Temporomandibular Disorders Priorities for Research and Care (2020) / Chapter Skim
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Appendix C: Commissioned Paper by Gary Slade and Justin Durham: Prevalence, Impact, and Costs of Treatment for Temporomandibular Disorders
Appendix C: Commissioned Paper by Gary Slade and Justin Durham: Prevalence, Impact, and Costs of Treatment for Temporomandibular Disorders
Pages 361-402
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From page 361... ...
adults report having experienced orofacial pain in the preceding 3 months, a prevalence rate that has persisted for three decades. The prevalence of orofacial pain symptoms varies substantially according to gender, age, and household income.
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From page 362... ...
Moreover, one-quarter of people with orofacial pain symptoms report highimpact chronic pain from any anatomical location, compared with only 7 percent for people without orofacial pain symptoms. The cost burdens of TMDs have been investigated most thoroughly in a study of adults with persistent orofacial pain living in the northeast of England.
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From page 363... ...
National Health Interview Survey (NHIS) and two studies conducted by the authors: • The U.S.-based OPPERA study1: Orofacial Pain: Prospective Evalu ation and Risk Assessment • The UK-based DEEP study2: Developing Effective and Efficient Care Pathways for Patients with Chronic Pain The report is limited to studies of painful TMDs where the defining features are pain in the joints and/or muscles of the jaws; and limitation in jaw function due to the pain.
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From page 364... ...
For this report the data were downloaded from the NHIS website, and relevant data items from the "family" and "adult" were merged, along with survey design variables. The data were analyzed with survey estimation procedures in the SAS statistical analysis program, observing guidelines described by the National Center for Health Statistics.3 In most of the NHIS annual surveys conducted since 1989, orofacial pain symptoms have been assessed using a single-item question asked of all respondents aged 18 years or more: BOX C-1 National Health Interview Survey • onducted annually since 1957 C • ationally representative sample of the civilian, non-institutionalized popula N tion of the United States • 0 states and the District of Columbia 5 • 5,000 households containing about 87,500 persons 3 • 70 percent response rate among eligible households ~ • ace-to-face, computer-assisted personal interviews F • rained interviewers from the U.S.
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From page 365... ...
The NHIS also collects extensive data about socio-demographic characteristics, other health conditions, and the study participants' use of health care. It is therefore possible to examine cross-sectional variation in the TABLE C-1 Prevalence of Orofacial Pain Symptoms in the U.S.
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From page 366... ...
For example, as noted below, TMD prevalence is inversely associated with income, but that does not necessarily mean that low income contributes causally to the symptoms, nor that orofacial pain symptoms reduce people's income, notwithstanding that both causal processes are plausible. In 2017–2018, the prevalence of orofacial pain symptoms among U.S.
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From the authors' analysis of data from n=52,159 participants in the 2017–2018 NHIS surveys.
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From page 368... ...
SOURCES: From the authors' analysis of NHIS: 1A is based on data from n=52,159 participants in the 2017–2018 NHIS surveys; 1B is based on data NHIS surveys conducted in 1989 (n=42,370 participants) , 1999 (n=30,780 participants)
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From page 369... ...
Prevalence of Orofacial Pain Symptoms According to Health Care Usage and Other Pain Conditions (NHIS 2017–2018) In 2017–2018 the prevalence of orofacial pain symptoms tended to be greater among people who had used health care in the preceding year than among those who had not (see Table C-3)
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From page 370... ...
Yes 34.3 8.9 (8.4, 9.3) # body pain symptoms 0 46.8 1.1 (0.9, 1.3)
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From page 371... ...
A recent survey of adult dental patients found that prevalence of orofacial pain symptoms was 6.6 percent among those attending dental providers in the Northwest Practice-Based Research Collaborative in Evidence-Based Dentistry.10 Although NHIS surveys show small differences in orofacial pain symptom prevalence between Hispanic and non-Hispanic adults, the survey lacks the precision needed to evaluate heterogeneity within the Hispanic population. Instead, the Hispanic Community Health Study/Study of Latinos (HCHS/SoL)
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From page 372... ...
Specifically, respondents were asked, "Other than a toothache or sinus pain, did you have pain in your face, in the front of your ear or jaw, more than one time, in the last 6 months? " Respondents were also invited to a research dental clinic where examiners determined presence or absence of TMD using Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD)
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From page 373... ...
Adults The prevalence of orofacial pain symptoms in the U.S. population is consistent at 5 percent, although there are marked differences in prevalence according to age, gender, and income.
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From page 374... ...
TMD Incidence in the OPPERA Study In the OPPERA prospective cohort study, facial pain symptoms were assessed by questionnaire, once every quarter (3-month period) among 2,719 adults aged 18–44 years who had no history of a TMD when enrolled.
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From page 375... ...
A simple checklist of general health conditions was also a strong predictor, although examiner-assessed joint sounds, jaw function or parafunction, and depression were not.21 Seven years later, 45 of the 147 subjects with a first-onset TMD were again re-examined to classify their clinical TMD status.22 Overall, 53 percent (24/45) were again found to have a clinical TMD (see Table C-7)
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From page 376... ...
Status 6 Months and 7 Years After Development of First-Onset TMD, OPPERA 2006–2016 Number of Study Participants: 7-Year Follow-Up Examination Status 6-Month Follow-Up Examination Status Non-TMD TMD All Subjects Non-TMD 14 5 19 TMD 7 19 26 All subjects 21 24 45 NOTE: n=45 people with a first-onset TMD who were re-examined 6 months and 7 years after onset in the OPPERA prospective cohort study, 2006–2016.22 the 6-month follow-up examination. However, that overall rate disguises the fact that 27 percent (7/23)
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From page 377... ...
