Investigation of the relationship between psychosocial stress and temporomandibular disorder in adults by measuring salivary cortisol concentration: A case-control study

Prevalence of psychological disorders in patients with temporomandibular disorders: A systematic review and meta-analysis

STATEMENT OF PROBLEM

Temporomandibular disorders (TMDs) affect the muscles of mastication, the temporomandibular joint, and associated structures. They are generally classified as muscular or articular and are the main cause of pain in the orofacial region, eventually causing psychological problems. However, the real burden of psychological disorders is unknown.

PURPOSE

The purpose of this systematic review and meta-analysis was to assess the prevalence of psychological disorders in patients with TMDs.

MATERIAL AND METHODS

The study was conducted through a bibliographic search carried out without initial limit until July 2021 in the following electronic databases: MEDLINE/PubMed, Scopus, and PsycINFO. Clinical observational studies investigating depression and somatization in patients with TMD diagnosed by the Diagnostic Research for Temporomandibular Disorders (RDC/TMD) criteria in muscular, articular, and disc disorders were included. A descriptive analysis of the included studies and a meta-analysis for the prevalence data were performed for the synthesis of evidence.

RESULTS

A total of 2320 studies were found, of which 48 complete articles were assessed for eligibility and 22 were included in the analysis. The general prevalence of depression and moderate and severe somatization in patients diagnosed with TMD was estimated at 43.0% (95% confidence interval (CI), 36.0% to 50.0%) and 60.0% (95% CI 52.0 - 67, 0%). The average overall score for depression was estimated at 0.92 (95% CI, 0.69-1.15), being classified as moderate depression. The average overall score for somatization was estimated at 1.09 (95% CI, 0.81-1.36), being classified as severe somatization. All analyses showed high heterogeneity (I2>90%). Based on the quality assessment, 80.9% of studies included in the review had low to moderate risk of bias.

CONCLUSIONS

Patients with TMDs who seek clinical care show a high prevalence of depression and somatization.

Data analysis for differentiating temporo mandibular disorders (TMD) pain from tooth pain

The factors differentiating temporomandibular disorders (TMD) pain from tooth pain is of interest to dentists. Prior to receiving therapy, participants answered the six-question TMD Pain Screener questionnaire. Applying validated Diagnostic Guidelines for TMD (DC/TMD), an orofacial pain specialist and endodontic resident with board certification performed endodontic and TMD examinations. In our study, sensitivity was higher for TMD screener regarding identification of all types of TMDs (0.94 (0.80-0.97), TMD pain not referring to teeth (0.94 (0.76-0.98), TMD pain referring to teeth only (0.94 (0.64-1.00)). TMD Pain Screener questionnaire can be applied in identification of TMDS in patient seeking endodontic therapy.

Salivary Biomarkers and Temporomandibular Disorders: A Systematic Review conducted according to PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions

BACKGROUND

The present review aimed to investigate the association between salivary biomarkers and temporomandibular disorders (TMD). TMD is a multifactorial condition characterised by pain and dysfunction in the temporomandibular joint (TMJ) and surrounding structures. Salivary biomarkers have emerged as potential diagnostic tools due to their non-invasiveness and easy accessibility. However, the literature on salivary biomarkers in relation to TMD is limited and inconsistent.

METHODS

Electronic databases of Pubmed, Embase, Web of Science, Scopus, Cochrane Library, PsychINFO, CINAHL and Medline were searched using specific search terms and Boolean operators. The search was limited to articles published in English that assessed salivary biomarkers in individuals diagnosed with TMD. Two reviewers independently screened the articles and extracted data. ROB-2 was used to assess the risk of bias.

RESULTS

Eleven clinical papers met the inclusion criteria and were included in the review. The findings provided consistent evidence of a clear association between salivary biomarkers and TMD. Various biomarkers, including cortisol, IL-1, glutamate and several others, were assessed. Some studies reported higher levels of cortisol and IL-1 in TMD patients, indicating potential involvement in stress and inflammation. Glutamate levels were found to be elevated, suggesting a role in pain modulation. Other biomarkers also showed alterations in TMD patients compared to controls: CONCLUSION: The findings from the included studies suggest that salivary biomarkers may play a role in TMD pathophysiology. Though a definitive conclusion can be drawn regarding the specific salivary biomarkers and their association with TMD, the results must be interpreted with caution considering the heterogeneity of the biomarkers assessed. Further research with larger sample sizes, standardised methodology and rigorous study designs is needed to elucidate the role of salivary biomarkers in TMD.

