Temporomandibular pain and depression in adolescents—a case–control study

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for adolescents

BACKGROUND

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for use in adults is in use worldwide. Until now, no version of this instrument for use in adolescents has been proposed.

OBJECTIVE

To present comprehensive and short-form adaptations of the adult version of DC/TMD that are appropriate for use with adolescents in clinical and research settings.

METHODS

International experts in TMDs and experts in pain psychology participated in a Delphi process to identify ways of adapting the DC/TMD protocol for physical and psychosocial assessment of adolescents.

RESULTS

The proposed adaptation defines adolescence as ages 10-19 years. Changes in the physical diagnosis (Axis I) include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for adolescents, (ii) adding two general health questionnaires, one for the adolescent patient and one for their caregivers and (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire. Changes in the psychosocial assessment (Axis II) include (i) adapting the language of the Graded Chronic Pain Scale to be developmentally appropriate for adolescents, (ii) adding anxiety and depression assessment that have been validated for adolescents and (iii) adding three constructs (stress, catastrophizing and sleep disorders) to assess psychosocial functioning in adolescents.

CONCLUSION

The recommended DC/TMD, including Axis I and Axis II for adolescents, is appropriate to use in clinical and research settings. This adapted first version for adolescents includes changes in Axis I and Axis II requiring reliability and validity testing in international settings. Official translations of the comprehensive and short-form to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Sex hormones associated with temporomandibular pain on palpation in male adolescents-Results of the epidemiologic LIFE child study

OBJECTIVE

This study aimed to investigate whether the sex steroid precursor hormone dehydroepiandrosterone sulphate (DHEA-S), sex hormone-binding globulin (SHBG) and testosterone (TT) are associated with temporomandibular (TM) pain on palpation in male adolescents.

METHODS

Out of the LIFE Child study dataset containing 1022 children and adolescents aged 10-18 years (496 males, 48.5%), we used a subsample of 273 male adolescents (mean age: 13.8 ± 2.3 years) in advanced pubertal development (PD) to analyse the association between hormones and TM pain. The Tanner scale was applied to describe the stage of PD. Pain on palpation of the temporalis and masseter muscles and the TM joints (palpation pain) was assessed using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Serum levels of sex hormones (DHEA-S, SHBG and TT) were determined using standardised laboratory analyses. Free TT was estimated from the ratio between TT and SHBG (free androgen index[FAI]). We calculated the risk of perceived positive palpation pain for male participants as a function of hormone levels (DHEA-S, FAI) taking into account age and body mass index (BMI).

RESULTS

Among more developed (Tanner stage 4-5) male adolescents, 22.7% (n = 62) reported palpation pain in the TM region. In these participants, FAI levels were approximately half that of individuals without such pain (p < .01). DHEA-S levels were about 30% lower in the pain group (p < .01). In multivariable regression analyses, the odds ratio (OR) for pain on palpation decreased to 0.75 (95% confidence interval [CI]: 0.57-0.98) per 10 units of FAI level compared to those without pain, after controlling for the effects of age and adjusted BMI. We observed the same effect for this subgroup per unit of DHEA-S serum level (OR = 0.71; 95% CI: 0.53-0.94).

CONCLUSION

At subclinical lower levels of serum free TT and DHEA-S, male adolescents are more likely to report pain on standardised palpation of the masticatory muscles and/or TM joints. This finding supports the hypothesis that sex hormones may influence pain reporting.

Focus Groups to Inform the Development of a Patient-Reported Outcome Measure (PROM) for Temporomandibular Joint Disorders (TMDs)

BACKGROUND

Understanding symptoms of temporomandibular joint disorders (TMDs) can help doctors and patients document, monitor, and manage the disease and help researchers evaluate interventions. Patients with TMDs experience symptoms ranging from mild to severe, primarily in the head and neck region. This study describes findings from formative patient focus groups to capture, categorize, and prioritize symptoms of TMDs towards the development of a patient-reported outcome measure (PROM).

METHODS

We conducted ten focus groups with 40 men and women with mild, moderate, and severe TMD. Focus groups elicited descriptions of symptoms and asked participants to review a list of existing patient-reported outcomes (PROs) from the literature and patient advisor input and speak to how those PROs reflect their own experience, including rating their importance.

