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Temporomandibular Disorders and Bruxism Outbreak as a Possible Factor of Orofacial Pain Worsening during the COVID-19 Pandemic - Concomitant Research in Two Countries

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Background: In late December 2019, a new pandemic caused by the SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection began to spread around the world. The new situation gave rise to severe health threats, economic uncertainty, and social isolation, causing potential deleterious effects on people's physical and mental health. These effects are capable of influencing oral and maxillofacial conditions, such as temporomandibular disorders (TMD) and bruxism, which could further aggravate the orofacial pain. Two concomitant studies aimed to evaluate the effect of the current pandemic on the possible prevalence and worsening of TMD and bruxism symptoms among subjects selected from two culturally different countries: Israel and Poland. Materials and methods: Studies were conducted as cross-sectional online surveys using similar anonymous questionnaires during the lockdown practiced in both countries. The authors obtained 700 complete responses from Israel and 1092 from Poland. In the first step, data concerning TMDs and bruxism were compared between the two countries. In the second step, univariate analyses (Chi2) were performed to investigate the effects of anxiety, depression, and personal concerns of the Coronavirus pandemic, on the symptoms of TMD, and bruxism symptoms and their possible aggravation. Finally, multivariate analyses (logistic regression models) were carried out to identify the study variables that had a predictive value on TMD, bruxism, and symptom aggravation in the two countries. Results: The results showed that the Coronavirus pandemic has caused significant adverse effects on the psychoemotional status of both Israeli and Polish populations, resulting in the intensification of their bruxism and TMD symptoms. Conclusions: The aggravation of the psychoemotional status caused by the Coronavirus pandemic can result in bruxism and TMD symptoms intensification and thus lead to increased orofacial pain.
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Journal of
Clinical Medicine
Article
Temporomandibular Disorders and Bruxism
Outbreak as a Possible Factor of Orofacial Pain
Worsening during the COVID-19
Pandemic—Concomitant Research in Two Countries
Alona Emodi-Perlman 1, , Ilana Eli 1, , Joanna Smardz 2, Nir Uziel 1,
Gniewko Wieckiewicz 3, Efrat Gilon 1, Natalia Grychowska 4and Mieszko Wieckiewicz 2,*
1Section of Dental Education, Department of Oral Rehabilitation, The Maurice and Gabriela Goldshleger
School of Dental Medicine, Tel Aviv University, Tel Aviv 6139001, Israel; dr.emodi@gmail.com (A.E.-P.);
elilana@tauex.tau.ac.il (I.E.); niruziel@gmail.com (N.U.); gilon.efrat@gmail.com (E.G.)
2Department of Experimental Dentistry, Wroclaw Medical University, 50-425 Wroclaw, Poland;
joannasmardz1@gmail.com
3Department and Clinic of Psychiatry, Medical University of Silesia, 42-612 Tarnowskie Gory, Poland;
gniewkowieckiewicz@gmail.com
4Department of Prosthetic Dentistry, Wroclaw Medical University, 50-425 Wroclaw, Poland;
natgrychowska@gmail.com
*Correspondence: m.wieckiewicz@onet.pl
Equal contribution.
Received: 23 August 2020; Accepted: 27 September 2020; Published: 12 October 2020
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Abstract:
Background: In late December 2019, a new pandemic caused by the SARS-CoV-2 (Severe
Acute Respiratory Syndrome Coronavirus 2) infection began to spread around the world. The new
situation gave rise to severe health threats, economic uncertainty, and social isolation, causing
potential deleterious eects on people’s physical and mental health. These eects are capable of
influencing oral and maxillofacial conditions, such as temporomandibular disorders (TMD) and
bruxism, which could further aggravate the orofacial pain. Two concomitant studies aimed to
evaluate the eect of the current pandemic on the possible prevalence and worsening of TMD and
bruxism symptoms among subjects selected from two culturally dierent countries: Israel and Poland.
Materials and Methods: Studies were conducted as cross-sectional online surveys using similar
anonymous questionnaires during the lockdown practiced in both countries. The authors obtained
700 complete responses from Israel and 1092 from Poland. In the first step, data concerning TMDs and
bruxism were compared between the two countries. In the second step, univariate analyses (Chi
2
) were
performed to investigate the eects of anxiety, depression, and personal concerns of the Coronavirus
pandemic, on the symptoms of TMD, and bruxism symptoms and their possible aggravation. Finally,
multivariate analyses (logistic regression models) were carried out to identify the study variables that
had a predictive value on TMD, bruxism, and symptom aggravation in the two countries. Results:
The results showed that the Coronavirus pandemic has caused significant adverse eects on the
psychoemotional status of both Israeli and Polish populations, resulting in the intensification of their
bruxism and TMD symptoms. Conclusions: The aggravation of the psychoemotional status caused
by the Coronavirus pandemic can result in bruxism and TMD symptoms intensification and thus
lead to increased orofacial pain.
Keywords:
COVID-19; SARS-CoV-2; coronavirus pandemic; temporomandibular disorders; bruxism;
orofacial pain
J. Clin. Med. 2020,9, 3250; doi:10.3390/jcm9103250 www.mdpi.com/journal/jcm
J. Clin. Med. 2020,9, 3250 2 of 15
1. Introduction
Temporomandibular disorders (TMD) are a group of conditions that cause pain and dysfunction
of the masticatory muscles, the temporomandibular joints (TMJs), and associated structures. The most
common features of TMD are regional pain, limited jaw movements, and acoustic sounds from
TMJs during motions [
1
]. The prevalence of TMD in the general population is estimated at about
10–15% [
2
4
], and these conditions aect women more frequently than men. Psychosocial factors,
such as anxiety, stress, depression, coping strategies, and catastrophizing, may influence the onset
of pain, as well as precipitate or prolong the TMD pain [
5
8
]. The International Association for the
Study of Pain (IASP) reported that TMD-related facial pain occurs in 9–13% of the general population,
while only 4–7% seek treatment. The TMD-related pain may also aect the daily activities, physical
and psychosocial functioning, and quality of life of the aected individuals [9].
Bruxism is a repetitive jaw muscle activity characterized by clenching or grinding of the teeth,
and/or bracing or thrusting of the mandible [
10
]. It can act as a potential risk factor for several negative
consequences of health such as masticatory muscle pain, oral mucosa damage, mechanical tooth wear,
and failures of prosthodontic constructions [
11
13
]. This condition is divided into sleep bruxism (SB)
awake bruxism (AB). The prevalence of SB is estimated at about 16% among young adults and at 3–8%
among adults, while the prevalence of AB in the general population is estimated at about 22–30%.
Both forms of bruxism men and women equally [14].
Psychosocial factors, such as stress and anxiety, have been indicated as associated with both
SB and AB [
15
20
]. However, the latest research showed that self-reported perceived stress was not
correlated with the intensity of SB [21].
In late December 2019, a new unfamiliar and threatening pandemic called COVID-19 (Coronavirus
2019 disease), which is caused by the SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)
infection, began to spread around the world. Due to almost complete uncertainty about the ways of
virus spread [
22
] and the appropriate modes of treatment, insucient availability of health services,
and no existing vaccine or ecient drug for treatment, most countries adopted the policies of social
distancing and partial to total lockdown.
The situation continued, and within weeks, routine life was drastically altered. This gave rise to
severe health threats, economic uncertainty, and social isolation, causing potential deleterious eects
on the physical and mental health of the people. The common psychological responses of individuals
to the Coronavirus pandemic included stress, anxiety, and depression [
22
]. All these are capable of
influencing the oral and maxillofacial syndromes, such as TMD and bruxism, which could further
aggravate the orofacial pain [23].
Studies aimed to: (i) evaluate the eect of the current Coronavirus pandemic on the possible
prevalence and worsening of TMD and bruxism symptoms, among subjects selected from two culturally
dierent countries: Israel and Poland; and (ii) to define the predictors of TMD and bruxism during the
lock down periods, in the above countries.
2. Materials and Methods
Studies were conducted as cross-sectional online surveys using anonymous questionnaires.
The final questionnaire was compiled from tools commonly used with regard to TMD, bruxism, anxiety
and depression (3Q/TMD, possible/probable bruxism, and Patient Health Questionnaie-4, as detailed
below), and specific questions referring to demographics, concerns specific to the Coronavirus, media
consumption, etc. The latter were agreed upon, and tested for content validity, by a group of subject
matter experts (SMEs). The group consisted of four dentists (AE-P, IE, NU, and EG) who work at
the Tel Aviv University School of Dental Medicine and have vast clinical and academic experience in
working with patients suering from TMD and bruxism. Each SME proposed questions for the study
and, following discussions, the final questions were agreed upon. The questionnaire was compiled in
Hebrew and translated to Polish by the Polish group. The surveys were carried out one month after
the start of the total lockdown periods in each of the countries.
