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326
Relationship between stress levels and treatment in patients
with temporomandibular disorders
Hyung-Jun Yoon1, Sung-Hee Lee2, Jun-Young Hur3, Hye-Sun Kim3,
Jeong-Ho Seok1, Hyung-Gon Kim3, Jong-Ki Huh3
1Department of Psychiatry, Gangnam Severance Hospital, College of Medicine, Yonsei University, Seoul,
2Department of Dentistry, Yongin Severance Hospital, Yonsei University, Yongin,
3Department of Oral and Maxillofacial Surgery, Gangnam Severance Hospital, College of Dentistry, Yonsei University, Seoul, Korea
Abstract (J Korean Assoc Oral Maxillofac Surg 2012;38:326-31)
Objectives:
Stress may have an impact on treatment types that patients receive for temporomandibular disorders (TMDs). This study sought to
investigate the relationship between the stress index and type of treatments in patients with TMD.
Materials and Methods:
The psychosocial well-being index-short form (PWI-SF) was used to evaluate stress levels in ninety-two patients with
TMD. Treatment types were classified into two groups: one group received counseling, physical therapy or medication, while the second group
received splint therapy or surgical intervention.
Results:
The high-risk group (PWI-SF≥27, the higher the points, the more severe the stress level) was more frequently treated by splint therapy than
the low-risk group (PWI-SF<27). Female TMD patients reported higher PWI-SF scores than male TMD patients.
Conclusion:
This study suggests a relationship between stress levels and treatment types for patients with TMD. Thus, the appropriate evaluation and
management of stress could be an important factor in treating TMD.
Key words:
Temporomandibular disorders, Psychological stress, Occlusal splints
[paper submitted 2012. 5. 29 / revised 1st 2012. 8. 15, 2nd 2012. 10. 15 / accepted 2012. 10. 29]
factorintheassessmentandtreatmentofTMDpatientssince
itcontributesto the occurrence andaggravationofvarious
psychiatricdisorderssuchasdepressionand TMD2.Dueto
thepatient'slackofunderstandingandcooperation,however,
itisdifficult to conduct theAxisIItest6which provides
thecriteriafor diagnosing the psychosocialconditions
fortheResearch Diagnostic Criteria forTMDpresented
as a methodologyfor studies onTMD andtorequire the
collaborationwiththe psychiatric department basedonthe
testresult.ThisstudysoughttoexplaintheTMDmoreclearly
tothepatientandapproachtotheTMDofapatientvisitinga
dentalclinicwithdepression,anxiety,andemotionalstress.
Asimplesurvey on emotional stresswasusedtoidentify
therelationshipbetweenemotionalstressandTMDandwas
madeassimpleaspossible.
Itwasassumed that if emotionalstressaffectedthe
occurrence,progress,andtreatmentoftheTMD;logically,the
varyingstresslevelscalledfordifferenttypesoftreatments.
Toconfirmthisassumption,TMDpatientsvisitingourdental
clinicforthefirsttimewereassessedin termsoftheirlevel
I. Introduction
Theincreaseof emotional stress maybeafactorin the
occurrence,progress,andtreatmentofatemporomandibular
disorders(TMDs)since it causes theriseoftension in the
headandneckmuscles,declineofphysiologicaltoleranceof
noxiousstimuli,andpersistenceofadversemuscleactivities
includingclenchingandbruxism1,2.Acuteandchronicstress
isknownto cause and exacerbatedepression3whichis
consideredtobeworsenedbynegativestressincidentssuch
asdeathof a loved one,divorce,andunemploymenteven
further4,5.Therefore,emotionalstressmaybeacrucialclinical
Jong-Ki Huh
Department of Oral and Maxillofacial Surgery, Gangnam Severance Hospital,
College of Dentistry, Yonsei University, 211, Eonju-ro, Gangnam-gu, Seoul
135-720, Korea
TEL: +82-2-2019-4560 FAX: +82-2-3463-4052
E-mail: omshuh@yuhs.ac
This is an open-access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/),
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
CC
ORIGINAL ARTICLE
http://dx.doi.org/10.5125/jkaoms.2012.38.6.326
pISSN 2234-7550·eISSN 2234-5930
Relationship between stress levels and treatment in patients with temporomandibular disorders
327
levels.Thegender groups and 3agegroups(10-20s,30-
40s,and50-60s)wereanalyzedwithPWI-SFresults,stress
groups,andtreatmenttypedistribution.
