Temporomandibular Disorders Priorities for Research and Care (2020) / Chapter Skim
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3 Individual and Societal Burden of TMDs
3 Individual and Societal Burden of TMDs
Pages 81-122
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From page 81... ...
This chapter reviews temporomandibular disorders (TMDs) from a public health perspective -- examining the individual and societal burdens of living with a TMD.1 The chapter begins by summarizing TMD prevalence estimates (i.e., the number of TMD cases present in a population at a given time)
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From page 82... ...
Given that many individuals may have intermittent pain that does not progress to a diagnosed TMD, the NHIS question about whether an individual experienced pain in the temporomandibular joint region for one whole day may lead an overestimation of individuals with orofacial pain. However, major health surveys such as NHIS are common sources for estimating the national or statelevel prevalence of various diseases and behaviors, and the committee believes this prevalence estimate provides a valid analysis using some of the best national data available.
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From page 83... ...
While there are limitations in comparing the relative magnitude of painful conditions (e.g., how the question was asked of study or survey participants) , the committee believes estimates of the prevalence of orofacial pain or TMD symptoms place TMDs well within the context of other highly prevalent conditions and therefore demanding equal attention and care in addressing the burden of TMDs.
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From page 84... ...
According to 2016 NHIS data of 42,370 adult participants, the prevalence of high-impact chronic pain was also elevated nearly four-fold (26.9 percent versus 7.0 percent) in people with orofacial pain symptoms (Slade and Durham, 2020)
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From page 85... ...
had pain in the m region of the temporomandibular joint that could be related to TMDs. Based on this information, it is likely that TMDs are the most prevalent type of chronic orofacial pain and TMDs may be comparable in prevalence to other chronic pain conditions such as fibromyalgia, chronic low back pain, and migraine disease.
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Larger differences in prevalence were seen relative to the presence of other pain conditions (i.e., other than orofacial pain symptoms; see Table C-3 in Appendix C)
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% of TMD Prevalence* Population Group Population (%, 95% CL)
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. Using a simple count of those four body pain symptoms, the 3-month period prevalence of orofacial pain symptoms was 32.4 percent among people with all four body pain symptoms, compared with 1.1 percent among people with no body pain symptoms.
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. Early Studies of TMD Incidence Prior to the OPPERA study, investigators at the North Carolina study site conducted a 3-year prospective cohort study of women age 18 to 34
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TMD Pain (%) Diagnosis Al-Khotani et al., 456 (GP)
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. The larger OPPERA effort comprised four observational studies including a prospective cohort study of the first onset of TMDs, a baseline case–control study of chronic TMD, a matched case–control study of incident TMDs, and a prospective case–cohort study looking at the course of TMDs.
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From page 92... ...
In a prospective cohort study of 11-year-olds who were enrollees in the Group Health Cooperative in Washington State, 6.8 percent developed examiner-verified TMD during the 3-year follow-up period, for an annualized incidence rate of 2.3 percent (LeResche et al., 2007)
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From page 93... ...
of facial pain in a biracial cohort; the prevalence and incidence were higher in white women than in black women. TMD Incidence in the OPPERA Study In the OPPERA prospective cohort study, facial pain symptoms were assessed by questionnaire once every 3 months among 2,719 adults aged 18 to 44 years who had no history of a TMD when enrolled (Slade et al., 2013c)
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. The threshold for incident case classification was ≥5 days with TMD pain symptoms per month over more than 1 month during a 3-month reporting period (Slade et al., 2013a)
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may also play a role in the onset and persistence (clinical course) of TMD symptoms.
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From page 96... ...
9–11) and include the following barriers, challenges, and experiences: • "Women treated in a male-dominated environment; • Failure of health professionals to acknowledge or explain the sever ity and complexity of TMD in marketing to the public; • Chaos and controversy that abounds in the TMD treatment arena where patients receive different diagnoses and treatment plans from different practitioners, risking patient healthcare decisions in the face of sometimes conflicting information; • Patient abandonment when the treatments prescribed by the pro vider doesn't alleviate their condition or worsen it; • Patients blamed when the treatments fail; • Financial loss and bankruptcy due to the costs of TMD health care, unpredictable insurance coverage for TMD treatments, requirement by practitioners for patients to pay for services in cash in advance, encouraging patients to take personal loans, and sign contracts with financial companies affiliated with the dental practice; • Harm from treatments that received FDA approval; • Betrayal by and loss of trust in dentists and other practitioners with whom they have entrusted their well-being; • Desperation to get relief trying any treatment, regardless of its sci entific validity; • The stigma of a condition that isn't readily obvious to friends, fam ily, and the general public; • Social isolation from friends and family leading to loneliness, anxi ety, and depression; • Dramatic changes in physical appearance resulting from the disorder, treatment, nutritional problems, and severe weight gain/loss.
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From page 97... ...
TMD Care Usage and Costs The health impacts of TMDs have been examined primarily in smaller clinical studies or with surveys, with the general finding that both acute and chronic TMD-associated pain motivate most individuals to seek professional health care. Moreover, chronic TMD pain is often comorbid with migraine, fibromyalgia, and other forms of widespread pain.
