Temporomandibular disorder pain in adult Saudi Arabians referred for specialised dental treatment

The aim of this study was to determine the frequency of Temporomandibular Disorders (TMD) pain in Saudi Arabians,aged 20-40, who were referred to the Specialist Dental Centre in Makkah. The material included 325 patients (135 males,190 females) who answered a history questionnaire. Patients reportingTMD pain in the last month were offered a clinical examination. History questionnaires and clinical examinations were done according to the Arabic version of the Research Diagnostic Criteria for TMD (RDC/TMD). Fifty-eight patients (18%) reported TMD pain; 46 were clinically examined. Mean age of clinically examined TMD pain patients was 30 +/- 7 years with a male-female ratio of 1:6 (P < 0.001). All TMD pain patients had a diagnosis of myofascial pain, and 65% had diagnoses of arthralgia or osteoarthritis. Headaches or migraines in the last 6 months and headaches in the last month were reported in high frequencies in the TMD pain group, 93% and 71% respectively, with differences (P < 0.001) between the TMD pain and non-TMD pain groups. Graded Chronic Pain Scale assessments classified 45% of the TMD pain patients in grade 1, 53% in grade II, 2% in grade III, and 0% in grade IV. Severe depression scores were found in 38% of the TMD pain patients and severe somatisation scores in 60% with differences (P < 0.001) between the TMD pain and non-TMD pain groups. In conclusion, the study found a frequency of TMD pain in this Saudi Arabian cohort of 18%. The TMD pain group presented high scores of depression and somatisation but low disability grades on the Graded Chronic Pain Scale.     

Diurnal variation in pain reports in temporomandibular disorder patients and control subjects

AIMS: To test the hypothesis that temporomandibular disorder (TMD) patients have characteristic diurnal patterns of pain that are associated with diurnal or nocturnal parafunctions. METHODS: Experience sampling methods were used to obtain information on pain from subjects (n = 84) diagnosed, according to the Research Diagnostic Criteria for TMD, with myofascial pain, myofascial pain and arthralgia, disc displacement, and from non-TMD controls. Variations in pain as reported on the pager questionnaire form were modeled as linear, exponential, and quadratic effects. RESULTS: Between 8.7% and 23.8% of TMD subjects with pain showed significant patterns to their daily pain reports, compared to 4.5% of non-TMD controls. Groups did not differ significantly in the proportions of those with increasing (59.5%) vs. decreasing (40.5%) pain levels. Self-reported clenching during the day and grinding at night were weakly associated with an increasing or decreasing pattern of pain during the day (P < .10). Pain levels during weekends were significantly lower for all groups. CONCLUSIONS: Strongly linear or curvilinear patterns of pain were not characteristic of this sample of subjects. More than half the subjects reported slightly increasing pain during the day, but the variability within groups was considerable. Increasing and decreasing patterns of pain were independent of self-reported daytime and nighttime clenching and grinding. Self-reported pain patterns may not be used to reliably infer the times when parafunctional activities occur. The presence of lower pain levels during the weekend probably reflects reduction in psychosocial stressors associated with the work week.     

Tooth contact in patients with temporomandibular disorders

Both experimental and retrospective studies suggest a link between parafunctions and pain in temporomandibular disorder (TMD) patients. To investigate the role of parafunctions in TMD, experience sampling methodology was used as a prospective test of the hypothesis that patients with TMD have higher levels of tooth contact and tension than non-TMD controls. Three groups of TMD patients and a group of normal controls carried pagers for one week, were contacted approximately every two hours by an automated calling system, and completed questionnaires assessing tooth contact, tension, and pain at each contact. Results showed that tooth contact was much more frequent among normal controls than is commonly presumed. Patients with myofascial pain with/without arthralgia reported more frequent contact, higher intensity contact, and more tension than patients with disk displacement or normal controls. Increased masticatory muscle activity responsible for tooth contact and tension may be an important mechanism in the etiology and maintenance of the myofascial pain and arthralgia of TMD.     

Clinical decision making for temporomandibular disorders.

