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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 30  |  Issue : 1  |  Page : 13-18

Psychological appraisal in temporomandibular disorders: A cross-sectional study


Department of Oral Medicine, Diagnosis and Radiology, Swami Devi Dyal Dental College and Hospital, Barwala, Haryana, India

Date of Web Publication7-Jan-2016

Correspondence Address:
Dr. Deepa Jatti Patil
Department of Oral Medicine, Diagnosis and Radiology, Swami Devi Dyal Dental College and Hospital, Golpura, Panchkula, Barwala - 125 121, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.173447

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  Abstract 

Aims and Objectives: The objective of this study was to investigate the prevalence of stress and depression within temporomandibular disorder (TMD) patient subgroups with chronic facial pain (cfp) and healthy controls and to assess possible relationships among the different subgroups. It also evaluated the correlation among pain, stress, and depression scores. Materials and Methods: A total number of 120 patients, 60 cases and 60 controls aged 20-40 years were included in the study. The study group after clinical examination was assigned into subgroups depending on the Research Diagnostic Criteria for TMD (RDC/TMD). Age- and sex-matched patients with no complaints of TMD formed the control group. Both the groups were administered the Beck's inventory of depression (BDI) and stress symptom rating scale (SSRS) questionnaires. Pain intensity was measured by the visual analogue scale. All the scores were statistically analyzed. Results: Depression and stress scores were seen more in the myofascial pain group. Depression was prevalent in 53.3% and stress in 60% of the study group. Positive correlation was seen among pain scores, depression, and stress scores (P < .001). Conclusion: The findings are consistent with previous research indicating a link among depression, stress, and TMD. Screening for such symptoms should be an integral part of the evaluation for effective cognitive behavioural therapy.

Keywords: Beck′s inventory of depression (BDI), stress symptom rating scale (SSRS), orofacial pain, depression, stress, temporomandibular disorder (TMD)


How to cite this article:
Patil DJ, Dheer DS, Puri G, Konidena A, Dixit A, Gupta R. Psychological appraisal in temporomandibular disorders: A cross-sectional study. Indian J Pain 2016;30:13-8

How to cite this URL:
Patil DJ, Dheer DS, Puri G, Konidena A, Dixit A, Gupta R. Psychological appraisal in temporomandibular disorders: A cross-sectional study. Indian J Pain [serial online] 2016 [cited 2020 May 31];30:13-8. Available from: http://www.indianjpain.org/text.asp?2016/30/1/13/173447


  Introduction Top


Temporomandibular disorder (TMD) is a collective term for a heterogeneous array of psychosocial and physiological disorders associated with the temporomandibular joint (TMJ) and related musculature. TMD is the most common cause of noninfective and nondental pain in the orofacial region. [1] The etiology of TMD is regarded as multifactorial but the relative importance of the individual factors is still unclear. The subgroups of this entity are muscular pathology (myofascial pain) joint pathology, for example internal disc derangement and osteoarthrosis, which are not always painful. [2] Due to the ramifications of the masticatory system, TMD symptoms may be caused by different physiological and/or psychosocial factors such as malocclusion and occlusal interferences, alterations in the masticatory muscles, direct trauma to the jaw or TMJ, microtrauma due to parafunctional habits, or variations resulting from stress. [3] The prevalence of TMD symptoms among the general population is around 40%. [4]

TMD patients may report with temporomandibular (TM) joint pain, headache, earache, clicking and popping sounds, and alteration in jaw movements. Apart from orofacial pain and alteration in jaw mechanics, TMD patients demonstrate elevated pain sensitivity and psychological dysfunction due to impairment in CNS-mediated regulatory processes. [5] Furthermore, physical and emotional stress, along with altered adrenergic receptor-mediated responses due to gene polymorphisms can increase the chances of developing TMD. [6]

