Pain Duration and Intensity Are Related to Coexisting Pain and Comorbidities Present in Temporomandibular Disorder Pain Patients

Aims: To investigate the relationships between three pain parameters (duration, intensity, and frequency), the number of pain sites and comorbidities, and the risk of having coexisting pain and/or comorbidities in patients with temporomandibular disorder (TMD) pain. Methods: The sample consisted of 198 outpatients attending the Dental Hospital of Chulalongkorn University. TMD pain was determined using the Diagnostic Criteria for TMD. Pain lasting 3 months or longer was defined as chronic pain. Pain intensity was reflected using a 0- to 10-point numeric rating scale, and pain frequency was assessed with the percentage of pain days over a 2-week period. The number of pain sites was evaluated using the Widespread Pain Index. The presence of comorbidities was assessed with a validated diagnostic questionnaire. The associations were analyzed using Spearman rho test, multiple linear regression, and logistic regression, with a significance level of P≤ .05. Age and gender were analyzed as confounders. Results: The number of pain sites was related to pain duration, pain intensity, and age. The number of comorbidities was associated with pain duration. Neither pain frequency nor gender were related to the number of pain sites or comorbidities. When the pain duration reached 1 month, patients had a 1.045-times higher probability of pain beyond the orofacial area (odds ratio [OR] = 1.045; 95% confidence interval [CI]= 1.024 to 1.066; P = .001) and a 1.028-times higher probability of comorbidities (OR = 1.028; 95% CI = 1.005 to 1.05; P = .008). For an increase of 1 score on the numeric rating scale, patients had a 1.206-times higher probability of pain presence beyond the orofacial area (OR = 1.206; 95% CI =1.068 to 1.344; P = .026). Conclusion: High pain intensity and long pain duration increase the probability of having coexisting pain and comorbidities in TMD pain patients.

comorbidities;pain parameters;questionnaires;regression analysis;TMD pain

1. de Leeuw R. Diagnosis and management of TMDs. In: de Leeuw R, Klasser GD (eds). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management, ed 5. Chicago: Quintessence, 2013:196–288. 2. Furquim BD, Flamengui LM, Conti PC. TMD and chronic pain: A current view. Dental Press J Orthod 2015;20:127–133.

3. Chen H, Slade G, Lim PF, Miller V, Maixner W, Diatchenko L. Relationship between temporomandibular disorders, wide­ spread palpation tenderness, and multiple pain conditions: A case­control study. J Pain 2012;13:1016–1027.

4. Bonato LL, Quinelato V, De Felipe Cordeiro PC, De Sousa EB, Tesch R, Casado PL. Association between temporomandibu­ lar disorders and pain in other regions of the body. J Oral Re­ habil 2017;44:9–15.

5. Plesh O, Adams SH, Gansky SA. Temporomandibular joint and muscle disorder­type pain and comorbid pains in a nation­ al US sample. J Orofac Pain 2011;25:190–198.

6. Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states—Maybe it is all in their head. Best Pract Res Clin Rheu­ matol 2011;25:141–154.

7. Lim PF, Smith S, Bhalang K, Slade GD, Maixner W. Develop­ ment of temporomandibular disorders is associated with great­ er bodily pain experience. Clin J Pain 2010;26:116–120.

8. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24: 769–781.

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

10. Chen H, Nackley A, Miller V, Diatchenko L, Maixner W. Multi­ system dysregulation in painful temporomandibular disorders. J Pain 2013;14:983–996.

11. Dahan H, Shir Y, Velly A, Allison P. Specific and number of comorbidities are associated with increased levels of tem­ poromandibular pain intensity and duration. J Headache Pain 2015;16:528.

12. Coronado RA, Simon CB, Valencia C, George SZ. Experi­ mental pain responses support peripheral and central sen­ sitization in patients with unilateral shoulder pain. Clin J Pain 2014;30:143–151.

13. Rammelsberg P, LeResche L, Dworkin S, Mancl L. Longitu­ dinal outcome of temporomandibular disorders: A 5­year ep­ idemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain 2003;17:9–20.

14. Silva AG, Alvarelhão J, Queirós A, Rocha NP. Pain intensity is associated with self­reported disability for several domains of life in a sample of patients with musculoskeletal pain aged 50 or more. Disabil Health J 2013;6:369–376.

15. Grimby­Ekman A, Gerdle B, Björk J, Larsson B. Comorbidi­ ties, intensity, frequency and duration of pain, daily function­ ing and health care seeking in local, regional, and widespread pain—A descriptive population­based survey (SwePain). BMC Musculoskelet Disord 2015;16:165.

16. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 2011;152(suppl 3):s2–s15.

17. Staud R. Chronic widespread pain and fibromyalgia: Two sides of the same coin? Curr Rheumatol Rep 2009;11:433–436.

18. Bair E, Ohrbach R, Fillingim RB, et al. Multivariable modeling of phenotypic risk factors for first­onset TMD: The OPPERA pro­ spective cohort study. J Pain 2013;14(12 suppl 12):T102–T115.

19. Okeson JP (ed). Functional neuroanatomy and physiology of the masticatory system. In: Management of Temporoman­ dibular Disorders and Occlusion, ed 6. St Louis: Elsevier, 2012:25–57.

20. Ray AL. Neuroplasticity, sensitization, and pain. In: Deer TR, Leong MS, Ray AL (eds). Treatment of Chronic Pain by Integra­ tive Approaches, ed 1. New York: Springer, 2015:15–24.