J. Clin. Med. 2020,9, 3250 3 of 15
2.1. Population
The questionnaire was distributed through the internet (in Hebrew in Israel, in Polish in Poland).
In Israel, the study questionnaire was posted on SurveyGizmo (https:www.mysurveygizmo.
com/s3) and distributed through mailing lists of dental clinics and social media (e.g., Facebook and
WhatsApp).
In Poland, the questionnaire was posted on Reddit, an American social news aggregation platform
that allows the users to interact on community-created discussion forums, and on r/Polska sub-reddit.
In both countries, the responses were given anonymously by the participants.
Studies were conducted in full accordance with the World Medical Association Declaration of
Helsinki. In Israel, all the study procedures were approved by the Ethics Committee of the Tel Aviv
University in Israel (ID: 0001332-1). In Poland the Bioethical Committee of the Wroclaw Medical
University approved the study protocol (ID: KB-302/2020). Informed consent was obtained from all the
subjects as required.
2.2. Instruments
The following data were collected from the participants:
1.
Demographic and general information: This included the consent to participate in the study, age,
gender, and conjugal status (with partner and children, with partner but no children, with children
but no partner, with roommate, alone).
2.
Concerns specific to the Coronavirus: These included worries about the risk of being contaminated
(yes/no), and about the financial aspects, physical health, mental health, and relationship with
relatives and friends (ranging from 1—not at all to 5—very worried).
3.
TMD screening: The 3Q/TMD questionnaire, which is a reliable and acceptable tool for screening
the TMD conditions, was used for collecting data [
24
,
25
]. The questionnaire has an excellent
negative predictive value and is regarded as a valid tool for screening [
24
,
25
]. It asks about the
existence of pain in the temple, face, and jaw during mouth opening or chewing, and whether
there is an experience of jaw locking. A positive response to one of these confirms the presence
of TMDs.
4.
Possible/probable AB: An accepted way to assess possible AB and/or SB is the use of a self-report
questionnaire [12,17,26]. The questions are related to awareness (by self or being told by others)
of grinding, clenching, and holding the teeth together and/or tightening the masticatory muscles
during the day (scale ranging from 0—never to 4—all the time). A positive answer to one of these
(either than “never”) confirms the presence of “possible AB”. An additional positive response to
the question that refers to “being told by a dentist that you clench/grind your teeth” confirms the
presence of “probable AB” [10,27].
5.
Possible/probable SB: It is assessed through the question, “Do you know or have been told that you
clench or grind your teeth while you sleep?” A scale ranging from 0 (never) to 4 (4–7 nights/week)
is used for this assessment. Any score above 0 (never) confirms the presence of “possible SB”.
An additional positive response to the question that refers to “being told by a dentist that you
clench/grind your teeth” confirms the presence of “probable SB” [10,27].
6.
Possible aggravation of symptoms associated with TMDs and bruxism (“since the beginning of
the Coronavirus confinement do you feel any changes in
. . .
etc.”). The evaluated symptoms
referred to: (i) pain in temple, face, jaw or jaw joint, pain at mouth opening or chewing and jaw
locking (for TMD); (ii) headache during the day in the temple area, exacerbation in pain levels
during the day and change in the temple pain upon functioning (for TMD and AB); and (iii)
diculties in mouth opening upon awaking, jaw and/or muscle stiness upon awaking and
temple headache that is reduced after some time (for SB) [
28
]. The scores were as follows: no
change, slight aggravation, significant aggravation, and improvement.
J. Clin. Med. 2020,9, 3250 4 of 15
7.
Anxiety and depression: The Patient Health Questionnaire-4, a brief screening tool, is used for
assessing anxiety and depression [
29
]. The total score of this questionnaire ranges from 0 to 12,
and the conditions are usually evaluated using the following cut-oscores: 0–2, normal; 3–5, mild;
6–8, moderate; 9–12 severe [
29
]. The questionnaire also allows performing a separate evaluation
for anxiety and depression.
8.
Media consumption: Report of news consumption concerning the Coronavirus pandemic through
television, internet, and/or social media was also assessed (scale ranging from 1—not at all to
4—all reports/all the time).
All questions were formulated in a first person voice (referring to self), and referred to the last
30 days, namely, to the period of the lock down.
The surveys were open to anyone who entered the SurveyGizmo (https:www.mysurveygizmo.
com/s3) site and/or the Facebook and/or WhatsApp apps (in Israel) or the r/Polska sub-reddit in Poland.
In Israel, complete lock down was imposed on 19 March 2020. Data were collected from 16 April
(namely, four weeks after the beginning of the complete lock down) to 20 May 2020. In Poland,
complete lock down was imposed on 31 March 2020. Data were collected from 29 April (four weeks
after the beginning of the lockdown) to 3 May 2020.
2.3. Statistical Analysis of Data
Data analysis was performed using STATISTICA PL Version 12 software (Tulsa, OK, USA), with the
level of significance set at p<0.05. In the first step, the data concerning TMDs, AB, and SB were
compared between the two countries (descriptive analyses). In the second step, univariate analyses
(Chi
2
) were performed to investigate the eects of anxiety, depression, and personal concerns of the
Coronavirus pandemic (being contaminated, being influenced financially, experiencing negative eects
on physical and/or mental health and on the relationship with relatives and friends) on the symptoms
of TMDs, SB, and AB and their possible aggravation. Finally, multivariate analyses (logistic regression
models—binomial logit models) were carried out to identify the study variables that had a predictive
value on the symptoms of TMDs, AB, and SB and their aggravation.
3. Results
In Israel, a total of 867 subjects responded to the questionnaire, out of whom 80.74% (N=700)
fully completed it. In Poland, a total of 1096 subjects responded to the questionnaire, of which 99.63%
(N=1092) fully completed it.
The age groups of participants were defined according to “young adults” (age of 18–35 years)
and “adults” (36–56 years old) as accepted in the literature [
30
]. Some significant dierences existed
between the two populations with regard to gender and age groups (Tables 1and 2).
Table 1. Gender of study populations.
Gender Percent Israel Count Percent Poland Count
Male 33.6% 235 41.6% 454
Female 66.4% 465 58.4% 638
Total 100% 700 100% 1092
The Polish population had more females (p<0.05), and the participants were significantly younger
compared to their Israeli counterparts (p<0.05).
Due to these significant dierences in age and gender between the studied populations,
comparisons were carried out separately for males and females, categorized into predefined age groups.
J. Clin. Med. 2020,9, 3250 5 of 15
Table 2. Age of study populations.
Age Israel Poland
Female N (%) Male N (%) Total Female N (%) Male N (%) Total
18–35 142 (30.5) 61 (26.0) 203 443 (69.4) 385 (84.8) 828
36–55 185 (39.8) 98 (41.7) 283 171 (26.8) 63 (13.9) 234
>56 127 (27.3) 73 (31.1) 200 24 (3.8) 6 (1.3) 30
N/A 11 (2.4) 3 (1.3) 14 0 0 0
Total 465 235 700 638 454 1092
3.1. Descriptive Analyses—TMDs, Possible/Probable AB, and Possible/Probable SB
1. TMD screening: The results showed that the odds of occurrence of TMDs among the Polish
young adult and adult age groups (18–35 years and 36–55 years) were significantly higher for both
males and females as compared to the Israeli groups (odds ratios ranged from 3.04 to 5.37). However,
no such dierences were observed for the elderly group (>56 years) between the populations (Table 3).
Table 3. Temporomandibular disorders (TMD) distribution.
TMD Positive TMD Negative
p*OR (95% CI) #
Age Gender Israel Poland Israel Poland
18–35 Male N (%) 7 ((1.6) 158 (35.4) 54 (12.1) 227 (50.9) 0.0000 5.37 (2.38, 12.11)
Female N (%) 48 (8.2) 280 (47.8) 94 (16.1) 163 (27.9) 0.0000 3.36 (2.26, 5.00)
36–55 Male N (%) 13 (8.1) 20 (12.4) 85 (52.8) 43 (26.7) 0.005 3.04 (1.38, 6.69)
Female N (%) 47 (13.2) 105 (29.5) 138 (38.8) 66 (18.5) 0.0000 4.67 (2.9, 7.34)
>56 Male N (%) 10 (12.7) 1 (1.3) 63 (79.7) 5 (6.3) >0.05 1.26 (0.13, 11.93)
Female N (%) 25 (16.6) 12 (7.9) 102 (67.6) 12 (7.9) 0.003 4.08 (1.64, 10.16)
N/A 2 0 12 0 - - - - - - - -
Total 152 576 548 516
* Comparison of countries in regard to TMD positive/TMD negative in particular age and gender groups (Chi
2
).
#OR comparing Poland versus Israel in regard to TMD positive in particular age and gender groups.