3. Statistical assessment
Anindependentsample t-test was conductedtoseeif
differentgendergroups had differentPWI-SFpoints.A
chi-squaretest wasdonetoidentify thedifferenceinstress
andtreatmenttypes in different gendergroupsand3age
groups(10-20s,30-40s,and50-60s).ThedifferenceinPWI-
SFpointsin varying age groupswereverifiedby one-way
ANOVA.Multiplelogisticregression was performed to
identifytheeffectofeachofgender,age,andstresslevelon
thetreatmenttype.Thelevelofsignificancewassetat0.05,
andPASW18.0(IBMCo.,Armonk,NY,USA)wasusedfor
statisticalanalysis.
III. Results
1. Stress levels and stress group distribution based
on demographic characteristics
Ofthe92 subjects of thisstudy,22weremale (23.9%)
and70were female (76.1%), i.e., therewere3timesmore
womenthanmen, and theiraverageagewas29.5±11.7. In
termsofthefrequencydistributionofthestressgroupbased
ontheirstress levels, the low-riskgroup(1subject in the
healthygroup,57subjectsinthepotentialstressgroup)had
58subjects(63.0%), whereas the high-riskgrouphad34
subjects(37.0%).Amongthesubjects,themeanstresslevels
ofmalesandfemaleswere19.45±9.57and25.30±7.38each,
indicatingthatwomen’sstresslevelwassignificantlyhigher
thanthatofmen(
P
=0.003).(Table1)Afrequencydifference
analysisofthelow-andhigh-riskgroupsbygenderdidnot
revealasignificantdifference(χ2=2.513,
P
=0.113).(Table1)
Nosignificantdifference was observed inthecomparison
ofthemean stresslevelandstressgroup distribution(low-
riskandhigh-riskgroups)basedonagegroups(10-20s,30-
40s,and50-60s;meanstresslevel:F=0.071,
P
=0.931;stress
group:χ2=0.095,
P
=0.954).
2. Treatment types for gender and age groups
Thedistributionof varying treatment typesshowedthat
moresubjectspreferredsplintorsurgicaltreatmenttocoun-
seling,self-physiotherapy,ormedication.Morespecifically,
ofemotionalstress with the helpofthepsychosocial well-
beingindex-shortform (PWI-SF)7 asastress-measuring
instrument.Thepatientswereallocatedto agroupreceiving
counseling,self-physiotherapy,ormedicationandtoanother
grouptreatedwith splint or surgicalproceduresandthen
studiedretrospectively in connectionwiththeinitialstress
indicesandrelationshipwithtreatmenttypes.
II. Materials and Methods
1. Subjects
Ninetytwopatients are included in this study out of the
169patientswho hadvisitedGangnamSeverance Hospital
andYonginSeveranceHospitalforTMD,agreedtoasurvey,
andcompletedthesurvey.Thisstudyexcludedpatientswho
neededtomakeno moreappointmentsatfirstvisitbecause
oftheirslight disease status andwasinstructedself-care
and/ormedicationorwhosemedicalrecordswere notfully
completed.
