Clinical factors affecting depression in patients with painful temporomandibular disorders during the COVID-19 pandemic

Climate temperature and seasonal influences on the prevalence of temporomandibular disorders in South Korea

This study aimed to explore seasonal variations in temporomandibular disorder (TMD) prevalence in South Korea, utilizing nationwide population-based big data. Data corresponding to the Korean Standard Classification of Diseases code of K07.6, which identifies TMD, were extracted from the Health Insurance Review and Assessment Service online platform for the period from 2010 to 2022. Additionally, we integrated these data with climate temperature records from the Korean Meteorological Administration. We subsequently conducted a statistical analysis of TMD patient data on a monthly and seasonal basis over the past 13 years to assess prevalence. Over the past 13 years, the number of TMD patients in Korea has steadily increased. The prevalence of TMD rose from 0.48% (224,708 out of a total population of 50,515,666) in 2010 to 0.94% (482,241 out of a total population of 51,439,038) in 2022, marking a 1.96-fold increase. Among children under 10 years of age, no significant differences were observed in TMD prevalence between boys and girls. However, a distinct female predominance emerged after the age of 10, with an average female-to-male ratio of 1.51:1. The peak prevalence of TMD occurred in individuals in their 20 s, followed by adolescents in their late 10 s. The majority of TMD patients were concentrated in Seoul and Gyeonggi province, with metropolitan areas accounting for 50% of the total patient count. Seasonally, TMD patient numbers showed no significant increase in winter compared with spring or summer. The temperature difference, defined as the absolute difference between the highest and lowest temperatures for each month, showed a positive correlation with TMD patient counts. A greater temperature difference was associated with higher patient counts. The strongest correlation between temperature differences and TMD patient numbers was observed in winter (r = 0.480, p < 0.01), followed by summer (r = 0.443, p < 0.01), and spring (r = 0.366, p < 0.05). Temperature differences demonstrated a significantly stronger correlation with the increase in the number of TMD patients than absolute climate temperatures. This aspect should be a key consideration when examining seasonal trends in TMD prevalence in South Korea.

Comparison of ultrasonography-based masticatory muscle thickness between temporomandibular disorders bruxers and temporomandibular disorders non-bruxers

To compare masticatory muscle thickness in patients with temporomandibular disorders (TMDs) during rest and clenching, and by body position, using ultrasonography. This prospective study included 96 patients with TMD (67 females, 29 males; mean age: 40.41 ± 17.88 years): group 1, comprising 66 patients with TMD without bruxism (TMD_nonbruxer), and group 2, comprising 30 patients with concurrent TMD and bruxism (TMD_bruxer). In patients with TMD, bruxism was correlated with the presence of tinnitus, muscle stiffness, sleep problems, psychological stress, and restricted mouth opening. The masseter muscle significantly thickened during clenching (11.16 ± 3.03 mm vs 14.04 ± 3.47 mm, p < 0.001), whereas the temporalis muscle showed no significant increase in thickness from resting to clenching in an upright position (7.91 ± 1.98 vs 8.39 ± 2.08, p = 0.103). Similarly, during clenching in the supine position, the masseter muscle was significantly thicker compared with rest (11.24 ± 2.42 vs 13.49 ± 3.09, p < 0.001), but no significant difference was observed in temporal muscle thickness (8.21 ± 2.16 vs 8.43 ± 1.94, p = 0.464). In comparison between two groups, the average thickness of the masseter muscle was greater among TMD_bruxers than among TMD_nonbruxers in both the upright and supine positions (all p < 0.05). In the generalized lineal model, female sex (B = - 1.018, 95% confidence interval [CI] - 1.855 to - 0.181, p = 0.017) and bruxism (B = 0.868, 95% CI 0.567 to 1.169, p = 0.048) significantly predicted changes in masseter muscle thickness. Female sex (B = - 0.201, 95% CI - 0.299 to - 0.103, p = 0.011), increased age (B = - 0.003, 95% CI - 0.005 to 0.000, p = 0.038), and muscle stiffness (B = - 1.373, 95% CI - 2.369 to - 0.376, p = 0.007) were linked to decreased temporal muscle thickness. Comparing TMD nonbruxer and bruxer muscle thicknesses in upright and supine positions revealed significant increased thickness in the masseter muscle during clenching but not in the temporalis muscle. Masseter muscle thickness varied significantly by sex, body position, and resting/clenching, notably influenced by bruxism. These findings emphasize the relevance of these factors in clinical examinations of patients with TMD.

