadinah Almunawwarah community population and to focus on the population’s awareness of the appropriate clinical management of the disorders using the Fonseca questionnaire, which hasn’t been used in our population before."

Methodology

Inclusion Criteria, 1st paragraph, line 2: " …Saudi Arabia, seeking dental treatment from March 2020 to March 2022 were included in the study."
Last paragraph: "...as in the verified Fonseca questionnaire, which is structured, has adequate length, and understandable language, and also by limiting the patient experience to the previous three months."

Results

Line 4: "study final analysis leaving a total of 518..."
Paragraph 4 should read:
"In regards to whom to seek treatment, 51.6% of the participants chose a dentist, while 41.8% chose an orthopedic specialist (P > 0.05). Based on participants who have suffered or are suffering from TMDs, only 40% sought treatment, out of which, 64.6% of them chose a dentist or orofacial pain specialist for their management while 24.6% chose orthopaedic specialist (P ≤ 0.008)."

Discussion

Paragraph 3, line 3: "no conclusive results achieved to date."

Competing Interests

No competing interests were disclosed.

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

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2 Views

02 May 2023 | for Version 4

Essam Ahmed Al‐Moraissi, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Dhamar, Yemen

2 Views Cite this report Responses(0)

Approved

Authors addressed all comments perfectly.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Oral and Maxillofacial Surgery

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

20 Views

07 Mar 2023 | for Version 3

Shakeerah Olaide Gbadebo, Department of Restorative Dentistry, Faculty of Dentistry, College of Medicine, University of Ibadan, Ibadan, Oyo, Nigeria

Olayinka D. ADEOSUN, University College Hospital, University of Ibadan, Ibadan, Oyo, Nigeria

20 Views Cite this report Responses(1)

Approved With Reservations

Thank you for the opportunity to review this work.

Temporomandibular joint disorders (TMDs) is not an uncommon disease of the orofacial region, it is the third on the list of the new classification of orofacial pain by ICOP¹, and there is a need to create more awareness of this disorder as well as create awareness on the right set of physicians to be consulted for management. The study is relevant and it is important, to assess the level of knowledge of people and to give adequate education and referral for effective management. However, the manuscript requires an overall review.

Title: says "appropriate clinical practice" This refers to the physician rather than the health-seeking behavior or knowledge of who to seek treatment from by the patient regarding TMD.

Is the study design appropriate and is the work technically sound?
This is a cross-sectional observational study which is accurate for the survey on prevalence but the technicality of carrying the survey out needs to be explained more.

Introduction: all paragraphs should be reviewed. e. g. paragraph 2 should read: "The prevalence of TMDs have been associated with gender, with a twice higher prevalence reported among females compared to males [8]. Also, the pain intensity was reported to be greater among women."

Are sufficient details of methods and analysis provided to allow replication by others?
Partly. The questionnaire for data collection was discussed, but not in detail. Nothing was mentioned on questions that addressed awareness.
Other areas in methodology to look into:

The statement "during the last 2 years/ in the previous 2 years" - the year in question should be specific.
Fonseca's questionnaire translation process to the Arabic language should be explained. Was the translated questionnaire pre-tested or not for validation? All should be stated. These two references are given for the authors to check the protocol on translation of data collection tool, such as the questionnaire used²^,³.
Sample size: what was the basis for the extension of the size from 523 to 598? How and what was the formula used?
The statement of Instrument for data collection should be reviewed for English and clarity.

If applicable, is the statistical analysis and its interpretation appropriate?
Partly.

p should be written as p ≤0.05.
SPSS version 25 should be IBM SPSS version 25.
There was no mention of where the student t-test was used.

Are all the source data underlying the results available to ensure full reproducibility?

Partly. Only Fonseca's questionnaire is presented in English.

Results:

Total numbers 598 and 80 were removed due to exclusion criteria to give 518. The 598 was taken as a corrected sample size to avoid insufficient or missing data. So why remove from the total data 598 again?
Exclusion Criteria should have been considered at the point of recruitment of participants for the study not when cleaning data. The total data left cannot be said to be adequate again because it is less than the calculated sample size of 523 even before adjustment for dropout or insufficient data. Why then did the author adjust to 598 to later remove 80 due to exclusion criteria?
Fig 1: first age group should be ≤20 years not ≥, as used in the figure.
The survey participants should be referred to as "participants" and not "samples".
The result, paragraph 4: Should be reviewed for clarity.
"In regards to whom to seek for treatment", "Participants" not 'sample" and "participants who have suffered or are suffering".

Discussion
Total review and proofreading are necessary.

