“Grin(d) and Bear it”: Narratives from Sami Women With and Without Temporomandibular Disorders. A Qualitative Study

Aims: To explore thoughts, experiences, and beliefs regarding temporomandib-ular disorders (TMD) among Sami women with and without TMD in order to gain insights into their health care experiences and to generate a hypothesis regard-ing factors associated with long-standing TMD. Methods: Qualitative thematic interviews were conducted with a strategic sample of 17 Sami women, of whom 10 had a TMD diagnosis according to the Research Diagnostic Criteria for TMD and 7 age-matched women who had no signs or symptoms of TMD. Their ages were between 23 and 58 years. The thematic interviews were audiotaped, tran-scribed verbatim, and analyzed based on Grounded Theory, a qualitative method-ology aiming to generate hypotheses grounded in the gathered data. Results: The core category that evolved was “Grin(d) and bear it,” which summarizes the Sami participants’ various ways and stages of processing and handling the inter-acting categories (triggers, strains, distrust, and reconciliation with pain and/or difficulties in life). They described divergent as well as similar understandings of triggering factors. Maintaining factors were described as mental-physical strain and stress, and also a jaw-clenching behavior. Women without TMD contributed with factors that helped them to handle strains, reconcile, and stay healthy. They relied on strong social support. Conclusion: Based on the analysis, the follow-ing hypothesis was generated: Women with TMD, associated headaches, and neck-shoulder pain may benefit from efforts aimed at empowering them to use their own abilities to reduce stress behavior, strain, and disuse of the jaw. Rehabil-itation strategies in groups might increase their sense of coherence and increase social support, which seems to be more limited than in women with no symptoms of TMD.

chronic pain; consultation; qualitative research; Sami; temporomandibular; women’s health

1. Solbakk JT. The Sámi people—A Handbook. Karasjok, Norway: Davvi Girji OS, 2006.

2. Hassler S, Sjölander P, Ericsson AJ. Construction of a database on health and living conditions of the Swedish Sami population. In: Lantto P, Sköld P (eds). Befolkning och bosättning i Norr-etnicitet, identitet och gränser i historiens sken. Miscellaneous publications no. I. Umeå: Centre for Sami Research, Umeå University, 2004:107–124.

3. Hassler S, Johansson R, Sjölander P, Grönberg H, Damber L. Causes of death in the Sami population of Sweden, 1961–2000. Int J Epidemiol 2005;34:623–629.

4. Hassler S, Soininen L, Sjölander P, Pukkala E. Cancer among the Sami—A review on the Norwegian, Swedish and Finnish Sami populations. Int J Circumpolar Health 2008;67:421–432.

5. Sjölander P, Hassler S, Janlert U. Stroke and acute myocardi-al infarction in the Swedish Sami population—Incidence and mortality in relation to income and level of education. Scand J Public Health 2008;36:84–91.

6. Sjölander P. What is known about the health and living conditions of the indigenous people of northern Scandinavia, the Sami? Glob Health Action 2011;4:8457. doi: 10.3402/gha. v4i0.8457.

7. Helkimo M, Carlsson GE, Hedegard B, Helkimo E, Lewin T. Function and dysfunction of the masticatory system in Lapps in northern Finland. Preliminary report of an epidemiological investigation. Sven Tandlak Tidskr 1972;65:95–105.

8. Anastassaki A, Magnusson T. Patients referred to a specialist clinic because of suspected temporomandibular disorders: A survey of 3194 patients in respect of diagnoses, treatments, and treatment outcome. Acta Odontol Scand 2004;62: 183–192.

9. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington H. Oro-facial pain in the community: Prevalence and associated impact. Community Dent Oral Epidemiol 2002; 30:52–60.

10. Wänman A. Longitudinal course of symptoms of craniomandibu-lar disorders in men and women. A 10-year follow-up study of an epidemiologic sample. Acta Odontol Scand 1996;54:337–342.

11. Shinal RM, Fillingim RB. Overview of orofacial pain: Epidemiology and gender differences in orofacial pain. Dent Clin North Am 2007;51:1–18.

12. LeResche L. Epidemiology of temporomandibular disorders: Implications for the investigation of etiologic factors. Review. Crit Rev Oral Biol Med 1997;8:291–305.

13. Johansson A, Unell L, Carlsson G, Söderfeldt B, Halling A. Gender difference in symptoms related to temporomandibular disorders in a population of 50-year-old subjects. J Orofac Pain 2003;17:29–35.

14. Suvinen TI, Reade PC, Kemppainen P, Könönen M, Dworkin SF. Review of aetiological concepts of temporomandibular pain disorders: Towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Review. Eur J Pain 2005;9:613–633.

15. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Review. Psychol Bull 2007;133:581–624.