2. Possible/probable AB: Similar results were found for possible/probable AB. The odds of
occurrence of these conditions among the Polish participants were significantly higher in general
than among the Israeli participants (except the young and elder males), with the odds ratios ranging
between 2.51 and 6.41 (Table 4).
Table 4. Awake bruxism (AB) distribution.
Probable AB (I) Possible AB (II) AB Negative (III)
p*OR (95% CI) #
Age Gender Israel Poland Israel Poland Israel Poland
18–35 Male N (%) 8 (1.8) 71 (15.9) 21 (4.7) 138 (30.9) 32 (7.2) 176 (39.5) >0.05 1.31 (0.76, 2.25)
Female N (%)
40 (6.8) 187 (32.0) 38 (6.5) 151 (25.8) 64 (10.9) 105 (17.9) 0.0000 2.64 (1.78, 3.93)
36–55 Male N (%)
19 (11.8)
17 (10.6) 15 (9.3) 19 (11.8) 64 (39.7) 27 (16.8) 0.015 2.51 (1.31, 4.81)
Female N (%)
46 (12.9)
94 (26.4)
38 (10.7)
50 (14.0) 101 (28.4) 27 (7.6) 0.0000 6.41 (3.88, 10.60)
>56 Male N (%) 8 (10.1) 0 4 (5.1) 1 (1.3) 61 (72.2) 5 (6.3) >0.05 1.02 (0.11, 9.50)
Female N (%)
30 (19.9)
9 (6.0) 9 (6.0) 6 (4.0) 88 (58.3) 9 (6.0) 0.007 3.76 (1.52, 9.33)
N/A 2 0 0 0 12 0 - - - - - - - -
Total 153 378 125 365 422 349
* Comparison of countries in regard to Possible/Probable AB/AB negative in particular age and gender groups
(Chi
2
).
#
OR comparing Poland versus Israel in regard to AB positive (Possible and Probable AB) in particular age
and gender groups.
3. Possible/probable SB: The findings for possible/probable SB were also consistent. The odds
of occurrence of these conditions among the Polish subjects (except for males in the two higher age
J. Clin. Med. 2020,9, 3250 6 of 15
groups) were similar to those of the Israeli subjects, with the odds ratios ranging from 1.4 to 3.99
(Table 5).
Table 5. Sleep bruxism (SB) distribution.
Probable SB (I) Possible SB (II) SB Negative (III)
p*OR (95% CI) #
Age Gender Israel Poland Israel Poland Israel Poland
18–35 Male N (%) 8 (1.8) 61 (13.7) 9 (2.0) 74 (16.6) 44 (9.8) 250 (56.0) 0.008 1.40 (0.77, 2.54)
Female N (%)
34 (5.8) 182 (31.1) 21 (3.6) 90 (15.4) 87 (14.9) 171 (29.2) 0.0000 2.52 (1.71, 3.71)
36–55 Male N (%)
22 (13.7)
16 (9.9) 9 (5.6) 7 (4.4) 67 (41.6) 40 (24.8) >0.05 1.24 (0.64, 2.42)
Female N (%)
50 (10.7)
84 (23.6) 23 (6.5) 21 (5.9) 112 (31.5) 66 (18.5) 0.0000 2.44 (1.59, 3.74)
>56 Male N (%) 6 (7.6) 0 4 (5.1) 1 (1.3) 63 (79.8) 5 (6.3) >0.05 1.26 (0.13, 11.93)
Female N (%)
29 (19.2)
8 (5.3) 4 (2.7) 6 (4.0) 94 (62.2) 10 (6.6) 0.0008 3.99 (1.62, 9.84)
N/A 3 0 0 0 11 0 - - - - - - - -
Total 152 351 70 199 478 542
* Comparison of countries in regard to Possible/Probable SB/SB negative in particular age and gender groups (Chi
2
).
#
OR comparing Poland versus Israel in regard to SB positive (Possible and Probable SB) in particular age and
gender groups.
3.2. Aggravation of AB, SB and TMD Symptoms
Almost half (48.8%) of the Poles reported experiencing at least once a week pain in temple, face,
jaw or jaw joint during the past 30 days, namely, since the beginning of the lockdown. A total of 247
individuals (22.6%) declared pain during mouth opening or chewing and 101 (9.2%) jaw locking or
getting stuck at least once a week. Among the Israelis, the numbers were 166 (23.7%), 91 (13.0%),
and 35 (5.0%), respectively.
Among the Polish responders, 372 (34%) reported TMD symptoms aggravation, 372 (34%) AB
aggravation, and 311 (28%) SB aggravation. Among the Israeli responders, 107 (15%) reported TMD
symptoms aggravation, 111 (16%) AB symptom aggravation, and 94 (13%) SB symptom aggravation.
Both in Israel and in Poland, females reported more symptoms of TMD, AB, SB and symptom
aggravation, than males (Chi
2
,p<0.05 for all). However, further logistic regression analyses, performed
among Israeli population (see below), rejected gender as a predictor of SB. Distributions of TMD, AB,
SB among males and females in Poland and in Israel are presented in Tables 35.
3.3. The Eect of Conjugal Status
Significant relationships were observed between subjects’ conjugal status and TMD aggravation,
AB aggravation and SB aggravation among the Polish responders (Chi
2
,p<0.05, for all). Respondents
living with a roommate or sharing apartment with a partner, reported more TMD and AB aggravation
than those living with a spouse without children (Chi
2
,p<0.001 for both). They also reported higher
SB symptom aggravation than those with children but with no partner or spouse (p<0.001).
In Israel, no dierences in TMD, AB. and SB symptom aggravation were observed among subjects
with dierent conjugal status.
3.4. The Eect of Demographic Data on Anxiety and Depression
In Poland, anxiety was more frequent among females than males (Chi
2
,p<0.05). Additionally,
a significant relationship was found between subjects’ conjugal status and depression (p<0.05).
Depression was more often among respondents living with a roommate or sharing an apartment with a
partner than among responders living with spouse and children (p<0.001). There were no significant
relationships between gender and depression or age and depression, between age and anxiety and
between conjugal status and anxiety.
In the Israel, anxiety and depression were more frequent among females than males (Chi
2
,
p<0.05
).
No relationships between conjugal status and depression or anxiety, and between age and depression
were detected. Anxiety was more frequent among young adults (18–35 years) than among the elderly
group (>56 years) (Chi2,p<0.001).
J. Clin. Med. 2020,9, 3250 7 of 15
3.5. Eect of Anxiety, Depression, and Personal Concerns on TMD, SB, and AB (Chi2)
1. TMD: The presence of anxiety, depression, or personal concerns significantly increased the
odds of occurrence of TMDs among both populations. The odds ratio ranged between 1.32 (concerns
of being contaminated by the virus) and 2.75 (anxiety) for the Polish subjects, while it ranged between
1.46 (concerns about personal finances due to the pandemic) and 6.4 (anxiety) for the Israeli population.
2. Possible/probable AB: The presence of anxiety, depression, and personal concerns significantly
increased the odds of occurrence of possible/probable AB among both populations. The odds
ratios ranged from 1.45 (concerns of being aected financially, for Polish subjects) to 2.85 (anxiety,
for Israeli subjects).
3. Possible/probable SB: Mixed results were observed for possible/probable SB. In Poland the odds
ratios ranged from 1.34 (concerns of being aected mentally) to 1.84 (anxiety). No eect was observed
for the concerns regarding personal finances or depression. Among the Israeli subjects, the odds ratios
ranged from 1.38 (worries of being aected financially) to 2.27 (anxiety). No eect was observed for
worries of being contaminated by the virus.
3.6. Eect of Anxiety, Depression, and Personal Concerns on the Possible Aggravation of TMD, SB, and AB
Symptoms (Chi2)
1. Aggravation of TMD symptoms: Anxiety, depression, and personal concerns significantly
increased the odds of aggravation of TMD symptoms in both populations. The odds ratios ranged from
1.58 (concerns regarding personal finances, for Polish subjects) to 3.03 (anxiety, for Polish subjects).
2. Aggravation of possible/probable AB symptoms: The obtained results were similar with regard
to the aggravation of AB symptoms. The odds ratios ranged from 1.36 (concerns regarding personal
finances, for Polish subjects) to 3.95 (anxiety, for Israeli subjects).
3. Aggravation of possible/probable SB symptoms: Similar results were observed for the
aggravation of SB symptoms. The odds ratios ranged from 1.60 (concerns regarding personal finances,
for Polish subjects) to 3.32 (anxiety, for Israeli subjects).
3.7. Multivariate Analyses (Logistic Regression)
1. TMD: The best predictors of TMD in Poland were female gender, anxiety, and personal concerns
(worries of being contaminated by the virus and about the pandemic’s eect on mental health) (Table 6).
Aggravation of TMD was best predicted by female gender, worries of being contaminated, use of social
media to look for information about the pandemic, and worries about the pandemic’s eect on mental
health (Table 7).
