Oral parafunction during waking comprises possible behaviors that can be measured with a comprehensive checklist or behavioral monitoring. Multiple studies lead to largely consistent findings: ...stressful states can trigger parafunctional episodes that contribute to myofascial pain. However, this simple causal pathway coexists with at least 3 other pathways: anxiety and stress are potent direct contributors to pain, pain results in maladaptive behaviors such as parafunction, and parafunction may be a coping response to potential threat coupled with hypervigilance and somatosensory amplification. Awake parafunction remains an important risk factor for myofascial pain onset and overuse models alone of causation are insufficient.
The psychosocial and functional consequences of chronic pain disorders have been well documented as having significant effects on the experience of pain, presentation to health care providers, ...responsiveness to and participation in treatment, disability, and health-related quality of life. Thus, psychosocial and functional consequences have been incorporated as 1 of the 5 dimensions within the integrated Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT): 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. In this article we review the rationale for a biopsychosocial perspective, on the basis of current evidence, and describe a set of key psychosocial and behavioral factors (eg, mood/affect, coping resources, expectations, sleep quality, physical function, and pain-related interference with daily activities) that are important consequences of persistent pain and that should be considered when classifying patients within the comprehensive AAPT chronic pain structure. We include an overview of measures and procedures that have been developed to assess this set of factors and that can be used as part of the comprehensive assessment and classification of pain and to address specific research questions.
Psychosocial and functional consequences are important considerations in the classification of individuals with chronic pain. A set of key psychosocial and behavioral factors (eg, mood/affect, coping resources, expectations, sleep quality, physical function, and pain-related interference with daily activities) that should be considered when classifying patients within the comprehensive classification of chronic pain disorders developed by the AAPT are outlined and examples of assessment methods for each are described.
Painful temporomandibular disorders (TMDs) are both consequence and cause of change in multiple clinical, psychosocial, and biological factors. Although longitudinal studies have identified ...antecedent biopsychosocial factors that increase risk of the TMD onset and persistence, little is known about long-term change in those factors after TMD develops or remits. During a 7.6-year median follow-up period, we measured change in psychosocial characteristics, pain sensitivity, cardiovascular indicators of autonomic function, and clinical jaw function among 189 participants whose baseline chronic TMD status either persisted or remitted and 505 initially TMD-free participants, 83 of whom developed TMD. Among initially TMD-free participants who developed TMD, symptoms and pain sensitivity increased, whereas psychological function worsened. By contrast, participants with chronic TMD at baseline tended to show improved TMD symptoms, improved jaw function, reduced somatic symptoms, and increased positive affect. In general, clinical and psychosocial variables more frequently changed in parallel with TMD status compared with pain sensitivity and autonomic measures. These findings demonstrate a complex pattern of considerable changes in biopsychosocial function associated with changes in TMD status. In particular, several biopsychosocial parameters improved among participants with chronic TMD despite pain persisting for years, suggesting considerable potential for ongoing coping and adaptation in response to persistent pain.
Objective As part of the Multisite Research Diagnostic Criteria For Temporomandibular Disorders (RDC/TMD) Validation Project, comprehensive temporomandibular joint diagnostic criteria were developed ...for image analysis using panoramic radiography, magnetic resonance imaging (MRI), and computerized tomography (CT). Study design Interexaminer reliability was estimated using the kappa (κ) statistic, and agreement between rater pairs was characterized by overall, positive, and negative percent agreement. Computerized tomography was the reference standard for assessing validity of other imaging modalities for detecting osteoarthritis (OA). Results For the radiologic diagnosis of OA, reliability of the 3 examiners was poor for panoramic radiography (κ = 0.16), fair for MRI (κ = 0.46), and close to the threshold for excellent for CT (κ = 0.71). Using MRI, reliability was excellent for diagnosing disc displacements (DD) with reduction (κ = 0.78) and for DD without reduction (κ = 0.94) and good for effusion (κ = 0.64). Overall percent agreement for pairwise ratings was ≥82% for all conditions. Positive percent agreement for diagnosing OA was 19% for panoramic radiography, 59% for MRI, and 84% for CT. Using MRI, positive percent agreement for diagnoses of any DD was 95% and of effusion was 81%. Negative percent agreement was ≥88% for all conditions. Compared with CT, panoramic radiography and MRI had poor and marginal sensitivity, respectively, but excellent specificity in detecting OA. Conclusion Comprehensive image analysis criteria for the RDC/TMD Validation Project were developed, which can reliably be used for assessing OA using CT and for disc position and effusion using MRI.
