Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature

Counselling for patients with a temporomandibular disorder: A scoping review and concept analysis

BACKGROUND

An integral component of comprehensive temporomandibular disorder (TMD) treatment involves what is commonly referred to in literature as patient counselling or patient education. Despite its importance, a clear definition of the concept is lacking.

OBJECTIVES

To describe the concept of counselling (i.e. what is it, what should it consist of, and when should it be given) through a concept analysis of the literature.

ELIGIBILITY CRITERIA

All papers that include a description of counselling or education for TMD are included.

SOURCES OF EVIDENCE

Literature searches were performed in the electronic databases PubMed, Cinahl, and PsycInfo.

CHARTING METHODS

A qualitative analysis was done using the principle-based concept analysis approach, where descriptions of counselling from the included papers were analysed by the researchers.

RESULTS

A total of 71 articles were included. Based on the qualitative analysis of the included articles and descriptions of counselling, the following content themes were identified: (1) general information on TMD; (2) overuse of the masticatory system; (3) posture education; (4) lifestyle and psychosocial factors; (5) exercise- and thermotherapy; and (6) additional information and therapies.

CONCLUSIONS

A definition and framework of counselling for TMD has been provided, which can be used in the clinic, research, and educational programs.

Risk factors for temporomandibular disorders: a systematic review of cohort studies

OBJECTIVE

A systematic review was performed to synthesize and identify risk factors involved in TMD onset.

STUDY DESIGN

Electronic searches were conducted in PubMed, Web of Science, Scopus, Embase, PsyInfo and Lilacs databases, as well as in three gray literature databases (Google Scholar, ProQuest and Open grey). The studies were blindly assessed by two reviewers and selected by a pre-defined eligibility criterion. Risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was evaluated for most related factors.

RESULTS

Twenty-one cohort studies were included. Significant factors were female gender, symptoms of depression and anxiety, perceived stress, sleep quality, symptoms of obstructive sleep apnea and presence of any comorbidity, such as Irritable Bowel Syndrome, lower back pain, headache frequency, tension-type headache, migraine and mixed headache. Moreover, high estrogen and low testosterone levels in utero, greater pain perception, jaw mobility pain, pain during palpation, orofacial anomalies, as well as extrinsic and intrinsic injuries were also significant.

CONCLUSIONS

Several factors seems to be involved in TMD onset, however, more studies with standardized methodology are necessary to confirm these findings.

Comparative evaluation of cognitive behavioural therapy versus standard treatment in temporomandibular disorders: A systematic review

BACKGROUND

Temporomandibular disorders (TMDs) are musculoskeletal and neuromuscular conditions affecting the temporomandibular joint and associated structures. Cognitive-behavioural therapy (CBT) has emerged as a potential intervention for TMDs, but its comparative effectiveness against standard treatments remains unclear. This systematic review aimed to evaluate and compare the efficacy of CBT versus standard treatment interventions in managing TMDs.

METHODS

A comprehensive search was conducted across multiple databases using MeSH keywords and Boolean operators. Inclusion criteria encompassed clinical trials comparing CBT/CBT in combination with standard treatment interventions or a control group in individuals with TMDs. The primary outcome measured was pain. Secondary outcomes such as disability, depression and jaw function were also looked into. Two reviewers independently assessed for the eligibility of the articles and conducted data extraction. Quality assessments were performed using RoB 2.0 for randomised clinical trials.

RESULTS

The initial search identified 623 articles, of which a total of eight clinical studies met the inclusion criteria and were included in the systematic review. Seven out of eight studies demonstrated improvements in outcomes related to TMD. Pain was significantly decreased in studies that showed a positive outcome. Jaw function, quality of life and psychological well-being were superior among individuals receiving CBT alone or in combination with conventional modalities, as well as hypnotic therapy coupled with CBT-based interventions. The quality of studies assessed showed all articles to be of good quality as per RoB-2 evaluation.

CONCLUSION

This systematic review highlights the potential benefits of CBT in managing TMDs, suggesting its effectiveness in improving pain outcomes and enhancing overall well-being. The findings indicate that CBT may be a valuable adjunct or alternative to standard treatment interventions for individuals with TMDs. However, further research with larger sample sizes and standardised outcome measures is warranted to establish definitive conclusions regarding the comparative efficacy of CBT versus standard treatments in TMD management.

Dental practitioners' knowledge, management practices, and attitudes toward collaboration in the treatment of temporomandibular joint disorders: a mixed-methods study

BACKGROUND

Temporomandibular joint disorders (TMDs) are a variety of conditions that affect different parts of the temporomandibular joints (TMJ) and can cause orofacial pain and functional impairment. This study aims to investigate dental practitioners' knowledge and management of Temporomandibular Joint Disorders (TMDs), particularly their knowledge of the role physical therapy plays in TMD treatment.

METHODS

A mixed-methods approach was adopted to provide a comprehensive view of current knowledge, management practices, and attitudes toward collaboration among dental practitioners in treating TMD. Data were collected from a convenience sample of 335 dentists in Karachi using a detailed questionnaire to assess their knowledge of the role of physical therapy in the treatment of TMD. Twenty dentists were chosen for face-to-face, in-depth interviews to explore their experiences and challenges in managing TMDs based on their responses to the administered questionnaire.

RESULTS

The cumulative quantitative and qualitative findings of the study revealed a landscape marked by individualized approaches to referral practices and significant gaps in interdisciplinary collaboration. Most practitioners holding a bachelor's degree predominantly used medication (65.2%) and cause-specific treatment (65.3%) for TMD treatment. Thematic analysis of clinical efficacy and practitioner challenges in managing TMD revealed significant issues faced by dental professionals.

CONCLUSIONS

The study successfully validated a questionnaire to understand dental practitioners' knowledge regarding physical therapy in TMD treatment. The study identified significant gaps in knowledge and a lack of collaboration between dentists and physiotherapists. The limited referral practices highlighted in the study, along with insights from dentist interviews, emphasize the need for improved interdisciplinary approaches to managing TMDs within dental practice.

Age distribution of East Asian TMD patients and age-related differences in DC/TMD axis I findings

OBJECTIVES

The pattern of age distribution in East Asian temporomandibular disorder (TMD) patients and age-related differences in DC/TMD diagnostic subtypes/categories were evaluated.