2. Study methods
Duringthefirstvisit,theTMDpatients’stresslevelswere
assessedbasedonthe PWI-SF form, astressquestionnaire
adaptedtoKorea7withprovenfeasibilityinselectinggroups
forthetreatmentofpsychiatricdisorderssuchasdepression
andanxietydisorder.The18questionsinthePWI-SFform
canbeanswered and are scoredwith0,1,2, or 3 points;
thehigher thepoints, the moresevere the stresslevel. As
suggestedbythe developer ofPWI-SF7, the subjects of
thisstudywere divided into thehealthygroupwithless
than8points, potential stressgroupwith9-26points, and
high-riskgroupwith 27 points orhigher.Inthis study, the
authorsdividedtwogroups;low-andhighriskgroup.Low-
riskgroupwas setwith26pointsor lesssincetherewas 1
subjectinthehealthygroup.The typeof treatmentgivento
each patientwere divided into twogroups. Thetreatment
typeofonegroupwasoneofcounseling,self-careandself-
physiotherapy(mandibularexercise, trigger pointmassage,
moistheatpack, etc.), and medication.Thetreatmenttype
ofanothergroup was one ofsplinttherapyor arthroplasty
oftemporomandibularjoint. If a patienthasreceived2or
moretypesof treatment, counseling, self-careandself-
physiotherapy,medication,splint therapy, and surgical
treatmentwereprioritized(e.g.,surgicaltreatmenthashigher
prioritythanmedication) and were comparedwithstress
J Korean Assoc Oral Maxillofac Surg 2012;38:326-31
328
treatment)usedby varying stress groupswereanalyzed
bychi-squaretest, which showed thatthehigh-riskgroup
significantlypreferredsplintandsurgicaltreatmentmorethan
thelow-riskgroup (χ2=4.239,
P
=0.040).(Table2)Multiple
logisticregressionwas performed to considerthegender,
age,andstressgroupsandtheireffectonthetreatmenttypes
selected.(Table3)Theresultshowedthatgenderandagedid
notwield a significantinfluence,andthatthestress groups
did not show a statisticallysignificant difference,butthe
high-riskgroup preferredsplint andsurgicaltreatment than
thelow-riskgroup(gender:
P
=0.388;age:
P
=0.227; stress
level:
P
=0.070).
IV. Discussion
TMDisagenerictermreferringtothedysfunctionofthe
masticatorysystemincluding muscles and skeletonandis
55subjects(59.8%) chosetheformer,whereas37 (40.2%)
chosethelatter.Distributionofthetreatmenttypedepending
onthegender and age groupwasnotsignificant(gender
group:χ2=1.151,
P
=0.283;agegroup:χ2=0.608,
P
=0.738).
3. Treatment types for stress groups
Inthelow-riskgroup,28ofthe58subjects(48.3%)were
treatedbycounseling, self-physiotherapy, and medication,
and30(51.7%)receivedsplinttherapyorsurgicaltreatment
(1subject).In other words, bothtypesoftreatment were
usedalmostequally.Inthehigh-riskgroup,9of34subjects
(26.5%)usedcounseling,self-physiotherapy,andmedication,
whereas25(73.5%) received splint andsurgicaltreatment
(2subject).Thissuggested that the lattertypeoftreatment
waspreferred.(Table2) The treatment types(counseling,
self-physiotherapy,and/ormedicationandsplintorsurgical
Table 1.
Comparison of the mean PWI-SF score and proportions of the stress group and treatment type between male and female TMD
patient groups
Sex,N(%) Tvalue,χ2df
P
-value
Male Female
PWI-SF(Mean±SD)
Stressgroup
Low-riskgroup
High-riskgroup
Treatmenttype
Counseling/PTx/medication
Splintorsurgery
19.45±9.57
17(77.3)
5(22.7)
11(50.0)
11(50.0)
25.30±7.38
41(58.6)
29(41.4)
26(37.1)
44(62.9)
-3.008
2.513
1.151
90
1
1
0.003
0.113
0.283
(PWI-SF:psychosocial well-being index-shortform,TMD: temporomandibulardisorder,df: degree offreedom,SD: standarddeviation,PTx:
physicaltherapy)
Hyung-Jun Yoon et al: Relationship between stress levels and treatment in patients with temporomandibular disorders. J Korean Assoc Oral Maxillofac Surg 2012
Table 2.
Comparison of treatment type depending on the stress group in patients with TMD
Stressgroup,N(%) χ2df
P
-value
Low-riskgroup High-riskgroup
Treatmenttype
Counseling/PTx/medication
Splintorsurgery
28(48.3)
30(51.7)
9(26.5)
25(73.5)
4.239 1 0.040
(TMD:temporomandibulardisorder,df:degreeoffreedom,PTx:physicaltherapy)
Hyung-Jun Yoon et al: Relationship between stress levels and treatment in patients with temporomandibular disorders. J Korean Assoc Oral Maxillofac Surg 2012
Table 3.