Temporomandibular Disorders (TMD) encompass a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ), or both. In any given patient, there exists the possibility of several overlapping TM disorders, an orofacial pain condition mimicking a TMD, or a concomitant TMD and non-TMD disorder. Since differential diagnosis involves the determination of which diseases or disorders a patient is suffering from by systematically contrasting the clinical characteristics, differentiation from among multiple possible conditions complicates the diagnostic process, which often must be approached with a certain degree of uncertainty. In addition, the therapeutic decisions that emanate from the diagnostic process have their own predictive uncertainties. These uncertainties can be ameliorated by coupling available clinical research data with structured clinical problem solving methods during the diagnostic-therapeutic decision making process. It is within this context that this article includes a discussion of the rationale for why the clinician should use decision making methods for TMD, a review of previous attempts at developing decision models for TMD, a discussion of the diagnosis of TMD with particular emphasis on the reliability and validity of their diagnostic criteria, a summary of the efficacy of therapeutic modalities and their application to treatment decisions, a sample decision tree analysis of a TM disorder, and some general recommendations for dental education.     

Measuring the Impact of a Dental Practice on TM Disorder Symptoms

This article describes a practical, quantitative method of measuring changes in temporomandibular disorder (TMD) symptoms in a dental practice. It applies the TMJ Scale? * to produce a number of clinically important measures of treatment effectiveness. Those measures include pre- and post-treatment symptom severity, percent of patients improved, level of improvement, and percent of patients converting to non-symptomatic after treatment. All of these outcome parameters were applied to a sample of the practice and to subgroups based on age, sex and problem length. The treated patients were compared to a group of diagnosed but untreated patients. The specific target symptoms of TMD are analyzed including pain, palpation pain, joint dysfunction and limited range of motion of the mandible. In addition, the overall symptom severity of the TM disorder, psychological factors and stress are studied, leading to an assessment of symptom change. The results support the concept that patients with acute problems are more treatment responsive than are patients with chronic problems. This suggests that careful screening and earlier detection of TMD may have an important impact on ultimate treatment outcome.     

Analysis of thermal pain sensitivity and psychological profiles in different subgroups of TMD patients

This study evaluated differences in pain sensitivities and psychological profiles among different temporomandibular disorder (TMD) pain subtypes. Evaluation was done on 36 normal subjects and 39 TMD patients with high Graded Chronic Pain scale scores. TMD patients were placed in three pain subgroups (myogenous, arthrogenous, mixed) using the Research Diagnostic Criteria for TMD (RDC/TMD) axis I guidelines. RDC/TMD axis II profiles including depression and somatization were analysed. Cold pain threshold (CPT), heat pain threshold (HPT), and heat pain tolerance threshold (HPTT) were measured on three facial regions (anterior temporalis, masseter, TMJ) and a leg region (anterior tibialis). The arthrogenous pain subgroup showed significantly higher CPT and lower HPT and HPTT in the facial region, and lower HPTT in the anterior tibialis region compared with normal and myogenous pain subgroups. The myogenous pain subgroup had significantly higher somatization scores than normal and arthrogenous pain subgroups, and higher depression scores than normal subjects. The results suggest that peripheral and/or central sensitization are present in chronic arthrogenous pain more so than in myogenous pain, and this phenomenon appears to take place regardless of the patient's psychological profiles. These results may explain the underlying mechanism that aggravates TMD pain.     

Efficacy of an early intervention for patients with acute temporomandibular disorder-related pain: a one-year outcome study

BACKGROUND: The authors conducted a randomized clinical trial to evaluate the efficacy of a biopsychosocial intervention for patients who were at high risk (HR) of progressing from acute to chronic temporomandibular disorder (TMD)-related pain. METHODS: The authors classified subjects' risk using a predictive algorithm and randomized them into an early-intervention (EI) or a nonintervention (NI) group. The EI included cognitive behavioral skills training and biofeedback. The authors assessed pain and psychosocial measures at intake and at a one-year follow-up. Subjects' self-reported pain levels were measured on an analog scale and as a response to palpation. RESULTS: At one year, EI-group subjects had significantly lower levels of self-reported pain and depression. At one year, more NI-group subjects than EI-group subjects had utilized health care for jaw-related pain. NI-group subjects were 12.5 times as likely to have a somatoform disorder, more than seven times as likely to have an anxiety disorder, and 2.7 times more likely to have an affective disorder at one year, compared with EI-group subjects. CONCLUSIONS: EI-group subjects had reduced pain levels, improved coping abilities and reduced emotional distress at one year. CLINICAL IMPLICATIONS: The TMD-related pain experience is complex and requires early identification with a biopsychosocial EI to achieve maximal, sustainable results.     