RESULTS

We identified 52 distinct concepts across six domains: somatic, physical, social, sexual, affective, and sleep. Focus groups identified the ability to chew and eat; clicking, popping, and other jaw noises; jaw pain and headaches; jaw misalignment or dislocation; grinding, clenching, or chewing, including at night; and ear sensations as most important. Participants with severe TMDs more often reported affective concepts like depression and shame than did participants with mild or moderate TMDs.

CONCLUSION

Findings support PROM item development for TMDs, including selecting existing PROMs or developing new ones that reflect patients' lived experiences, priorities, and preferred terminology. Such measures are needed to increase understanding of TMDs, promote accurate diagnosis and effective treatment, and help advance research on TMDs.

Painful and non-painful comorbidities associated with short- and long-term painful temporomandibular disorders: A cross-sectional study among adolescents from Brazil, Canada, and France

BACKGROUND

Temporomandibular disorder (TMD) pain is common among adolescents. The association between painful TMD and other comorbidities has been demonstrated. However, the difference between short-term (<6 months) and long-term (≥ 6 months) painful TMD is not yet clear.

OBJECTIVE

The aim of this study was to assess the association between comorbidities and short- and long-term painful TMD among adolescents.

METHODS

In this cross-sectional study, adolescents were recruited from Montreal (Canada), Nice (France), and Arceburgo (Brazil). Self-reported painful TMD, comorbidities, school absence, and analgesic intake were assessed using reliable instruments. Multivariable logistic regression analyses were conducted to assess the study aims.

RESULTS

The prevalence of short- and long-term painful TMD was estimated at 22.29% and 9.93%, respectively. The number of comorbidities was associated with short- (OR = 1.71, 95%CI = 1.53-1.90) and long-term painful TMD (OR = 1.79, 95%CI = 1.55-2.08) compared to controls. Frequent headaches (OR_short-term = 4.39, 95%CI = 3.23-5.98, OR_long-term = 3.69, 95%CI = 2.45-5.57) and back pain (OR_short-term = 1.46, 95%CI=1.06-2.03, OR_long-term  = 1.69, 95%CI = 1.11-2.59) were associated with both painful TMD groups. Frequent neck pain (OR = 2.23, 95%CI = 1.53-3.26) and allergies were only associated with short-term painful TMD (OR = 1.54, 95%CI = 1.13-2.10). Frequent stomach pain was related to long-term (OR = 2.01, 95%CI = 1.35-3.26), and it was the only comorbidity significantly more frequent among the long than short-term TMD (OR = 1.82, 95%CI: 1.14-2.90). These analyses were adjusted by sex, age, and city.

CONCLUSION

In this multi-center study, both short- and long-term painful TMD are associated with frequent headaches and back pain, whereas frequent neck pain and allergies are related to only short-term, and frequent stomach pain with long-term painful TMD.

Association of psychological distress and widespread pain with sympatoms of temporomandibular disorders and self-reported bruxism in students

Objectives

The aim of this study was to evaluate the association of psychosocial distress and widespread pain with self‐reported symptoms of temporomandibular disorders (TMD) and bruxism, in two cross‐sectional surveys in 2012 and 2016, and whether there are temporal changes in the magnitude of associations.

Materials and methods

The data were gathered from Finnish university students in 2012 and 2016. TMD symptoms were assessed with three validated questions and bruxism with one frequently used question. Psychosocial distress was assessed with the General Health Questionnaire‐12 (GHQ‐12), and widespread pain with questions of pain in the extremities, the neck or upper back, and lower back. The associations of GHQ‐12, widespread pain and background variables with TMD symptoms and bruxism were analyzed with chi‐square tests, t‐test and binary logistic regression models stratified by gender, and adjusted for age‐group, self‐reported general health/wellbeing and presence of widespread pain.

Results

Higher GHQ‐12 score and presence of widespread pain were significantly associated with TMD symptoms in both genders at both time points. The association of higher GHQ‐12 score with sleep bruxism and awake bruxism were inconsistent. In the adjusted model higher GHQ‐12 score and widespread pain were significantly related to TMD pain symptoms in both genders at both time points, and to bruxism in 2012. Between the two time points a greater variability in these associations was seen in men than in women.

Conclusions

Psychological distress and widespread pain are significant determinants in perceived TMD pain and bruxism among students. No significant temporal alterations were observed.

Oral Health and Psychosocial Predictors of Quality of Life and General Well-Being among Adolescents in Lesotho, Southern Africa

BACKGROUND

Adolescents' quality of life is reported to be significantly associated with physical and social wellbeing. Although adolescents are 30% of the Southern African population, no previous studies have focused on this group in relation to oral health and quality of life.

