Level of Depression in Temporomandibular Disorder Patients

Tooba Saeed¹                                                               FCPS

Nabeela Riaz²                                              FCPS, MCPS

INTRODUCTION

Temporomandibular disorders (TMDs) are musculoskeletal¹ pain conditions characterized by pain in the temporomandibular joint (TMJ) and/or the masticatory muscles.² The prevalence of TMD symptoms among the general population is around 40%.³

Epidemiological studies show that 50-75% of the persons in a certain population have at least one sign of TMDs during their life, while 20-25% of the persons suffer from significant symptoms related to the TMDs.⁴ The most important symptom is pain, followed by restricted mandibular movements, which can cause difficulty in eating or speaking; noises from the temporomandibular joints during jaw movement are also recorded. The etiology and pathogenesis of this condition is poorly understood, therefore treatment of temporomandibular joint diseases is sometimes difficult. Understanding the etiology of temporomandibular joint disorders is extremely important in identifying and avoiding potential pathologic factors.⁵ Due to the complexity 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 caused by continuous parafunctional habits or alterations secondary to stress.³

The role of stress and personality in the etiology of the temporomandibular pain dysfunction syndrome has undergone extensive scrutiny. Psychological studies have shown that patients with TMD have similar psychological profiles and psychological dysfunction as other chronic musculoskeletal pain disorders, such as tension type headache and back or arthritic pain. There is considerable evidence that psychological and psychosocial factors are of great importance in the understanding of TMD, but there is less evidence that these factors are etiologic.⁵

Laskin⁶ was the first to suggest that the main factor responsible for TMD is the emotional instead of the physical aspect. During the last decade, numerous investigations have been devoted to understand the relationship between psychological stress and TMD. Patients suffering from this condition report that their symptoms increase during stressful situations . De Leeuw et al⁷ consider that muscle dysfunction and accompanying pain are very often the result of stress induced muscular hyperactivity . Stress-induced muscular dysfunction may induce secondary changes in the TMJ. Raised elevator tonus leads to increased intraarticular pressure in TMJ and alteration in the normal biomechanics, resulting in microtraumatic damage to the joint capsules and disk attachment. However, the studies that investigate psychological factors present mixed results. Some investigators related electromyographic changes in masticatory muscle baseline values between patients with TMD and control individuals, while others did not find significant differences in electromyographic activity baseline values between patients and controls. These inconsistencies may be probably due to different methodologies used.⁸ Nowadays the association between depression and stress and different physical symptoms of TMD is widely acknowledged.⁵ The purpose of this study is to determine the level of depression in patients with TMD. These findings can guide the diagnosis, prevention, and treatment of TMDs.

METHODOLOGY

We undertook  a prospective study, on patients who presented with Temporomandibular disorders (TMDs), in the department of oral and maxillofacial surgery, King Edward medical university, Mayo hospital Lahore from Aug, 2017 to Dec, 2017.  Prior to enrollment in the study, participants were screened and underwent a baseline physical examination of the head and neck, conducted according to the research diagnostic criteria (RDC/TMD) for TMD.¹ 150 patients completed psychological questionnaire with their informed consents. Questionnaire selected was Beck’s Depression Inventory, to assess the level of depression in patients with TMDs. Variables were Patients age, gender and level of depression. Data was entered in SPSS. We also categorized patients in 15-30 year age group and the 31-50 year age group. Chi-square test was used to determine statistically significant difference in level of depression among age groups and male female patients (p<0.05).

RESULTS

Mean age of patients was 31years, with minimum age 17 years and maximum 50 years. Of them, in age group 15-30 years, there were 91 (60.7%) patients. While, 59(39.3%) patients were belonged to 31-50 years age group( Fig 1). Out of total 150 patients, 93 (62%) were females and 57(38%) were males (Fig 2). Among females 69.9 % were from 15-30 years age group, while 45.6 % of males were belonged

Table 1: Patient Level of Depression

Fig 1: Frequency of  age groups in TMD patients

Figure 2: Frequency of  male and female TMD patients

to15-30 years age group. But the difference was not significant statistically.  Among patients, moderate depression was more frequent i.e., 30.7%. Severe depression was 22.0 % while extreme depression was 16 %. 10% of patients were with borderline clinical depression (Fig 3). Moderate and severe depressions were significant in female patients. In females

