ASSOCIATION BETWEEN ANXIETY - AS STATE OR TRAIT - AND THE SIGNS AND SYMPTOMS OF CRANIOMANDIBULAR DISORDERS

Headnote

Abstract

The lack of sufficient scientific evidence to support the role of occlusion as an etiologic factor in craniomandibular disorders gave credit to the role of the psycho-emotional factors able to predispose to this condition and to perpetuate it. Among them, anxiety holds a prioritary position. The aim of the research was to shed light on the signs and symptoms of craniomandibular disfunction manifested in a group of patients and on their possible association with psycho-emotional characteristics (stress, anxiety). Materials and method. A cross-sectional study was performed on a group of 54 subjects (16M, 38W), by means of a screening questionnaire for craniomandibular disfunction, containing 20 questions structured on five issues: pain, disfunction, parafunction, psycho-emotional status, trauma/iatrogenic condition. For psychological examination, the STAI I and II (State-Trait Anxiety Inventory) questionnaires were applied. These psychometric instruments, containing 20 items, provide the current level of anxiety scores of the subject and the degree to which he/she is prone to anxiety. The NCSS Dawson edition statistical program was used to analyze the collected data. Results. The score of psycho-emotional characteristics evaluation correlates with the severity of craniomandibular disfunction (r = 0.5743). The specific score of the signs and symptoms manifested in craniomandibular disfunctions shows a good correlation with the disfunctional condition (0.7737). In the investigated group, fewer subjects assessed anxiety, however the predisposition to anxiety is the dominant trend, more evident in male subjects. Conclusions. Within the limits of this investigation, the psycho-emotional factors included in the screening questionnaire appear to play a role in defining a prioritary craniomandibular disfunctional state. At the same time, the results provided by the used psychometric instruments are less conclusive. Further studies are required, on more numeorus groups of subjects, for permitting a more reliable comparison between the data of the screening questionnaire for craniomandibular disfunction and those of psychological evaluation (STAI I and II).

Keywords: craniomandibular disfunction, anxiety, depression, psychological evaluation.

1. INTRODUCTION

The craniomandibular disfunction (CMD) is a disease characterized by pain in the masticatory muscles and temporomandibular joints, by joint noises, limitation or atypical trajectory of mandibular kinematics during mouth opening [1]. The etiology of this condition is multifactorial. The poor scientific evidence to support the etiologic role of occlusal factors gave more credit to the psycho-emotional factors capable to predispose to this condition or to perpetuate it. Among them, stress, anxiety and depression rank as a priority [2]. Although only 3-11% of the symptomatic patients require treatment, the psycho-emotional factors manifested in such cases are quite obvious. This comorbidity contributes greatly to an altered, sometimes severe, quality of life [3].

Starting with the reference work of Mohl and Ohrbach (1992) on the occlusal features as contributing factors to craniomandibular disorders, most recent data from the literature suggest that occlusion has a secondary role, following trauma, oral parafunctional activities, stress, anxiety and depression [4].

Patients with CMD, especially the myogenic ones, show a more pronounced tendency for somatization [5], depression [6] or alexithymia [7]. Undoubtedly, considering the psychosocial impact of this condition in relation with an impaired quality of life, it is important to have a standardized diagnostic for avoiding delayed decisions and treatment of such disfunctions.

Several psychological assessment tools have been used for defining a typically personified profile of the condition [8-11]. The psychosocial factors (stress, anxiety, depression) are not only etiologic, but also therapeutic targets in patients with CMD, so that psychotherapy has a crucial role in the initial phases of treatment [12-15].

The aim of the present research was to shed light on the signs and symptoms of craniomandibular disfunction manifested in a group of patients and on their possible association with psycho-emotional characteristics (stress, anxiety).