Depression levels in chronic orofacial pain patients: a pilot study

The assessment of depressive behaviour in chronic pain patients is especially important, because depression is commonly associated with chronic pain. The aim of this pilot study was to compare depression levels between patients with head and neck cancer pain and temporomandibular disorders (TMD), and to determine whether there is an association between depression levels and chronic pain severity. This study was an observational and sectional study and the sample consisted of 40 patients, uniformly divided into those with chronic orofacial pain related to cancer and those with painful TMD classified with research diagnostic criteria for temporomandibular disorders (RDC/TMD) axis I. Depression levels, pain intensity and severity were assessed with RDC/TMD axis II. The study demonstrated statistically significant differences in depression levels present in the head and neck cancer pain group and the painful TMD group, with the occurrence of a moderate statistically significant correlation between depression levels and chronic pain severity.     

Self-efficacy is associated with pain, functioning, and coping in patients with chronic temporomandibular disorder pain

AIMS: To examine the psychometric characteristics of a measure of self-efficacy for managing temporomandibular disorders (TMD) and to determine whether scores on this measure were related to pain, disability, and psychological distress in patients with chronic TMD pain. METHODS: Patients seeking treatment for chronic TMD pain (n = 156, 87% female, mean age = 37 years) completed measures assessing pain, disability, mental health, pain-coping strategies, and self-efficacy for managing their pain. RESULTS: The self-efficacy measure, which was adapted from arthritis research, demonstrated good psychometric characteristics (Cronbach's alpha = 0.91, minimal floor and ceiling effects, and validity). Greater self-efficacy was associated with significantly (P < .05) lower levels of pain, disability, and psychological distress. Self-efficacy remained significantly associated with disability and mental health measures even after controlling for demographic variables and pain intensity. In addition, patients with higher self-efficacy reported significantly (P < .05) greater use of an active, adaptive chronic pain-coping strategy (task persistence) and less use of a passive, maladaptive chronic pain-coping strategy (rest). CONCLUSION: Self-efficacy for managing pain appears to be important in the adjustment of patients with chronic TMD pain. Research is needed to determine whether treatments designed to increase self-efficacy improve TMD patient outcomes.     

Waking-state oral parafunctional behaviors: specificity and validity as assessed by electromyography

In contrast to sleep-related oral parafunctional behaviors, little is known about waking oral parafunctional behaviors. The Oral Behaviors Checklist contains terms referring to a variety of non-observable behaviors that are reliable when prompted (e.g. 'clench') but validity data are absent. Our goal was to assess whether (i) each behavioral term is distinct electromyographically, and (ii) temporomandibular disorder (TMD) subjects differ from non-TMD subjects in their performance. Surface electromyographic (EMG) activity was used to measure bilateral masseter, temporalis, and suprahyoid muscles while subjects (27 patients with TMD; 27 healthy controls) performed ten oral behaviors without explanation. Electromyographic data were averaged between bilateral muscles and two trials. A multivariate construct (jaw muscle activity) was analyzed using Wilks lambda within multivariate analysis of variance (manova). Obvious behaviors (e.g. clench, read, tongue press) exhibited expected EMG patterns, and patients and controls produced identical profile plots of the EMG data. Of 10 tested behaviors, nine were found to be associated with significantly differing proportions of amplitudes across muscles and were thus unique. Behaviors with similar terms were associated with different EMG patterns. The present data support the specificity of behavioral terms and performances. Implications include causation related to TMD based on subtle behaviors that occur at a high frequency.     

Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients.

PURPOSE: This study investigated the role of psychological factors in temporomandibular disorders (TMD). Orofacial pain patients' pretreatment levels of depression, disability caused by pain, and exposure to stressful life events were measured, and differences on these variables between temporomandibular joint (TMJ) disease patients and patients whose pain was of muscular origin (MPD) were evaluated. The use of these variables and patient diagnostic status in predicting response to treatment in a subsample of these patients was also evaluated. PATIENTS AND METHODS: Before undergoing treatment, 258 patients were administered the Beck Depression Inventory (BDI), the Pain Disability Index (PDI), and the Social Readjustment Rating Scale (SRRS). Follow-up data on pain disability, current level of pain, depression, and satisfaction with treatment were obtained on 48 of these patients who were contacted at varying intervals after completing treatment. RESULTS: BDI scores obtained at the outset of treatment were significantly elevated and were positively correlated with SRRS and PDI scores. MPD patients had higher SRRS, BDI depression, and PDI pain disability scores than TMJ patients, and differences between the 2 groups in pain disability were greatest in areas that are often sources of interpersonal stress. Among follow-up patients, PDI scores declined after treatment, with MPD patients showing greater decreases than TMJ patients. Independent of patients' diagnostic status, their pretreatment PDI scores were predictive of their pain level at follow-up and were inversely related to their degree of satisfaction with treatment at follow-up; their pretreatment BDI scores were predictive of their depression level at follow-up. CONCLUSIONS: The findings are consistent with previous research indicating a link between emotional dysfunction and TMD and are largely supportive of the conclusion that psychological factors play a more pronounced role when pain is of muscular origin. Promising behavioral interventions are available for TMD patients in whom psychological factors appear to be playing a significant role.     