Table 6. Prediction of temporomandibular disorders (TMD) in Poland.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.384 0.065 34.516 1 2.16 (1.67, 2.78) 0.0000
Risk of contamination * Yes 0.237 0.065 13.526 1 1.61 (1.25, 2.07) 0.0002
Anxiety Yes 0.372 0.082 20.505 1 2.10 (1.53, 2.90) 0.0000
Mental health ** II 0.160 0.069 5.354 1 1.38 (1.05, 1.80) 0.0207
Link function: Logit. * Feeling at high risk of being contaminated (yes/no). ** Worries about the eect of the
Coronavirus on mental health (not at all/a little worried (I) versus somewhat worried/worried/very worried (II)).
On the other hand, the only significant predictor of TMDs in Israel was anxiety (Estimate: 0.917,
S.E.: 0.107, Wald: 73.922, df: 1, odds ratio 6.25, 95% confidence interval 4.11–9.49).
The best predictors of TMD aggravation in Israel were female gender, concerns about the
pandemic’s eect on the relationship with family and friends, and anxiety (Table 8).
J. Clin. Med. 2020,9, 3250 8 of 15
Table 7. Prediction of temporomandibular disorders (TMD) aggravation in Poland.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.321 0.072 19.715 1 1.90 (1.43, 2.52) 0.0000
Risk of contamination * Yes 0.218 0.069 10.150 1 1.55 (1.18, 2.03) 0.0014
Social media ** II 0.249 0.069 12.929 1 1.65 (1.25, 2.16) 0.0003
Anxiety Yes 0.389 0.08 23.579 1 2.18 (1.59, 2.98) 0.0000
Mental health *** II 0.224 0.073 9.372 1 1.57 (1.18, 2.09) 0.0022
Link function: Logit. * Feeling at high risk of being contaminated (yes/no). ** How often connecting to social media
to check for news regarding the pandemic (not checking at all/checking once a day (I) versus checking several times
a day/checking all the time (II)). *** Worries about the eect of the Coronavirus on mental health (not at all/a little
worried (I) versus somewhat worried/worried/very worried (II)).
Table 8. Prediction of temporomandibular disorders (TMD) aggravation in Israel.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.255 0.127 4.041 1 1.66 (1.01, 2.74) 0.0444
Relations * II 0.375 0.112 11.155 1 2.12 (1.36, 3.29) 0.0008
Anxiety Yes 0.351 0.123 8.184 1 2.02 (1.25, 3.26) 0.0042
Link function: Logit. * Worries regarding the eect of the Coronavirus pandemic on relations with relatives and
friends (not at all/a little worried (I) versus somewhat worried/worried/very worried (II).
2. Possible/probable AB: In Poland, the best predictors of possible/probable AB were female gender,
concerns of being contaminated by the virus, and concerns about the pandemic’s eect on mental
health (Table 9). The aggravation of AB was best predicted by concerns about being contaminated by
the virus, anxiety, concerns of the pandemic’s eect on physical and/or mental health, and use of social
media for obtaining information about the pandemic (Table 10).
Table 9. Prediction of awake bruxism (AB) in Poland.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.472 0.069 46.245 1 2.57 (1.96, 3.37) 0.0000
Risk of contamination * Yes 0.212 0.070 9.089 1 1.53 (1.16, 2.01) 0.0026
Mental health ** II 0.249 0.075 11.041 1 1.64 (1.23, 2.21) 0.0009
Anxiety Yes 0.334 0.095 12.215 1 1.95 (1.34, 2.83) 0.0005
Link function: Logit. * Feeling at high risk of being contaminated (yes/no). ** Worries about the eect of the
Coronavirus on mental health (not at all/a little worried (I) versus somewhat worried/worried/very worried (II).
Table 10. Prediction of awake bruxism (AB) aggravation in Poland.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.349 0.074 22.300 1 2.01 (1.50, 2.69) 0.0000
Risk of contamination * Yes 0.208 0.071 8.615 1 1.51 (1.15, 2.00) 0.0033
Anxiety Yes 0.461 0.081 32.200 1 2.51 (1.82, 3.46) 0.0000
Physical health ** II 0.217 0.075 8.371 1 1.54 (1.15, 2.07) 0.0038
Mental health *** II 0.260 0.076 11.781 1 1.68 (1.25, 2.26) 0.0006
Social media **** II 0.241 0.071 11.516 1 1.62 (1.23, 2.14) 0.0007
Link function: Logit. * Feeling at high risk of being contaminated (yes/no). ** Worries about the eect of the
Coronavirus on one’s physical health (not at all/a little worried (I) versus somewhat worried/worried/very worried
(II)). *** Worries about the eect of the Coronavirus on one’s mental health (not at all/a little worried (I) versus
somewhat worried/worried/very worried (II)). **** How often connecting to social media to check for news regarding
the pandemic (not checking at all/checking once a day (I) versus checking several times a day/checking all the
time (II).
In Israel, the best predictors of possible/probable AB were female gender, depression, concerns
regarding personal finances, and anxiety (Table 11). The aggravation of AB was best predicted by
female gender, concerns about the pandemic’s eect on the relationship with relatives and friends and
on mental health, and anxiety (Table 12).
J. Clin. Med. 2020,9, 3250 9 of 15
Table 11. Prediction of awake bruxism (AB) in Israel.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.175 0.088 3.946 1 1.42 (1.00, 2.00) 0.0470
Depression
Yes 0.202 0.101 4.000 1 1.50 (1.01, 2.23) 0.0455
Finances * II 0.233 0.081 8.283 1 1.59 (1.16, 2.19) 0.0040
Anxiety Yes 0.383 0.109 12.472 1 2.15 (1.41, 3.30) 0.0004
Link function: Logit. * Worries about finances (not at al/a little worried (I) versus somewhat worried/worried/very
worried (II)).
Table 12. Prediction of awake bruxism (AB) aggravation in Israel.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.333 0.134 6.208 1 1.95 (1.15, 3.29) 0.0127
Relations * II 0.250 0.123 4.156 1 1.65 (1.02, 2.67) 0.0417
Anxiety Yes 0.445 0.131 11.522 1 2.44 (1.46, 4.08) 0.0007
Mental health ** II 0.292 0.134 4.737 1 1.79 (1.06, 3.04) 0.0295
Link function: Logit. * Worries regarding the eect of the Coronavirus pandemic on relations with relatives and
friends (not at all/a little worried (I) versus somewhat worried/worried/very worried (II)). ** Worries about the eect
of the Coronavirus on one’s mental health (not at all/a little worried versus somewhat worried/worried/very worried).
3. Possible/probable SB: In Poland, the best predictors of possible/probable SB were female gender,
worries of being contaminated by the virus, and anxiety (Table 13). The aggravation of SB was best
predicted by female gender, worries of being contaminated by the virus, anxiety, use of social media,
and concerns of the pandemic’s eect on mental health (Table 14).
Table 13. Prediction of sleep bruxism (SB) in Poland.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.485 0.065 55.413 1 2.64 (2.04, 3.41) 0.0000
Risk of contamination * Yes 0.198 0.064 9.646 1 1.49 (1.16, 1.91) 0.0019
Anxiety Yes 0.225 0.074 9.341 1 1.57 (1.18, 2.09) 0.0022
Link function: Logit. * Feeling at high risk of being contaminated (yes/no).
Table 14. Prediction of sleep bruxism (SB) aggravation in Poland.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.329 0.077 18.030 1 1.93 (1.42, 2.61) 0.0000
Risk of contamination * Yes 0.301 0.072 17.302 1 1.83 (1.38, 2.43) 0.0000
Anxiety Yes 0.405 0.083 24.071 1 2.25 (1.63, 3.11) 0.0000
Social media ** II 0.230 0.073 10.026 1 1.58 (1.19, 2.11) 0.0015
Mental health *** II 0.245 0.078 9.939 1 1.63 (1.20, 2.21) 0.0016
Link function: Logit. * Feeling at high risk of being contaminated (yes/no)
.
** How often connecting to social media
to check for news regarding the pandemic (not checking at all/checking once a day (I) versus checking several times
a day/checking all the time (II)).*** Worries about the eect of the Coronavirus on one’s mental health (not at all/a
little worried (I) versus somewhat worried/worried/very worried (II).
In Israel, possible/probable SB was best predicted by anxiety and concerns regarding the pandemic’s
eect on the relationship with relatives and friends (Table 15). The aggravation of SB was best predicted
by female gender, anxiety, and concerns about mental health (Table 16).
J. Clin. Med. 2020,9, 3250 10 of 15
Table 15. Prediction of sleep bruxism (SB) in Israel.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Anxiety Yes 0.323 0.103 9.762 1 1.91 (1.27, 2.86) 0.0018
Relations * II 0.359 0.091 15.516 1 2.05 (1.43, 2.92) 0.0001
Link function: Logit. * Worries regarding the eect of the Coronavirus pandemic on relations with relatives and
friends (not at all/a little worried (I) versus somewhat worried/worried/very worried (II)).