SUBJECTS AND METHODS

TMD patients from two University-based centers in China and South Korea were enrolled. Axis I physical diagnoses were rendered according to DC/TMD. Patients were categorized into six age groups (15-24, 25-34, 35-44, 45-54, 55-64, and 65-84 years; Groups A-F respectively).

RESULTS

Youths/young adults (Groups A-C) formed 74.1% of TMD patients. TMJ disc displacements (74.9%), arthralgia (49.2%), and degenerative joint disease [DJD] (36.8%) were the most common TMD subtypes. The majority had combined (54.0%) and chronic (58.5%) TMDs. Youths/young adults and middle-aged/old adults had substantially lower frequencies of merely pain-related (6.2-14.5%) and intra-articular (13.8-16.8%) TMDs correspondingly. "Being female" increased the prospects of pain-related/combined TMDs by 96%/49%, respectively.

CONCLUSIONS

East Asian TMD patients comprised mostly of youths/young adults who had an alarmingly high prevalence of TMJ DJD.

Current Clinical Concepts: Integration of Psychologically Informed Practice for Management of Patients With Sport-Related Injuries

Psychologically informed practice is an approach to patient management that encourages clinicians to treat patients from a biopsychosocial perspective and can be adopted by athletic trainers to manage sport-related injuries. As described in the domains of athletic training clinical practice, athletic trainers are expected to identify, address, and make appropriate referrals regarding psychosocial responses to injuries and mental health symptoms. Psychologically informed practice suggests addressing physical impairments in addition to screening and intervening for psychosocial responses with patients. In this Current Clinical Concepts paper, we discuss appropriate patient-reported outcome measures used to screen for mental health symptoms and psychosocial responses, provide recommendations on psychological interventions that can be integrated to enhance patient outcomes, and describe how to effectively refer a patient to an appropriate mental health professional.

Einfluss von aktiven Übungsprogrammen und Aufbissschienen auf die kraniomandibuläre Dysfunktion

Hintergrund

Rund 40 % der Weltbevölkerung sind von einer kraniomandibulären Dysfunktion (CMD) betroffen. Diese äußert sich durch Schmerzen, Bewegungseinschränkungen und/oder Kiefergelenkgeräusche und wird durch die große Varianz an Symptomen meist erst spät diagnostiziert und behandelt. Nicht selten kommt es zu Einschränkungen der Lebensqualität der Betroffenen. In der Behandlung der CMD spielen Physiotherapie und Schienenversorgung eine wichtige Rolle.

Ziel

Ziel dieser Arbeit ist es, die Auswirkungen von Heimübungsprogrammen (HÜs) und Schienentherapie (ST) auf die Hauptsymptome der CMD zu klären. Es soll herausgefunden werden, ob eine Kombination der beiden Therapien einen therapeutischen Mehrwert darstellt.

Material und Methoden

Mittels Literaturrecherche in den Datenbanken PubMed, PEDro und Cochrane wurden Studien recherchiert und nach Durchsicht adäquater Abstracts die Volltexte zusammengefasst und kritisch diskutiert.

Ergebnisse

Sowohl HÜs als auch ST führen zu einer Verbesserung der beschriebenen Symptome und der Lebensqualität. Bei myogener CMD zeigen HÜs einen besseren Therapieeffekt auf die Kiefergelenkbeweglichkeit. Bei der Diagnose Diskusverlagerung mit Reposition waren im Gegensatz dazu keine deutlichen Therapieerfolge feststellbar. In keiner der analysierten Studien ergab eine Kombination der beiden Interventionen einen Mehrwert. Bei der Analyse der Lebensqualität war die Vergleichbarkeit aufgrund unterschiedlicher und nicht optimaler Fragebögen nur beschränkt möglich. Vergleicht man die Ergebnisse der durchgeführten Maßnahmen in Bezug auf die Interventionsdauer, ließ sich feststellen, dass zu Beginn der Therapien bessere Ergebnisse erzielt wurden als nach längerer Behandlungszeit. Auch die Dropout-Raten nahmen bei längeren Follow-up-Zeiten zu.

Schlussfolgerungen

Eine individuelle Anpassung der HÜs fördert die Compliance und Therapieadhärenz. Aufgrund der aktuellen Studienlage wird davon ausgegangen, dass sowohl HÜs als auch ST angemessene Methoden darstellen, um Schmerzen und Kiefergelenkgeräusche zu reduzieren und eine Verbesserung der Kiefergelenkbeweglichkeit und Lebensqualität zu erzielen. Bei myogener CMD stellen HÜs eine adäquate, kostengünstige Alternative zur ST dar. Weitere Forschung ist notwendig, um die genaue Therapiewirkung auf die verschiedenen Diagnosegruppen zu analysieren. Bezüglich der Lebensqualität sind weitere Analysen mit adäquaten Fragebögen notwendig.

A novel treatment modality for myogenous temporomandibular disorders using aromatherapy massage with lavender oil: A randomized controlled clinical trial

OBJECTIVE

To investigate the effect of aromatherapy massage on pain intensity and maximal mouth opening (MMO) in patients with myogenous TMD.

METHODS

Ninety-one patients were randomly assigned to three groups: Group L (aromatherapy massage with lavender oil, test), group P (massage with sweet almond oil, placebo), and group C (control). Participants were evaluated at T0 (before the intervention), T1 (immediately after the intervention), and T2 (2-month follow-up). Data were analyzed using one-way ANOVA, Tukey's HSD, and Kruskal-Wallis tests.

RESULTS

For T1 and T2, group L showed the greatest MMO values (48.01 ± 0.85 mm; 45.67 ± 0.84 mm), while group C exhibited the lowest values (39.13 ± 0.49 mm; 39.66 ± 0.82 mm) (p < 0.001). For VAS, group L revealed the lowest pain values at T1 (2) and T2 (2) (p < 0.001).

DISCUSSION

Aromatherapy massage with lavender oil was effective in the management of painful TMD conditions and limited mouth opening.