METHODS

A 40-item survey and clinical oral examinations were conducted in public schools in Maseru from 10 to 25 August 2016. Simple, bivariate, and multivariate regressions were used to evaluate the associations of oral health and psychosocial factors with self-reported general health status and quality of life.

RESULTS

A total of 526 participants, aged 12-19 years old, responded to the survey and participated in the clinical examinations. The majority reported a good (good/very good/excellent) quality of life (84%) and general health (81%). Bivariate results showed that self-reported general health in this population was significantly influenced by age. The presence of toothache and sensitivity in the adolescents were significantly associated with poor (fair/poor) self-reported general health and were found to be the best predictors for self-general health and quality of life.

CONCLUSIONS

The absence of dental conditions such as toothache and tooth sensitivity can lead to a better perception of general health and Quality of Life in adolescents.

The course of pain intensity and frequency of adolescents treated because of temporomandibular disorders: A long-term follow-up

OBJECTIVES

To evaluate the course of pain intensity and frequency related to temporomandibular disorders (TMDs) 15 years (range 5-21 years) after having received TMD treatment as adolescents due to frequent (at least once a week) TMD pain in two controlled trials.

MATERIALS AND METHODS

In the first trial, subjects (n = 122) were randomly allocated to either information only, received in a control condition (Co), or information and an occlusal appliance (OA) versus relaxation therapy (RT). In the second trial, including 64 subjects, nonresponders to OA or RT were subsequently allocated to the alternate treatment (ST). All study participants having completed the trials (n = 167) were invited to a long-term follow-up evaluations, with a response rate of 69.5% (n = 116). Patient-reported outcomes of TMD-related frequency and intensity were appraised relative to baseline data and short-term outcomes as observed in the two trials by use of general linear mixed model and generalized estimation equation statistics.

RESULTS

A significantly higher proportion of participants treated with OA and in the combined RT/Co condition than those in the ST group, reported a frequency level of TMD pain less than once week at post-treatment and the long-term follow-up. Adolescents treated with OA showed significantly lower TMD pain intensity levels post-treatment than those in the other two treatment conditions. While no difference between the OA and the RT/Co conditions was found in the long-term follow-up, participants in these two conditions were significantly more improved than those in the ST group.

CONCLUSION

Adolescents treated with an OA clearly showed better outcome with regard to intensity and frequency in a long-term follow-up of TMD pain than those treated with RT and ST for nonresponders. These latter individuals need special clinical attention and more effective supplementary treatment methods to be developed.

Comorbid conditions associated with painful temporomandibular disorders in adolescents from Brazil, Canada and France: A cross-sectional study

BACKGROUND

Painful temporomandibular disorder (TMD) is common among adolescents. Presence of painful comorbidities may worsen painful TMD and impact treatment effectiveness.

OBJECTIVE

The aim of this study was to assess the association between painful TMD and comorbidities.

METHODOLOGY

In this cross-sectional study, adolescents were recruited in Montreal (Canada), Nice (France) and Arceburgo (Brazil). Reliable instruments were used to assess painful TMD and comorbidities. Multivariable logistic and linear regression analyses were conducted to assess the study aims.

RESULTS

The prevalence of self-reported painful TMD was estimated at 31.6%; Arceburgo (31.6%), Montreal (23.4%) and Nice (31.8%). Painful TMD was more common among girls than boys (OR = 1.96). Painful TMD was associated with a higher number of comorbidities (OR = 1.77); Arceburgo (OR = 1.81), Montreal (OR = 1.80) and Nice (OR = 1.72). A stronger association was found between painful TMD and headaches (OR = 4.09) and a weaker one with stomach pain (OR = 1.40). Allergies were also related to painful TMD (OR = 1.43).

CONCLUSION

Painful TMD was associated with comorbidities. Headaches were consistently associated with painful TMD. Other associations were modified by sex and/or covariates related to the cities where participants were recruited.

Long-term treatment outcome for adolescents with temporomandibular pain

OBJECTIVES

This study aims to evaluate long-term, self-perceived outcome in adulthood for individuals treated as adolescents for temporomandibular disorder (TMD) pain in two previous randomized controlled trials (RCTs).