Reduced heart rate variability and increased saliva cortisol in patients with TMD

Temporomandibular disorders (TMD) are the most common source of non-dental pain. The pathogenesis of TMD is multifactorial, involving biological, psychological and behavioral factors. Those factors are involved with alterations of the autonomic nervous system (ANS) and stressful conditions. Heart rate variability (HRV) has been used as a marker of ANS function. Increased cortisol level (a stress indicator), has been found in chronic pain. Therefore, the present study aimed to compare pain intensity, HRV, psychological factors, and salivary cortisol level between TMD patients and a control group. Twenty-one TMD patients and twenty-three healthy control subjects participated in the study. All participants underwent 24-h-Holter monitoring to record HRV. Morning unstimulated saliva samples were collected from each participant for cortisol analysis. The pain intensity was assessed using a visual analog scale. The participants were evaluated for anxiety and depression via the Hospital Anxiety and Depression Scales. We found that pain intensity and psychological distress in the TMD group were significantly greater than those of the control (p < 0.01). Pain intensity showed a positive correlation with psychological distress (p < 0.01). HRV parameters in the TMD group were significantly lower than those in the control, suggesting reduced HRV in TMD patients. Pain intensity was negatively associated with HRV. Salivary cortisol level of the TMD group was greater than that of control. Our findings indicate that reduced HRV with higher psychological distress and increased salivary cortisol levels were observed in the TMD group. Therefore, TMD patients may benefit from interventions that can restore ANS function and stress balance.     

Increased pain sensitivity of the upper extremities of TMD patients with myalgia to experimentally-evoked noxious stimulation: possibility of worsened endogenous opioid systems

The purpose of this study was to examine whether or not temporomandibular disorder (TMD) patients with chronic masticatory myalgia have increased pain sensitivity at remote sites outside of the head and neck region, and to evaluate whether the endogenous pain inhibitory systems triggered ischemic pain functions favorably in those patients. Twenty female TMD patients with chronic myalgia and 20 controls participated in this study. Ischemic pain was produced to activate endogenous opioids. The pain threshold time, pain tolerance time, pain intensity and pain unpleasantness were compared between the TMD patients and controls. The pressure pain thresholds in the hand were also compared before, between, and immediately after the ischemic pain. The TMD patients showed higher severe pain intensity and unpleasantness values and had lower pressure pain thresholds in the hand. Although both groups showed an increase in the pressure pain threshold, there was less of an increase in the pressure pain threshold in the TMD patients than in the controls. These findings indicate that TMD patients have increased pain sensitivity at remote sites, and also indicate additional evidence that the endogenous opioid systems may become impaired in TMD patients with chronic masticatory myalgia.     

Multiple pains and psychosocial functioning/psychologic distress in TMD patients

PURPOSE: This study assessed multiple pain conditions and their association with psychosocial functioning, psychologic distress, and somatization in patients with temporomandibular disorders (TMD) based on RDC/TMD Axis II findings. Nonspecific pain items examined included headaches, heart/chest pain, lower back pain, nausea/abdominal pain, and muscle pain. MATERIALS AND METHODS: In this study, 202 TMD patients (58 men and 144 women) referred to two TMD clinics participated. The mean age of the predominantly Chinese patient population (82%) was 32.6 years (range 13 to 65). The RDC/TMD history questionnaire was input directly into computers by patients. Graded chronic pain and SCL-90 scales were generated online and automatically archived for statistical analysis. Data were subjected to Spearman's rank-order correlation and Kruskal-Wallis and Mann-Whitney tests at a significance level of .05. RESULTS: Of the patients, 43% were moderately to extremely distressed by headaches. The percentage of patients who were distressed by heart/chest pain (7%), lower back pain (26%), nausea/abdominal pain (17%) and soreness of muscles (22%) was lower. Of the TMD patients, 16% experienced more than three pain items. Significant and positive correlations were observed between number of pain items experienced and graded chronic pain severity, depression, and somatization. Correlation coefficients ranged from .27 to .65 for graded chronic pain scales and somatization (without pain items) scores, respectively. CONCLUSION: Results suggest that the number of nonspecific pain conditions reported may be a predictor of psychosocial dysfunction, depression, and somatization.     