Almadinah was written as Almadianh in paragraph 1 line 7.
Paragraph 4: "Although more than 70% of the TMD-positive participants have mild TMD, only 51.6% know who to see for TMD therapy." - Who should be seen for TMD? This was not mentioned in any part of the manuscript.
The authors should realize that not all dentists can treat TMJ pain. As a recognized specialty under dentistry, there are orofacial pain specialists for the management of such, and the general dentist may just be in the position to refer accordingly/appropriately. So concluding that some participants that chose dentists have adequate knowledge may not be right.
Further in Paragraph 4, line 2; "TMD treatment varies from one physician to another". We want to believe this statement is not meant to be. Treatment of TMD depends on the cause whether it is Primary(idiopathic) or Secondary(has a specifically identified cause). Also, based on the presentation of symptoms and level of possible degeneration if there is any at presentation. it is not based on the physician. Rewrite the statement "No TMD recurrence in the majority of patients who could be examined 4 to 6 years after treatment". It should be continuous with the first statement on conservative treatment or it should reflect that it is related to conservative treatment earlier mentioned in the paragraph.

Are the conclusions drawn adequately supported by the results?
Partly. Yes, but the issue of awareness was not seen in the result.

Statement "participants lacking the knowledge of TMD"? is queried. There was nothing in the result or discussion on knowledge of TMD rather, the question was about who the participants will seek treatment from.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

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

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. International Classification of Orofacial Pain, 1st edition (ICOP).Cephalalgia. 2020; 40 (2): 129-221 PubMed Abstract | Publisher Full Text
2. Tsang S, Royse CF, Terkawi AS: Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine.Saudi J Anaesth. 2017; 11 (Suppl 1): S80-S89 PubMed Abstract | Publisher Full Text
3. Pan Y, de la Puente M: Census Bureau Guideline for the Translation of DataCollection Instruments and Supporting Materials:Documentation on how the Guideline Was Developed. U.S. Census Bureau. 2005. Reference Source

Competing Interests

No competing interests were disclosed.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

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Responses (1)

Author Response

12 Apr 2023

Shadia Elsayed, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

Thank you very much for your thorough and helpful review, which gave us another opportunity to improve the article.

Temporomandibular joint disorders (TMDs) is not an uncommon disease of the orofacial region, it is the third on the list of the new classification of orofacial pain by ICOP¹, and there is a need to create more awareness of this disorder as well as create awareness on the right set of physicians to be consulted for management. The study is relevant and it is important, to assess the level of knowledge of people and to give adequate education and referral for effective management. However, the manuscript requires an overall review.

Title: says "appropriate clinical practice" This refers to the physician rather than the health-seeking behavior or knowledge of who to seek treatment from by the patient regarding TMD.

Answer: Thank you so much for your remark, I appreciate it. The title has been updated to reflect the helpful feedback.

Is the study design appropriate and is the work technically sound?
This is a cross-sectional observational study which is accurate for the survey on prevalence but the technicality of carrying the survey out needs to be explained more.

Answer: Thank you so much for your comment, I appreciate it. The study data collecting section has been updated with a more explanation of survey collection methodology.

Introduction: all paragraphs should be reviewed. e. g. paragraph 2 should read: "The prevalence of TMDs have been associated with gender, with a twice higher prevalence reported among females compared to males [8]. Also, the pain intensity was reported to be greater among women."
Answer: Many thanks for your comment. All paragraphs have been revised.

Are sufficient details of methods and analysis provided to allow replication by others?
Partly. The questionnaire for data collection was discussed, but not in detail. Nothing was mentioned on questions that addressed awareness.
Other areas in methodology to look into:

The statement "during the last 2 years/ in the previous 2 years" - the year in question should be specific.

Thank you so much for your comment, we appreciate it. The year is added.
Fonseca's questionnaire translation process to the Arabic language should be explained. Was the translated questionnaire pre-tested or not for validation? All should be stated. These two references are given for the authors to check the protocol on translation of data collection tool, such as the questionnaire used²^,³.

Answer: I appreciate your comment very much. The questionnaire used was a valid, reliable Fonseca questionnaire, and translation was done in collaboration with the arbic English editors translation team. It was revised and approved with the institutional expert committee, then it was preliminary tested for the research. All of this was done in accordance with Siny Tsang et al(2017) .'s guidelines and recommendations. Thank you very much for this helpful tip.
Sample size: what was the basis for the extension of the size from 523 to 598? How and what was the formula used?

Answer: Thank you for your comment. This is because we began the survey by piloting it on 75 patients to confirm the survey construct and consistency, and these patients were excluded at the end of the study analysis.
The statement of Instrument for data collection should be reviewed for English and clarity

Response: Thank you for your comment. This section is revised for English clarity

If applicable, is the statistical analysis and its interpretation appropriate?
Partly.

p should be written as p ≤0.05.

Answer: Thank you very much for your comment. Done

SPSS version 25 should be IBM SPSS version 25.

Answer: Thank you very much for your comment. Corrected
There was no mention of where the student t-test was used.