Although cross-sectional studies of temporomandibular disorder (TMD) often report elevated prevalence in young women, they do not address the risk of its development. Here we evaluate ...sociodemographic predictors of TMD incidence in a community-based prospective cohort study of U.S. adults. Symptoms and pain-related disability in TMD cases are also described. People aged 18 to 44 years with no history of TMD were enrolled at 4 study sites when they completed questionnaires about sociodemographic characteristics. During the median 2.8-year follow-up period, 2,737 participants completed quarterly screening questionnaires. Those reporting symptoms were examined clinically and 260 had first-onset TMD. Additional questionnaires asked about severity and impact of their symptoms. Univariate and multivariable Cox regression models quantified associations between sociodemographic characteristics and TMD incidence. First-onset TMD developed in 3.9% of participants per annum, typically producing mild to moderate levels of pain and disability in cases. TMD incidence was positively associated with age, whereas females had only slightly greater incidence than males. Compared to whites, Asians had lower TMD incidence whereas African Americans had greater incidence, although the latter was attenuated somewhat after adjusting for satisfaction with socioeconomic circumstances.
In this study of 18- to 44-year-olds, TMD developed at a higher rate than reported previously for similar age groups. TMD incidence was positively associated with age but weakly associated with gender, thereby differing from demographic patterns of prevalence found in some cross-sectional studies. Experiences related to aging merit investigation as etiologic influences on development of TMD.
Papers in this issue investigate when and how putative risk factors influence development of first-onset, painful temporomandibular disorder (TMD). The results represent first findings from the ...Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) prospective cohort study that monitored 2,737 men and women aged 18 to 44 years recruited at 4 U.S. study sites. During a median 2.8-year follow-up period, 260 participants developed TMD. The average incidence rate of 4% per annum was influenced by a broad range of phenotypic risk factors including sociodemographic characteristics, health status, clinical orofacial factors, psychological functioning, pain sensitivity, and cardiac autonomic responses. A novel method of multivariable analysis used random forest models to simultaneously evaluate contributions of all 202 phenotypic variables. Variables from the health status domain made the greatest contribution to TMD incidence, followed closely by psychological and clinical orofacial domains. However, only a few measures of pain sensitivity and autonomic function contributed to TMD incidence, and their effects were modest. Meanwhile, age and study site were independent predictors of TMD incidence, even after controlling for other phenotypes. Separate analysis of 358 genes that regulate pain found several novel genetic associations with intermediate phenotypes that, themselves, are risk factors for TMD, suggesting new avenues to investigate biological pathways contributing to TMD.
Collectively, the papers in this issue demonstrate that TMD is a complex disorder with multiple causes consistent with a biopsychosocial model of illness. It is a misnomer and no longer appropriate to regard TMD solely as a localized orofacial pain condition.
Clinical characteristics might be associated with temporomandibular disorders (TMD) because they are antecedent risk factors that increase the likelihood of a healthy person developing the condition ...or because they represent signs or symptoms of either subclinical or overt TMD. In this baseline case-control study of the multisite Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project, 1,633 controls and 185 cases with chronic, painful TMD completed questionnaires and received clinical examinations. Odds ratios measuring association between each clinical factor and TMD were computed, with adjustment for study-site as well as age, sex, and race/ethnicity. Compared to controls, TMD cases reported more trauma, greater parafunction, more headaches and other pain disorders, more functional limitation in using the jaw, more nonpain symptoms in the facial area, more temporomandibular joint noises and jaw locking, more neural or sensory medical conditions, and worse overall medical status. They also exhibited on examination reduced jaw mobility, more joint noises, and a greater number of painful masticatory, cervical, and body muscles upon palpation. The results indicated that TMD cases differ substantially from controls across almost all variables assessed. Future analyses of follow-up data will determine whether these clinical characteristics predict increased risk for developing first-onset pain-related TMD PERSPECTIVE: Clinical findings from OPPERA's baseline case-control study indicate significant differences between chronic TMD cases and controls with respect to trauma history, parafunction, other pain disorders, health status, and clinical examination data. Future analyses will examine their contribution to TMD onset.
The advances made in recent years regarding technological approaches to medical and dental diagnosis are impressive. However, while those tools, procedures, and instruments may produce an improved ...clinical diagnosis or discover a new disorder, they also can be misused and misinterpreted in various ways. In the field of temporomandibular disorders (TMDs), the very nature of those conditions is similar to common orthopedic problems elsewhere in the body. Yet, beyond imaging of the affected areas, there have been few important new technological approaches to augment the traditional history and examination for a sufficient diagnosis of such problems. The traditional approach is exemplified by the Diagnostic Criteria for Temporomandibular Disorders which has high inter-examiner reliability and diagnostic validity; translations into over 20 languages allow for widespread use. In contrast and unfortunately, the TMD field is replete with a variety of so-called diagnostic instruments and procedures, which have not been tested for diagnostic validity; these instruments and procedures, through misuse, are capable of complicating a true diagnosis of patients who present with symptoms, while also creating new patients by finding so-called abnormalities in healthy subjects. This paper discusses those technological approaches and their misuse with respect to TMD diagnosis from a critical viewpoint, and the authors argue that there are significant risks for patients if their uncritical implementation becomes accepted and widespread. Therefore, dentists are encouraged to reject the proposed application of such technological approaches to diagnosis of the stomatognathic system.
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