The role of psychological factors varies in many cases according to the TMD diagnostic subgroup. [7],[8] In particular, a high incidence of exposure to stressful life events and elevated levels of anxiety and stress-related somatic symptoms have been reported in TMD patients. [9] Findings regarding depression have been less consistent. Some investigators have reported elevated levels of depression [10],[11] and stress, [12] whereas others have found no difference between TMD patients and normal controls. [13] Overall, it has been concluded that even though no definitive psychological profile has been identified, small elevations in stress, depression, and somatisation have been consistently identified in TMD patients. [14] Although there is no consensus regarding the percentage of TMD patients in whom psychological factors play a role, it is clear that such factors need to be taken into account, along with structural indicators to properly diagnose and plan management strategies. [15] This has led to a multidisciplinary approach including the psychological component in the management of TMD. Moreover, psychosocial factors vary according to the etiologic subgroup of diagnosis. In general, these factors are more frequently observed in patients with myogenous TMD. [7],[16]

Taking these factors into consideration, the objective of this study was to analyze the role of stress and depression in TMDs and investigate the prevalence rates of stress and depression in individuals affected with TMD subgroups and healthy controls. Our assumption was that the levels of depression and stress are higher in patients with TMD than in controls.


  Materials and Methods Top


The samples for this cross-sectional study were obtained from patients reporting to the Department of Oral Medicine and Radiology of the institution. The samples were selected by the nonprobabilistic method of sampling. The total sample size was 60, 30 each for the control group and the study group. The samples included male and female patients in the age group of 20-40 years. The duration of the study was 3 months. The study group included patients reporting with a complaint of chronic facial pain (cfp) of more than 6 months and TMJ-related problems. Patients who had no orofacial pain and TMD-related signs were included in the control group. Exclusion criteria were patients with history of trauma, orthodontic treatment, and incomplete data. The study was approved by the ethical committee of the institution and informed consent was taken from the patients.

Diagnostic subgroups

Clinical data collection was performed during the daylight. The examiner was located in front of the subject for the examination of the inner mouth, the masticator muscles, and the external articulations.

Examination of TMD was performed in accordance with the Research Diagnostic Criteria for TMD (RDC/TMD), [17] in which the diagnoses were divided into three groups:

Group 1: In the myofascial pain group, the patient had unilateral, dull, aching preauricular pain radiating to the temporal region, the angle of the mandible, and the occiput; tenderness in one or more of the muscles of mastication; limited mouth opening; and no radiographic evidence of joint pathology.

Group 2: There were further two groups, 2A and 2B; internal derangement with reduction and without reduction.

The diagnosis of an internal derangement was based on the presence of persistent unilateral or bilateral clicking or locking of the TMJ associated with pain and difficulty in opening the mouth.

Group 3: Articular bone (arthritic changes): Degenerative arthritis was diagnosed when the patient had unilateral or bilateral TMJ pain and tenderness associated with radiographic changes and possible crepitant sounds in the joint.

After examination, the patients were administered the following standardized self-report instruments. Beck's inventory of depression (BDI) and stress symptom rating scale (SSRS) (Heilburn and Pepe 1985) were used to assess the presence and degree of depression and stress, respectively, in the study group. The BDI is a state measure of depression, asking patients to respond in terms of how they "have been feeling during the past week, including today." The depression inventories categorize subjects with scores ranging 1-41. SSRS measures the number and severity of stress-related symptoms with scores ranging 1-125. Pain intensity was assessed using visual analogue scale. Its scores ranged 0-10, with 0 for no pain and 10 for severe pain.

Baselines demographic were compared among the samples by using t-test. Mann-Whitney U test was used to analyze the SSRS and chi-square test assessed the BDI. Spearman's rho test was performed to assess the correlation among pain, depression, and stress scores.


  Results Top


The study sample accounted for a total of 120 patients (60 cases and 60 controls) 75% females, 25% males). The mean age in the cases was 25 (SD ± 3.582) years and controls was 27 (SD ± 6.602) years (P > .001). The mean pain duration at the time of the assessment was 23 months.

