Title
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Stress and salivary cortisol levels among temporomandibular disorders: a case-control study
1Oral Medicine and Diagnostic Sciences Department, College of Dentistry, King Saud University Riyadh, 57448 Riyadh, Saudi Arabia
2Faculty of Dentistry, Royal College of Surgeons, D02YN77 Dublin, Ireland
DOI: 10.22514/jofph.2025.039 Vol.39,Issue 2,June 2025 pp.202-209
Submitted: 28 January 2025 Accepted: 27 March 2025
Published: 12 June 2025
*Corresponding Author(s): Lujain AlSahman E-mail: 442203369@student.ksu.edu.sa
Background: This study investigated how cumulative lifetime stress, as measured by the Stress and Adversity Inventory (STRAIN) scale, relates to salivary cortisol levels in temporomandibular disorders (TMD) patients compared to controls. Furthermore, to determine which specific lifetime stress domains are the strongest predictors of TMD. Methods: The study was conducted with 110 participants (55 TMDs patients, 55 controls). Lifetime stress was assessed using the STRAIN questionnaire, and salivary cortisol levels were measured at two time points (7 AM and 10 AM) using Enzyme-Linked Immunosorbent Assay (ELISA). Statistical analyses included t-tests, Analysis of variance (ANOVA) and multiple regression to identify significant stress predictors for TMD. Results: The TMDs patients had significantly higher stress scores (11.10 ± 3.26) compared to the controls (1.43 ± 0.99) (p = 0.001). Myalgia showed highest stress levels (11.69 ± 3.72), while patients with myofascial pain had the lowest (8.80± 1.14) (p = 0.043). Cortisol levels were highest in the of disc displacement without reduction with limited mouth opening (DDWoR with LO) group (82.49 ± 124.34) and lowest in myalgia patients (4.69 ± 3.90) (p = 0.001). Significant stress predictors for TMDs included relationship stress (p = 0.04), humiliation (p = 0.02), marital/partner stress (p < 0.001) and death-related stress (p = 0.01). Conclusions: TMDs patients experience significantly higher lifetime stress and cortisol levels than controls. Myalgia patients showed a complex psychological and physiological stress link, whereas the DDWoR with LO subgroup exhibited a distinct physiological stress response. Specific life stressors, particularly relationship- and partner-related stress, are key predictors of TMDs. These findings reinforce the importance of a biopsychosocial approach in understanding and managing TMDs. Future research should focus on longitudinal and interventional studies to further elucidate causal mechanisms and effective therapeutic strategies.
Cortisol; Facial pain; Inflammation mediators; Psychological stress; Saliva; Temporomandibular disorders
Lujain Alsahman, Hamad Albagieh, Roba Alsahman. Stress and salivary cortisol levels among temporomandibular disorders: a case-control study. Journal of Oral & Facial Pain and Headache. 2025. 39(2);202-209.
[1] Wroclawski C, Mediratta JK, Fillmore WJ. Recent advances in temporomandibular joint surgery. Medicina. 2023; 59: 1409.
[2] Li DTS, Leung YY. Temporomandibular disorders: current concepts and controversies in diagnosis and management. Diagnostics. 2021; 11: 459.
[3] Suprajith T, Wali A, Jain A, Patil K, Mahale P, Niranjan V. Effect of temporomandibular disorders on cortisol concentration in the body and treatment with occlusal equilibrium. Journal of Pharmacy and Bioallied Sciences. 2022; 14: S483–S485.
[4] Aranha RLB, Martins RC, de Aguilar DR, Moreno-Drada JA, Sohn W, Martins CC, et al. Association between stress at work and temporomandibular disorders: a systematic review. BioMed Research International. 2021; 2021: 2055513.
[5] Slade GD, Fillingim RB, Sanders AE, Bair E, Greenspan JD, Ohrbach R, et al. Summary of findings from the OPPERA prospective cohort study of incidence of first-onset temporomandibular disorder: implications and future directions. The Journal of Pain. 2013; 14: T116–T124.
[6] Anker EA, Sande T, Arefjord K, Hystad SW, Rosen A. The association between pain-related factors and psychological distress in patients with temporomandibular disorder. Psychology, Health & Medicine. 2023; 28: 1049–1056.