Answer: Thank you so much for your comment, we appreciate it. We regret the typo and have removed it from the text because it was not utilized.

Are all the source data underlying the results available to ensure full reproducibility?
Partly. Only Fonseca's questionnaire is presented in English.

Answer: Many thanks for your comment. The share fie contains all data English and Arabic version tools.

Results:

Total numbers 598 and 80 were removed due to exclusion criteria to give 518. The 598 was taken as a corrected sample size to avoid insufficient or missing data. So why remove from the total data 598 again?

Answer: Thank you for your comment. This is because we began the survey by piloting it on 75 patients to confirm the survey construct and consistency, and these patients were excluded at the end of the study analysis.

Exclusion Criteria should have been considered at the point of recruitment of participants for the study not when cleaning data. The total data left cannot be said to be adequate again because it is less than the calculated sample size of 523 even before adjustment for dropout or insufficient data. Why then did the author adjust to 598 to later remove 80 due to exclusion criteria?

Answer: Thank you very much for your comment. This is because we began the survey by piloting it on 75 patients to confirm the survey construct and consistency, and these patients were excluded at the end of the study analysis. Another 5 patients' data were excluded from analysis Due to missing patient outcome information

Fig 1: first age group should be ≤ 20 years not ≥, as used in the figure.
Answer: Thank you very much for your comment. Corrected

The survey participants should be referred to as "participants" and not "samples".
Answer: Thank you very much for your comment. Corrected
The result, paragraph 4: Should be reviewed for clarity.
Answer: Thank you very much for your comment.
"In regards to whom to seek for treatment", "Participants" not 'sample" and "
Answer: Thank you very much for your comment

Discussion
Total review and proofreading are necessary.

Almadinah was written as Almadianh in paragraph 1 line 7.
Answer: Thank you very much for Your comment.
Paragraph 4: "Although more than 70% of the TMD-positive participants have mild TMD, only 51.6% know who to see for TMD therapy." - Who should be seen for TMD? This was not mentioned in any part of the manuscript.
The authors should realize that not all dentists can treat TMJ pain. As a recognized specialty under dentistry, there are orofacial pain specialists for the management of such, and the general dentist may just be in the position to refer accordingly/appropriately. So concluding that some participants that chose dentists have adequate knowledge may not be right.
Thank you so much for your comment, I appreciate it. We take into account this point during the survey process, and the text writing is now revised.
Further in Paragraph 4, line 2; "TMD treatment varies from one physician to another". We want to believe this statement is not meant to be. Treatment of TMD depends on the cause whether it is Primary(idiopathic) or Secondary(has a specifically identified cause). Also, based on the presentation of symptoms and level of possible degeneration if there is any at presentation. it is not based on the physician. Rewrite the statement "No TMD recurrence in the majority of patients who could be examined 4 to 6 years after treatment". It should be continuous with the first statement on conservative treatment or it should reflect that it is related to conservative treatment earlier mentioned in the paragraph.
Answer: Thank you very much for your comment. This section was modified based on your kind suggestion.

Are the conclusions drawn adequately supported by the results?
Partly. Yes, but the issue of awareness was not seen in the result.

Statement "participants lacking the knowledge of TMD"? is queried. There was nothing in the result or discussion on knowledge of TMD rather, the question was about who the participants will seek treatment from.

Answer: Thank you very much for your comment. this is now corrected based on your kind suggestion

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Competing Interests

I declare no competing interest.

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Reviewer Report

12 Views

07 Jul 2022 | for Version 3

Essam Ahmed Al‐Moraissi, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Dhamar, Yemen

12 Views Cite this report Responses(0)

Approved

Authors addressed my comments appropriately.

Competing Interests

I don't have any financial conflict of interest. I know only Dr. Shayma S. Alsayed (via social media) for 2 years from the ResearchGate. We have been contacted intermittently (from time to time) for an independent scientific discussion before and during and after reviewing process. Our communications have never had an effect on the transparency, confidentiality, and impartiality of the reviewing process.

Reviewer Expertise

Oral and Maxillofacial Surgery

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

22 Views

13 Apr 2022 | for Version 2

Essam Ahmed Al‐Moraissi, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Dhamar, Yemen

22 Views Cite this report Responses(1)

Approved With Reservations

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study."

My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?
Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.
It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study."

So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.
Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.
In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)
The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation
Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.
Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Competing Interests

Reviewer Expertise

Oral and Maxillofacial Surgery

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Author Response

04 Jul 2022

Shadia Elsayed, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

Thank you for your feedback, which provided us with another opportunity to edit the article.

Authors stated in the inclusion criteria that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." My question is what are the purposes of visiting participants? What did they seek treatments for? Were they asked about treatments for TMDs?

Answer: Thank you for your input. The study included individuals who came to the TUDC for routine dental screening, with the goal of determining the prevalence of TMJ problems in this specific demographic.
Since this is an observational cross-sectional study, authors should clarify if this study was performed retrospectively or prospectively and should state this information in the methods and abstract.