MATERIALS AND METHODS

The study included 116 subjects (81% females) treated for frequent TMD pain in two separate RCTs 5-21 (M = 14.8, SD =4.9) years previously. Treatment consisted of occlusal appliance (OA) (n = 41, 35.3%) or relaxation training (RT) combined with information for the control (Co) group (n = 50, 43.1%), both compared to non-responders receiving additional, sequential treatment (ST) in a crossover study (n = 25, 21.6%). Participants answered a questionnaire on their experience of frequency and intensity of TMD pain impaired chewing capacity and daily social activities, help-seeking behaviour and treatment, general health, other pain, and depressive symptoms.

RESULTS

Older participants reported lower levels of frequency and intensity of TMD pain, impairment, and depressive symptoms, as well as better general health. Females reported more frequent and more intense TMD pain, greater impairment and more often reported 'other pain' compared to males. Non-responders receiving ST experienced significantly more TMD, and other pain and higher impairment levels compared to other groups. Those treated with an OA had sought additional treatment significantly less often since the RCTs than ST and RT/Co-treated individuals.

CONCLUSIONS

Adolescents treated with OA showed somewhat better sustained improvement over the extended follow-up period than those treated with RT/Co. Non-responders to treatment and females exhibited a poorer outcome. These groups need particular attention and extended or different treatments to achieve a better long-term outcome.

Prevalence of temporomandibular disorders discovered incidentally during routine dental examination using the Research Diagnostic Criteria for Temporomandibular Disorders

OBJECTIVES

The aim of this study was to assess the prevalence of temporomandibular disorders (TMDs) discovered incidentally during routine dental examination, identify disease patterns, and evaluate patients' attitude toward accepting treatment.

STUDY DESIGN

A total of 3009 patients were examined at the University Dental Hospital Sharjah (Sharjah, United Arab Emirates). Research Diagnostic Criteria for TMD (RDC/TMD) Axes I and II were used for assessment. Patients with acute/serious dysfunction symptoms underwent cone beam computed tomography examination. Magnetic resonance imaging was used to confirm the diagnosis of disk displacement.

RESULTS

Non-self-reported TMD prevalence was 10.8% (n = 325). Among patients with TMDs, women were diagnosed more often (65.85%) (P < .05) and those between ages 25 and 45 years (65.54%) (P < .05). Axis I assessment revealed disk displacement with reduction (group IIa) was the most common (40.92%). Axis II chronic pain grade showed that 32.62% of patients with TMDs experienced chronic pain, whereas 66.77% had mild disability. Interest in pursuing treatment was indicated by 92.31% of patients. Cone beam computed tomography and magnetic resonance imaging assessments changed the primary diagnosis in 26.08% and 18.47% of cases, respectively.

CONCLUSIONS

TMD screening during routine dental examination led to the diagnosis of non-self-reported TMDs, most commonly related to disk displacement with reduction. Radiographic assessment was important to confirm TMD diagnosis. Patients diagnosed with TMD during dental screening expressed interest in pursuing treatment.

Headache and co-morbid pains associated with TMD pain in adolescents

This case-control study evaluated the association of headache and other co-morbid pain with temporomandibular disorder (TMD) pain in adolescents and explored the temporal co-variance of headache and TMD pain. In a population-based sample of 12- to 19-year-olds, 350 patients with self-reported TMD pain and 350 healthy age- and sex-matched individuals were mailed questionnaires. Descriptive statistics, 95% CI, and OR analyses--logistic regression models with TMD pain as the outcome variable and adjusted for age and gender--were used for the analysis of individuals' responses. Headache, whether defined as once a week or more (OR = 6.6) or as moderate or severe (categorical), was significantly related to TMD pain. Severe headache (vs. mild) showed stronger associations with TMD (OR = 10.1) than between moderate and mild headache (OR = 5.5). Neck (OR = 4.0) and back (OR = 2.6) pain was also significantly related to TMD pain. When participants were grouped according to headache onset and TMD pain, the highest association between headache and TMD pain was found in the subgroup "Headache onset before TMD pain" (OR 9.4). In conclusion, headache appears to be independently and highly associated with TMD pain in adolescents. Neck pain and somatic complaints were also significantly associated with TMD pain. Headache seems to precede TMD pain in many adolescents with pain.

The LIFE child study: a life course approach to disease and health

BACKGROUND

Profound knowledge about child growth, development, health, and disease in contemporary children and adolescents is still rare. Epidemiological studies together with new powerful research technologies present exciting opportunities to the elucidation of risk factor-outcome associations with potentially major consequences for prevention, diagnosis and treatment.