[7] Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping chronic pain conditions: implications for diagnosis and classification. The Journal of Pain. 2016; 17: T93–T107.
[8] Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE, et al. Painful temporomandibular disorder: decade of discovery from OPPERA studies. Journal of Dental Research. 2016; 95: 1084–1092.
[9] Paludo B, Trevizan PC, Boamah NAA, Rigo L. Prevalence of temporomandibular disorder and its association with anxiety in academics: a cross-sectional study. Sao Paulo Medical Journal. 2024; 143: e2023338.
[10] Yap AU, Kim S, Lee BM, Jo JH, Park JW. Sleeping and waking-state oral behaviors in TMD patients: their correlates with jaw functional limitation and psychological distress. Clinical Oral Investigations. 2024; 28: 332.
[11] Yap AU, Sultana R, Natu VP. Stress and emotional distress: their associations with somatic and temporomandibular disorder-related symptoms. Psychology, Health & Medicine. 2022; 27: 876–887.
[12] Knezevic E, Nenic K, Milanovic V, Knezevic NN. The role of cortisol in chronic stress, neurodegenerative diseases, and psychological disorders. Cells. 2023; 12: 2726.
[13] Eller-Smith OC, Nicol AL, Christianson JA. Potential mechanisms underlying centralized pain and emerging therapeutic interventions. Frontiers in Cellular Neuroscience. 2018; 12: 35.
[14] Staniszewski K, Lygre H, Bifulco E, Kvinnsland S, Willassen L, Helgeland E, et al. Temporomandibular disorders related to stress and HPA-axis regulation. Pain Research and Management. 2018; 2018: 7020751.
[15] Kapos FP, Exposto FG, Oyarzo JF, Durham J. Temporomandibular disorders: a review of current concepts in aetiology, diagnosis and management. Oral Surgery. 2020; 13: 321–334.
[16] Wu G, Chen L, Su Y, Zhu G, Wang P, Wang Y, et al. The influence of psychological stress on the rat temporomandibular joint with the application of countermeasures. Journal of Surgical Research. 2012; 178: 728–736.
[17] Braz MA, Freitas Portella F, Seehaber KA, Bavaresco CS, Rivaldo EG. Association between oxidative stress and temporomandibular joint dysfunction: a narrative review. Journal of Oral Rehabilitation. 2020; 47: 536–546.
[18] James KA, Stromin JI, Steenkamp N, Combrinck MI. Understanding the relationships between physiological and psychosocial stress, cortisol and cognition. Frontiers in Endocrinology. 2023; 14: 1085950.
[19] Wilkowicz W, Byś A, Zieliński G , Gawda P. The impact of stress on psychological and physiological aspects of health of patients with TMD: a literature review from 2015–2020. Polish Annals of Medicine. 2020; 28: 82–87.
[20] Akhter R, Murray A, Hassan N, Wickham J. Temporomandibular disorder symptoms and their association with anxiety and depression among university students. Advances in Dentistry & Oral Health. 2019; 10: 1–5.
[21] Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, 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 groupdagger†. Journal of Oral & Facial Pain and Headache. 2014; 28: 6–27.
[22] Slavich GM, Shields GS. Assessing lifetime stress exposure using the stress and adversity inventory for adults (Adult STRAIN): an overview and initial validation. Psychosomatic Medicine. 2018; 80: 17–27.
[23] Amasi-Hartoonian N, Sforzini L, Cattaneo A, Pariante CM. Cause or consequence? Understanding the role of cortisol in the increased inflammation observed in depression. Current Opinion in Endocrine and Metabolic Research. 2022; 24: 100356.
[24] Rajasundaram S, Rahman RP, Woolf B, Zhao SS, Gill D. Morning cortisol and circulating inflammatory cytokine levels: a mendelian randomisation study. Genes. 2022; 13: 116.
[25] Smith GD, Ho K, Penny KI. The importance of STROBE checklist adherence in reporting of observational studies: not just a tick box exercise. Journal of Advanced Nursing. 2023; 79: 4431–4433.