A case-control investigation of the psychological and physiological stress markers with salivary cortisol levels in patients with temporomandibular joint disorders: A short clinical study

Aims

This study aimed to determine the association of stress and salivary cortisol levels in the adult Indian population with and without temporomandibular disorder (TMD) and to validate it with bite force.

Settings and Design

The present study had an observational, case-control study design.

Materials and Methods

This study sample comprised two groups of 25 cases and 25 controls between 18 and 45 years of age. Diagnostic criteria-TMD questionnaire Axis I was used to assess TMD classification, the TMD Disability Index and modified Perceived Stress Scale (PSS) questionnaires were filled, and salivary cortisol levels were measured using electrochemiluminescence immunoassay (ECLIA). Bite force analysis was performed using a portable load indicator.

Statistical Analysis Used

To characterize and analyze the study variables, means, standard deviations, Mann-Whitney U-test, and logistic regression were employed (STATA 14.2 [Texas, USA]). Shapiro-Wilk test was used to test the normality of the data. P < 0.05 was considered statistically significant (95% power).

Results

Female gender was proportionately higher in both the groups (P = 0.508), TMD Disability Index was significantly higher for cases (P < 0.001), TMD cases perceived higher stress levels (P = 0.011), there was no statistically significant difference in salivary cortisol level between cases and controls (P = 0.648), and the median bite force was lower for cases (P = 0.0007).

Conclusions

This study concluded that the chance of developing TMD increased with age. An increase in the TMD Disability Index score and modified PSS scores; and a decrease in the bite force increased the likelihood of TMD. Modified PSS score was negatively correlated with salivary cortisol concentrations, indicating a two-way response to TMD symptoms.

Stress Experience, Depression and Neck Disability in Patients with Temporomandibular Disorder-Myofascial Pain with Referral

The etiology of temporomandibular disorders (TMDs) is firmly anchored in the biopsychosocial model in which a special role is attributed to the stress, depression, somatic symptoms, and anxiety. The aim of the study was to assess the level of stress, depression and neck disability in patients with temporomandibular disorder-myofascial pain with referral. The study group enrolled 50 people (37 women and 13 men) with complete natural dentition. All the patients underwent a clinical examination according to the Diagnostic Criteria for Temporomandibular Disorders and were diagnosed as individuals with myofascial pain with referral. The questionnaires were associated with stress, depression, and neck disability; Perceived Stress Scale (PSS-10), Beck Depression Inventory(BDI), and Neck Disability Index (NDI) were evaluated. Of the individuals evaluated, 78% showed elevated levels of stress, and the average value of the PSS-10 in the study group was 18 points (Me = 17). Furthermore, 30% of the subjects presented depressive symptoms, with the average value of BDI was 8.94 points (Me = 8), and 82% of the subjects showed neck disability. The multiple linear regression model revealed that BDI and NDI allowed explanations for the 53% differentiation of PSS-10. In conclusion, stress, depression, and neck disability coexist with temporomandibular disorder-myofascial pain with referral.

Accurate Diagnosis and Treatment of Painful Temporomandibular Disorders: A Literature Review Supplemented by Own Clinical Experience

Introduction

Temporomandibular disorders (TMD) is a multifactorial group of musculoskeletal disorders often with combined etiologies that demand different treatment plans. While pain is the most common reason why patients decide to seek help, TMD is not always painful. Pain is often described by patients as a headache, prompting patients to seek the help of neurologists, surgeons, and ultimately dentists. Due to the unique characteristics of this anatomical area, appropriate diagnostic tools are needed, as well as therapeutic regimens to alleviate and/or eliminate the pain experienced by patients. Aim of the Study. The aim of this study is to collect and organize information on the diagnosis and treatment of pain in TMD, through a review of the literature supplemented by our own clinical experience. Material and Methods. The study was conducted by searching scientific databases PubMed, Scopus, and Google Scholar for documents published from 2002-2022. The following keywords were used to build the full list of references: TMD, pain, temporomandibular joint (TMJ), TMJ disorders, occlusal splint, relaxing splints, physiotherapy TMD, pharmacology TMD, natural therapy TMD, diagnostic criteria for TMD, and DC/TMD. The literature review included 168 selected manuscripts, the content of which was important for pain diagnosis and clinical treatment of TMD.