21. Doan L, Manders T, Wang J. Neuroplasticity underlying the comorbidity of pain and depression. Neural Plast 2015; 2015:504691.

22. Lüscher C, Malenka RC. NMDA receptor­dependent long­ term potentiation and long­term depression (LTP/LTD). Cold Spring Harb Perspect Biol 2012;4(6).

23. Puretic´ MB, Demarin V. Neuroplasticity mechanisms in the pathophysiology of chronic pain. Acta Clin Croat 2012;51: 425–429.

24. Rodriguez­Raecke R, Niemeier A, Ihle K, Ruether W, May A. Structural brain changes in chronic pain reflect probably nei­ ther damage nor atrophy. PLoS One 2013;8:e54475.

25. Kuner R, Flor H. Structural plasticity and reorganisation in chronic pain. Nat Rev Neurosci 2016;18:20–30.

26. Apkarian AV, Bushnell MC, Schweinhardt P. Representation of pain in the brain. In: McMahon SB (ed). Wall & Melzack’s Text­ book of Pain, ed 6. Philadelphia: Elsevier, 2013:111–128.

27. Dahan A, van Velzen M, Niesters M. Comorbidities and the com­ plexities of chronic pain. Anesthesiology 2014;121:675–677. 28. Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: Mechanisms and practical management. Gut 2007;56:1770–1798.

29. Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014;311: 1547–1555.

30. Shors TJ, Matzel LD. Long­term potentiation: What’s learning got to do with it? Behav Brain Sci 1997;20:597–614.

31. Fleming KC, Volcheck MM. Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: A re­ view. Rambam Maimonides Med J 2015;6:e0020.

32. 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.

33. Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD­11. Pain 2015;156:1003–1007.

34. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short­Form McGill Pain Questionnaire (SF­MPQ), Chronic Pain Grade Scale (CPGS), Short Form­36 Bodi­ ly Pain Scale (SF­36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63(suppl 11):s240–s252.

35. Salamon KS, Davies WH, Fuentes MR, Weisman SJ, Hainsworth KR. The pain frequency­severity -duration scale as a measure of pain: Preliminary validation in a pediatric chronic pain sample. Pain Res Treat 2014;2014:653592.

36. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46:319–329.

37. Passavanti MB, Pota V, Sansone P, Aurilio C, De Nardis L, Pace MC. Chronic pelvic pain: Assessment, evaluation, and objectivation. Pain Res Treat 2017;2017:9472925.

38. Hadzi­Pavlovic D, Hickie IB, Wilson AJ, Davenport TA, Lloyd AR, Wakefield D. Screening for prolonged fatigue syndromes: Validation of the SOFA scale. Soc Psychiatry Psychiatr Epide­-miol 2000;35:471–479.

39. Ford AC, Bercik P, Morgan DG, Bolino C, Pintos­Sanchez MI, Moayyedi P. Validation of the Rome III criteria for the diag­ nosis of irritable bowel syndrome in secondary care. Gastro­ enterology 2013;145:1262–1270.e1.

40. Kushner L, Moldwin RM. Efficiency of questionnaires used to screen for interstitial cystitis. J Urol 2006;176:587–592.

41. Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: Previously unrecognized urologic and gyne­ cologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urology 2002;60:573–578.

42. Fillingim RB, King CD, Ribeiro­Dasilva MC, Rahim­Williams B, Riley JL 3rd. Sex, gender, and pain: A review of recent clinical and experimental findings. J Pain 2009;10:447–485.

43. Robinson LJ, Durham J, Newton JL. A systematic review of the comorbidity between temporomandibular disorders and chronic fatigue syndrome. J Oral Rehabil 2016;43:306–316.

44. Canavan C, West J, Card T. The epidemiology of irritable bow­ el syndrome. Clin Epidemiol 2014;6:71–80.

45. Ahangari A. Prevalence of chronic pelvic pain among women: An updated review. Pain Physician 2014;17:e141–e147.

46. Andersson HI, Ejlertsson G, Leden I, Scherstén B. Impact of chronic pain on health care seeking, self care, and medication. Results from a population­based Swedish study. J Epidemiol Community Health 1999;53:503–509.

47. Gerdle B, Björk J, Henriksson C, Bengtsson A. Prevalence of current and chronic pain and their influences upon work and healthcare­seeking: A population study. J Rheumatol 2004; 31:1399–1406.

48. Hunter M, Philips C, Rachman S. Memory for pain. Pain 1979;6:35–46.

49. Pincus T, Morley S. Cognitive­processing bias in chronic pain: A review and integration. Psychol Bull 2001;127:599–617. 50. Hasenbring MI, Verbunt JA. Fear­avoidance and endur­ ance­related responses to pain: New models of behavior and their consequences for clinical practice. Clin J Pain 2010; 26:747–753.

51. Karimi Z, Pilenko A, Held SM, Hasenbring MI. Recall bias in patients with chronic low back pain: Individual pain response patterns are more important than pain itself! Int J Behav Med 2016;23:12–20.

52. King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: A systemat­ ic review. Pain 2011;152:2729–2738.

53. Salive ME. Multimorbidity in older adults. Epidemiol Rev 2013;35:75–83.

54. Sanders AE, Slade GD, Bair E, et al. General health status and incidence of first­onset temporomandibular disorder: The OPPERA prospective cohort study. J Pain 2013;14(suppl 12):T51–T62.

55. Ohrbach R, Bair E, Fillingim RB, et al. Clinical orofacial charac­ teristics associated with risk of first­onset TMD: The OPPERA prospective cohort study. J Pain 2013;14(suppl 12):T33–T50.