Multiple logistic regression of the treatment type depending on age, sex, and stress group (low risk=0, high risk=1) in patients with
TMD (counseling/PTx/medication group=0, splint or surgery group=1)
B SE Wals Sig Exp(B) 95%condenceinterval
Sex(female=1)
Age
Stressgroup(highrisk=1)
0.443
-0.023
0.868
0.514
0.019
0.479
0.744
1.458
3.290
0.388
0.227
0.070
1.558
0.977
2.383
0.569
0.942
0.932
4.265
1.014
6.088
(TMD:temporomandibular disorder, PTx:physical therapy, B:coefcient,SE: standarderror,Wals: waldchi-square,Sig: signicance, Exp(B):
exponentiationofthecoefcient,anoddsratio)
Hyung-Jun Yoon et al: Relationship between stress levels and treatment in patients with temporomandibular disorders. J Korean Assoc Oral Maxillofac Surg 2012
Relationship between stress levels and treatment in patients with temporomandibular disorders
329
symptomsofthis disorder along withundesirablehabits
suchasclenchingandbruxismwerealsosignificantlyrelated
withstress.Nifosì et al.21, assessed thestresslevelofthe
TMDpatientswith masticatory muscle disordersandonly
withtemporomandibularjoint disorders, with theformer
foundtohavehigherlevelofstress.Thisstudyrevealedthat
womensufferedsignificantly highermeanstresslevel than
men.Althoughtheresultmayvarydependingonthesocio-
culturalbackgroundof the subjects ormethodofresearch,
womenwereshown to have twiceashighdepressionthan
men22;fourtimesasmanywomenthanmenwerealsoknown
tosufferfrom anxiety disorders suchaspanicdisorder23 .
Althoughthisstudy did not includediagnosticinterviews
withsubjects,PWI-SFhasalreadybeenproventobefeasible
inselectinggroups for studiesindepression,anxiety,and
otherpsychiatricdisorders7,24. Therefore, this study'sresult
shows thatwomen may bemore susceptible to emotional
stressamongTMD patients as inthecaseof other general
demographicgroups.
ThePWI-SFform is an abbreviatedformwith18ques-
tionsofGeneral Health Questionnaire (GHQ)-60PWIand
45questions to suitKoreans. Developedmoretomeasure
thestresslevelofnormalpeoplethantodiagnosepsychiatric
issues,thistool assigns 0, 1,2,or3points to each item
basedonthe 4-point Likert scalewith“Always”, “Almost
always”, “Sometimes”, and “Never”. Pointsgiventoeach
itemareadded up, with thesubjectsgarnering8points or
lesscategorizedasthehealthygroup,thosewith9-26points
aspotentialstressgroup,andthosewith27pointsormoreas
high-riskstressgroup.Thehealthy,potentialstress,andhigh-
riskgroupswere found to accountfor19.4%,61.3%,and
19.3%,respectively,amongthegeneralworkingpopulation.
Inthisstudy, almost none ofthesubjectsbelongedto
thehealthygroup. Thus, the healthygroupandpotential
stressgroupwere combined and namedlow-riskgroup.
Only1 belonged tothehealthygroup, andthissubject had
receivedsplinttherapyformasticatorymuscledisordersand
temporomandibularjointdisorders. Since the developerof
PWI-SFnotedthat19.4%ofthegeneralworkingpopulation
belongedtothehealthygroup7,thefactthatthehealthygroup
inthisstudyonTMDpatientsmaybefarsmallershouldbe
considered.
Inthisstudy,37%ofallsubjectsbelongedtothehigh-risk
stressgroup.Thispercentageismuchhigherthan 19.3%of
thegeneralworking population as notedbythedeveloper
ofPWI-SF,indicatingthatTMDpatientsarelikelytosuffer
fromconcomitantemotionalstress.The2typesoftreatment
reportedlycausedbymalocclusion,emotionalstress,trauma,
introductionofheart pain, and abnormalfunctionactivity,
amongothers8-10.Psychiatricfactors, e.g., emotional stress,
anxiety,anddepression, may cause generalfunctional
disordersandTMD. Increase of emotionalstresslevel
intensifiesthehead and neck muscletensionandlowers
thepatient’sphysiological tolerance to noxiousstimuli1.