The Association Between Orofacial Pain and Depression: A Systematic Review

Background

The occurrence of orofacial pain is often accompanied by comorbid conditions such as depression. Even though previous studies suggested a bidirectional correlation between orofacial pain and psychological factors, some studies still provided contradictory results.

Objective

This systematic review aimed at providing scientific evidence regarding the association between orofacial pain and depression in published literature.

Methods

The current study is a systematic literature review (PROSPERO registration no. CRD42023438596) that was conducted by reviewing cross-sectional studies that investigated the association between orofacial pain and depression. Article selection was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Articles searching was performed by using three databases, namely PubMed, ScienceDirect, and Scopus using the Boolean operator method. Article screening was carried out by applying the inclusion and exclusion criteria, as well as duplication checking, suitability checking, and compatibility checking. Reviewed articles went through the risk of bias evaluation form from the Joanna Briggs Institute (JBI). Extracted data were analyzed in a qualitative method.

Results

Twelve studies that were conducted on 5557 participants were included in the final review. After all articles were analyzed, the correlation between orofacial pain and depression was revealed. Most articles revealed a positive correlation between orofacial pain and depression, and the rest showed how orofacial pain patients showed significantly higher depression scores compared to those individuals without orofacial pain.

Conclusion

The results of this systematic review suggested a correlation between orofacial pain and depression with varying degrees. Incorporating potential depressive symptoms' treatment, when treating orofacial pain patients, should be part of the treatment plan.

Association Between Orofacial Pain and Anxiety: A Systematic Review

The prevalence of orofacial pain continues to increase. Additionally, the rising number has been accompanied by reduced quality of life of its sufferers. An assumed association between orofacial pain and anxiety has surfaced due to the results of several studies that show higher occurrence of anxiety in people experiencing orofacial pain, compared to those who are orofacial-pain-free. The aim of this systematic review was to discover past research on orofacial pain and its relationship to anxiety, and to understand the relationship between acute and chronic orofacial pain and anxiety. The current systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) rules. Study searches were carried out using three databases, namely PubMed, ScienceDirect, and Scopus. Article selection was carried out in several stages and was based on inclusion and exclusion criteria and continued by assessing the methodological quality and risk of bias of each article. The risk of bias was analyzed by using the critical review tool for cross-sectional studies from the Joanna Briggs Institute (JBI). The selection process led to a review process of 13 cross-sectional research articles. The systematic review showed a positive relationship between orofacial pain and anxiety, with variations in the strength of the relationship (weak to moderate). Most articles revealed that anxiety is a risk factor for orofacial pain. A correlation between chronic orofacial pain and anxiety was mentioned in several studies. It can be concluded that there is an existing relationship between orofacial pain and anxiety, especially chronic orofacial pain. Prospero registration number: CRD42023385409.

Machine learning analysis with population data for the associations of preterm birth with temporomandibular disorder and gastrointestinal diseases

This study employs machine learning analysis with population data for the associations of preterm birth (PTB) with temporomandibular disorder (TMD) and gastrointestinal diseases. The source of the population-based retrospective cohort was Korea National Health Insurance claims for 489,893 primiparous women with delivery at the age of 25-40 in 2017. The dependent variable was PTB in 2017. Twenty-one predictors were included, i.e., demographic, socioeconomic, disease and medication information during 2002-2016. Random forest variable importance was derived for finding important predictors of PTB and evaluating its associations with the predictors including TMD and gastroesophageal reflux disease (GERD). Shapley Additive Explanation (SHAP) values were calculated to analyze the directions of these associations. The random forest with oversampling registered a much higher area under the receiver-operating-characteristic curve compared to logistic regression with oversampling, i.e., 79.3% vs. 53.1%. According to random forest variable importance values and rankings, PTB has strong associations with low socioeconomic status, GERD, age, infertility, irritable bowel syndrome, diabetes, TMD, salivary gland disease, hypertension, tricyclic antidepressant and benzodiazepine. In terms of max SHAP values, these associations were positive, e.g., low socioeconomic status (0.29), age (0.21), GERD (0.27) and TMD (0.23). The inclusion of low socioeconomic status, age, GERD or TMD into the random forest will increase the probability of PTB by 0.29, 0.21, 0.27 or 0.23. A cutting-edge approach of explainable artificial intelligence highlights the strong associations of preterm birth with temporomandibular disorder, gastrointestinal diseases and antidepressant medication. Close surveillance is needed for pregnant women regarding these multiple risks at the same time.