2. MATERIAL AND METHODS

A cross-sectional study was performed on a group of 54 subjects (16M, 38W), representing randomly selected students with a mean age of 22 years. Two of them did not complete the questionnaire and, therefore, were excluded from the study. A screening questionnaire was applied for CMD, containing 20 questions grouped into five sections: pain, disfunction, parafunction, psycho-emotional status, trauma/ iatrogenic condition. The score for this questionnaire ranges between 0-5. For psychological examination, STAI I and II (StateTrait Anxiety Inventory) questionnaires were applied. The scores of this psychometric tool range from 20 to 80.

The psychometric instruments with 20 items provide the current level of anxiety scores of the subject and the degree to which he/she is prone to anxiety. Each participant has expressed informed consent to participate in the study. The data obtained from the questionnaires were listed in table I. The NCSS Dawson edition statistical program was applied to analyze the collected data and Pearson correlation was applied to measure the relation between CMD severity and the five dimensions of the CMD Questionnaire. Descriptive statistics was used to show the prevalence of anxiety - as either state or trait - among the subjects with and without CMD.

3. RESULTS

The values collected from the CMD, STAI I and STAI II questionnaires are listed in Table 1.

The score evaluating the psycho-emotional characteristics is linearly related to the severity of CMD. The correlation coefficient r is 0.5743, and the coefficient of determination r^sup 2^=0.2995. Specific signs and symptoms of CMD show a good correlation with the degree of the disfunctional condition (r = 0.7737 and r^sup 2^ = 0.5086) (Figs. 1 and 2). The prevalence of anxiety as a state or trait among subjects with CMD is presented in Table 2.

4. DISCUSSION

In patients with craniomandibular disfunction, psychometric assessments are necessary, if considering the significant psychological differences recorded among subjects affected with disfunctional symptoms. When a psycho-emotional impairment is present in these patients, the role of the psychologist is essential [16].

In the investigated group, few subjects assesed anxiety, however the predisposition to anxiety is the dominant trend, more evident in male subjects. Baujardins et al. studied the prevalance of craniomandibular disorders in a group of students according to gender, occlusion and psychosocial factors, finding no statistically significant association between disfunction severity and HADS and no association between the CMD score and HADS [17]. Other authors, who observed children with disfunctional symptoms, registered different levels of anxiety, the association being a bidirectional one [18].

Kindler et al. pereformed a general population analysis in a prospective cohort study devoted to the signs and symptoms of depression and anxiety as risk factors for craniomandibular disorders, which involved clinical examination and CID-S (Composite International Diagnostic-Screener) utilization. They discovered anxiety symptoms associated with joint and muscle pain and concluded that, for an effective treatment, the diagnosis, prevention and treatment of such disfunctions should take into account the symptoms of depression and anxiety [19].

Mighelli et al. investigated - on a sample group of 1,493 students - the prevalence of CMD and its association with anxiety and depression. As assessment tools, they used the Fonseca Anamnestic Questionnaire and HADS. A percentage of 42.4% of the subjects evidenced disfunctional symptoms and 30.5% of them - signs of anxiety and depression. Also, 61.4% of the subjects suffering from anxiety had CMD. The authors' conclusion was that psychosocial factors (anxiety, stress, depression) have a role in the multifactorial etiology of CMD. Students often experience emotional stress, and it is important to recognize the manifestation of CMD signs for the establishment of a timely treatment [20].

In patients with CMD, a psychometric approach that assesses how the patient is able to cope with the disfunction and with its etiological causes (psychological defense mechanisms) would be probably more appropriate.

5. CONCLUSIONS

Within the limits of this investigation, the psycho-emotional factors included in the screening questionnaire appear to play a role in defining a prevalent craniomandibular disfunctional condition. However, the results provided by psychometric instruments are less conclusive.

Further studies are still necessary, on more numerous groups of subjects, permitting a more complete comparison of the data from the screening questionnaire for craniomandibular disfunction with those of psychological evaluation.

References

References

1. Okeson JP, editor. Differential diagnosis and management consideration of temporomandibular disorders. In: Oroffacial Pain: Guidelines for assessment, diagnoses and management, Chicago: Quintenssence 1996

2. Benoliel R, Svensson P, Eliav E. Pathophysiology of Masticatory Myofascial Pain. In:Greene CS, Laskin DM, editors. Treatment of TMD s. Bridging the gap between Advances in Research and Clinical Patient Management. Hanover Park. Quintessence Publishing Co.;2013. p.1732.

