Subjective Sleep Quality in Temporomandibular Disorder Patients and Association with Disease Characteristics and Oral Health–Related Quality of Life

Aims: To measure sleep quality in temporomandibular disorder (TMD) patients, to compare it with that of control subjects, and to analyze its association with disease characteristics and oral health–related quality of life (OHRQoL). Methods: The collected data included demographics, tobacco use, the Pittsburgh Sleep Quality Index (PSQI), trauma history, presence of coexisting headaches and/or body pain, parafunctional habits, pain scores, muscle tenderness to palpation scores, and the Oral Health Impact Profile-14 (OHIP-14). Differences between groups were examined with Pearson chi-square test for categorical variables and independent t test and analysis of variance (ANOVA) for numeric variables. Significant differences were then further tested with multivariate backward stepwise linear regression analysis. Results: The final analysis was performed on 286 individuals (187 TMD patients and 99 controls). Poor sleep (PSQI global score > 5) was exhibited in 43.3% of the TMD group and in 28.3% of the control group (P = .013) (mean ± standard deviation [SD] PSQI score = 5.53 ± 2.85 for TMD patients and 4.41 ± 2.64 for controls, P = .001). TMD patients had significantly worse scores in the sleep quality component of the PSQI questionnaire (P = .006). Higher PSQI global scores and poor sleep were positively associated with whiplash history (P = .009 and P = .004, respectively), coexisting headaches (P = .005 and P = .002), body pain (P = .001 and P < .001), clenching habit (P = .016 and P = .006), reduced unassisted (P = .014 and P = .042) and assisted (P = .005 and P = .006) mouth opening, higher muscle tenderness scores, higher pain scores, and higher OHIP-14 global and dimension scores. Conclusion: TMD patients had poorer sleep than controls. Sleep quality was positively associated with TMD disease characteristics, comorbid pain conditions, and poorer OHRQoL. Assessing sleep quality should be a routine part of the diagnostic work-up of TMD patients. A multidisciplinary management approach is needed to address all the factors—including sleep—that modulate pain experience.

Oral Health Impact Profile-14 (OHIP-14); oral health–related quality of life (OHRQoL); orofacial pain; pain; Pittsburgh Sleep Quality Index (PSQI); sleep; temporomandibular disorders (TMD)

1. Almoznino G, Benoliel R, Sharav Y, Haviv Y. Sleep disorders and chronic craniofacial pain: Characteristics and management possibilities. Sleep Med Rev 2017;33:39–50.

2. Sharav Y, Benoliel R. Orofacial Pain and Headache, ed 2. Chicago: Quintessence, 2015.

3. National Institute of Dental and Craniofacial Research. Facial pain. http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/FacialPain. Accessed August 22, 2017.

4. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 2014;28:6–27.

5. Almoznino G, Zini A, Zakuto A, et al. Oral health-related quality of life in patients with temporomandibular disorders. J Oral Facial Pain Headache 2015;29:231–241.

6. Smith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep 2009;32:779–790.

7. Porto F, de Leeuw R, Evans DR, et al. Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients. J Orofac Pain 2011;25:117–124.

8. Lei J, Liu MQ, Yap AU, Fu KY. Sleep disturbance and psychologic distress: Prevalence and risk indicators for temporomandibular disorders in a Chinese population. J Oral Facial Pain Headache 2015;29:24–30.

9. Yatani H, Studts J, Cordova M, Carlson CR, Okeson JP. Comparison of sleep quality and clinical and psychologic characteristics in patients with temporomandibular disorders. J Orofac Pain 2002;16:221–228.

10. Selaimen CM, Jeronymo JC, Brilhante DP, Grossi ML. Sleep and depression as risk indicators for temporomandibular disorders in a cross-cultural perspective: A case-control study. Int J Prosthodont 2006;19:154–161.

11. Vazquez-Delgado E, Schmidt JE, Carlson CR, DeLeeuw R, Okeson JP. Psychological and sleep quality differences between chronic daily headache and temporomandibular disorders patients. Cephalalgia 2004;24:446–454.

12. Sommer I, Lavigne G, Ettlin DA. Review of self-reported instruments that measure sleep dysfunction in patients suffering from temporomandibular disorders and/or orofacial pain. Sleep Med 2015;16:27–38.

13. Lei J, Fu J, Yap AU, Fu KY. Temporomandibular disorders symptoms in Asian adolescents and their association with sleep quality and psychological distress. Cranio 2016;34:242–249.

14. Fernandes G, Franco AL, Gonçalves DA, Speciali JG, Bigal ME, Camparis CM. Temporomandibular disorders, sleep bruxism, and primary headaches are mutually associated. J Orofac Pain 2013;27:14–20.

15. Sanders AE, Slade GD, Bair E, et al. General health status and incidence of first-onset temporomandibular disorder: The OPPERA prospective cohort study. J Pain 2013;14(suppl):T51–T62.

16. Karibe H, Goddard G, Okubo M. Comparison of masticatory muscle myofascial pain in patients with and without a chief complaint of headache. Cranio 2014;32:57–62.

17. Dahan H, Shir Y, Nicolau B, Keith D, Allison P. Self-reported migraine and chronic fatigue syndrome are more prevalent in people with myofascial vs nonmyofascial temporomandibular disorders. J Oral Facial Pain Headache 2016;30:7–13.

18. John MT, Reissmann DR, Schierz O, Wassell RW. Oral health-related quality of life in patients with temporomandibular disorders. J Orofac Pain 2007;21:46–54.