AIM

To conduct a unique prospective longitudinal cohort study in order to assess how environmental, metabolic and genetic factors affect growth, development and health from fetal life to adulthood.

METHODS

The 'Leipzig Research Centre for Civilization Diseases (LIFE) Child Study' focuses on two main research objectives: (1) monitoring of normal growth, development and health; (2) non-communicable diseases such as childhood obesity and its co-morbidities, atopy and mental health problems. Detailed assessments will be conducted alongside long-term storage of biological samples in 2,000 pregnant women and more than 10,000 children and their families.

RESULTS

Close coordination and engagement of a multidisciplinary team in the LIFE Child study successfully established procedures and systems for balancing many competing study and ethical needs. Full participant recruitment and complete data collection started in July 2011. Early data indicate a high acceptance rate of the study program, successful recruitment strategies and the establishment of a representative cohort for the population of Leipzig. A series of subprojects are ongoing, and analyses and publications are on their way.

DISCUSSION

This paper addresses key elements in the design and implementation of the new prospective longitudinal cohort study LIFE Child. Given the recognized need for long-term data on adverse effects on health and protective factors, our study data collection should provide magnificent opportunities to examine complex interactions that govern the emergence of non-communicable diseases.

Alexithymic and somatisation scores in patients with temporomandibular pain disorder correlate with deficits in facial emotion recognition

Current studies suggest dysfunctional emotional processing as a key factor in the aetiology of temporomandibular disorder (TMD). Investigating facial emotion recognition (FER) may offer an elegant and reliable way to study emotional processing in patients with TMD. Twenty patients with TMD and the same number of age-, sex- and education-matched controls were measured with the Facially Expressed Emotion Labelling (FEEL) test, the 26-item Toronto Alexithymia Scale (TAS-26), the Screening for Somatoform Symptoms (SOMS-2a), the German Pain Questionnaire and the 21-item Hamilton Depression Rating Scale (HAMD). The patients had significantly lower Total FEEL Scores (P = 0·021) as compared to the controls, indicating a lower accuracy of FER. Furthermore, we were able to demonstrate significant group differences with respect to the following issues: patients were more alexithymic (P = 0·006), stated more somatoform symptoms (P < 0·004) and had higher depressive scores in the HAMD (P < 0·003). The factors alexithymia and somatisation could explain 31% (adjusted 27%) of the variance of the FEEL Scores in the sample. The estimation of the standardised regression coefficients suggests an equivalent influence of TAS-26 and SOMS-2a on the FEEL Scores, whereas 'group' (patients versus healthy controls) and depressive symptoms did not contribute significantly to the model. Our findings highlight FER deficits in patients with TMD, which are partially explained by concomitant alexithymia and somatisation. As suggested previously, impaired FER in patients with TMD may further point to probable aetiological proximities between TMD and somatoform disorders.

Associations between oral health-related quality of life and emotional statuses in children and preadolescents

OBJECTIVES

To evaluate the associations between oral health-related quality of life (OHRQoL) and emotional statuses in children and preadolescents.

METHODS

One hundred and forty-five Brazilian students (8-14 years) were clinically examined for caries, gingivitis, fluorosis, malocclusions, and temporomandibular disorders (TMD). OHRQoL was measured using two global ratings of oral health (OH) and overall well-being (OWB). The Revised Children's Manifest Anxiety Scale (R-CMAS) and Children's Depression Inventory (CDI) were used to assess anxiety and depression, respectively. Saliva was collected 30 min after waking and at night to determine the diurnal decline in salivary cortisol (DDSC). The results were analyzed using non-paired t test/one-way ANOVA, Pearson's correlation test, and multiple linear regression analyses.

RESULTS

11-14-year-old participants had higher CDI scores (P < 0.01) and DDSC concentrations (P < 0.001). Participants with fewer caries and without gingivitis had higher DDSC concentrations (P < 0.05). TMD patients had higher DDSC concentrations and OWB ratings (P < 0.001). Girls had higher Revised Children's Manifest Anxiety Scale (RCMAS) scores (P < 0.01). There was positive correlation between RCMAS and CDI scores and OWB ratings (P < 0.05). The OH model retained age (β =0.312; P < 0.001) and the OWB model retained TMD (β = 0.271; P < 0.001) and CDI scores (β=0.175; P < 0.05).

CONCLUSIONS

Children and preadolescents with poor emotional well-being are more sensitive to the impacts of OH and its effects on OWB.