Multimodal pain therapy for persistent idiopathic facial pain - a pilot study

OBJECTIVE

Persistent Idiopathic Facial Pain (PIFP) is a pain syndrome with missing evidence-based therapy recommendations. According to the biopsychosocial pain model, multidisciplinary pain treatment (MPT) offers a promising therapeutic option for chronic pain syndromes. MPT is an interprofessional treatment procedure, consisting of medical, physiotherapeutic and psychotherapeutic treatment units, which has not yet been studied in PIFP.

METHODS

This retrospective study included 25 patients with PIFP, who had been treated with MPT. Pain intensity on the numerical rating scale (NRS), perceived disability, habitual well-being, as well as anxiety/depression and stress scales were recorded. Moreover, the patients evaluated the efficacy of each type of the single therapeutic interventions.

RESULTS

There was a highly significant decrease in the characteristic pain intensity. Also habitual well-being improved significantly, as did anxiety and depression. The perceived disability and stress also improved, but without statistical significance. Physiotherapy was rated as the most effective therapeutic unit. Among the medical measures, consultations took first place (40% of the participants). Nearly three-fourths of the patients (72%) would recommend MPT.

CONCLUSION

The present study shows beneficial outcomes in patients with PIFP following MPT. Patients evaluate physiotherapeutic treatment as particularly efficacious. Therefore, MPT can be considered as a therapeutic option in patients with PIFP.

Diagnosis and Treatment of Myogenous Temporomandibular Disorders: A Clinical Update

Myogenous temporomandibular disorders (M-TMDs) are the most common chronic orofacial pain, affecting the masticatory muscles and, thus, jaw movement. While a concise diagnosis is crucial to formulate a rational treatment plan, the similarities in clinical presentations that M-TMDs share with other neuromuscular disorders affecting the temporomandibular joint (TMJ) could easily confuse physicians. In addition to the basics, such as thorough history taking and meticulous clinical examinations, different imaging techniques are useful adjuncts to facilitate the diagnostic process. This review presents an overview of the current understanding on a variety of diagnostic and treatment modalities for M-TMD patients. It is essential to highlight that there is not a single treatment for all, and the benefits of multidisciplinary strategies have been noted for the effective management of myogenous TMD pain. Treatment modalities ranging from conservative to minimally invasive options are discussed in this review.

DISFUNÇÕES TEMPOROMANDIBULARES E FATORES PSICOLÓGICOS: UMA REVISÃO DE LITERATURA

As disfunções temporomandibulares (DTM) são condições biológicas que envolvem sinais e sintomas como dores crônicas na articulação temporomandibular e nos músculos da mastigação. O presente estudo tem como objetivo identificar quais e como conceitos psicológicos são descritos em artigos de intervenções odontológicas relacionadas à DTM, em artigos de revisão sistemática. Para isto foram utilizadas três bases de dados na busca e seleção: PubMed, Scopus e Web of Science. Aplicou-se em todas estas bases de dados a mesma formulação de termos-chave. Foram selecionados os artigos de revisões, publicados entre 2000 e 2017, escritos em inglês. Dos 4.092 artigos encontrados, sete foram selecionados descrevendo intervenções psicológicas envolvidas com o tratamento da DTM. Todos os artigos selecionados foram analisados com base em seus objetivos e discussões, considerando as características de apresentação e compreensão das variáveis psicológicas relacionadas à disfunção temporomandibular e às intervenções utilizadas. Para tanto, foram realizadas análises qualitativas e quantitativas. Pode-se concluir que a compreensão e a definição das variáveis psicológicas relacionadas à DTM não são evidentes, o que dificulta a produção de resultados claros sobre a eficácia dos diagnósticos e intervenções para DTM. 

Temporomandibular Disorder Patients Benefit From Intramuscular Botulinum Toxin Type a Injections

PURPOSE

The aim of this study was to analyze the clinical outcome of the use of botulinum toxin type A (BTX) intramuscular injections to the head and neck, particularly the masticatory muscles of patients with temporomandibular disorder (TMD).

METHODS

The medical records of all patients who had received intramuscular BTX injections between 2005 and 2018 at Päijät-Häme Central Hospital, Lahti, Finland were analyzed retrospectively. Gender, age, previous medical history, number of injections, injection areas, and therapeutic results were collected and analyzed. The outcome was divided into three categories based on the patients' subjective reports: not beneficial, beneficial, and highly beneficial.

RESULTS

A total of 68 patients had received intramuscular BTX injections in our unit for TMD symptoms. Clinical effectiveness could be analyzed from 63 patients. Overall, 87% of them reported favorable outcomes. 8 (13%) reported BTX injections as not beneficial, 15 (24%) as beneficial, and 40 patients (63%) as highly beneficial.Most patients had already received conventional treatment with an occlusal splint (93%) combined with pain medication (60%) in the primary care units before they were referred to our hospital.There were 59 (83%) female patients, and they responded better to BTX therapy than the male patients: 91% versus 57% (P value = 0.04). Average age at the first BTX injection visit was 44.6 years (range 17.8-77.2). Most commonly (65%), BTX was divided bilaterally to the masseter and temporalis muscles.

CONCLUSIONS

BTX injections had good therapeutic outcomes for our TMD patients. However, most patients require multiple injection visits.

A novel method to treat recurrent facial pain: a case report

Background

Chronic facial pain is a serious condition affecting millions of people worldwide. The reasons for chronic facial pain vary, and currently, the methods of treating chronic facial pain are expensive, invasive, and, based on current findings, ineffective. The purpose of this study is to develop and test an effective, cost-friendly method to treat patients with chronic facial pain. This study will examine the effectiveness of a novel treatment of a patient suffering from trigeminal neuralgia.

Case presentation

A 70-year-old Thai female visited the advanced general dentistry clinic at the Faculty of Dentistry, Mahidol University, Bangkok, Thailand. She was suffering from facial pain on her left side and was diagnosed by a physician as having trigeminal neuralgia. She experienced a sharp shooting pain that was triggered by facial movements such as chewing, speaking, or brushing teeth, and touching certain areas of her face. Bouts of pain lasted from a few seconds to several minutes, and episodes of several attacks lasted days, weeks, months, or longer prior to her visit to the advanced general dentistry clinic at Mahidol University. Physician designed an occlusal equilibration appliance for treating the patient by inserting the appliance in the mouth for dental occlusal equilibration (deprogram). The patient used this appliance by placing it in the mouth continuously (day and night) and removed it only when eating. After using the appliance for 2 weeks, the patient appeared to feel and look better prior to taking medication and was able to eat normally. The patient was pain free after treatment for a duration of 9 months. However, after 9 months, the pain reoccurred and manifested itself.