In the study group, 48 (80%) were females and 12 (20%) were males. TMD was more commonly seen in females than males. According to the TMD/RDC criteria 1 (myofascial pain) was seen in 36 (60%) in the population and Research Diagnostic Criteria (RDC) 2A (internal derangement with reduction) was seen in 24 (40%) in the population.

According to the BDI scores, 53.3% suffered from varying degrees of depression and 47.7% were considered normal in the study group, whereas in the control group 76.7% were normal and 23.3% suffered from depression [Table 1]. Depression was seen in 66% of the myofascial pain group and in 55% of the internal derangement group. Mean BDI score was 12.77 (SD 8.157) in the study group. 50% of the population had scores of 11.50, 75% had 17.50, and 25% had 6.5. In controls, the mean score was 6.13 (SD 6.301) Mann-Whitney U test was performed and was statistically significant P (< 0.001) [Table 2].
Table 1: BDI scores in the study group and control group


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Table 2: SSRS scores in the study group and control group


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Regarding the SSRS scores, varying levels of stress were seen in 60% and very low stress in 40% of the study group. In the control group, very low stress was seen in 56.7% [Table 3]. Likewise, stress also manifested in 58% of the myofascial pain group and 44% in the internal derangement group. Pearson's chi-square test was performed to assess the stress score and was statistically significant (P < 0.01) [Table 4]. Pain intensity levels also correlated with the depression and stress scores. Spearman's rho showed positive correlation among BDI, SSRS, and pain scores (P < .001) [Table 5].
Table 3: Mann-Whitney U test for BDI scores


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Table 4: Chi square test for SSRS scores


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Table 5: Correlation among VAS for pain, BDI, and SSRS scores


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  Discussion Top


In today's world, the common man faces undue pressure both professionally as well as in the domestic forefront causing anxiety, stress, and depression. Many stress-related disorders are now surfacing and TMD is one of them.

Biopsychosocial factors such as increased anxiety levels, depression, somatization, and psychological stress play an important role in the development and progression of TMD. [18] Therefore, these factors must be considered while treating these patients to have a better treatment outcome.

In the present study, we have tried to explore the psychosocial aspect of TMD and considerable differences existed in the levels of stress and depression between the TMD subjects and control subjects. Depression was seen in 53.3% of the patients and stress in 60% of the patients. Patients' depression and stress levels as measured by the BDI and SSRS were significantly elevated in the present study and were highly correlated with pain scores obtained at that time. These results are in concordance with previous research, signifying a potential link between emotional dysfunction and TMD. Several studies have shown a symbiotic relationship between TMD and negative effects such as depression and pain severity. [19],[20] Some authors have quoted high rates of psychopathology in most of the TMD patients. [21],[22] The present results are in agreement with Lundeen et al., [23] who concluded that that only a certain set of patients are clinically depressed, thereby emphasizing the role of tailored treatment therapies for individual TMD patients due to its multifactorial etiology.

In our study, data obtained using the BDI and SRRS were mainly supportive of the notion that psychological factors play a more pronounced role in TMD when pain is of muscular origin. Myofascial patients had higher depression, stress exposure, and overall pain intensity scores. Emotional dysfunctions in an individual may increase the masticatory muscle activity, which in turn may cause TMD. [24] Experimentally induced stress is found to increase masseter activation, [25] which may predispose the individual to develop TMD. These patients are more sensitive and over-imprudent than the healthy normal individuals. [26]

Depression is an affective disorder characterized by a pessimistic sense of inadequacy and a despondent lack of activity. Moderate and severe depressions are very common psychological disorders in the general population. Women in nonclinical samples have more symptoms or a more severe type of depression than men, [27] with a sex ratio of 1.5:2.1 (females:males). [28] The prevalence of depression in the population of patients with chronic pain has been estimated to be 30-54%. [29]