Inaddition,increased emotional stress maycauseadverse
muscleactivitiesincludingclenchingandbruxismtopersist.
AnxietymayalsocontributetoTMDasreportedbyFricton
etal.11,i.e.,26%ofthe 164 TMD patientsdisplayeda
clinicallyclearanxiety syndrome. Gerschman etal.12,also
reportedthat17%ofTMDpatientssufferedseriousanxiety.
Suchanxietymaybetheresultofthepainandresultinthe
droppingofthe threshold ofthepatient’spainlevel10,13.
AccordingtoManfredini et al.14, among TMD patients,
thegroupof patients with facialmusclepaincompared to
thegroupsuffering no pain hadahigherprevalencerate
ofpsychiatricsyndromes including depression andpanic
disorder.Such studyresultssuggestthat someoftheTMD
patientsalsosufferfromanxietydisorder.
Depressionmayalso lower the painthresholdofTMD
patients13.Accordingtostudiesreportingadirectrelationship
betweendepressionand physical symptoms15,16, morethan
halfofthedepressionpatients experienced prominently
evidentphysicalsymptoms including fatigue andgeneral
musclepain,whichwerepurelyphysical.As indicatedbya
multinationalreportbyWorldHealthOrganization(WHO)17,
69%ofdepressionpatientswereinitiallytreatedforphysical
symptomsonly.Depressionwasalsomorecommonamong
patientssufferingfromphysicalsymptoms18,andtherewasa
directquantitativerelationshipbetweenthenumberofphysical
symptomssuffered andoccurrencerateofdepression19.
Gerschmanetal.12,alsoreportedthat18%ofthe 368TMD
patientssufferedfromseveredepression.Therefore,thepain
thresholdformanyTMDpatientsmaylikelybeloweredas
wellbyconcomitantdepression.
TMDisobservedtoberelatedcloselytostress;therefore,
thestresslevelshouldbeassessedwhentreatingpatientswith
thesedisorders.Speculand et al.20, studiedtheoccurrences
ofstressfor6monthspriorto themanifestationofTMDin
85patientsand a control groupwiththesamenumber of
subjects.Thepatientgroupsufferedfromtwiceas manyas
theoccurrencesof stress from day-to-daylifecomparedto
thecontrolgroup. Kanehira et al.2,studiedtherelationship
betweenstressand TMD based onasurvey.Cracking
jaw,pain,and mouth opening limitationasthe3major
J Korean Assoc Oral Maxillofac Surg 2012;38:326-31
330
ditions.Theexistenceofconcomitantdepressionoranxiety
disordersshouldbeaccuratelyassessed;iftheydoexist,they
shouldbeadequatelyunderstoodbythepatientsconcernedso
thatcollaborationwiththepsychiatricdepartmentisenabled
attherighttimeforprofessionaltreatment.
Thisstudyhad the following limitations:1)difficulty
inanalyzingthe relationship between masticatorymuscle
disorders or joint disorderswith stress sincemostpatients
visitingthestudy institution suffered fromjointdisorders,
notothertypes of disorders; 2)difficultyinaccurately
concludingwhetherTMDactuallyinvolveddepressionand
anxietydisordersamong other psychiatric conditionssince
onlythestresslevelwasmeasuredbyPWI-SFwithoutusing
clinicalscalessuchas BDIor BAIorpsychiatricdiagnostic
interviews;3)lack of research onsocio-economicoredu-
cationalbackgrounds-exceptgenderandage-amongother
demographicandsocialfactorsthatmayaffecttheselection
oftreatmenttypes; 4) lack ofdiversityofsubjectssince
theywereonly divided into low-riskandhigh-riskgroups
regardlessofstresslevels,andtreatmenttypesonlyincluded
counseling-self-physiotherapy-medicationor splint-surgical
treatment,and;5)possibilitythattheTMDpatientsincluded
inthestudywereonlythosewhohadvisitedacertainclinic
inadefinedareaandmighthavesufferedfromactuallymore
severeconditionor concomitantpsychiatricissues,thereby
makingitimpossible to generalize theresultofthisstudy.