Conclusion

This novel treatment of recurrent facial pain showed an improvement of the patient’s chronic facial pain and serves as evidence to being a novel method for treating those suffering from trigeminal neuralgia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02888-1.

Temporomandibular Disorders: Current Concepts and Controversies in Diagnosis and Management

Temporomandibular disorders (TMD) are a group of orofacial pain conditions which are the most common non-dental pain complaint in the maxillofacial region. Due to the complexity of the etiology, the diagnosis and management of TMD remain a challenge where consensus is still lacking in many aspects. While clinical examination is considered the most important process in the diagnosis of TMD, imaging may serve as a valuable adjunct in selected cases. Depending on the type of TMD, many treatment modalities have been proposed, ranging from conservative options to open surgical procedures. In this review, the authors discuss the present thinking in the etiology and classification of TMD, followed by the diagnostic approach and the current trend and controversies in management.

Temporomandibular Disorders: Fundamental Questions and Answers

This review aimed to present the current evidence-based answers to a questionnaire which was developed to evaluate the beliefs and knowledge of dental professionals concerning temporomandibular disorder (TMD). A literature review was conducted using the PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane, Google Scholar, and Scopus search engines from January 1980 to June 2020 corresponding to TMD diagnosis, causes, management, and consequences. A total of 50 articles were considered relevant and selected for full review. The etiology of TMD is multifactorial and complicated and involves several direct and indirect factors. Orthodontic treatment does not appear to either prevent or relieve TMD to a great degree. Nevertheless, condylar and occlusal stability reduces the risk of TMD development. As a result, an assessment of the function of masticatory system prior to beginning orthodontic therapy is fundamental. If signs and symptoms of TMD are significantly present, they should be managed before any orthodontic intervention. Moreover, psychological disorders are strongly associated with joint and facial pain. Thus, professionals who work with chronic TMD patients need to be aware of the psychological aspects of chronic pain and refer the patient for psychological evaluation when warranted. Future research elucidating a cause-effect relationship and neurobehavioral processes underlining chronic pain should be performed.

Effects of cognitive behavioral therapy on orofacial pain conditions

Numerous studies have confirmed the effectiveness of cognitive behavioral therapy (CBT) for chronic pain, and it is generally regarded as an appropriate intervention. However, it may not be effective for some pain sites, and the duration of the effect may be limited. In addition, some studies of CBT lacked a comparison group. This review summarizes evidence for the effectiveness of CBT for orofacial pain and assists in the development of guidelines for orofacial pain management. A literature search in PubMed was performed for studies published from April 1990 through March 2020. The search keywords were "burning mouth syndrome," "temporomandibular disorders," "myofascial pain syndrome,""chronic orofacial pain conditions," "cognitive behavioral therapy," and "non-pharmacological therapy." The results indicate that CBT alone or in combination with other treatments, such as intraoral appliance, stress management, or biofeedback, is effective for the vast majority of orofacial pain cases. Therefore, dentists should consider using CBT to manage orofacial pain in their patients.

Coronavirus Lockdown as a Major Life Stressor: Does It Affect TMD Symptoms?

Temporomandibular disorders are multi-factorial conditions that are caused by both physical and psychological factors. It has been well established that stress triggers or worsens TMDs. This paper looks to present early research, still unfolding, on the relationship between COVID-19 as a major life stressor and TMDs. The main aims of this study were to: investigate the presence of symptoms related to TMDs and the time of onset and the worsening of painful symptoms in relation to the changes in social life imposed by the coronavirus pandemic; and to evaluate the perception of COVID-19 as a major stressful event in subjects who report worsening of painful TMD symptoms. One hundred and eighty-two subjects answered questionnaires-Axis II of the RDC/TMD, the PSS, and specific items about coronavirus as a stressful event-during the lockdown period for COVID-19 in Italy to evaluate the presence of reported symptoms of TMD and the level of depression, somatization, and stress perceived. The results showed that 40.7% of subjects complained about TMD symptoms in the past month. Regarding the time of onset, 60.8% of them reported that facial pain started in the last three months, while 51.4% of these subjects reported that their symptoms worsened in the last month and were related to the aggravation of pain due to the coronavirus lockdown as a major life event and to the stress experienced. The results of this study seem to support the hypothesis that stress during the pandemic lockdown influenced the onset of temporomandibular joint disorders and facial pain, albeit with individual responses.

Internet-Based Multimodal Pain Program With Telephone Support for Adults With Chronic Temporomandibular Disorder Pain: Randomized Controlled Pilot Trial

BACKGROUND

Chronic pain from temporomandibular disorders remains an undertreated condition with debate regarding the most effective treatment modalities.

OBJECTIVE

The aim of the study was to investigate the treatment effect of an internet-based multimodal pain program on chronic temporomandibular disorder pain and evaluate the feasibility of a larger randomized controlled trial.

METHODS

An unblinded randomized controlled pilot trial was conducted with 43 participants (34 females, 9 males; median age 27, IQR 23-37 years) with chronic temporomandibular pain. Participants were recruited within the Public Dental Health Service and randomized to intervention (n=20) or active control (n=23). The intervention comprised a dentist-assisted internet-based multimodal pain program with 7 modules based on cognitive behavior therapy and self-management principles. The control group received conventional occlusal splint therapy. Primary outcomes included characteristic pain intensity, pain-related disability, and jaw functional limitation. Secondary outcomes were depression, anxiety, catastrophizing, and stress. Outcomes were self-assessed through questionnaires sent by mail at 3 and 6 months after treatment start. Feasibility evaluation included testing the study protocol and estimation of recruitment and attrition rates in the current research setting.