Depression may also decrease the threshold of pain in TMD patients. [30] Several studies have stated a, unswerving association between depression and physical symptoms such as fatigue and general muscle pain, [31] For TMD, especially, depression has been shown to affect expression of its signs and symptoms. [32] In the present study, stress and depression were seen in 60% and 53.3%, respectively, as compared to the controls. Gerschman et al. [33] in his study reported that 18% of the 368 TMD patients experienced depression. Yap et al. and Korszun et al. found no significant difference between comorbidity of depression in TMD and non-TMD patients. [34],[35] It is noteworthy to mention here that the instrument, viz, BDI was utilized in the present study, which actually diagnoses depression, in contrast to the Hospital Anxiety and Depression Scale or other questionnaires, which are used only for screening purposes.

Auerbach et al. [7] and Yoon et al. [36] emphasized the use of BDI, which is a proclamatory instrument for depression among other tools and diagnostic interviews for psychiatric conditions in order to recognize associated psychiatric conditions.

Stress is the response of the individual to environmental stimuli. As stated previously, TMD is linked to stress and its evaluation is important in these patients. In the present study, stress was seen in 60% of the patients as compared to the controls. Manfredino et al., [12] in his study used stress measurement questionnaires and specified that among various psychosomatic conditions of the oral cavity, stress was considerably elevated in patients with TMD. Yoon et al. in their study also reported that 37% of all patients belonged to the high-risk stress category.

This study found that females (75%) were more affected than males with stress and depression than in the control group. This was in accordance with Auerbach et al., [7] and others who by utilizing Laskin's criteria for diagnosing TMD and the BDI, found that female TMD patients were significantly more depressed than males. Parker [37] proposed that it was due to the structural differences between men and women in the components of the articulation, which predisposes females to TMD.

Most of our study subjects were students and professionals who were exposed to psychological stress on account of targets, accomplishments, and rapport with fellow colleagues. [38] A depressed mood is one of the significant factors contributing to TMD-related symptoms in the working population. Physical symptoms such as pain in the head and neck region, eye strain, and chronic back pain can increase due to office environmental factors such as the sitting posture and working for long hours on computers. This can alter the psychological profile of the subject with increased levels of stress, anxiety, and depression. These changes may predispose the individual to develop TMD. [39]

The data sets obtained from this study found a positive relationship among three instruments, viz, VAS for pain intensity, BDI, AND SSRS. The major limitations of this study include a small sample size. Future studies are recommended on a larger TMD population. A larger sample would possibly bring up more irrefutable results.


  Conclusion Top


This study has shown the presence of significant levels of stress and depression in TMD patients. This will help us to better understand the specific areas of psychological dysfunction in TMD to develop more effective early intervention and pain management programs for them, thereby reducing pain, depression, and medication use in TMD patients with high levels of affective distress. Screening for psychological factors should be an integral part of the evaluation of TMD patients. A multidisciplinary approach should be followed in treating these disorders. Tailored treatment therapies should be inculcated, paving the way for cognitive behavioural therapy in emotionally dysfunctional patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc 1993;124:115-21.  Back to cited text no. 1
    
2.
Sipila K, Veijola J, Jokelainen J, Järvelin MR, Oikarinen KS, Raustia AM, et al. Association between symptoms of temporomandibular disorders and depression: An epidemiological study of the Northern Finland 1966 Birth Cohort. Cranio 2001;19:183-7.  Back to cited text no. 2
    
3.
American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Cranio 2003;21:68-76.  Back to cited text no. 3
    
4.
Gonçalves DA, Dal Fabbro AL, Campos JA, Bigal ME, Speciali JG. Symptoms of temporomandibular disorders in the population: An epidemiological study. J Orofac Pain 2010;24:270-8.  Back to cited text no. 4
    
5.
Dougall AL, Jimenez CA, Haggard RA, Stowell AW, Riggs RR, Gatchel RJ. Biopsychosocial factors associated with the subcategories of acute temporomandibular joint disorders. J Orofac Pain 2012;26:7-16.  Back to cited text no. 5
    