Among subjects who had no history of a TMD when enrolled, 6.5 percent reported orofacial pain symptoms 3 years later. Although the rate did not differ to a statistically significant degree, it was inversely associated with age, and it was 7.7 percent in females compared to 4.8 percent in males.
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From page 378... ...
Chronic TMD and High-Impact Chronic TMD (NHIS 1989) The National Pain Strategy defines chronic pain as "pain that occurs on at least half the days for six months or more" and high-impact chronic pain as chronic pain that is "associated with substantial restriction of participation in work, social, and self-care activities for six months or more."26 Data in Table C-8 provide some insight into duration and impact of TMD pain symptoms in the U.S.
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From page 379... ...
1–3 27.8 4–6 36.2 7–10 36.0 Behavioral Responses to Facial Pain† Take over-the-counter medication 50.7 Take prescription medication(s) 22.9 Use a hot or cold compress 17.0 Stay at home more than usual 8.3 Avoid family or friends 6.3 Drink some liquor 5.4 Take time off work 4.8 Anything else 13.8 None of the above 22.7 Health care providers seen for TMD pain† Any health care provider 48.4 Dentist 32.8 Medical doctor 23.8 Other health care provider 6.3 *
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From page 380... ...
The same 2016 NHIS data were analyzed for this report, focusing on the relationship between orofacial pain symptoms and chronic pain or high-impact chronic pain from any anatomical location. The prevalence of chronic pain at any anatomical location was elevated nearly three-fold in people with orofacial pain symptoms (52.7 percent)
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From page 381... ...
In addition to a TMD examination, study participants were classified according to the presence or absence of four other idiopathic pain conditions (IPCs) : headache, irritable bowel syndrome (IBS)
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Overlap of TMDs with Other Pain Conditions In people with examiner-classified TMDs at the follow-up examination, fewer than one-quarter had a TMD alone, as shown in the cut-out slice of the pie chart in Figure C-2. One-third had one other condition, one-quarter had two, 12 percent had three, and 5 percent had all four other conditions.
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From page 383... ...
56.0 (6.9) NOTES: Unpublished results from 384 subjects with one or more of five index pain conditions classified in the OPPERA-2 7-year follow-up study.
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From page 384... ...
with examinerclassified TMD in the OPPERA-2 7-year follow-up study. The five pain conditions are B = low back pain; F = fibromyalgia; H = headache; I = irritable bowel syndrome; and T = TMD.
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From page 385... ...
Headache or body pain lasting ≥1 day within previous 3 months Proportion reporting pain FIGURE C-3 Pain symptoms at 42 body locations reported by people with chronic TMDs. SOURCE: Unpublished results from n=182 subjects (weighted n=107)
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From page 386... ...
adult population is approximately 1 percent. • Meanwhile, using the higher threshold of at least one-half of the days in the preceding 6 months to define chronic pain as per the National Pain Strategy, the prevalence of chronic pain from any anatomical location was 20 percent in 2016.27 • Of note, the prevalence of chronic pain, regardless of its anatomical location, was elevated nearly threefold, to 53 percent, among people with orofacial pain symptoms (see Table C-9)
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From page 387... ...
The origin of the pain was identified using validated screening instruments32,33 and if odontogenic pain was identified, individuals were excluded from participating. No changes to individuals' care pathways were made, and they progressed within existing structures in both community ("primary")
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. Sample Characteristics -- DEEP Study Of the 279 individuals screened to enter the DEEP study, 268 met the inclusion criteria and 239 agreed to participate, with 198 returning data at M0.
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TABLE C-12 Socio-Demographic Characteristics of DEEP Study Participants Time Point M0 (n=87)
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TABLE C-12 Continued 390 Time Point M0 (n=87)
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As demonstrated in Table C-15 by the wide confidence intervals for each state, data were skewed in the high GCPS state. There were transitions
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M24 (n=60) Graded chronic pain scale: n (%)
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. Indirect Costs At each of the time points, between 38 percent and 46 percent of DEEP study participants reported being employed.
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From page 394... ...
Mean of cohort 534 458 433 426 612 Bootstrapped CI for cohort 419; 253; 256; 238; 89; 661 661 608 613 1,133 Mean low GCPS 408 235 235 227 238 Mean high GCPS 865 992 956 932 1,556 Mean medication costs* Simple analgesia 1 2 3 3 4 Opioids 3 3 7 7 12 Antidepressants 7 9 13 7 4 Antiepileptics 10 40 53 63 85 Migraine therapy 1 0 1 1 0 Topical therapy 1 1 1 1 0 Total medication costs (b)
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From page 395... ...
These reported losses were used to estimate mean employer costs of £905 (95% CL=584, 1225) per person per 6-month period due to presenteeism.
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From page 396... ...
334 (290; 378) TABLE C-17 Mean Indirect Costs per 6-Month Period in the DEEP Study Costs at Each Time Point M0 (n=38)
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From page 397... ...
It is clear from both the quantitative data presented in this report and the qualitative data available freely elsewhere49 that the journey to seek appro riate diagnosis and care is long and costly in terms of the impact p both on the individual and on his or her personal finances. This is mirrored in the health care usage costs and the economic costs.
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From page 398... ...
It may, however, be that in wholly privately delivered health care differences exist. Further research using representative datasets or cohorts within the United States will be required in order to fully understand the care pathways for TMDs.
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From page 399... ...
A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac Pain.
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From page 400... ...
Care pathways in persis tent orofacial pain: Qualitative evidence from the DEEP study. JDR Clin Trans Res.
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From page 401... ...
:82. Potential conflicts of interest: Robert Kerns reports receiving honoraria for serving as a member of a research grant review board for the American Pain Society and as senior editor for the journal Pain Medicine.
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