Thesocio-demographicfactors and psychiatric diagnosis
procedureareexpected to be consideredcomprehensively
withmorepatientsin futurestudiesto enableunderstanding
oftherelationship between TMD andemotionalstressas
wellasconcomitantpsychiatricdisorders.
V. Conclusion
IntheTMD patient groupundermoreemotionalstress,
splinttherapyor surgical treatment waspreferredtocoun-
seling,self-physiotherapy,and/ormedication;thusshowing
thatmoreemotional stress likely ledtomoresevere sym-
ptomsandchronicdevelopmentofthecondition.Inaddition,
womenwerefound morelikelytoexperience greater emo-
tionalstressand concomitant psychiatric disorders;thus
suggestingtheneedto considergenderandemotionalstress
intheclinical assessment and treatmentofTMDpatients.
Inconclusion,consideringpsychiatricfactorssuchasstress
willbehelpfulindeterminingtheoveralltreatmentplanfor
TMDpatientsvisitingtheclinic,sinceemotionalstressmay
beacrucial factor in theselectionofmethodfor treating
consideredin thisstudywerecounseling/self-physiotherapy/
medicationandsplint therapy/surgical treatment. Patients
whohavelongsufferedfromjawormasticatorymusclepain
ormouthopening limitation along withjawormasticatory
musclepain or thosewhohad not respondedtoprior treat-
mentchose thelatter.Counselingincludedhelpingpatients
developawarenessofandunderstandthecauseandcondition
ofthedisorderandguidingthepatientstoavoidundesirable
habitssuchasrestingthechinononehand,sleepingonone's
stomach,andexcessive chewing habit. Ontheotherhand,
self-physiotherapyincludedlower jaw exercise, painful
spotmassage,moist heat pack, etc.,whichcouldbedone
anywhereoutsideof the clinic facilitiesoreasilyusinga
simpleinstrumentat home; medication includedtheuse
ofmusclerelaxant and anti-inflammatory painkillerand-
dependingonthe condition of thepatient-anti-depressant
andminortranquilizer. Splint therapy includedtheuseof
occlusalstabilizing splintoranteriorpositioning appliance,
whereassurgicaltreatmentincludedopenjointsurgeriessuch
asarticulardiscrepositioningorremoval,eminoplasty,and
condyloplasty,oneof which can beselecteddependingon
theconditionofthepatients.Multiplemethodswereusedon
thesubjectsof thisstudy25.Patientswithchronicandminor
TMDwereasked to use counseling, self-physiotherapy,
andmedication,whereas thosewhosufferedfrom a severe
conditionorwhohadnotrespondedtoself-physiotherapyor
medicationweredirectedtousesplintorsurgicaltreatment
methods.Consideringthefactthatonly1patientunderwent
surgeryamong all subjects,wecanconclude thatthehigh-
riskgroupismorelikelytousesplinttherapy.Therefore,ifa
patientisfoundtobelongtothehigh-riskgroupuponthefirst
visit,splinttherapymaybeconsidered.AccordingtoGerrits
etal.26,depressionoranxiety disorder patientssuffering
from pain weremore likelytosuffer chronically.Though
thisstudydidnotincludeprofessionaldiagnosticinterviews,
asmentioned earlier,amajority ofpatientsin the high-risk
grouparelikelytosufferconcomitantdepressionoranxiety
disorders.Moreover,concomitant depression and anxiety
disordersmaylower the pain threshold,aggravate,and
makechronicthe symptomsofTMD13,asaresultofwhich
additionalsplintor surgical treatmentmaybeprovided.
Therefore,in futurestudies,itmay benecessarytouse not
onlyPWI-SFbutalsotheBeckDepressionInventory(BDI)27
orBeckAnxiety Inventory (BAI)28 which is selfreporting
instrumentfordepressionandanxietydisorder,amongother
clinicalscalesand diagnostic interviews forpsychiatric
conditionsinorderto identifyconcomitantpsychiatriccon-
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