6.
Diatchenko L, Slade GD, Nackley AG, Bhalang K, Sigurdsson A, Belfer I, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet 2005;14:135-43.  Back to cited text no. 6
    
7.
Auerbach SM, Laskin DM, Frantsve LM, Orr T. Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients. J Oral Maxillofac Surg. 2001;59:628-34.  Back to cited text no. 7
    
8.
Lindroth JE, Schmidt JE, Carlson CR. A comparison between masticatory muscle pain patients and intracapsular pain patients on behavioral and psychosocial domains. J Orofac Pain 2002;16:277-83.  Back to cited text no. 8
    
9.
Speculand B, Hughes AO, Goss AN. Role of recent stressful life events experience in the onset of TMJ dysfunction pain. Community Dent Oral Epidemiol 1984;2:197-202.  Back to cited text no. 9
    
10.
Gallagher RM, Marbach JJ, Raphael KG, Dohrenwend BP, Cloitre M. Is major depression comorbid with temporomandibular pain and dysfunction syndrome? A pilot study. Clin J Pain 1991;7:219-25.  Back to cited text no. 10
    
11.
Gerschman JA, Wright JL, Hall WD, Reade PC, Burrows GD, Holwill BJ. Comparisons of psychological and social factors in patients with chronic orofacial pain and dental phobic disorders. Aust Dent J 1987;32:331-5.  Back to cited text no. 11
[PUBMED]    
12.
Manfredini D, Marini M, Pavan C, Pavan L, Guarda-Nardini L. Psychosocial profiles of painful TMD patients. J Oral Rehabil 2009;36:193-8.  Back to cited text no. 12
    
13.
Moss RA, Adams HE. Physiological reactions to stress in subjects with and without myofascial pain dysfunction symptoms. J Oral Rehabil 1984;11:219-32.  Back to cited text no. 13
[PUBMED]    
14.
Dahlström L. Psychometrics in temporomandibular disorders: An overview. Acta Odontol Scand 1993;51:339-52.  Back to cited text no. 14
    
15.
Rugh JD, Woods BJ, Dahlström L. Temporomandibular disorders: Assessment of psychological factors. Adv Dent Res 1993;7:127-36.  Back to cited text no. 15
    
16.
Visscher CM, Lobezzoo F, de Boer W, van der Meulen M, Naeije M. Psychological distress in chronic craniomandibular and cervical spinal pain pacients. Eur J Oral Sci 2001;209:165-71.  Back to cited text no. 16
    
17.
Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301-55.  Back to cited text no. 17
    
18.
Pizolato RA, Freitas-Fernandes FS, Gavião MB. Anxiety/depression and orofacial myofacial disorders as factors associated with TMD in children. Braz Oral Res 2013;27:152-62.  Back to cited text no. 18
    
19.
Brown FF, Robinson ME, Riley JL, Gremillion HA. Pain severity, negative effect, and microstressors as predictors of life interference in TMD patients. Cranio 1996;14:63-70.  Back to cited text no. 19
    
20.
Romano JM, Turner JA. Chronic pain and depression: Does the evidence support a relationship? Psychol Bull 1985;97:18-34.  Back to cited text no. 20
[PUBMED]    
21.
Kight M, Gatchel RJ, Wesley L. Temporomandibular disorders: Evidence for significant overlap with psychopathology. Health Psychol 1999;18:177-82.  Back to cited text no. 21
    
22.
Gatchel RJ, Garofalo JP, Ellis E, Holt C. Major psychological disorders in acute and chronic TMD: An initial examination. J Am Dent Assoc 1996;127:1365-70, 1372, 1374.  Back to cited text no. 22
    
23.
Lundeen TF, Sturdevant JR, George JM. Stress as a factor in muscle and temporomandibular joint pain. J Oral Rehabil 1987;14:447-56.  Back to cited text no. 23
    