Unveiling the Unspoken: Exploring Oral Manifestations of Psychological Disorders

Psychological variables also interact closely with several tissues and systems leading to several diseases. The oral cavity is also linked to potential physical manifestations of psychological origin. Oral symptoms such as facial pain, oral dysaesthesia, extreme palatal erosion, or self-inflicted harm are perhaps the first or sole signs of mental health issues. It is crucial to remember that oral symptoms are frequently complex. Different people may respond differently to psychological variables and varied oral health. It is essential for dentists and medical professionals to recognize and resolve these vital problems. In this review, we have summarized the changes to oral mucosa and hard tissues and other pain disorders associated with psychological factors. Oral manifestations of a few known psychological disorders are also enumerated. This review emphasizes the role of the dentist in identifying the underlying psychological factors with oral changes. In conclusion, continuous dental care should be insisted on for patients with known mental illness to improve their quality of life. Oral health should be taken into account as part of the heightened emphasis on the overall physical well-being of those suffering from severe mental illnesses.

Orofacial Pain with Cardiac Origin of Coronary Artery Disease: A Case Report and Literature Review

When diagnosing orofacial pain, clinicians should also consider non-odontogenic origin and systemic diseases as possible etiological factors, along with odontogenic origin. This case report aimed to provide information for early detection of orofacial pain of cardiac origin by dentists, when pain due to coronary artery disease is the only presenting symptom. A 60-year-old male patient with unexplained isolated bilateral jaw pain that had persisted for the past 5 years was referred to a dentist by an anesthesiologist who suspected temporomandibular joint disorder. In oral examination, no specific pathological changes were observed in the oral cavity, including teeth, surrounding alveolar bone, and buccal mucosa. Magnetic resonance imaging and conventional radiography showed no pathological destruction or abnormalities of bone and soft tissue in the temporomandibular joint region. However, pain was precipitated by ordinary daily activities, and the pain alleviating factor was rest. Eventually, the patient was referred to a cardiologist for further evaluation since his pain was induced by physical activity. Coronary artery disease (CAD) was diagnosed using coronary computed tomography angiography, and the pain was considered to be angina pectoris. Percutaneous coronary intervention was successfully done for the patient, after which his orofacial symptoms disappeared. To conclude, isolated craniofacial pain of cardiac origin may lead to patients seeking dental care or visiting orofacial pain clinics. In these settings, dentists and orofacial pain specialists may contribute to the diagnosis of CAD and refer patients for cardiac evaluation and appropriate management.

Comparison of painful temporomandibular disorders, psychological characteristics, sleep quality, and oral health-related quality of life of patients seeking care before and during the Covid-19 pandemic

BACKGROUND

Literature concerning Temporomandibular disorders (TMDs) and the Covid-19 pandemic is limited and disparate findings related to TMD frequencies, psychological distress, and quality of life were presented. This study investigated the prevalence of painful Temporomandibular disorders (TMDs) and compared the psychological, sleep, and oral health-related quality of life profiles of patients seeking TMD care before and during the Covid-19 pandemic.

METHODS

Data were accrued from consecutive adult patients 12 months before (BC; control) and during (DC; case group) the Covid-19 pandemic. The Diagnostic Criteria for TMDs (DC/TMD), Depression, Anxiety, Stress Scales (DASS)-21, Pittsburgh Sleep Quality Index (PSQI), and Oral Health Impact Profile (OHIP)-TMDs were utilized and statistical analysis was performed using Chi-square/non-parametric tests (α = 0.05).

RESULTS

The prevalence of painful TMDs was 50.8% before and 46.3% during the pandemic. Significant differences in PSQI and OHIP component scores were discerned between the BC and DC groups contingent on TMD pain. Total-DASS was moderately correlated to total-PSQI/OHIP (rs = 0.41-0.63).

CONCLUSION

The covid-19 pandemic did not appear to exacerbate psychological distress but affected sleep and increased unease over TMD dysfunction.