Fig 3: Frequency of Patient Level of Depression

Fig 4: Level of depression in Age groups

Fig 5: Level of depression among male and female patients

moderate depression was 28%, while severe depression was 30.1%. Extreme depression in females was only8.6 %. On contrary, extreme depression was more significant in males, 28.1 %. In male patients, moderate depression was 35.1% and severe depression was only 8.8 %. In 21.5 % of females, there were normal ups and downs in mood. While 8.8% of males had normal ups and downs in mood (Fig 5). Similarly, mild mood disturbance in females was relatively more pronounced, 7.5%. Border line clinical depression was 19.3 % in males and 4.3% in female patients. Level of depression is significantly different in age groups and male female patients i.e, p=0.01and p=0.04 respectively.

DISCUSSION

Over the last 75 years, a variety of etiologic factors has been suggested as the cause of pain and dysfunction in the temporomandibular system. The earliest and still-popular etiologic theory proposed that temporomandibular disorders are induced by abnormal structure, usually described as a malocclusion of the teeth or jaws. The fact that this theory was based on mechanical concepts, ignored biologic diversity, and had limited factual experimental evidence to support it as well as extensive evidence in opposition did not seem to matter to its proponents. In the late 1960’s and early 1970’s, the structural occlusal model for TM Disorders was challenged and has yielded ground to a more multifactorial model of TMD causation. Other etiologic factors for TM disorders-such as anatomical susceptibility of TM tissues to trauma, polyarthritic diseases, joint laxity, repetitive parafunctional behaviors, and stress-related muscle dysfunction–were recognized.⁹

Importance of the psychological factors for development of the TMD grows every day and is potentiated by the inability of proving any other valid etiological factors. According to Green¹⁰ unresolved psychological issues, such as depression and anxiety, can cause tension which inevitably leads to bruxism and parafunctions, which in turn cause TMD. Psychological factors as etiological factors in development of the TMD cannot be ignored, since they play a great role in many painful conditions in the organism, including the TMD. Kinney et al¹¹ in their research noted that the psychological disorders are the key factors in the development of TMD. The most recent investigations on TMD focus on the relationship between the physical and psychological factors. A number of published papers proved the relationship between the TMD and anxiety, depression and stress, but they failed to reveal the cause of this relationship.¹²

Most studies on TMDs had been carried out in developed countries, and little is known about TMDs in developing countries such as Pakistan for development of standardized clinical measures, have been suggested to improve reliability, potentially and validity of clinical examinations. The Research Diagnostic Criteria for TMD (RDC/TMD) was established to allow standardization and replication of the most common forms of research relating muscle and joint.¹³ Since RDC/TMD is an internationally recognized and widely adopted tool for TMD research, its methodology was used in this study.^1,2

These data essentially support and extend prior studies, which have shown that TMD patient samples report relatively more psychologic and somatic symptoms. Most previous studies, however, have used ill-defined control groups.¹⁴ TMDs have been reported to primarily affect young and middle-aged adults, and they are approximately twice more common in women than in men in the general population.¹⁵ These findings are in accordance with our study. Mean age group of TMDs patient was 31years, females were 62 % while males were 38%.  Diracoglu (2016) revealed in his study that, among the patients with TMD, the groups who were considered to have anxiety and depression were female patients, patients with deficient social support system, and patients with myofacial pain alone or patients with myofacial pain accompanying an existing TMJ disorder.¹⁶ Both the women and men TMD patients in the present study reported significantly more and/or more frequent somatic, psychologic, and behavioral symptoms on the Beck’s Depression Inventory, on average. Thus, there is some justification for concluding that the results of prior studies using largely female TMD patient samples might be generalized to male TMD patient samples.