24.
de Lucena IM, Rodrigues LL, Teixeira ML, Pozza DH, Guimaraes AS. Prospective study of a group of pre-university students evaluating anxiety and depression relationships with temporomandibular disorders. J Clin Exp Dent 2012;4:e102-6.  Back to cited text no. 24
    
25.
Tsai CM, Chou SL, Gale EN, Mccall WD Jr. Human masticatory muscle activity and jaw position under experimental stress. J Oral Rehabil 2002;29:44-51.  Back to cited text no. 25
    
26.
Bonjardim LR, Gavião MB, Pereira LJ, Castelo PM. Anxiety and depression in adolescents and their relationship with signs and symptoms of temporomandibular disorders. Int J Prosthodont 2005;18:347-52.  Back to cited text no. 26
    
27.
Hildebrandt MG, Stage KB, Kragh-Soerensen P. Gender and depression: A study of severity and symptomatology of depressive disorders (ICD-10) in general practice. Acta Psychiatr Scand 2003;107:197-202.  Back to cited text no. 27
    
28.
Sherman JJ, LeResche L, Huggins KH, Mancl LA, Sage JC, Dworkin SF. The relationship of somatization and depression to experimental pain response in women with temporomandibular disorders. Psychosom Med 2004;66:852-60.  Back to cited text no. 28
    
29.
Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: A diathesis-stress framework. Psychol Bull 1996;119:95-110.  Back to cited text no. 29
    
30.
Tylee A, Gastpar M, Lépine JP, Mendlewicz J. DEPRES II (Depression Research in European Society II): A patient survey of the symptoms, disability and current management of depression in the community. DEPRES Steering Committee. Int Clin Psychopharmacol 1999;14:139-51.  Back to cited text no. 30
    
31.
Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;341:1329-35.  Back to cited text no. 31
    
32.
Dworkin SF, Sherman J, Mancl L, Ohrbach R, LeResche L, Truelove E. Reliability, validity, and clinical utility of the research diagnostic criteria for Temporomandibular Disorders Axis II Scales: Depression, non-specific physical symptoms, and graded chronic pain. J Orofac Pain 2002;16:207-20.  Back to cited text no. 32
    
33.
Gerschman JA, Wright JL, Hall WD, Reade PC, Burrows GD, Holwill BJ. Comparisons of psychological and social factors in patients with chronic oro-facial pain and dental phobic disorders. Aust Dent J 1987;32:331-5.  Back to cited text no. 33
[PUBMED]    
34.
Yap AU, Chua EK, Hoe JK. Clinical TMD, pain-related disability and psychological status of TMD patients. J Oral Rehabil 2002;29:374-80.   Back to cited text no. 34
    
35.
Yap AU, Chua EK, Tan KB. Depressive symptoms in Asian TMD patients and their association with non-specific physical symptoms reporting. J Oral Pathol Med 2004;33:305-10.  Back to cited text no. 35
    
36.
Yoon HJ, Lee SH, Hur JY, Kim HS, Seok JH, Kim HJ, et al. Relationship between stress levels and treatment in patients with temporomandibular disorders. J Korean Assoc Oral Maxillofac Surg 2012;38:326-31.  Back to cited text no. 36
    
37.
Parker MW. A dynamic model of aetiology in temporomandibular disorders. J Am Dent Assoc 1990;120:283-90.  Back to cited text no. 37
    
38.
Sugisaki M, Takano N, Kino K, Hayashi K, Saito T, Nishiyama A, et al. Prevalence of temporomandibular disorders among working population of Tokyo. J Jpn Soc TMJ 2008;20:127-33.  Back to cited text no. 38
    
39.
Vasudeva S, Iyengar A, Seetaramaiah N. Correlation of anxiety levels between temporomandibular disorder patients and normal subjects. Journal of Oral Diseases 2014;2014:1-5.  Back to cited text no. 39
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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