Answer: Thank you for your input. The study was conducted as a prospective observational study, and this is now addressed in the methodology and abstract.
It's clear that sample size calculation was not reliable and convincing because sample size calculation for cross-sectional study requires statistical formula, the prevalence of an indicator (which should be estimated from the previous published similar studies), level of significance, correlation coefficient, etc.

Answer: I appreciate your input. The study sample calculation was determined using the OpenEpi tool kit application with a confidence level of 99 percent and estimated the entire Madinah population to be above one million and estimated prevalence indicator of 27% (Al-Khotani, A., Naimi-Akbar, A., Albadawi, E. et al. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain 17, 41 (2016). https://doi.org/10.1186/s10194-016-0642-9) and the sample size was calculated to be 523 participants. To avoid missing or insufficient data, we extend the total to 598.

Based on methods authors stated clearly that "All adult males and females who visited Taibah University’s Oral and Maxillofacial Surgery clinics in Almadinah Almunawwarah, Saudi Arabia, in the previous two years were included in the study." So, all patients that visited the clinic within 2 years have been included, is this means no actual sample size calculation was performed? Please clarify. Otherwise, the authors should address these points as a study limitation.

Answer: Thank you for your comment. The study was conducted during the last two years, and the sample was drawn from clinic visitors on a daily basis.
Based on the methodology, the authors included all patients who visited the Department at a specific time. Also, based on the Arabic Questionnaire, and the author's exclusion criteria, they excluded some patients. So, it's mandatory to clarify the total number of participants who were initially recruited (based on sample size calculation, in the case this has been done prospectively) and agreed to participate, then the number of patients who were excluded with reasons using flow diagram.

Answer: Thank you for your comment. The study included A total of 598 participants answered the questionnaire, based on the mentioned exclusion criteria, 80 (13.4 %) participants were removed from the study. Thus, leveeing a total of 518 (86.6%) recruited participants
In Conclusion, the authors should address the primary aim of the study which estimated the prevalence of TMDs in the City. As this study is a cross-section study, the causation between the risk factor and outcome is impossible to assess. Then I think, some part of the conclusion is not supported by the findings (Fonseca's Anamnestic Index could also be considered a useful instrument for early identification and measuring the severity of TMDs in the general population.)

Answer: Thank you for your comment. Conclusion section has been updated in accordance with your thoughtful advice.
The authors stated in the exclusion criteria those patients who wear removable dentures or splints were excluded, please give an explanation.

Answer: In order to assess the actual prevalence among the population that did not get prosthodontic devices like splints, we eliminated patients receiving splint therapy and removable prosthodontics, which could be a contributing confounding cause of TMJ adaptive modifications.
Another problem could be introducing a bias within the study, and difficulties for patients to fill and complete the questionnaire.

Answer: thank you for your comment. The questionnaires were filled out by well-trained two investigators who collect data from patients and contribute to the current study's authorship.
Title: abbreviation of (TMJ) should be removed from the title. The title should be short more focused and mention the study design

Answer: Thank you for your comment. The title has been updated in response to your helpful suggestion.

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Competing Interests

I declare no conflict of interest.

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Reviewer Report

20 Views

06 Apr 2022 | for Version 1

Essam Ahmed Al‐Moraissi, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Dhamar, Yemen

20 Views Cite this report Responses(0)

Not Approved

Authors completely failed to state the rationale of the study (why it's important to do this study) or show the size of the gap in the literature. Unfortunately, the indexing of this study will not add any new material to the existing literature.
Authors did not state the inclusion criteria completely, only mentioned the exclusion criteria. So authors should state inclusion criteria based on PICOS criteria.
Authors did not present adequately information about how they calculated the sample size.
Authors should explain why they chose a modified version of Fonseca's questionnaire.
The generalizability of this study is not applicable.
Authors should include others predictors variables to be analysed type of TMDs if myogenous or arthrogenous, chronicity, signs and symptoms of TMDs such as clicking, muscles tenderness, headache, limited mouth opening etc.
Authors did not clarify who performed the assessment.
This study is based on a survey so its mandatory to clarify the limitations of this study.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

Reviewer Expertise

Oral and Maxillofacial Surgery

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Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Temporomandibular joint (TMJ) disorders prevalence and awareness of appropriate clinical practices, among Al-Madinah community in Saudi Arabia

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Study design and setting

Inclusion and exclusion criteria

Sample size

Instrument for data collection

Statistical analysis

Results

Figure 1. Age group distribution.

Figure 2. Level of education.

Figure 3. The level of TMDs in regard to gender distribution.

Table 1. The frequency of the most common symptoms for patient with TMDs.

Discussion

Conclusion

Data availability

Underlying data

Extended data

References

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