[26] AlSahman L, AlBagieh H, AlSahman R, Mehta NR, Correa LP. Does salivary cortisol serve as a potential biomarker for temporomandibular disorders in adults? BMC Oral Health. 2024; 24: 1364.
[27] Akbulut A, Kurt H, Uslu Toygar H, Yildirim E. Does anxiety have an impact on temporomandibular disorders? A study in a Turkish sample by using specific questionnaires. Cranio. 2024; 42: 620–629.
[28] Wieckiewicz M, Jenca A, Seweryn P, Orzeszek S, Petrasova A, Grychowska N, et al. Determination of pain intensity, pain-related disability, anxiety, depression, and perceived stress in Polish adults with temporomandibular disorders: a prospective cohort study. Frontiers in Integrative Neuroscience. 2022; 16: 1026781.
[29] Tosato Jde P, Caria PH, Gomes CA, Berzin F, Politti F, Gonzalez Tde O, et al. Correlation of stress and muscle activity of patients with different degrees of temporomandibular disorder. The Journal of Physical Therapy Science. 2015; 27: 1227–1231.
[30] Janal MN, Lobbezoo F, Quigley KS, Raphael KG. Stress-evoked muscle activity in women with and without chronic myofascial face pain. Journal of Oral Rehabilitation. 2021; 48: 1089–1098.
[31] Zhao YJ, Liu Y, Wang J, Li Q, Zhang ZM, Tu T, et al. Activation of the mesencephalic trigeminal nucleus contributes to masseter hyperactivity induced by chronic restraint stress. Frontiers in Cellular Neuroscience. 2022; 16: 841133.
[32] Vrbanovic E, Lapic I, Rogic D, Alajbeg IZ. Changes in salivary oxidative status, salivary cortisol, and clinical symptoms in female patients with temporomandibular disorders during occlusal splint therapy: a 3-month follow up. BMC Oral Health. 2019; 19: 100.
[33] AlSahman L, AlBagieh H, AlSahman R. Is there a relationship between salivary cortisol and temporomandibular disorder: a systematic review. Diagnostics. 2024; 14: 1435.
[34] Wyns A, Hendrix J, Lahousse A, De Bruyne E, Nijs J, Godderis L, et al. The biology of stress intolerance in patients with chronic pain-state of the art and future directions. Journal of Clinical Medicine. 2023; 12: 2245.
[35] Armstrong M, Castellanos J, Christie D. Chronic pain as an emergent property of a complex system and the potential roles of psychedelic therapies. Frontiers in Pain Research. 2024; 5: 1346053.
[36] Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy. 2014; 94: 1816–1825.
[37] Warzocha J, Gadomska-Krasny J, Mrowiec J. Etiologic factors of temporomandibular disorders: a systematic review of literature containing diagnostic criteria for temporomandibular disorders (DC/TMD) and research diagnostic criteria for temporomandibular disorders (RDC/TMD) from 2018 to 2022. Healthcare. 2024; 12: 575.
[38] Speculand B, Hughes AO, Goss AN. Role of recent stressful life events experience in the onset of TMJ dysfunction pain. Community Dentistry and Oral Epidemiology. 1984; 12: 197–202.
[39] Reis PHF, Laxe LAC, Lacerda-Santos R, Munchow EA. Distribution of anxiety and depression among different subtypes of temporomandibular disorder: a systematic review and meta-analysis. Journal of Oral Rehabilitation. 2022; 49: 754–767.
[40] Urbani G, Cozendey-Silva EN, Jesus LF. Temporomandibular joint dysfunction syndrome and police work stress: an integrative review. Cien Saude Colet. 2019; 24: 1753–1765.
[41] Araújo Oliveira Ferreira DM, de Oliveira Vaz CC, Stuginski-Barbosa J, Rodrigues Conti PC. Post-traumatic stress disorder and temporomandibular dysfunction: a review and clinical implications. British Journal of Pain. 2018; 1: 55–59.
[42] Minervini G, Franco R, Marrapodi MM, Fiorillo L, Cervino G, Cicciu M. Economic inequalities and temporomandibular disorders: a systematic review with meta-analysis. Journal of Oral Rehabilitation. 2023; 50: 715–723.
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