3. De Freitas RF, Ferreira MA, Barbosa GA, Calderon PS. Counselling and self-management therapies for temporomandibular disorders: a systematic review. J Oral Rehabil. 2013; 40(11): 864-74.

4. Mohl ND, Ohrbach R. The dilemma of scientific knowledge versus clinical management of temporomandibular disorders. J Prosthet Dent. 1992;67(1):11320.

5. McGregor NR, Butt HL, Zerbes M, Klineberg, Dunstan RH, Roberts TK. Assessement of pain ( distribution and onset), symptoms, SCL-90-R Inventory responses, and the association with infectious events in patients with chronic orofacial pain. J Orofac Pain. 1996; 10(4):339-50.

6. Madland G, Feinmann C, Newan S. Factors associated with anxiety and depression in facial arthromyalgia. 2000; 84(2-3):225-32.

7. Spila K: Facial pain and temporomandibular disorders, Oulu University Press, 2002.

8. Turner JA, Dworkin SF. Screening for psychosocial risk factors in patients with chronic orofacial pain. J Am Dent Assoc. 2004;135(8):1119-5.

9. Jerjes W, Madland G, Feinmann C, El Maaytah M, Kumar M, Hopper C, Upile T, Newman S. Psychoeeducation programme for temporomandibular disorders: a pilot study. J Negat Results Biomed. 2007;6(4): 1-7.

10. Vasudeva S, Iyengar A, Seetaramaiah N. Correlation of Anxiety Levels between Temporomandibular Disorder Patients and Normal Subjects. Journal of Oral Research, 2014; http://dx.doi.org/10.1155/ 2014/579674.

11. Boscato N., Almeida RC, Koller CD, Presta AA, Goettems ML. Influence of anxiety on temporomandibular disorders - an epidemiological survey with elders and adults in Southern Brazil. J Oral Rehabil. 2013; 40(9): 643-9.

12. Jedel, E, Carlsson J. Biofeedback, acupuncture and transcutaneous electric nerve stimulation in the management of temporo-mandibular disorders: a systematic review. Phys Ther Rev. 2003; 8(4):217-23.

13. Celic R, Panduric J, Dulcic P. Psychologic Status in Patients with Temporomandibular Disorders. Int J Prosthodont. 2006; 19(1):28-9.

14. Selaimen CM, Jeronymo JC, Brilhante D, Grossi ML. Sleep ans Depression as Risk Indicators for Tempo-romandibular Disorders in a Cross-Cultural Perspective: A Case- Control Study. Int J Prosthodont. 2006; 19(2): 154-61.

15. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electro-therapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther. 2006;86(7):955-73.

16. Mutulu N, Herken H, Gunay E, Oz F, Kalayci A. Evaluation of the Prevalence of Temporomandibular Joint Disorders Syndrome in Dental School Students with Psychometric Analysis. Turk J Med Sci. 2002; 32:345-50.

17. Bonjardim LR, Lopes-Filho RJ, Amado G, Albuquerque RL, Goncalves SR. Association between symptoms of temporomandibular disorders and gender, morphological occlusion, and psychological factors in a group of university students. Indian J Dent Res. 2009; 20(2):190-4.

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(2):155-62.

19. Kindler S, Samietz S, Houshmand M, Grabe HJ, Bernhardt O, Biffar R, Kocher T, Meyer G, Völzke H, Metelmann HR, Schwahn C. Depressive and Anxiety Symptoms as Risk Factors for Temporomandibular Joint Pain: A Prospective Cohort Study in the General Population. J Pain. 2012;13(12):1188-97.

20. Minghelli B, Morgado M, Caro T. Association of temporomandibular disorder symptoms with anxiety and depression in Portuguese college students. J Oral Sci. 2014; 56(2):127-33.