RESULTS

Only 49% of participants (21/43) provided data at the 6-month follow-up (internet-based multimodal pain program: n=7; control: n=14). Of the 20 participants randomized to the internet-based multimodal pain program, 14 started treatment and 8 completed all 7 modules of the program. Between-group analysis showed no significant difference for any outcome measure at 3- or 6-month follow-up-characteristic pain intensity (3 months: P=.58; 6 months: P=.41), pain-related disability (3 months: P=.51; 6 months: P=.12), jaw functional limitation (3 months: P=.45; 6 months: P=.90), degree of depression (3 months: P=.64; 6 months: P=.65), anxiety (3 months: P=.93; 6 months: P=.31), stress (3 months: P=.66; 6 months: P=.74), or catastrophizing (3 months: P=.86; 6 months: P=.85). Within-group analysis in the internet-based multimodal pain program group showed a significant reduction in jaw functional limitation score at the 6-month follow-up compared to baseline (Friedman: χ2=10.2, P=.04; Wilcoxon: z=-2.3, P=.02). In the occlusal splint group, jaw function limitation was also reduced at the 6-month follow-up (Friedman: χ2=20.0, P=.045; Wilcoxon: z=-2.3, P=.02), and there was a reduction in characteristic pain intensity at the 3- and 6-month follow-up (Friedman: χ2=25.1, P=.01; Wilcoxon 3 months: z=-3.0, P=.003; Wilcoxon 6 months: z=-3.3, P=.001).

CONCLUSIONS

This study was not able to demonstrate a difference in treatment outcome between an internet-based multimodal pain program and occlusal splint therapy in patients with chronic temporomandibular pain. However, the findings suggested that the internet-based multimodal pain program improves jaw function. The results also confirmed the treatment effect of occlusal splint therapy for chronic temporomandibular pain. Furthermore, because of the high attrition rate, this pilot study showed that a randomized controlled trial with this design is not feasible.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04363762; https://clinicaltrials.gov/show/NCT04363762.

Osteovox self-management concept study. Part 2: focus on the therapy

Objective: To evaluate the effect of a self-management program on a population with both painful temporomandibular disorder (TMD) and parafunctional behaviors. Methods: One hundred-seven participants enrolled in a program called Osteovox Self-Management Concept (OSMC). The primary outcome measure was the overall relief (OR) based on four pain and three functional limitation parameters. The secondary outcome measures concerned parafunctional behaviors, compliance with treatment, and several psychological and otological symptoms. Results: The mean OR was 47% (standard deviation (SD): 28%) after 1 month, 72% (SD: 26%) after 3 months, and 77% (SD: 23%) after 6 months. Significant OR (i.e., 60%-100%) was observed in 80.11% of the patients. OR was strongly correlated with compliance. The OSMC efficiently reduced parafunctional behaviors and otological symptoms. Discussion: This study demonstrated that OSMC is an effective, simple, short, and inexpensive therapy. This type of treatment follows the international recommendations of using reversible treatment for TMD.

Correlation of somatization, depression, and chronic pain with clinical findings of the temporomandibular disorders in asymptomatic women

Objective: The aim of this study was to correlate degree of depression, somatization, and chronic pain in asymptomatic women with clinical findings, using Research Diagnostic Criteria/Temporomandibular disorders (RDC/TMD). Methods: A total of 200 female participants, ages 18-65, filled out a standard RDC/TMD axis II form for the assessment of chronic pain, disability, depression, and non-specific physical symptoms and underwent clinical examination of the temporomandibular joint. Correlation of clinical findings (axis I) and axis II assessment was performed using Spearman's correlation test, with significance set at p < 0.05. Results: There was a significant correlation between depression scores (p < 0.04), chronic pain (p < 0.001), and non-specific physical symptoms without questions about pain (p = 0.008). Discussion: The highest scores on the Graded Chronic Pain Scale were observed in patients with arthralgia, while patients with myofascial pain scored higher on depression and somatization tests.

Conservative therapy for the treatment of patients with somatic tinnitus attributed to temporomandibular dysfunction: study protocol of a randomised controlled trial

BACKGROUND

Tinnitus is a highly prevalent symptom affecting 10-15% of the adult population. It often affects patient quality of life and frequently causes distress. When subjective tinnitus can be elicited by the somatosensory system of the cervical spine or temporomandibular area it is termed somatic tinnitus. The first aim of the current study is to investigate the effect of the best evidence conservative temporomandibular disorder (TMD) treatment on tinnitus in patients with co-existence of tinnitus and TMD or oral parafunctions compared to no treatment. The second aim is to identify a subgroup of patients with tinnitus that benefits from the conservative temporomandibular joint treatment.

METHODS AND DESIGN

This study is a randomised controlled trial with a delayed treatment design. Patients with a TMD (TMD pain screener ≥ 3 points) or oral parafunctions (such as clenching and bruxism), who are suffering from moderate to severe subjective tinnitus (Tinnitus Functional Index (TFI) between 25 and 90 points), will be recruited from the tertiary tinnitus clinic of the University Hospital of Antwerp, Edegem, Belgium. Patients will be excluded in case of clear otological or neurological causes of the tinnitus, progressive middle ear pathology, intracranial pathology, traumatic cervical spine or temporomandibular injury in the past 6 months, severe depression as diagnosed by a psychologist, tumours, previous surgery in the orofacial area, substance abuse that may affect the outcome measures, any contra-indication for physical therapy treatment directed to the orofacial area or when they received TMD treatment in the past 2 months. After screening for eligibility, baseline data among which scores on the TFI, tinnitus questionnaire (TQ), mean tinnitus loudness as measured with visual analogue scale (VAS), TMD pain screener, and a set of temporomandibular joint tests will be collected. Patients will be randomised in an early-start group and in a delayed-start group of therapy by 9 weeks. Patients will receive conservative TMD treatment with a maximum of 18 sessions within 9 weeks. At baseline (week 0), at the start of therapy (weeks 0 or 9), 9 weeks after therapy (weeks 9 or 18), and at follow-up (weeks 18 or 27) data from the TFI, TQ, VAS mean tinnitus loudness and the TMD pain screener will be collected.

DISCUSSION

Herein, we aim to improve the quality of care for patients with tinnitus attributed to TMD or oral parafunctions. By evaluating the effect of state-of-the-art TMD treatment on tinnitus complaints, we can investigate the usefulness of TMD treatment in patients with somatic tinnitus.