Table 16. Prediction of sleep bruxism (SB) aggravation in Israel.
Eect Predictor Estimate S.E. Wald df OR (95% CI) p
Gender Female 0.419 0.147 8.160 1 2.31 (1.30, 4.11) 0.0043
Anxiety Yes 0.358 0.139 6.665 1 2.05 (1.19, 3.53) 0.0098
Mental health * II 0.346 0.131 6.971 1 2.00 (1.20, 3.34) 0.0083
Link function: Logit. * Worries about the eect of the Coronavirus on one’s mental health (not at all/a little worried
(I) versus somewhat worried/worried/very worried (II))
4. Discussion
The two studies, carried out in two dierent countries, used similar tools and collected data
at similar points in time, as far as the pandemic progression and lock down periods are concerned.
In Israel, data collection started four weeks after the beginning of a total lockdown in the country.
Schools, kindergartens, and universities were closed. Leaving home for a distance more than 100 m was
prohibited, except for emergency, buying basic products, or work in vital posts (specifically defined by
the government). All nonemergency medical and dental treatments were stopped. Shops, restaurants,
and most public places were shut down. Personal contact with family members not cohabitating in the
same home and/or with friends was forbidden. Similarly, in Poland, data collection started four weeks
after the beginning of a total lockdown in the country, when the country was practicing an almost
complete lockdown with similar regulations as mentioned above for Israel (with minor exceptions,
e.g., there were no limitations on the distance of leaving home). Although the studied populations in
Poland and in Israel were not similar, age- and/or gender-wise, the similarity in research tools and in
the point in time allows us to evaluate some interesting dierences between the two societies.
The first emerging finding of the two studies is that significant dierences existed in the odds of
occurrence of bruxism (AB and SB) and TMD between the Polish and Israeli populations during the
lock down periods in the two countries. Except in a few cases (higher age group), the odds in Poland
were found to be higher by several hundred percent than those in Israel.
In the general population, the prevalence of bruxism is estimated at 8–31% and tends to decrease
with age [
31
]. SB prevalence is about 16% among young adults and 3–8% among adults, while the AB
prevalence in the general population is 22–30% [
14
]. Even the reported prevalence of bruxing activities
has a large range (2.7–57.3% for AB, 4.1–59.2% for SB) [
26
]. When considering TMD, it is believed
that about 75% of the general population may experience at least one TMD-associated sign during
their lifetime and about 33% have at least one TMD symptom at each time [
32
]. The dierences origin
mostly in dierent modes of measuring.
Regretfully, accurate data on possible dierences in pre-pandemic occurrence of bruxism in
the Polish versus Israeli populations are not available. However, some studies from Poland and
from Israel suggest that the occurrence of TMD in the Polish population may dier from that in the
Israeli population. Wieckiewicz et al. reported that 54% of Polish university students present TMD
symptoms [
33
]. In another study, the same group of authors reported that 56% of participants were
diagnosed with pain-related TMD after a clinical examination [
34
]. In Israel, Winocur et al. reported
that 37% of individuals had at least one TMD symptom [
35
]. Thus, the dierences between countries,
observed in the present study, may be due to several reasons. First, the higher findings of TMD in
the Polish populations may have been there before the pandemic [
33
35
]. Possibly, the increase in
anxiety/depression in both countries aected TMD and bruxism in both countries in a proportional
J. Clin. Med. 2020,9, 3250 11 of 15
manner. Additionally, the dierences in the demographic properties of populations were significant,
a fact that might have aected the results.
As both bruxism and TMD can be caused and intensified by psychologic factors [
8
,
31
],
the dierences in their prevalence during the pandemic could have resulted from the psychological
dierences between the participants. These, in turn, may result from ethnic, socioeconomic, political,
and cultural dierences between the Polish and Israeli societies [
36
,
37
]. These factors could have
potentially modulated the psychoemotional status of the participants, influenced their coping strategies
during the Coronavirus pandemic, and in turn increased the prevalence of both bruxism and TMD in
Poland. However, this issue needs a further study focused on dierentiating between the populations.
It should also be emphasized that TMDs are closely associated with orofacial pain. The IASP
reported that TMD-related facial pain occurs in 9–13% of the general population. As TMD-related
pain can aect the daily activities, physical and psychosocial functioning, and quality of life of
the aected individuals, such a relationship could play an important role during the COVID-19
pandemic [
9
]. Increased psychosocial distress during the pandemic can exacerbate the TMD symptoms,
including those associated with orofacial pain, which in turn may further negatively aect the patients’
psychoemotional status.
When the eects of anxiety, depression, and personal concerns on TMD, SB, and AB, and the
aggravation of their symptoms (pain in temple, face or jaw, pain when opening mouth, sticking
of jaw, headache, diculty in mouth upon awaking, and stiness in jaw upon awaking, etc.) were
analyzed, some similarities were observed between the countries. Although the odds of occurrence of
TMD, SB, and AB in Poland were by far higher than in Israel, the eects of emotional factors and of
personal concerns on the associated symptoms and their aggravation were found to be similar in both
countries. Anxiety, depression, and worries regarding finances, health and relationships significantly
increased the odds of occurrence of bruxism and TMD in both the Polish and Israeli societies (with some
minor exceptions).
Apparently, anxiety, depression, and personal worries evoked by the Coronavirus pandemic
increased the prevalence of TMD and bruxism. This is in line with the literature results, that anxiety,
stress, depression, coping strategies, and catastrophizing may precipitate or prolong the TMD pain [
2
8
],
and that psychosocial factors are associated with both forms of bruxism [
13
,
14
,
16
20
]. When the
pandemic situation kept changing rapidly from day to day, uncertainty and worries about the present
and future were common and unavoidable [
38
,
39
]. Moreover, subjects had to stay home and many
were unemployed, with the media constantly broadcasting apocalyptic news. Under such conditions,
a significant increase in the odds of occurrence of TMD, SB, and AB is not surprising.
The one prominent dierence was observed between the studied populations. The studies show
that unlike the Polish participants, the worry of being contaminated by the virus did not increase the
odds of occurrence of AB and SB, or aggravate the symptoms of the conditions (TMD, SB, and AB)
among the Israeli subjects. This may be explained by the advanced and generally good public health
services available in Israel. All the Israeli citizens have governmental health insurance and are entitled
to all the necessary health services with no extra costs (besides a mandatory monthly fee). Furthermore,
hospitals are considered to meet high medical standards, and medical personnel are required to be
well trained. In Poland, citizens’ trust in national healthcare system is limited [40].
Logistic regression models used in this study for identifying the variables that can serve as
significant predictors of TMD, SB, AB, and/or the aggravation of their symptoms, showed that female
gender was significant in most of the calculations. In Poland, female gender played a significant role
in predicting the presence of TMD, AB, and SB, as well as the symptom aggravation, while in Israel
this factor played a significant role in predicting the presence of AB (but not TMD or SB) and the
aggravation of TMD, SB, and AB symptoms.
The role of gender is expected because most of the TMD patients worldwide are women [
1
].
In spite of the dierences between the two countries, results showed that women in both places are
highly vulnerable to the eects of unexpected prolonged stress situations. Aggravation of chronic pain
J. Clin. Med. 2020,9, 3250 12 of 15
symptoms such as TMD and symptoms associated with bruxism may be only some of the negative
consequences that aect women more severely than men [41,42].
Additional factors that were consistently identified as significantly predicting the TMD, AB, and SB
(and/or the symptom aggravation) in the present studies were anxiety, worries of being contaminated
by the virus, and concerns about the pandemic’s eect on physical or mental health (to slightly dierent
extents in the two countries). In some instances, two additional factors were identified in the regression
analyses: worries that the pandemic will aect the relationship with relatives and friends (in Israel) and
the use of social media (but not TV or internet) for checking news regarding the pandemic (in Poland).
In Israel, close family ties and long-term friendships are very common in the society [
43
].
Apparently, the social distancing period, which prevented face-to-face meetings, took its toll on Israeli
society. The fact that the use of social media aected, in some cases, the Polish, but not the Israeli,
participants, may be explained by the younger age of the former. Another explanation may be that
the Israeli society is constantly exposed to security tension and alerts making it more resilient [
44
].
The Israeli public extensively check the news at all times, and the Coronavirus crisis is no dierent
from many other emergencies experienced by these people.
In a recent study, Varshney et al. reported that during the initial stages of the Coronavirus
pandemic in India, almost one-third of the respondents manifested a significant psychological
impact [
45
]. The factors that predicted a higher psychological impact were young age, female gender,
and the presence of a physical comorbidity. The authors of the study also showed that males faced
a lesser psychological impact as compared to females [
45
]. Thus, in spite of the dierences between
countries and cultures, many of the basic factors aecting the public are similar.