The influence of the COVID-19 pandemic, sex, and age on temporomandibular disorders subtypes in East Asian patients: a retrospective observational study

BACKGROUND

Despite its major existential, societal, and health impacts, research concerning the COVID-19 pandemic and Temporomandibular disorders (TMDs) is still limited. This study examined the effect of the pandemic on TMD subtypes and elucidated the influence of the pandemic, sex, and age on the prospect of pain-related (PT) and/or intra-articular (IT) TMDs in East Asian patients.

METHODS

Data were accrued from consecutive new patients attending two university-based TMD/orofacial pain clinics in China and South Korea, 12 months before (BC; Mar 2019-Feb 2020) and during (DC; Mar 2020-Feb 2021) the COVID-19 pandemic. TMD diagnoses were derived from pertinent symptoms, signs, and radiographic findings according to the Diagnostic Criteria for TMDs (DC/TMD) methodology. Patients were subsequently categorized into those with PT, IT, and combined TMDs (CT) and also stratified by attendance period, sex, and age groups (adolescents/young adults [AY] and middle-aged/older adults [MO]) for statistical analyses using Chi-square/Mann-Whitney U tests and logistic regression analyses (α = 0.05).

RESULTS

The BC and DC groups comprised 367 (75.2% females; 82.8% AY) and 471 (74.3% females; 78.3% AY) patients correspondingly. No significant differences in sex and age group distributions were observed. The DC group had significantly more PT/IT conditions with higher prevalence of myalgia, headache, and degenerative joint disease than the BC group. Univariate analyses showed that PT/CT was associated with sex and age, whereas IT was related to the pandemic and age. However, multivariate analyses indicated that the odds of PT were affected by sex (OR = 2.52) and age (OR = 1.04) while the odds of IT (OR = 0.95) and CT (OR = 1.02) were influenced by age only.

CONCLUSIONS

The COVID-19 pandemic, as an impact event, did not influence the prospect of PT and/or IT. Sex and age appeared to play more crucial roles in the development of PT and IT/CT respectively.

The Association between COVID-19 Related Anxiety, Stress, Depression, Temporomandibular Disorders, and Headaches from Childhood to Adulthood: A Systematic Review

Objective: The coronavirus belongs to the family of Coronaviridae, which are not branched single-stranded RNA viruses. COVID-19 creates respiratory problems and infections ranging from mild to severe. The virus features mechanisms that serve to delay the cellular immune response. The host’s response is responsible for the pathological process that leads to tissue destruction. Temporomandibular disorders are manifested by painful jaw musculature and jaw joint areas, clicks, or creaks when opening or closing the mouth. All these symptoms can be disabling and occur during chewing and when the patient yawns or even speaks. The pandemic situation has exacerbated anxieties and amplified the vulnerability of individuals. Therefore, from this mechanism, how the COVID-19 pandemic may have increased the incidence of temporomandibular disorders is perceived. The purpose of this review is to evaluate whether COVID-19-related anxiety has caused an increase in temporomandibular dysfunction symptoms in adults to children. Methods: PubMed, Web of Science, Lilacs, and Scopus were systematically searched, until 30 July 2022, to identify studies presenting: the connection between COVID-19 with temporomandibular disorders. Results: From 198 papers, 4 studies were included. Literature studies have shown that the state of uncertainty and anxiety has led to an increase in the incidence of this type of disorder, although not all studies agree. Seventy-three studies were identified after viewing all four search engines; at the end of the screening phase, only four were considered that met the PECO, the planned inclusion, and the exclusion criteria. All studies showed a statistically significant correlation between temporomandibular disorders and COVID-19 with a p < 0.05. Conclusions: All studies agreed that there is an association between COVID-19 and increased incidence of temporomandibular disorders.