Results

An accurate diagnosis of TMD is the foundation of appropriate treatment. The most commonly described treatments include physiotherapy, occlusal splints therapy, and pharmacological treatment tailored to the type of TMD.

Conclusions

Based on the literature review and their own experience, the authors concluded that there is no single ideal form of pain therapy for TMD. Treatment of TMD should be based on a thorough diagnostic process, including the DC/TMD examination protocol, psychological evaluation, and cone beam computer tomography (CBCT) imaging. Following the diagnostic process, once a diagnosis is established, a treatment plan can be constructed to address the patient's complaints.

A novel approach to establishing a temporomandibular joint fibrocartilage cell line

Background/purpose

The temporomandibular joint (TMJ) is a bi-arthrodial joint that is composed of the temporal bone glenoid fossa and the condylar head of the mandible both having fibrocartilaginous articular surfaces. Functional overloading of the TMJ is the main cause of TMJ osteoarthritis (TMJ OA) disease. The aim of this study was to establish immortalized TMJ fibrocartilage cell clones to provide enough cells to adequately investigate the molecular mechanisms studies of TMJ OA.

Materials and methods

We have isolated temporomandibular condyle chondrocytes from adult Sprague Dawley rat. The cells were cultured and immortalized by treating with Y-27632, a well-characterized inhibitor of Rho-Associated Kinase (ROCK). Clones were characterized on the basis of cell morphology and analyses of marker gene expression through 45 passages.

Results

Cells from the condylar fibrocartilage of the TMJ were successfully immortalized by ROCK inhibitor, retaining a consistent cuboidal cell morphology and the expression of several cell markers of polymorphic cell fate. In addition, they retained phenotype features similar to the primary parental TMJ fibrocartilage cells when the cells were challenged with different cytokines and growth factors.

Conclusion

These studies establish a novel immortalized cell line through ROCK inhibitor Y-27632, that retains the polymorphic phenotype of primary cell lines from TMJ fibrocartilage chondrocyte cell through a high number of passages, serving as a valuable preclinical resource for mechanistic in vitro assessment of TMJ health, disease, and regeneration.

Effect of temporomandibular disorders on cortisol concentration in the body and treatment with occlusal equilibrium

Background:

Temporomandibular disorders (TMDs) are a group of symptoms concerning the temporomandibular joints, masticatory muscles, and occlusion, which include pain, restricted mouth opening and movement, joint tenderness, and intermittent joint noises. Women are more likely to suffer from temporomandibular problems than men. Patients with TMDs show a wide range of behavioral and psychosocial symptoms, including increased stress, anxiety, sadness, and somatization.

Materials and methods:

The patient group in this case–control research comprised 60 patients from the Department of Prosthodontics at Shri Dharmasthala Manjunatheswara College of Dental Sciences in Dharwad. Female subjects aged between 33 and 45 years, who were educated, had two children, and were housewives were included in the study. Only 96 individuals of those screened met the inclusion criteria, and these 96 patients were given a hair cortisol test. After 1, 2, and 3 months, cortisol testing was performed.

Results:

There were no significant differences between the groups at the start of the study; but after 30 min of the modified trier test, there was a statistically significant main effect across groups, as well as a significant main effect of salivary cortisol over time.

Conclusion:

The etiopathogenesis of TMD is complicated by psychosocial stress. When compared to men, women have a higher risk of TMD.

Risk factor assessments of temporomandibular disorders via machine learning

This study aimed to use artificial intelligence to determine whether biological and psychosocial factors, such as stress, socioeconomic status, and working conditions, were major risk factors for temporomandibular disorders (TMDs). Data were retrieved from the fourth Korea National Health and Nutritional Examination Survey (2009), with information concerning 4744 participants' TMDs, demographic factors, socioeconomic status, working conditions, and health-related determinants. Based on variable importance observed from the random forest, the top 20 determinants of self-reported TMDs were body mass index (BMI), household income (monthly), sleep (daily), obesity (subjective), health (subjective), working conditions (control, hygiene, respect, risks, and workload), occupation, education, region (metropolitan), residence type (apartment), stress, smoking status, marital status, and sex. The top 20 determinants of temporomandibular disorders determined via a doctor's diagnosis were BMI, age, household income (monthly), sleep (daily), obesity (subjective), working conditions (control, hygiene, risks, and workload), household income (subjective), subjective health, education, smoking status, residence type (apartment), region (metropolitan), sex, marital status, and allergic rhinitis. This study supports the hypothesis, highlighting the importance of obesity, general health, stress, socioeconomic status, and working conditions in the management of TMDs.