19. Mongini F, Ciccone G, Ceccarelli M, Baldi I, Ferrero L. Muscle tenderness in different types of facial pain and its relation to anxiety and depression: A cross-sectional study on 649 patients. Pain 2007;131:106–111.

20. Mongini F, Ciccone G, Deregibus A, Ferrero L, Mongini T. Muscle tenderness in different headache types and its relation toanxiety and depression. Pain 2004;112:59–64.

21. Mongini F, Rota E, Deregibus A, Mura F, Francia Germani A, Mongini T. A comparative analysis of personality profile and muscle tenderness between chronic migraine and chronic tension-type headache. Neurol Sci 2005;26:203–207.

22. Jensen K, Tuxen C, Olesen J. Pericranial muscle tenderness and pressure-pain threshold in the temporal region during common migraine. Pain 1988;35:65–70.

23. Jensen R, Rasmussen BK, Pedersen B, Olesen J. Muscle tenderness and pressure pain thresholds in headache. A populationstudy. Pain 1993;52:193–199.

24. Langemark M, Olesen J. Pericranial tenderness in tension headache. A blind, controlled study. Cephalalgia 1987;7:249–255.

25. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629–808.

26. de Leeuw R, Studts JL, Carlson CR. Fatigue and fatigue-related symptoms in an orofacial pain population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:168–174.

27. Rener-Sitar K, John MT, Bandyopadhyay D, Howell MJ, Schiffman EL. Exploration of dimensionality and psychometric properties of the Pittsburgh Sleep Quality Index in cases with temporomandibular disorders. Health Qual Life Outcomes 2014;12:10.

28. Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult—A mini-review. Gerontology 2010;56:181–189.

29. Almoznino G, Zini A, Sharav Y, et al. Sleep quality in patients with dental anxiety. J Psychiatr Res 2015;61:214–222.

30. Morris CJ, Aeschbach D, Scheer FA. Circadian system, sleep and endocrinology. Mol Cell Endocrinol 2012;349:91–104.

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

32. Shochat T, Tzischinsky O, Oksenberg A, Peled R. Validation of the Pittsburgh Sleep Quality Index Hebrew translation (PSQI-H) in a sleep clinic sample. Isr Med Assoc J 2007;9: 853–856.

33. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989; 28:193–213.

34. Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen

F. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosom Res 2002;53: 737–740.

35. Kushnir D, Zusman SP, Robinson PG. Validation of a Hebrew version of the Oral Health Impact Profile 14. J Public Health Dent 2004;64:71–75.

36. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997; 25:284–290.

37. Slade GD, Fillingim RB, Sanders AE, et al. Summary of findings from the OPPERA prospective cohort study of incidence of first-onset temporomandibular disorder: Implications and future directions. J Pain 2013;14(suppl):T116–T124.

38. Marcks BA, Weisberg RB, Edelen MO, Keller MB. The relationship between sleep disturbance and the course of anxiety disorders in primary care patients. Psychiatry Res 2010; 178:487–492.

39. Grossi ML, Goldberg MB, Locker D, Tenenbaum HC. Reduced neuropsychologic measures as predictors of treatment outcome in patients with temporomandibular disorders. J Orofac Pain 2001;15:329–339.

40. Lindroth JE, Schmidt JE, Carlson CR. A comparison between masticatory muscle pain patients and intracapsular pain patients on behavioral and psychosocial domains. J Orofac Pain 2002;16:277–283.

41. Sener S, Guler O. Self-reported data on sleep quality and psychologic characteristics in patients with myofascial pain and disc displacement versus asymptomatic controls. Int J Prosthodont 2012;25:348–352.

42. Manfredini D, Arveda N, Guarda-Nardini L, Segù M, Collesano V. Distribution of diagnoses in a population of patients with temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:e35–e41.

43. Custodio L, Carlson CR, Upton B, Okeson JP, Harrison AL, de Leeuw R. The impact of cigarette smoking on sleep quality of patients with masticatory myofascial pain. J Oral Facial Pain Headache 2015;29:15–23.

44. Radanov BP, Mannion AF, Ballinari P. Are symptoms of late whiplash specific? A comparison of SCL-90-R symptom profiles of patients with late whiplash and patients with chronic pain due to other types of trauma. J Rheumatol 2011;38:1086–1094.

45. Lavigne GJ, McMillan D, Zucconi M. Pain and sleep. In: Kryger MH, Dement WC, Roth T (eds). Principles and Practice of Sleep Medicine, Fourth Edition. Philadelphia: Elsevier, 2005: 1246–1255.

46. Rains JC, Poceta JS. Sleep-related headaches. Neurol Clin 2012;30:1285–1298.

47. Ohrbach R, Bair E, Fillingim RB, et al. Clinical orofacial characteristics associated with risk of first-onset TMD: The OPPERA prospective cohort study. J Pain 2013;14(suppl):T33–T50.

48. Schmitter M, Kares-Vrincianu A, Kares H, Bermejo JL, Schindler HJ. Sleep-associated aspects of myofascial pain in the orofacial area among temporomandibular disorder patients and controls. Sleep Med 2015;16:1056–1061.

49. Ohrbach R, Fillingim RB, Mulkey F, et al. Clinical findings and pain symptoms as potential risk factors for chronic TMD: Descriptive data and empirically identified domains from the OPPERA case-control study. J Pain 2011;12(suppl):T27–T45.