Several limitations of the studies should be pointed out. No inclusion and/or exclusion criteria were
specified and the study samples were not predetermined. The significant dierences in demographic
variables might have been a reason for some of the detected dierences, especially in view of the fact
that gender (but not age) came out as a predictive factor in most of the models calculated for TMD,
bruxism, and symptom aggravation, in both countries. Moreover, the studies were performed during
a specific point in time at the first phase of the pandemic and may be indicative of the immediate stress
evoked by the sudden health risk and changes in life style. Additionally, possible confounders that
could have influenced the results were not under control.
Further longitudinal studies are needed to evaluate the pandemic’s possible long-term mental
and physical consequences. Multifactorial and multicultural research should be performed to identify
the risk groups and counteract the aggravation of emotional and physical eects in the case of future
global crises.
5. Conclusions
The coronavirus pandemic has caused significant adverse eects on the psychoemotional status
of both Israeli and Polish populations, resulting in the intensification of their bruxism and TMD
symptoms and thus leading to increased orofacial pain.
Author Contributions:
A.E.-P., I.E., and M.W. contributed to study conception and design. A.E.-P., I.E., G.W.,
N.U., and E.G. collected the data. A.E.-P., I.E., N.G., and J.S. were involved in data analysis and interpretation.
A.E.-P., I.E., M.W., and J.S. drafted the article. A.E.-P., I.E. and M.W. critically revised the article. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
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... Positive answers to one of the questions indicate possible TMD, AB, and SB, respectively. The 3Q/TMD questionnaire, as well as self-report questionnaires, are acceptable tools for screening TMD symptoms [33][34][35], and to asses possible awake or sleep bruxism [9,11,35,36], respectively. ...
... Positive answers to one of the questions indicate possible TMD, AB, and SB, respectively. The 3Q/TMD questionnaire, as well as self-report questionnaires, are acceptable tools for screening TMD symptoms [33][34][35], and to asses possible awake or sleep bruxism [9,11,35,36], respectively. ...
... Moreover, subjects with TMD symptoms and possible bruxism chose Planning significantly less often than those without these symptoms. 35 Detailed analysis of most frequently chosen stress-coping strategies by subjects presenting with conditions (possible TMD, awake and sleep bruxism) and symptom-free subjects is given in Figure 2. Self-Blaming was the significantly more often chosen strategy among subjects with TMD symptoms, or possible awake and sleep bruxism than among asymptomatic subjects. Moreover, subjects with TMD symptoms and possible bruxism chose Planning significantly less often than those without these symptoms. ...
Article
Full-text available
The COVID-19 pandemic caught universities along with their students off-guard, enforcing online education. Fear of the unknown, disinformation, and isolation resulted in an increased stress level in the entire population. Medical university students are particularly endangered with high stress levels and developing TMD. Temporomandibular disorders (TMD) are of multifactorial etiology, and manifest with jaw dysfunction, masticatory muscle tension or pain, as well as headache. Though bruxism can act as an exacerbating factor for TMD, stress can also play crucial role in the onset. The study aimed to measure occurrence of TMD and bruxism symptoms in the medical student population, asses the stress level, and evaluate adopted stress-coping strategies during the COVID-19 pandemic outbreak. A survey study was performed among 1018 students at Medical University of Lodz during April 2020. A self-designed questionnaire for screening TMD and bruxism symptoms, Perceived Stress Scale (PSS-10), and Brief-COPE questionnaires were applied. TMD and bruxism symptoms were observed in the majority of subjects during social isolation. The perceived stress levels were significantly higher in those experiencing TMD and bruxism symptoms. Mostly maladaptive, emotion-focused coping strategies were chosen by study subjects experiencing high levels of stress. Choosing Self-Blaming as a coping strategy is the strongest predictor of perceived stress.
... Possible reasons for stress and perceptions of dental practice after the COVID-19 pandemic among dental practitioners were evaluated. The mean values of stress scores achieved using Cohen stress scores (low stress (0-13), moderate stress (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26), and high perceived stress (27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)) were compared based on sex, age, occupation, and qualification among the respondents. Two of the researchers (SSA and MSK) participated in the pilot study and had a consensus on the validity of the questionnaire. ...
... A population-based study [33] from Saudi Arabia reported that there would be a tremendous impact on health care services. Furthermore, a few researchers have studied stress and its impact on sleep [34], musculoskeletal disorders [35], and temporomandibular joints [36]. It shows the importance of counseling and wellbeing support from local health authorities. ...
Article
The coronavirus outbreak (COVID-19) significantly impacted dental health practitioners. Dentists are exposed to uncertain fears affecting them mentally and financially, leading to a multi-fold increase in anxiety and stress. To assess the stress levels among the dental practitioners during the COVID-19 pandemic and evaluate perceptions of dental practitioners after a pandemic outbreak. A well-self-administered questionnaire was designed, and Google forms were sent to participants. The questionnaire involves demographic details (section 1), Cohen's stress levels (section 2), and perceptions of dental practice after pandemic (section 3). The comparisons were made based on sex, age group, qualification, and occupation. Descriptive statistics were performed using SPSS (version 17.0, Chicago, IL, USA). Overall, 376 participants in the survey, 66.2% (249) were males, and 33.8% (127) were females. The most common age group of respondents was 31-40 years (44.7%). Occupation wise 44.4% were private practitioners, while postgraduates were 49.5% among the study population. The comparison of stress mean scores among the sexes showed non-significant (p > 0.05) while there was evidence of significance among the age group, qualifications, and occupations of the participants (p < 0.05). The overall mean stress score level was 19.95, whereas males (20 ± 7.7), private dental practitioners (21.9 ± 7.9), and participants of more than 50 years of age (26.1 ± 7.8) got high-stress scores, respectively. The dentists with graduates in the study showed (17.5 ± 7.5) had the least stress scores. Overall dental practitioners are at moderate stress levels; among them, males, private practitioners, and dentists above 50 years of age exhibited more stress, whereas graduates had the least stress scores.
... Some authors reported that the female gender played a significant role in predicting the presence of bruxism. The offered explanation was that women are more vulnerable to the effects of unexpected, prolonged stress situations than men [59]. The results of two recent studies are suggesting that the prevalence does not vary between genders [60] or that the male gender was indicated as a risk factor [61]. ...
Article
Full-text available
The COVID-19 pandemic has drastically changed the routine way of life, having consequences in many segments of life, including dental practice and education. The aim of this study was to evaluate the frequency of probable bruxism in a sample of dental students in Serbia and to estimate the potential association between psychological factors related to the COVID-19 pandemic and the presence of bruxism. A cross-sectional study included 178 dental students in Serbia, who were interviewed using a specially-designed self-administered online questionnaire, which consisted of three sections, and after that, a clinical examination for the presence of bruxism symptoms in the oral cavity. Psychological status was evaluated using the Depression, Anxiety and Stress Scale-21 (DASS-21) and the Fear of COVID-19 Scale (FCV-19S). Saliva samples were taken to analyze salivary cortisol levels. The prevalence of probable bruxism was 34.8%. Respondents with probable bruxism had significantly higher DASS-21 and FCV-19S scores and mean values of salivary cortisol compared to non-bruxers. A history of COVID-19 infection, high stress, and fear of COVID-19 scores were associated with the presence of probable bruxism. The findings suggest that the COVID-19 pandemic has had a great psychological impact and impact on the presence and worsening of bruxism symptoms in a sample of dental students in Serbia.
... The pandemic has had a significant impact not only on dentists and their colleagues [54], but also on patients' mental well-being. Frequently, the occurrence of depression, anxiety, stress, intrusion, avoidance, and hyperarousal were observed both in patients, as well as in healthcare workers [55][56][57][58][59]. ...
Article
Full-text available
With the arrival of the highly transmissible Omicron variants (BA.4 and BA.5), dentistry faces another seasonal challenge to preserve the biosafety of dental care and education. With the aim of protecting patients, students, teachers and healthcare professionals, this paper introduces a prospective sustainable biosafety setting for everyday dental care and education. The setting developed by dental clinicians, epidemiologists, and teachers of dentistry consists of a combination of modern technologies focused on the air-borne part of the viral pathway. The introduced biosafety setting has been clinically evaluated after 18 months of application in the real clinical environment. The protocol has three fundamental pillars: (1) UVC air disinfection; (2) air saturation with certified virucidal essences with nebulizing diffusers; (3) complementary solutions including telehealth and 3D printing. A pseudonymous online smart form was used as the evaluation method. The protocol operates on the premise that everybody is a hypothetical asymptomatic carrier. The results of a clinical evaluation of 115 patient feedbacks imply that no virus transmission from patient to patient or from doctor to nurse was observed or reported using this protocol, and vice versa, although nine patients retrospectively admitted that the clinic visit is likely to be infectious. Despite these promising results, a larger clinical sample and exposition to the current mutated strains are needed for reliable conclusions about protocol virucidal efficiency in current dental environments.