Temporomandibular dysfunction affects aerobic capacity in females: A preliminary study

Objective: The purpose of this study was to investigate the aerobic capacity in patients with temporomandibular dysfunction (TMD) and to compare the results with those of the asymptomatic individuals.Methods: The TMD group included a total of 31 females between the ages of 18 and 25 years. The control group consisted of 31 asymptomatic females with an age range of 18 to 27 years. A graded exercise test was performed using an electronically braked arm crank ergometer. An indirect calorimeter system was used to calculate the peak oxygen consumption (VO₂peak). In addition, peak heart rate (HR_peak) and respiratory quotient were calculated for each participant.Results: The TMD group had lower VO₂peak (p = 0.017) and HRpeak (p = 0.012) in aerobic capacity tests; however, respiratory quotient was similar in both groups (p = 0.446).Discussion: The TMD group had lower aerobic capacity compared to the asymptomatic individuals.

Induction, identification and genetics analysis of tetraploid Actinidia chinensis

Actinidia chinensis is a commercially important fruit, and tetraploid breeding of A. chinensis is of great significance for economic benefit. In order to obtain elite tetraploid cultivars, tetraploid plants were induced by colchicine treatment with leaves of diploid A. chinensis 'SWFU03'. The results showed that the best treatment was dipping leaves 30 h in 60 mg l^-1 colchicine solutions, with induction rate reaching 26%. Four methods, including external morphology comparison, stomatal guard cell observation, chromosome number observation and flow cytometry analysis were used to identify the tetraploid of A. chinensis. Using the induction system and flow cytometry analysis methods, 187 tetraploid plants were identified. Three randomly selected tetraploid plants and their starting diploid plants were further subjected to transcriptome analysis, real-time quantitative polymerase chain reaction (RT-qPCR) and methylation-sensitive amplification polymorphism (MSAP) analysis. The transcriptome analysis results showed that there were a total of 2230 differentially expressed genes (DEG) between the diploid and tetraploid plants, of which 660 were downregulated and 1570 upregulated. The DEGs were mainly the genes involved in growth and development, stress resistance and antibacterial ability in plants. RT-qPCR results showed that the gene expression levels of the growth and stress resistance of tetraploid plants were higher than those of diploid ones at the transcriptome level. MSAP analysis of DNA methylation results showed that tetraploid plants had lower methylation ratio than diploid ones. The present results were valuable to further explore the epigenetics of diploid and tetraploid kiwifruit plants.

Evaluation of the psychoemotional status of young adults with symptoms of temporomandibular disorders

BACKGROUND AND PURPOSE

Temporomandibular disorders (TMD) are among the most frequent pathologies of the stomatognathic system. One problem often associated with TMD is the psychoemotional status. The aim of study was to evaluate the psychoemotional status of young adults with pain symptoms associated with TMD.

MATERIAL AND METHODS

We analyzed the data of 260 volunteers. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) form was used to diagnose TMD. The relationships between TMD/RDC clinical diagnoses and psychoemotional status, as described by the Beck's Depression Inventory (BDI) and Perceived Stress Scale (PSS-10), were analyzed. We divide the group into four on the basis of RDC/TMD Axis I diagnosis. Group 0 included 30 students lacking TMD symptoms. Group I consisted of 30 people with myofascial pain (group IA in RDC/TMD). Group II contained 23 people with disk displacement with reduction (group IIA in RDC/TMD). Group III contained ten people (Group III diagnosis, often associated with pain).

RESULTS

We did not find statistically significant differences between the study groups. In subjects with pain (Groups I and III), we found the mean value on the BDI and PSS-10 scales to be higher than among the pain-free subjects (Groups 0 and II).

CONCLUSION

In young adults with TMD accompanied by pain, psychoemotional status should also be evaluated.

A Self-Reported Association between Temporomandibular Joint Disorders, Headaches, and Stress

AIMS AND OBJECTIVES

Temporomandibular joint disorder (TMD) is an umbrella term for a number of conditions in the area of the joint, temple, and masticatory system. Many of those with TMD also suffer from headaches and anxiety. The aims and objectives of this study were to determine if there exists an association between the Diagnostic Criteria of TMD (DC/TMD) symptom questionnaire and report of headaches as well as stress.