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From page 98... ...
The DEEP study found that orofacial pain had a substantial impact on the individual and the UK economy through lost productivity and on the health care system due to disorganized care pathways increasing the number of consultations required to diagnose the condition and care for the patient. (See Slade and Durham, 2020, in Appendix C for a detailed report of the UK study's methodology and outcomes.)
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From page 99... ...
from general medical practices in the United Kingdom with respect to broadly defined orofacial pain. The overall prevalence of orofacial pain was 26 percent with symptoms decreasing with age and being more common in women (30 percent)
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Commonly reported instruments include the Oral Health Impact Profile (Locker and Slade, 1993) and the Oral Health Impact Profile-14 (Locker and Allen, 2002)
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, where the more severe the TMD symptoms, the lower the quality of life. Importantly, the impact of TMDs on oral health–related quality of life is reported to be greater than almost all other orofacial diseases and illnesses or conditions (Dahlstrom and Carlsson, 2010)
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TMDs and Painful Comorbidities TMDs are among the group of chronic pain conditions that have been identified as chronic overlapping pain conditions due to their frequent comorbidity and shared risk factors (Maixner et al., 2016)
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The following systemic and comorbid conditions may co-exist with TMDs: • Ankylosing spondylitis in other body joints • Asthma • Back, neck, and joint pain • Chronic fatigue syndrome • Ehlers-Danlos syndrome • Endometriosis • Fibromyalgia • Headaches • Heart disease • Hypertension • Interstitial cystitis/painful bladder syndrome • Irritable bowel syndrome • Juvenile idiopathic arthritis in other body joints • Neural/sensory conditions • Osteoarthritis in other body joints • Poor nutrition due to alerted jaw function and/or pain while chewing • Psoriatic arthritis in other body joints • R espiratory conditions (e.g., sinus trouble, allergies or hives, asthma, tuberculosis, breathing difficulties) • Rheumatoid arthritis in other body joints • Sinusitis • Sjogren's syndrome • S leep disorders (e.g., insomnia, poor sleep quality, longer sleep latency, lower sleep efficiency)
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. Moreover, the presence of comorbid pain conditions is associated with a greater severity of TMD symptoms (Visscher et al., 2016; Florencio et al., 2017)
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. Hypermobility and Ehlers-Danlos Syndromes Ehlers-Danlos syndrome, a group of heritable connective tissue disorders, represents another set of systemic conditions associated with an increased risk of TMDs and other chronic pain conditions (De Coster et al., 2005; Chopra et al., 2017; Mitakides and Tinkle, 2017)
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From page 106... ...
. TMD symptoms in this syndrome are generally attributed to joint hypermobility and the resultant instability of the mandible during masticatory function as well as during maximal opening, which leads to protective muscle contraction and subsequent further problems in functioning (see Chapter 2)
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It is impossible to determine from cross-sectional studies whether these represent risk factors, consequences, or coincidences, but numerous prospective studies have identified premorbid factors that confer an increased risk of TMD onset or persistence, or both. Furthermore, several socio-demographic factors are known to be related to TMD risk.
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From page 108... ...
. The OPPERA study observed a slightly but non-significant increased incidence of first-onset TMDs in females, while female sex was strongly associated with chronic TMDs, suggesting that females have an increased risk of TMD persistence (Slade et al., 2013a,b, 2016)
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From page 109... ...
found a lower prevalence of TMDs among African Americans than among Caucasians after controlling for socioeconomic status. As yet another contrast, in the OPPERA study non-white racial/ ethnic groups had significantly lower odds of chronic TMDs than whites, while African Americans showed an increased incidence of first-onset TMDs compared with whites (Slade et al., 2011, 2013a,b)
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From page 110... ...
. Data Collection Challenges and Opportunities: Studies on Risk Factors In addition to the risk factors for TMD onset, several factors appear to increase the risk of the transition from acute to chronic TMD pain, including female sex, acute pain severity and related disability, and depressive and somatic symptoms (Garofalo et al., 1998)
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had pain in the m region of the temporomandibular joint that could be related to TMDs. Based on this information, it is likely that TMDs are the
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2015. Deficient cytokine control modulates temporomandibular joint pain in rheumatoid arthritis.
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Journal of Orofacial Pain 22(3)
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2016b. Healthcare cost and impact of persistent orofacial pain: The DEEP study cohort.
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Journal of Orofacial Pain 22(2)
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Journal of Orofacial Pain 13(1)
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2011. Orofacial Pain Prospective Evaluation and Risk Assessment study: The OPPERA study.
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2018. Evaluation of the prevalence of temporomandibular joint involvement in rheu matoid arthritis using Research Diagnostic Criteria for Temporomandibular Disorders.
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2013a. General health status and incidence of first-onset temporomandibular disorder: The OPPERA prospective cohort study.
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2013c. Preclinical epi sodes of orofacial pain symptoms and their association with healthcare behaviors in the O PPERA prospective cohort study.
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2011. The effect of catastrophizing and depression on chronic pain: A prospective cohort study of temporomandibular muscle and joint pain disorders.
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2017. Symptoms and signs of temporomandibular disorders in patients with knee osteoarthritis.
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