TRIAL REGISTRATION

3 July 2017, version 1 of the protocol, ClinicalTrials.gov NCT03209297 .

Temporomandibular disorder and comorbid neck pain: facts and hypotheses regarding pain-induced and rehabilitation-induced motor activity changes

According to the "pain adaptation model", temporomandibular disorder (TMD)-related pain induces a paradoxical activity of masticatory muscles: an agonistic hypoactivity during jaw closing and an antagonistic activity during jaw opening (agonist/antagonist co-activation). However, this model suffers several weaknesses; notably, it does not explain all types of neck muscle activities in neck pain (NP), which is a very prevalent TMD comorbid condition. In NP, neck muscle antagonistic activity is increased, and agonistic activity is decreased as postulated by the pain adaptation model. However, synergistic and compensatory activity may occur and agonistic activity may be unchanged or even increased as postulated within the "vicious cycle theory". Thus, both theories would apply partly as outlined currently in musculoskeletal disorders (MSD). Besides pain, psychological stress may also induce motor dysfunction in TMD and NP. In NP, rehabilitation may increase agonistic activity and decrease compensatory activity and antagonistic activity, thus inducing a switch from agonist/antagonist co-activation towards reciprocal inhibition. Thus, rehabilitation-induced motor activity changes constitute a new research field that should improve MSD therapeutics. Additionally, immature tongue function (so-called infantile swallow) might be connected to TMD where low agonistic activity of masticatory muscles would be compensated by facial muscle hyperactivity during oropharyngeal phase of deglutition.

A critical overview of the current myofascial pain literature - April 2018

Twenty-four basic and clinical studies and case reports are included in this quarterly review of the myofascial pain literature. The majority of publications focus on invasive techniques, especially dry needling. We hope, that this not suggest that clinicians and researchers are slowly moving away from manual trigger point (TrP) approaches. While some physiotherapists have bought into the notion that hands-on approaches are a thing of the past, since "pain is in the brain" and "the issues are not in the tissues," there is also a body of research that aims to combine so-called top-down and bottom-up therapies. Combining manual therapy and dry needling with pain neuroscience education is likely the preferred method using a multimodal approach (Puentedura and Flynn, 2016; Lluch Girbes et al., 2015).

Temporomandibular Disorders and Headache

Temporomandibular disorders (TMD) and primary headaches can be perpetual and debilitating musculoskeletal and neurological disorders. The presence of both can affect up to one-sixth of the population at any one time. Initially, TMDs were thought to be predominantly musculoskeletal disorders, and migraine was thought to be solely a cerebrovascular disorder. The further understanding of their pathophysiology has helped to clarify their clinical presentation. This article focuses on the role of the trigeminal system in associating TMD and migraine. By discussing recent descriptions of prevalence, diagnosis, and treatment of headache and TMD, we will further elucidate this relationship.

Cognitive behavioral therapy for psychosomatic problems in dental settings

Cognitive behavioral therapy (CBT) has been applied for various problems, including psychiatric diseases such as depression and anxiety, and for physical symptoms such as pain. It has also been applied for dental problems. Although the effect of CBTs on temporomandibular disorders and dental anxiety are well documented, its effectiveness on other types of oral symptoms remain unclear. Little information comparing the different types of CBTs in the dental setting is currently available. Because dental professionals are often expected to conduct CBTs in the dental setting, it is important to develop proper training programs for dental professionals.

In this review article, we demonstrate and discuss the application of CBTs for psychosomatic problems, including temporomandibular disorders, dental anxiety, burning mouth syndrome, and other oral complaints in dental settings.

Towards an optimal therapy strategy for myogenous TMD, physiotherapy compared with occlusal splint therapy in an RCT with therapy-and-patient-specific treatment durations

BACKGROUND

Temporomandibular Disorders (TMD) may be characterized by pain and restricted jaw movements. In the absence of somatic factors in the temporomandibular joint, mainly myogenous, psychobiological, and psychosocial factors may be involved in the aetiology of myogenous TMD. An occlusal appliance (splint) is commonly used as a basic therapy of the dental practice. Alternatively, a type of physiotherapy which includes, apart from massage of sore muscles, aspects of cognitive-behavioural therapy might be a basic therapy for myogenous TMD. Treatment outcome of physiotherapy (Ph-Tx) was evaluated in comparison to that of splint therapy (Sp-Tx), using the index Treatment Duration Control (TDC) that enabled a randomized controlled trial with, comparable to clinical care, therapy-and-patient-specific treatment durations.

METHODS

Seventy-two patients were randomly assigned to either Ph-Tx or Sp-Tx, with an intended treatment duration between 10 and 21 or 12 and 30 weeks respectively. Using TDC, the clinician controlled treatment duration and the number of visits needed. A blinded assessor recorded anamnestic and clinical data to determine TDC-values following treatment and a 1-year follow-up, yielding success rate (SR) and effectiveness (mean TDC) as treatment outcomes. Cohen's d, was determined for pain intensity. Overall SR for stepped-care was assessed in a theoretical model, i.e. a second of the two studied therapies was applied if the first treatment was unsuccessful, and the effect of therapy sequence and difference in success rates was examined.

RESULTS

SR and effectiveness were similar for Ph-Tx and Sp-Tx (long-term SR: 51-60%; TDC: -0.512- -0.575). Cohen's d was 0.86 (Ph-Tx) and 1.39 (Sp-Tx). Treatment duration was shorter for Ph-Tx (on average 10.4 weeks less; p < 0.001). Sp-Tx needed 7.1 less visits (p < 0.001).

CONCLUSIONS

Physiotherapy may be preferred as initial therapy over occlusal splint therapy in stepped-care of myogenous TMD. With a similar SR and effectiveness, physiotherapy has a shorter duration. Thus patients whose initial physiotherapy is unsuccessful can continue earlier with subsequent treatment. The stepped-care model reinforces the conclusion on therapy preference as the overall SR hardly depends on therapy sequence.

TRIAL REGISTRATION

isrctn.com/ISRCTN17469828 . Retrospectively registered: 11/11/2016.

Design, construction, and technical implementation of a web-based interdisciplinary symptom evaluation (WISE) - a heuristic proposal for orofacial pain and temporomandibular disorders

BACKGROUND

Medical symptoms independent of body location burden individuals to varying degrees and may require care by more than one expert. Various paper and computer-based tools exist that aim to comprehensively capture data for optimal clinical management and research.