MATERIALS AND METHODS

A cross-sectional study was implemented via the use of the DC/TMD symptom questionnaire and the perceived stress scale (PSS). This was distributed conveniently among dental students in a multi-dental school setting in Riyadh, Saudi Arabia, and was completed by 152 dental students. Odds ratios, Chi-square, and their corresponding 95% confidence intervals are reported. Statistical significance was set at P ≤ 0.05.

RESULTS

Those who ticked yes for pain on the TMD pain screener for pain with chewing hard or tough food, pain on mouth opening and lateral excursion, and pain with jaw habits as parafunction were at an odds risk from twice to thrice as likely to experience headaches. Similarly, those with poor coping skills on the PSS were more likely to have headaches (P = 0.002). Likewise, positive answers on the screener and symptom questionnaire were relevant with higher stress scores on the PSS.

CONCLUSION

This study clarifies and reiterates the intertwined power of both stress and headaches; the former being a role player in TMD progression and the latter its product. TMD is unfortunately on the rise; it should not be brushed off as a nuisance. A multidisciplinary approach in diagnosis and treatment of both TMD and headaches by a team of orofacial pain specialist, neurologist, psychiatrist and/or psychologist, and physical therapists to untangle the deceiving presentation of both conditions would not only provide a more favorable prognosis but also improve cost and time expenditures.

Temporomandibular Disorders Related to Stress and HPA-Axis Regulation

Temporomandibular disorders (TMDs) are characterized by pain and dysfunction in the masticatory apparatus and the temporomandibular joint (TMJ). Previous trauma, stress symptoms, psychosocial impairment, and catastrophizing have been related to TMD. To assess if the hypothalamic-pituitary-adrenal (HPA) axis is upregulated in TMD patients, we performed a cross-sectional study with saliva from 44 TMD patients and 44 healthy sex- and age-matched controls for cortisol (F) and cortisone (E) with liquid chromatography-tandem mass spectrometry. Furthermore, we calculated the F/E ratio for the evaluation of 11β-hydroxysteroid dehydrogenase activity. We also assessed anxiety/depression and pain catastrophizing scores from a questionnaire that participants completed prior to the examination. We found that F (P=0.01), E (P=0.04), the F/E ratio (P=0.002), and the sum of glucocorticoids (E + E) in saliva (P=0.02) were significantly higher in the TMD group. Anxiety/depression and catastrophizing scores were also significantly higher in the TMD group (P < 0.0001). Our findings indicate that patients with TMDs may have an upregulated HPA axis with higher F secretion from the adrenal cortex. Anxiety/depression and pain catastrophizing scores were significantly higher in the TMD group, and psychological factors may contribute to chronic upregulation of the HPA axis.

Estimation of salivary cortisol among subjects undergoing dental extraction

Background

Dental procedures can be stressful and studies have shown that salivary cortisol is elevated during such procedures. Our study aimed to evaluate saliva cortisol levels among the subjects who underwent dental extractions and to compare it with that of the controls. The secondary objective of the study was to evaluate any correlation between salivary cortisol and hemodynamic parameters.

Material and Methods

We conducted this clinical study among subjects, who were indicated for dental extraction. Saliva samples from the subjects in the study group were collected before and after (10 mins) the dental extraction. Hemodynamic parameters like heart rate, systolic (SBP) and diastolic blood pressure (DBP) and oxygen saturation (Sp O2) were measured 10 minutes prior to the dental extraction and after completion of the extraction by a single trained examiner. Salivary cortisol was estimated by solid phase enzyme-linked immunosorbent assay (ELISA).

Results

A total of 31 subjects in the study group and 24 subjects in control group have participated in this study. The mean salivary cortisol concentration was significantly higher after extraction (27.94±7.94) than before extraction (24.67±8.31) in the study group (P<0.001). No significant correlations were seen between salivary cortisol concentration and hemodynamic parameters except for diastolic blood pressure after extraction.

Conclusions

Dental extractions and local anaesthetic procedures can induce stress in subjects. Dental care providers should try to minimise the subject’s anxiety and stress to the maximum extent.

Key words:Cortisol, dental, extraction, saliva, stress.