16. Storm C, Wänman A. Temporomandibular disorders, headaches, and cervical pain among females in a Sami population. Acta Odontol Scand 2006;64:319–325.

17. Storm C, Wänman A. A two-year follow-up study of temporo-mandibular disorders in a female Sami population: Validation of cases and controls as predicted by questionnaire. Acta Odontol Scand 2007;65:341–347.

18. Mienna CS, Wänman A. Self-reported impact on daily life activities related to temporomandibular disorders, headaches, and neck-shoulder pain among women in a Sami population living in Northern Sweden. J Orofac Pain 2012;26:215–224.

19. Suka M, Yoshida K. Musculoskeletal pain in Japan: Prevalence and interference with daily activities. Mod Rheumatol 2005;15: 41- 47.

20. Leijon O, Wahlström J, Mulder M. Prevalence of self-reported neck-shoulder-arm pain and concurrent low back pain or psychological distress: Time-trends in a general population, 1990-2006. Spine 2009;34:1863-1868.

21. Wolf E, Birgerstam P, Nilner M, Petersson K. Nonspecific chronic orofacial pain: Studying patient experiences and perspectives with a qualitative approach. J Orofac Pain 2008;22:349–358.

22. Johansson EE, Hamberg K, Westman G, Lindgren G. The meanings of pain: An exploration of women’s descriptions of symptoms. Soc Sci Med 1999;48:1791–1802.

23. Johansson EE, Hamberg K, Lindgren G, Westman G. “I’ve been crying my way”—Qualitative analysis of a group of female patients’ consultation experiences. Fam Pract 1996;13:498–503.

24. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6: 301–355.

25. Strauss A, Corbin JM. Basics of qualitative research: Techniques and procedures for developing grounded theory, ed 2. Thousand Oaks, CA: Sage, 1998.

26. Sessle BJ, Hu JW, Amano N, Zhong G. Convergence of cutaneous, tooth pulp, visceral, neck and muscle afferents onto nociceptive and non-nociceptive neurones in trigeminal subnucleus caudalis (medullary dorsal horn) and its implications for referred pain. Pain 1986;27:219–235.

27. Piovesan EJ, Kowacs PA, Oshinsky ML. Convergence of cervical and trigeminal sensory afferents. Review. Curr Pain Headache Rep 2003;7:377–383.

28. Gonçalves DA, Dal Fabbro AL, Campos JA, Bigal ME, Speciali JGJ. Symptoms of temporomandibular disorders in the population: An epidemiological study. J Orofac Pain 2010;24:270–278.

29. Dao TT, LeResche L. Gender differences in pain. J Orofac Pain 2000;14:169–184.

30. Cairns BE. Pathophysiology of TMD pain—Basic mechanisms and their implications for pharmacotherapy. J Oral Rehabil 2010; 37:391–410.

31. Svensson P, Jadidi F, Arima T, Baad-Hansen L, Sessle BJ. Relationships between craniofacial pain and bruxism. Review. J Oral Rehabil 2008;35:524–547.

32. Glaros AG, Burton E. Parafunctional clenching, pain, and effort in temporomandibular disorders. J Behav Med 2004;27:91–100.

33. Molina OF, dos Santos Júnior J, Nelson SJ, Nowlin T. Profile of TMD and bruxer compared to TMD and nonbruxer patients regarding chief complaint, previous consultations, modes of therapy, and chronicity. Cranio 2000;18:205–219.

34. van der Meulen MJ, Lobbezoo F, Aartman IH, Naeije M. Self-reported oral parafunctions and pain intensity in temporoman-dibular disorder patients. J Orofac Pain 2006;20:31–35.

35. Manfredini D, Lobbezoo F. Relationship between bruxism and temporomandibular disorders: A systematic review of literature from 1998 to 2008. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:26–50.

36. Wolf E, Birgerstam P, Nilner M, Petersson K. Patients’ experiences of consultations for nonspecific chronic orofacial pain: A phenomenological study. J Orofac Pain 2006;20:226–233.

37. Eccleston C, Williams AC, Rogers WS. Patients’ and professionals’ understandings of the causes of chronic pain: Blame, responsibility and identity protection. Soc Sci Med 1997;45: 699–709.

38. SBU. Methods for the Treatment of Chronic Pain. A Systematic Literature Review. SBU report no. 177/1. Stockholm: Swedish Council on Technology Assessment in Health Care (SBU), 2006.

39. Hermansen R, Njolstad I, Fonnebo V. Physical activity according to ethnic origin in Finnmark County, Norway. The Finnmark Study. Int J Circumpolar Health 2002;61:189–200.

40. Dahlgren L, Emmelin M, Winkvist A. Qualitative Methodology for International Public Health. Umeå: Epidemiology and Public Health Sciences, Umeå University, 2004.