... TMDs often accompany stress, anxiety, depression, and psycho-emotional stress, so they are often present in college students during exams [9,10] or even during the COVID-19 pandemic [11], according to several studies [12][13][14][15][16]. Symptoms of TMJ disorders were present in adolescents [17], and myofascial pain was the most prevalent type. ...
Article
Full-text available
Background The temporomandibular joint (TMJ) is one of the most complex joints in the body. Temporomandibular disorders (TMD) are among the most troublesome disorders for patients, as they can cause pain, affect oral functions and disturb dentists on the level of diagnosis and treatment. The most common symptoms of temporomandibular joint disorders are articulated sounds (such as clicking or TMJ crepitation), joint pain in comfort and function situations (jaw movements), pain or strain in masseter and jaw muscles and or restricted mandibular movements. One of the most modern biocompatible substances used to treat joint disorders, including the TMJ, is platelet-rich plasma (PRP) and injectable platelet-rich fibrin (I-PRF). This study aims to evaluate the efficacy of platelet-rich fibrin (I-PRF) intra-articular injections in managing internal derangements of temporomandibular. Methods Twenty patients suffering from a unilateral click due to temporomandibular disorders were individually injected with 1 mL of (I-PRF) twice 1 week apart into the superior joint space of the TMJ with the internal disorder. Data were recorded and evaluated by the Helkimo index. This evaluation was conducted three times; 1 week after the first injection, 1 week after the second injection, and 6 months after the first injection. Results The clicking disappeared entirely in 14 out of 20 patients after 1 week of getting the first injection, and in all patients after 1 week of getting the second injection, and returned to two of them after a six-month since the first injection. Conclusion Preliminary results showed the efficacy of the Injectable Platelet-Rich Fibrin (I-PRF) in managing articular clicking in patients with internal disorders of the temporomandibular joint. Injectable Platelet Rich Fibrin has significant clinical efficacy in treating the articular clicking resulting from internal temporomandibular joint disorders.
... Kardes et al., report that at the beginning of the year 2020, dental grinding presented an increase in public interest and demand worldwide, however, it was not significant until the period from May to October, where in the US and the rest of the world the number of reports of bruxism increased, along with grinding and clenching (28). This finding indicates that the COVID-19 pandemic had a negative impact on bruxism and its symptoms (29)(30)(31), consistent with our results. ...
Article
Bruxism is the repetitive muscle-mandibular behavior characterized by clenching and/or grinding of the teeth, which reflects the presence of one or more underlying conditions or factors. The objective of this descriptive study was to determine the association between bruxism and stress self-perceived during the pandemic, as well as their frequency by gender and academic area. An interrogation and self-perceived stress scale PSS-14 were applied to students from the different areas of the Institute of Health Sciences (ICSa) to determine the presence or absence of stress and bruxism symptom, a Chi-square was used for the comparison between variables, considering a value of p<0.005 as significant, a two-way ANOVA was performed to evaluate the difference between the symptoms before and during the isolation of the pandemic. The total number of participants was 825, a final sample of 420 students was obtained, made up of 297 (70.72%) women and 123 (29.28%) men, with an average age of 20±1.75 years. We found an association between the frequency of bruxism and severe stress generated during the social isolation of the COVID-19 pandemic, with a high perception of stress in the medicine area and a high frequency of bruxism in the area of nutrition p>0.005. ICSa students between 18 and 24 age perceive symptoms of bruxism and high levels of stress caused during the pandemic.
Article
In January 2020, the World Health Organization identified COVID-19, caused by the SARS-CoV-2 virus, as a global health emergency. Restrictive measures and uncertainties resulted in a time of high stress, anguish, anxiety, depression and other psychosomatic symptoms. Studies have indicated that oral health was affected by the increased frequency of caries, bruxism and periodontal disease related to the COVID-19 pandemic. The aim of this research was to evaluate the impairment of quality of life of individuals aged between 20 and 70 years, diagnosed with periodontal disease during the COVID-19 pandemic. Material and methods: After the approval of Ethics and Research, the data collection was done by online questionnaire, built on the Google Forms platform® and disclosed to periodontist dentists. The form was original multithematic containing 25 semi-structured questions, which were divided into sociodemographic questions and objective and subjective questions, according to the norms of resolution 510/16 (BRAZIL, 2016). The questionnaire was accessible for 3 months between June and September 2021. As a result, 125 responses were obtained, 14 of which were excluded: 13 because they corresponded to those over 70 years of age and 01 because the patient did not state age. The total number of valid answers was 111. It can be concluded that the COVID-19 Pandemic contributed to the impairment of quality of life and the appearance of oral alterations, bruxism and intensification of previously existing problems such as periodontal disease, mainly due to inadequate or insufficient self-care practices.
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Detecting cracks in teeth is a long-standing clinical challenge. Patients may complain of diffuse pain on chewing, pain, at times, on temperature change and pain that occurs episodically. Common diagnostic tools such as radiographs and visual examination may not detect cracks. This clinical case study shows how photothermal radiometry and luminescence (PTR-LUM), technology behind the Canary Dental Caries Detection System can detect and monitor cracks clinically as well as quantify the extent of crack. This important clinical feature is not yet available with other caries detection clinical devices. In this clinical situation, the cracks involved a large part of the mesial and distal of a mandibu-lar second molar and the adjacent first molar. It led to a diagnosis of parafunction and placement of a mandibular flat plane bite splint along with the placement of composite restorations to restore the fractures. The science behind the point scan lock-in signal processing results of PTR-LUM technology implemented in The Canary System to clinically detect visible cracks or cracks beneath the enamel surface as well as caries on all tooth surfaces and around restorations is discussed. Amplitude and phase results from PTR-LUM point scans are incorporated into a Canary number output developed for oral health providers and are disclosed for the first time in detail with clinical evidence.
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Background: The study aimed to compare psychopathological expressions during the COVID-19 (novel coronavirus disease 2019) pandemic, as declared on March 11th 2020 by the World Health Organization, with respect to which institutional variables might distinguish the impact of COVID-19 in medical and non-medical professionals. Methods: A cross-sectional study was performed nationwide between 16th March and the 26th April 2020 in Poland. A total of 2039 respondents representing all healthcare providers (59.8%) as well as other professionals filled in the sociodemographic section, the General Health Questionnaire-28 and the author's questionnaire with questions related to exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the availability of protective measures, quarantine, change of working hours and place of employment during the pandemic, as well as feelings associated with the state of the pandemic. Results: Medical professionals more often presented with relevant psychopathological symptoms (GHQ-28 (General Health Questionnaire-28) total score >24) than the non-medical group (60.8% vs. 48.0%, respectively) such as anxiety, insomnia and somatic symptoms even after adjustment for potential confounding factors. Male sex, older age and appropriate protective equipment were associated with significantly lower GHQ-28 total scores in medical professionals, whereas among non-medical professionals, male sex was associated with significantly lower GHQ-28 total scores. Conclusions: Somatic and anxiety symptoms as well as insomnia are more prevalent among medical staff than workers in other professions. Targeting the determinants of these differences should be included in interventions aimed at restoring psychological well-being in this specific population. Apparently, there are present gender differences in psychological responses that are independent of profession.
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Background The pandemic of Corona Virus (COVID-19) hit India recently; and the associated uncertainty is increasingly testing psychological resilience of the masses. When the global focus has mostly been on testing, finding a cure and preventing transmission; people are going through a myriad of psychological problems in adjusting to the current lifestyles and fear of the disease. Since there is a severe dearth of researches on this issue, we decided to conduct an online survey to evaluate its psychological impact. Methods From 26th to 29th March an online survey (FEEL-COVID) was conducted using principles of snowballing, and by invitation through text messages to participate. The survey collected data on socio-demographic and clinical variables related to COVID-19 (based on the current knowledge); along with measuring psychological impact with the help of Impact of Event–revised (IES-R) scale. Results There were a total of 1106 responses from around 64 cities in the country. Out of these 453 responses had at least one item missing; and were excluded from the analysis. The mean age of the respondents was around 41 years with a male female ratio of 3:1 and around 22% respondents were health care professionals. Overall approximately one third of respondents had significant psychological impact (IES-R score > 24). Higher psychological impact was predicted with younger age, female gender and comorbid physical illness. Presence of physical symptoms and contact history predicted higher psychological impact, but did not reach statistical significance. Conclusion During the initial stages of COVID-19 in India, almost one-third respondents had a significant psychological impact. This indicates a need for more systematic and longitudinal assessment of psychological needs of the population, which can help the government in formulating holistic interventions for affected individuals.