A model for predicting chronic TMD: practical application in clinical settings

BACKGROUND: Substantial cost is associated with the treatment of chronic temporomandibular disorders, or TMDs, and patients with TMDs often experience significant psychosocial distress. Early intervention based on identified risk factors has potential financial and functional benefits. METHODS: Two hundred four patients with acute TMD were evaluated via an assessment battery that included physical, psychological and social measures. All participants were diagnosed as having TMD on the basis of the research diagnostic criteria for TMD, Axis I. At the six-month follow-up assessment, patients were considered to have chronic TMD if they continued to have TMD pain. This resulted in 144 of the patients being classified in the chronic group and 60 being classified in the nonchronic group. RESULTS: A comparison of the acute TMD data demonstrated that the group that went on to develop chronic TMD and the group that did not differed significantly in their scores on numerous biopsychosocial indexes. Although several biopsychosocial measures were found to differentiate these two groups before the onset of chronic TMD, logistic regression analysis demonstrated that a two-variable predictive model consisting of the presence of a muscle disorder and characteristic pain intensity (that is, the mean of these three ratings: patient's report of current pain, worst pain in the last three months and mean pain in the last three months) accurately classified 91 percent of the subjects who went on to develop chronic TMD. CONCLUSIONS: During the acute phase of TMD, two variables allowed for an accurate prediction rate of 91 percent among patients who went on to develop chronic TMD. CLINICAL IMPLICATIONS: This model provides clinicians with the opportunity to identify at-risk patients early and initiate adjunctive or alternative treatments, thus reducing the likelihood of the development of TMD chronicity.     

Psychosocial impairment in temporomandibular disorders patients. RDC/TMD axis II findings from a multicentre study

Objectives

The relationship between the rate of chronic pain-related disability and depression and somatization levels as well as the influence of pain duration on Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis II findings were assessed in a three centre investigation.

Methods

The study sample (N = 1149; F:M 4.1:1, m.a. 38.6 years) consisted of patients seeking for TMD treatment and undergoing RDC/TMD axis II psychosocial assessment to be rated in chronic pain-related disability (Graded Chronic Pain Scale, GCPS), depression (Symptoms Checklist-90[SCL-90] scale for depression, DEP) and somatization levels (SCL-90 scale for non-specific physical symptoms, SOM). The null hypotheses to be tested were that (1) no correlation existed between GCPS categories and DEP and SOM scores, and (2) no differences emerged between patients with pain from more or less than 6 months as for the prevalence of the different degrees of pain-related impairment, depression, and somatization.

Results

In the overall sample, the prevalence of high pain-related disability (GCPS grades III or IV), severe depression and somatization was 16.9%, 21.4%, and 28.5%, respectively. A correlation was shown between GCPS and both DEP and SOM categories (Spearman's correlation test, p < 0.001). A significant association between pain lasting from more than 6 months and high GCPS scores was shown (χ², p < 0.001), while no association was found between DEP and SOM scores and pain duration in the overall sample (χ², p = 0.742 and p = 0.364, respectively).

Conclusions

Pain-related disability was found to be strongly related with depression and somatization levels as well as associated with pain duration. Depression and somatization scores were not associated with pain duration.     

Orthodontic Treatment, Genetic Factors and Risk of Temporomandibular Disorder

Traditionally, four groups of factors have been identified in the etiology of temporomandibular disorder (TMD): anatomical variation in the masticatory system; psychosocial characteristics; pain in other body regions; and demographics. Orthodontic treatment has been variously cited both as a protective and harmful factor in TMD etiology. Recently, a search has begun for a genetic influence on TMD etiology. Genetic markers can be of additional value in identifying gene-environment interactions, that is, isolating population sub-groups, defined by genotype in which environmental influences play a relatively greater or lesser etiological role. This paper reviews concepts and study design requirements for epidemiological investigations into TMD etiology. Findings are presented from a prospective cohort study of 186 females that illustrate an example of gene-environment interaction in TMD onset. Among people with a variant of the gene encoding catechol-O-methyl-transferase, an enzyme associated with pain responsiveness, risk of developing TMD was significantly greater for subjects who reported a history of orthodontic treatment compared with subjects who did not (P=0.04). While further studies are needed to investigate TMD etiology, this genetic variant potentially could help to identify patients whose risk of developing TMD is heightened following orthodontic treatment, hence serving as a risk marker useful in planning orthodontic care.