Individuals with TMD are more anxious and depressive than asymptomatic ones, and TMD symptoms have their onset and are exacerbated in periods of psychological stress. In addition, pain on the temporomandibular joints has been associated with general anxiety.¹⁷ TMD pain is the commonest symptom that compels patients to seek therapy. The prevalence of the signs and symptoms of TMD has been reported to vary from 6 to 93%, while only 3.6 to 7% of the general populations have been estimated to be in need of treatment. These wide ranges of prevalence may be probably due to different criteria and methodologies used.⁸ In TMDs, treatment is directed to the elimination of the pain and/or dysfunction such as limitation. Medicines such as analgesics and anti-inflammatory drugs, psychological consultation, TMJ imaging is necessary when the symptoms persist or worsen during the treatment. For cases with only clicking and/or deviation, TMJ imaging is not necessary. Different intraoral appliances and splints, and arthrocentesis (hydraulic distension) have been used for elimination of the etiologic factor(s) of the complaints.¹⁵

Bertoli (2016) reported elevated levels of suicidal ideation, depression, and anxiety in a chronic TMD population, especially in those with chronic muscle pain, compared to the general population. He emphasized the need for screening for suicidality and other comorbidities in TMD patients suffering from chronic pain.¹⁸ Brandini et al in his exploratory study has provided data suggesting that psychological factors, manifesting in depression and stress, play a role in influencing the association between pain and motor activity. In his study, there were significant (P < .05) positive correlations between depression and jaw amplitude and stress and jaw velocity for standardized but not free chewing.¹⁹ Some recent reports^2,20,21 also prove the multicausal etiology of the TMD, although anxiety and depression may also arise from some organic pathological condition. It is possible that in some patients the predisposing role is played by psychological factors coupled with a decreased tolerance to pain threshold and reduced tolerance to stress. Lajnert V(2010), recommended introduction of psychological therapy for the chronic painful conditions. Besides the traditional psychotropic drugs (trycyclic antidepressants), introduction of psychological intervention, stress management and change of habits as a part of the integral treatment of TMD patients with depression, can be effective in reduction of painful conditions and tension in various types of patients suffering from TMD.⁴

Velly AM,(2011) found a moderately positive correlation between depression and catastrophizing, which will in turn contribute to an increase in pain intensity, disability, and the onset and progression of clinically significant pain. These findings were not surprising since catastrophizing is an element of the distorted cognitive processes associated with clinical depression. It should also be noted that symptoms of depression are reported in a number of studies with TMD pain patients. They found that catastrophizing and depression both constitute factors that will complicate management of TMD and thus, are needed to be considered in both evaluation and management of TMD. Simple cases without or with minimal comorbid conditions involvement can be managed by a single clinician with single treatments. Nevertheless, it is critical to match the level of complexity of the management program with the comorbid conditions reported by the patient. Failure to identify and to address the entire scope of the problem may lead to no improvement in pain or function, and further perpetuation of the problem. Once identified, complex TMD patients, particularly those with comorbid conditions, can best be managed within an interdisciplinary pain clinic setting.²² Fernandes Azevedo AB, study results corroborates a previous paper²³, which stated that no significant association could be found between anxiety and disorders in general. However, many authors .^24-26 found a significant association between anxiety and TMD. This finding may be explained by methodological differences, since some studies comprised a sample of nonpatients, differing from the papers that measured anxiety levels in subjects seeking treatment.¹⁷

Some limitations in the present study need to be pointed out. First, standard questionnaires were used in the present study. However, inaccuracies may always occur when gathering data with questionnaires. The reporting of symptoms may depend on several factors, e.g., subjects’ motivation; therefore, comparing data of different studies may include bias due to cultural or societal differences. Sometimes individual with different kinds of stress may be more likely to perceive, over-react and complain about their sensations during reporting of symptoms. Also we did not categorized patients according to etiology of TMD, like mayofacial pain vs nonmayofacial pain groups and severity of TMD, like like acute vs chronic TMD patients.

CONCLUSION

TMD patients experienced different Level of depression from no depression to extreme depression. Moderate, severe and extreme depressions were remarkable among TMD patients. But further research on more selected groups of TMD patients is needed, including controlled studies of pharmacological and/or psychotherapeutic intervention, to clarify the role of depression in this condition.

CONFLICT OF INTEREST

There is no conflict of interest and funding.

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1. Senior Registrar, Department of Oral and Maxillofacial Surgery, The University of  Lahore.
2. Associate professor, HOD, Department of Oral and Maxillofacial Surgery, King  Edward Medical University/Mayo Hospital Lahore.

Corresponding author: “Dr. Tooba Saeed ” <drtoobasaeed@yahoo.com >