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About 83000 COVID-19 patients were confirmed in China up to May 2020. The effects of this public health crisis - and the varied efforts to contains its spread - have altered individuals’ “normal” daily functioning. This impact on social, psychological, and emotional well-being remain relatively unexplored, especially the ways in which Chinese men and women experience and respond to potential behavioral-related stressors. A cross-sectional study was conducted in late February 2020. Demographic characteristics and residential living conditions were measured along with psychological stress and behavior responses to the COVID-19 epidemic. 3088 questionnaires were received: 1749 females (56.6%) and 1339 males (43.4%). The mean level of stress, as measured by a visual analog scale, was 3.4 (SD=2.4) - but differed significantly by sex. Besides sex, factors positively associated with stress included: age (≤45 years), employment (unsteady income, unemployed), risk infection population (exposed to COVID-19, completed medical observation), difficulties encountered (diseases, work/study, financial, mental), behaviors(higher desire for COVID-19 knowledge, more time spent on the COVID-19). “Protective” factors included frequently contact with colleagues, calmness, and psychological resilience. Males and females also differed significantly in adapting to current living/working status, coping with heating, and psychological support service needs. Among Chinese, self-reported stress related to the COVID-19 epidemic were significantly related to sex, age, employment, resilience and coping styles. Future responses to such public health threats may wish to provide sex- and/or age-appropriate supports for psychological health and emotional well-being to those at greatest risk of experiencing stress.
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Background: The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference. Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21). Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). Conclusions: During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.
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Background and objectives: Sleep bruxism is a common phenomenon that can affect approximately 13% of adult population. It is estimated that bruxism can be caused by three types of factors: biological, psychological, and exogenous. There are many scientific reports about the coexistence of bruxism, stress, and psychoemotional disorders. The aim of this study is to evaluate the possible correlation between occurrence of sleep bruxism and perceived stress and depressive symptoms. Material and methods: The material of this study consisted of 77 patients of Clinic of Prosthetic Dentistry operating at the Department of Prosthetic Dentistry, Wroclaw Medical University, Poland in which after using guidelines of the American Academy of Sleep Medicine probable sleep bruxism was fund. Patients then underwent video-polysomnography. Exposure to perceived stress was evaluated with Perceived Stress Scale-10 (PSS-10). Occurrence of depressive symptoms was evaluated with Beck’s Depression Inventory (BDI). Results: The analysis showed lack of statistically significant correlation between Bruxism Episodes Index (BEI) and Perceived Stress Scale–10 and Beck’s Depression Inventory scores (p = 0.64, p = 0.65; respectively), also when comparing study group (bruxers) and control group (non-bruxers) (p = 0.88, p = 0.77; respectively). Conclusion: Intensity of sleep bruxism was not statistically significantly correlated with self-reported perceived stress and depression. This issue requires further research.
Article
In addition to being a public physical health emergency, Coronavirus disease 2019 (COVID-19) affected global mental health, as evidenced by panic-buying worldwide as cases soared. Little is known about changes in levels of psychological impact, stress, anxiety and depression during this pandemic. This longitudinal study surveyed the general population twice - during the initial outbreak, and the epidemic's peak four weeks later, surveying demographics, symptoms, knowledge, concerns, and precautionary measures against COVID-19. There were 1738 respondents from 190 Chinese cities (1210 first-survey respondents, 861 second-survey respondents; 333 respondents participated in both). Psychological impact and mental health status were assessed by the Impact of Event Scale-Revised (IES-R) and the Depression, Anxiety and Stress Scale (DASS-21), respectively. IES-R measures PTSD symptoms in survivorship after an event. DASS -21 is based on tripartite model of psychopathology that comprise a general distress construct with distinct characteristics. This study found that there was a statistically significant longitudinal reduction in mean IES-R scores (from 32.98 to 30.76, p<0.01) after 4 weeks. Nevertheless, the mean IES-R score of the first- and second-survey respondents were above the cut-off scores (>24) for PTSD symptoms, suggesting that the reduction in scores was not clinically significant. During the initial evaluation, moderate-to-severe stress, anxiety and depression were noted in 8.1%, 28.8% and 16.5%, respectively and there were no significant longitudinal changes in stress, anxiety and depression levels (p>0.05). Protective factors included high level of confidence in doctors, perceived survival likelihood and low risk of contracting COVID-19, satisfaction with health information, personal precautionary measures. As countries around the world brace for an escalation in cases, Governments should focus on effective methods of disseminating unbiased COVID-19 knowledge, teaching correct containment methods, ensuring availability of essential services/commodities, and providing sufficient financial support.
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Bruxism is a common condition that clinicians come across in both adult and children. Prevalence rates in adults range from 22% to 30% for awake bruxism (AB) and from 8% to 16% for sleep bruxism (SB), while in children they raise up to 40% for SB. Currently, bruxism is considered an ‘umbrella term’ for different jaw muscle activities, occurring during sleep and/or wakefulness. They have a different aetiology, but there is agreement on their central, not peripheral, origin. In otherwise healthy individuals, bruxism can be considered a muscle behaviour, which can be harmless or represent a risk and/or protective factor for clinical consequences, rather than being a disorder per se. Nonetheless, given the merging knowledge on the interaction with several associated factors and concurrent conditions, bruxism should be investigated for being a possible sign of an underlying primary condition. Consequently, treatment should be directed to the management of the possible clinical consequences and/or to the underlying primary conditions. It is generally based on the conservative strategies. The present manuscript summarises the available knowledge on bruxism aetiology, assessment and management for both SB and AB in adults and children, with focus on the future directions to implement the clinical relevance of bruxism researches. Clinical relevance A narrative overview summarising such a quickly evolving topic as bruxism may be useful to help clinicians understanding the complex relationship among bruxism, the possible underlying primary conditions, and the possible clinical consequences.
Article
This article analyzes the outcomes of the key healthcare reforms undertaken in Poland and assesses how successful they have been. Contrary to the governmental perspective on success, understood in terms of economic efficiency, we define it in terms of patient satisfaction. As such, health policy is treated as a political system’s response to the problems emerging in the public agenda. The analysis therefore focuses on the responsiveness of the healthcare system through patients’ eyes. This analysis takes three main reforms undertaken in post-1989 Poland as reference points. These were: Regional Sickness Funds (Kasy Chorych, 1999); the National Health Fund (Narodowy Fundusz Zdrowia, 2003/2004); and the waiting lists package and the oncological package (pakiet kolejkowy and pakiet onkologiczny, 2015). Each introduced key institutional changes, but also sparked media interest, public attention, and mass discourse. The article presents the main goals and the most important consequences of the reforms for patients. For the purposes of the analysis, the following patient-oriented indicators of reform success were chosen: (1) public satisfaction with healthcare, (2) waiting times, (3) number of health professionals. The assembled data from national and international databases leads to the conclusion that the reforms have not succeeded.
Article
Aims: To investigate the prevalence and overlaps of headaches and pain-related temporomandibular disorders (TMD) among the Polish urban population. Methods: The study was conducted in four Polish cities (Wroclaw, Lublin, Katowice, and Lodz) between February and November 2017. Participation in the study was voluntary. The examination consisted of two parts: a clinical examination of TMD using the Diagnostic Criteria for TMD Examination Form and the Head-HUNT Study questionnaire filled in by the participants to determine the occurrence and type of headaches. An experienced and qualified clinician trained all the examiners in the clinical examination protocol. Statistical analyses were based on descriptive and nonparametric statistics. In addition, univariate logistic regression was used. The significance level was set at α = .05. Results: Overall, 213 individuals were examined (149 women and 64 men). The mean age of the participants was 37 ± 15.82 years. The diagnosis for 55.9% of the participants was pain-related TMD, including myalgia (47.4%), myofascial pain (14.1%), arthralgia (21.1%), or headache attributed to TMD (10.3%). In the study population, 48.8% were diagnosed with temporomandibular joint disorders, most frequently disc displacement with reduction (47.9%). A total of 73% of the individuals had experienced headaches in the previous 12 months. The majority of the participants described the headache episodes as occurring less than 7 days/month and lasting less than 4 hours. Among people with painful TMD, the frequency of headaches was almost twice as high as that in nondisordered individuals (48.35% and 25.35%, respectively; P < .0001). The logistic regression model confirmed a significant overlap between headache and painful TMD (OR = 4.77, 95% CI 2.44-9.32, P = .0000). For the entire studied population, no statistically significant connections were established between the occurrence of identified TMJ disorders and headache reports or diagnoses (P > .05). Conclusion: Headaches and pain-related TMD are major problems among the Polish urban population. Headache was a much more frequent problem for participants with painful TMD. This issue requires further research and identification of cause-and-effect relationships. Considering the entire studied population, the relationship between identified TMJ disorders and headache is negligible.