METHODS

A web-based interdisciplinary symptom evaluation (WISE) was newly designed, constructed, and technically implemented. For worldwide applicability and to avoid copyright infringements, open source software tools and free validated questionnaires available in multiple languages were used. Highly secure data storage limits access strictly to those who use the tool for collecting, storing, and evaluating their data. Concept and implementation is illustrated by a WISE sample tailored for the requirements of a single center in Switzerland providing interdisciplinary care to orofacial pain and temporomandibular disorder patients.

RESULTS

By combining a symptom- burden checklist with in-depth questionnaires serving as case-finding instruments, an algorithm was developed that assists in clarifying case complexity and need for targeted expert evaluation. This novel modular approach provides a personalized, response-tailored instrument for the time- and cost-effective collection of symptom-burden focused quantitative data. The tool includes body drawing options and instructional videos. It is applicable for biopsychosocial evaluation in a variety of clinical settings and offers direct feedback by a case report summary.

CONCLUSIONS

In clinical practice, the new instrument assists in clarifying case complexity and referral need, based on symptom burden and response -tailored case finding. It provides single-case summary reports from a biopsychosocial perspective and includes graphical symptom maps. Secure, centrally stored data collection of anonymous data is possible. The tool enables personalized medicine, facilitates interprofessional education and collaboration, and allows for multicenter patient-reported outcomes research.

Clinical effects of an avocado-soybean unsaponifiable extract on arthralgia and osteoarthritis of the temporomandibular joint: preliminary study

The aim of the present preliminary study was to investigate the effectiveness of an avocado-soybean unsaponifiable extract (ASU) in patients with arthralgia and osteoarthritis of the temporomandibular joint (TMJ). A randomized, double-blind, placebo-controlled trial was carried out. Fourteen women diagnosed with arthralgia and osteoarthritis of the TMJ using the Research Diagnostic Criteria for Temporomandibular Disorders were included in the statistical analysis. The women were allocated randomly to two groups: ASU group and placebo group. Pain was measured using a visual analogue scale and pressure algometer. Mandibular function was evaluated through measurement of mandibular movements. Quality of life was measured using the Oral Health Impact Profile (OHIP-14). The medication (ASU capsules or placebo capsules) was used for 4 months and the total follow-up was 6 months. Those taking the ASU extract had a decrease in pain symptoms and an improvement in quality of life. Moreover, a significant reduction in the use of rescue medication was found in the ASU group compared to the placebo group. This preliminary study provides strong evidence of the effectiveness of an avocado-soybean unsaponifiable extract in patients with degenerative joint diseases and arthralgia in the TMJ. Further studies with larger samples should be performed.

Psychological profile and self-administered relaxation in patients with craniofacial pain: a prospective in-office study

INTRODUCTION

The objective of this study was to evaluate the psychological profile of craniofacial pain sufferers and the impact of patient subtype classification on the short-time effectiveness of a self-administered relaxation training.

METHODS

One hundred unselected in-office patients (67% females) suffering from chronic facial pain and/or headache with the presumptive diagnose of temporo-mandibular disorder (TMD) completed a questionnaire battery comprising craniofacial pain perception, somatic complaints, irrational beliefs, and pain behavior and were classified into subtypes using cluster analysis. They underwent a self-administered progressive relaxation training and were re-evaluated for pain perception after 3 months.

RESULTS

Pain was mild to moderate in the majority of patients. Symptom domains comprised parafunctional activities, temporo-mandibular pain and dysfunction, fronto-temporal headache, head/neck and neck/back pain. Three patient subtypes were identified regarding symptom/dysfunction level: (i) low burden (mild/moderate), (ii) psychosocial dysfunction (moderate/high), (iii) adaptive coping (moderate/mild). Self-rated adherence to the recommended relaxation training was moderate throughout the sample, but self-rated relief was significantly different between clusters. At follow-up, pain intensity was significantly decreased in all patients, whereas pain-related interference was improved only in dysfunctional and adaptive patients. Improvement of symptom domains varied between clusters and was most comprehensive in adaptive patients.

CONCLUSIONS

In conclusion, craniofacial pain sufferers can be divided in meaningful subtypes based on their pain perception, irrational beliefs, and pain behaviour. A self-administered relaxation training generally yielded positive effects on pain perception, however the benefit may be greater in patients with more marked symptom impact (both dysfunctional and adaptive).

Identifying potential predictors of pain-related disability in Turkish patients with chronic temporomandibular disorder pain

Background

The aims of this study were to examine whether patients’ psychosocial profiles influence the location of pain, and to identify the clinical and psychosocial predictors of high levels of pain-related disability in temporomandibular disorders (TMD) patients with chronic pain at least 6 months in duration.

Methods

The Research Diagnostic Criteria of TMD (RDC/TMD) data for Axis I and II were obtained for 104 consecutive patients seeking treatment.

Data were analyzed using descriptive statistics, t-test, Mann–Whitney U-test, chi-square test, One-way ANOVA, Kruskal-Wallis test, and binary multiple logistic regression tests. Patients were classified into two groups according to Graded Chronic Pain Scale scores: Grade III and IV were scored for patients with high levels of pain-related disability, whereas Grade I and II were scored for patients with low disability.

Results

Muscle and joint pain were found in 64.9% and 31.8% of the patients, respectively, and 27.3% of the patients suffered from both muscle and joint pain.

Psychosocial disability was found in 26% of patients. There were no statistically significant differences among the diagnostic subgroups with regards to the demographic, behavioral, psychological, and psychosocial characteristics. Patients with high levels of pain-related disability had significantly higher depression, somatization, pain intensity and jaw disability scores than those with low levels of pain-related disability.

Patients with high levels of pain-related disability were more likely to have higher pain intensity, to report higher somatization symptoms and functional impairment, and were less likely to have joint pain than those with low levels of pain related disability.

Conclusion

In conclusion, the Turkish version RDC/TMD, based on a dual axis system, may be used to screen chronic TMD patients at high-risk for pain-related disability who need comprehensive care treatment program.

Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique

A randomized controlled trial was performed to compare the short-term effectiveness of botulinum toxin injections and physiatric treatment provided by means of Fascial Manipulation techniques in the management of myofascial pain of jaw muscles. Thirty patients with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis of myofascial pain were randomized to receive either single-session botulinum toxin injections (Group A) or multiple-session Fascial Manipulation (Group B). Maximum pain levels (VAS ratings) and jaw range of motion in millimeters (maximum mouth opening, protrusion, right and left laterotrusion) were assessed at baseline, at the end of treatment, and at a three-month follow-up. Both treatment protocols provided significant improvement over time for pain symptoms. The two treatments seem to be almost equally effective, Fascial Manipulation being slightly superior to reduce subjective pain perception, and botulinum toxin injections being slightly superior to increase jaw range of motion. Differences between the two treatment protocols as to changes in the outcome parameters at the three-months follow-up were not relevant clinically. Findings from the present investigation are in line with literature data supporting the effectiveness of a wide spectrum of conservative treatment approaches to myofascial pain of the jaw muscles. Future studies on larger samples over a longer follow-up span are needed on the way to identify tailored treatment strategies.

Physiotherapy in the management of disorders of the temporomandibular joint--perceived effectiveness and access to services: a national United Kingdom survey

Up to a quarter of the general population has experienced temporomandibular joint disorder (TMD) at some point in time. Physiotherapy has been used in the management of TMD for many years, but evidence supporting its clinical effectiveness is limited. We investigated the perceived effectiveness of physiotherapy for patients with TMD among consultants in oral and maxillofacial surgery (OMFS) and the accessibility of these services in the United Kingdom (UK). Information was gathered from a postal or electronic questionnaire sent to the 356 OMFS consultants listed on the British Association of Oral and Maxillofacial Surgeons' website. A total of 208 responded (58%) and 72% considered physiotherapy to be effective. Amongst these respondents, jaw exercises (79%), ultrasound (52%), manual therapy (48%), acupuncture (41%) and laser therapy (15%) were considered to be effective. Twenty-eight percent of respondents did not consider physiotherapy to be effective. Reasons for this included lack of knowledge or expertise of the physiotherapist (41%) and lack of awareness of the benefits of physiotherapy (28%). In relation to access to physiotherapy services, 10% of respondents had a designated physiotherapist for patients with TMD, 89% could refer directly to physiotherapy and 7% worked in an environment that provided training for physiotherapists. Patients were prescribed jaw exercises by 69% of respondents. Despite limited evidence to support its effectiveness, approximately three-quarters of OMFS consultants in the UK regard physiotherapy to be beneficial in the management of TMD.

Intraoral myofascial therapy for chronic myogenous temporomandibular disorder: a randomized controlled trial

OBJECTIVE

Studies investigating the efficacy of intraoral myofascial therapies (IMTs) for chronic temporomandibular disorder (TMD) are rare. The present study was an expansion of a previously published pilot study that investigated whether chiropractic IMT and the addition of education and self-care were superior to no-treatment or IMT alone for 5 outcome measures-interincisal opening range, jaw pain at rest, jaw pain upon opening, jaw pain upon clenching, and global reporting of change-over the course of 1 year.

METHODS

Ninety-three participants with myogenous TMD between the ages of 18 and 50 years experiencing chronic jaw pain of longer than 3 months in duration were recruited for the study. Successful applicants were randomized into 1 of 3 groups: (1) IMT consisting of 2 treatment interventions per week for 5 weeks, (2) IMT plus education and "self-care" exercises (IMTESC), and (3) wait-list control. The main outcome measures were used. Range of motion findings were measured by vernier callipers in millimeters, and pain scores were quantified using an 11-point self-reported graded chronic pain scale. Global reporting of change was a 7-point self-reported scale, balanced positively and negatively around a zero midpoint.

RESULTS

There were statistically significant differences in resting, opening and clenching pain, opening scores, and global reporting of change (P < .05) in both treatment groups compared with the controls at 6 months and 1 year. There were also significant differences between the 2 treatment groups at 1 year.

CONCLUSIONS

The study suggests that both chiropractic IMT and IMTESC were superior to no-treatment of chronic myogenous TMD over the course of 1 year, with IMTESC also being superior to IMT at 1 year.

Effectiveness of cognitive-behavioral therapy and amitriptyline in patients with chronic temporomandibular disorders: a pilot study

The aim of this pilot study was to evaluate the effectiveness of cognitive-behavioral therapy (CBT) and use of amitriptyline, a tricyclic antidepressant, in patients with chronic temporomandibular disorders (TMD). Forty-seven women (mean age = 35.4 years old) with chronic TMD were enrolled in the study and divided into 4 groups: amitriptyline; amitriptyline and CBT; placebo and CBT; and placebo only (control). Patients were managed for 7 consecutive weeks. Follow-up evaluations were done at the 1st, 7th and 11th weeks of treatment. The presence and severity of pain, levels of depression, and quality of life and sleep were measured. Data were analyzed using ANOVA, Chi-square and Cochran tests, considering a significance level of 5%. Improvements were found for all factors considered in the intragroup analysis, although no significant differences were detected among groups. However, at the end of the treatment (11 weeks of follow-up), these positive outcomes persisted only for the women treated with amitriptyline and CBT. The obtained results suggest that the combination of amitriptyline and CBT may be effective in reducing pain and depression levels as well as in improving the quality of life and sleep in patients with chronic TMD.

Some dogmas related to prosthodontics, temporomandibular disorders and occlusion

It is the aim of this paper to give a few examples of dogmas related to prosthodontics and oral implants and to discuss the controversial role of occlusion in the aetiology of temporomandibular disorders. New knowledge is developing at a rapidly increasing rate in dentistry, as in other areas of society. Our lecturers at university taught us many useful things. But, as time goes by, what is still relevant? Some methods are so well established that they deserve to be called dogmas. It is implied that a dogma is not supported by strong evidence, even though it has existed and been practised for a long time. In the era of evidence-based dentistry it is appropriate to scrutinize such issues. A review of the current literature indicates that conflicting opinions exist concerning a number of common procedures in clinical dentistry, mainly due to a scarcity of good studies with unambiguous results. There is therefore a need for more high-quality clinical research in attempting to reach the goal of evidence-based clinical practice. The dental community should take an active part in this process.

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 (chi(2), p<0.001), while no association was found between DEP and SOM scores and pain duration in the overall sample (chi(2), 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.