A Survey of Living Conditions and Psychological Distress in Japanese University Freshmen during the COVID-19 Pandemic

Since the novel coronavirus disease 2019 (COVID-19) pandemic, educational institutions have implemented measures such as school closures, raising concerns regarding the increase in psychological distress among university students. The purpose of this study is to identify factors that have influenced psychological distress among college freshmen during the COVID-19 pandemic. A questionnaire survey was conducted at the conclusion of the sixth wave of COVID-19 in Japan. Psychological distress was measured using the six-item Kessler Psychological Distress Scale (K6). Factors affecting psychological distress were calculated using regression analysis. Of the 2536 participants, 1841 (72.6%) reported having no psychological distress, while 695 (27.4%) reported having psychological distress. Factors that were identified to contribute to psychological distress were lack of sleep, weight gain or loss, worsening of interpersonal relationships, and physical symptoms and illnesses. A willingness to join an athletic club and having an environment in which it is easy to discuss worries and anxieties with others were factors that were identified to hinder psychological distress. It is necessary for universities to offer enhanced supports for physical and interpersonal activities. Additionally, it is imperative to encourage students to look after their physical health and to actively utilize university-based consultation systems.

Investigation of Snoring and Obstructive Sleep Apnea Using Portable Polysomnography in Patients with Temporomandibular Disorder

Objective

To investigate snoring and obstructive sleep apnea (OSA) in patients with temporomandibular disorder (TMD) using portable polysomnography and identify sex-based differences in clinical features and sleep-related results.

Methods

Seventy consecutive patients (44 female; mean age, 46.6918.18 years) with myofascial pain-associated TMD, diagnosed based on the criteria for TMD Axis I, were enrolled. Sleep quality and quantity were measured using portable polysomnography. Clinical characteristics were investigated using well-structured standardized reports on clinical signs and symptoms, questionnaires, and clinical examination by TMD specialists.

Results

Among 70 TMD patients, 50.0% had OSA and 15.7% had snoring, with no sex-based differences. The mean Mallampati scores for OSA prediction (2.69±1.12 vs. 1.70±0.82, p<0.001), mean body mass index (BMI) (24.94±1.78 vs. 22.02±2.24, p<0.001), and ratio of overweight patients (57.7 vs. 11.4%) with BMI ≥25 were significantly higher in males than in females (all p<0.001). Conversely, the mixed sleep apnea index was significantly higher in females than in males (0.81±0.80 vs. 0.44±0.54, p=0.022). Female sex was associated with the absence of snoring (OR=0.146, p=0.022). Based on the area under curve (AUC) value for snoring prediction, Mallampati score was the strongest predictor (AUC>0.932, p<0.001), followed by BMI, overweight, and obstructive sleep apnea index (AUC>0.8, all p<0.001).

Conclusions

Our results support the necessity of investigating sex-based differences when examining sleep problems, including snoring and OSA, in TMD patients. Mallampati scoring could be a useful tool for physical examination prior to polysomnography. Sleep and biopsychosocial factors are important for the diagnosis and treatment of TMD.

Association between Stigma and Pain in Patients with Temporomandibular Disorders

OBJECTIVE

This study aims to explore the association between stigma and pain in patients with temporomandibular disorders (TMDs).

METHODS

Two hundred and twenty-five patients with TMDs were recruited, and they completed the questionnaires including the Visual Analogue Scale of Pain (VAS), Generalized Anxiety Disorder 7-Item (GAD-7), the Patient Health Questionnaire 9-item (PHQ-9), Jaw Functional Limitation Scale 8-item (JFLS-8), the Stigma Scale for Chronic Illness 8-item (SSCI-8), and other demographic and disease-related information. The total score of SSCI-8 indicated overall stigma, which could be classified into 2 subdomains, felt stigma and enacted stigma, according to their representative items, respectively. Then, the patients were divided into 2 groups in each subdomain of stigma according to their scores: stigma group (score ≥ 1) and no stigma group (score = 0).

RESULTS

Patients with overall stigma and enacted stigma presented significantly higher scores in VAS, GAD-7, PHQ-9, and JFLS-8 than those without overall stigma and those without enacted stigma, respectively. Significant differences between patients with and without felt stigma were only observed in GAD-7, PHQ-9, and JFLS-8. Patients with overall stigma and enacted stigma mainly suffered from pain-related TMDs (PTs) and combined TMDs (CTs). Overall stigma and enacted stigma rather than felt stigma were significantly associated with both PTs and CTs. Stigma, including overall stigma, enacted stigma, and felt stigma, was more associated with anxiety and depression and less related to jaw functional limitation of the patients with TMDs.

CONCLUSION

Stigma, specifically enacted stigma, was correlated to pain in patients with TMDs. Stigma was more related to psychological problems than jaw functional limitation.