Abstract

Objective:

To assess the influence of the COVID-19 pandemic on levels of anxiety, stress, and orofacial pain in individuals with and without TMD.

Material and Methods:

In this cross-sectional study, the participants were divided into two groups (n=10, each) experimental group (EG) TMD patients and control group (CG), without TMD. The presence of TMD was confirmed using the RDC/TMD. The Beck Anxiety Scale (BAI), Perceived Stress Scale (PSS), and Oral Analog Scale were used for assessment. The Beck Anxiety Scale is composed of 21 multiple-choice questions describing symptoms of anxiety, while the PSS is a measure that evaluates life situations as stressful. An Oral Analogue Scale was applied to each individual to quantify orofacial pain, with 0 (zero) without pain and 10 (ten) being the worst pain ever felt. The comparison between groups was performed using the Mann-Whitney test. Logistic regression was used to verify TMD dependence in relation to BAI and PSS-10. Quantitative variables were correlated with each other by Pearson's correlation coefficient. The level of significance considered for all tests was 5%.

Results:

The association was statistically significant (p≤0.05) for BAI and PSS with a TMD.

Conclusion:

Although the COVID 19 pandemic has had a psychological impact on the general population, patients with TMD have higher levels of anxiety and stress than the control group.

Keywords:
Coronavirus; Anxiety; Temporomandibular Joint Disorders; Psychological Distress

Introduction

The World Health Organization considers viral diseases a worrying threat to public health. Some epidemics caused by viruses have emerged over the past few years, such as severe acute respiratory syndrome (SARS) in 2003; influenza caused by the H1N1 subtype virus in 2009; Middle East respiratory syndrome (MERS) in 2012 and Ebola disease in 2014. In December 2019, the new coronavirus, SARS-CoV-2, appeared in Wuhan, the largest metropolitan area in China ^[1][1] Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ 2020; 369:1642. https://doi.org/10.1136/bmj.m1642
https://doi.org/10.1136/bmj.m1642... , and was considered pandemic in March 2020 ^[2][2] World Health Organization. WHO Announces COVID-19 Outbreak a Pandemic. Copenhagen: WHO; 2020. Available from: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid19/news/news/2020/3/who-announces-covid-19-outbreak-a-pandemic. [Accessed on January 27, 2020].
http://www.euro.who.int/en/health-topics... .

SARS-COV-2 is highly infectious, with transmission mainly by droplets of saliva, directly between humans, via oral, nasal, and ocular routes, and by contact with contaminated surfaces ^[3][3] Bulut C, Kato Y. Epidemiology of COVID-19. Turk J Med Sci 2020; 50(SI-1):563-70. https://doi.org/10.3906/sag-2004-172
https://doi.org/10.3906/sag-2004-172... . Therefore, masks and social distancing are recommended to prevent the spread of Coronavirus (SARS-CoV-2) ^[4][4] Lippi G, Sanchis-Gomar F, Henry BM. Coronavirus disease 2019 (COVID-19): the portrait of a perfect storm. Ann Transl Med 2020; 8(7):497. https://doi.org/10.21037/atm.2020.03.157
https://doi.org/10.21037/atm.2020.03.157... .

Quarantine has been adopted as a public health measure by the vast majority of countries and has been shown to have a positive role in controlling the epidemic. Prolonged social isolation, however, has negative psychological impacts, capable of causing palpitations, anxiety, insomnia, depression, anger, and stress ^[5][5] Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395(10227):912-20. https://doi.org/10.1016/S0140-6736(20)30460-8
https://doi.org/10.1016/S0140-6736(20)30... .

Temporomandibular Dysfunction (TMD) is a pathology of complex and multifactorial origin, belonging to a heterogeneous group of musculoskeletal and neuromuscular conditions promoting signs and symptoms in the temporomandibular joint, in the masticatory musculature, and in adjacent structures. The prevalence of TMD signs and symptoms varies from 20 to 75% in the general population, with severe cases requiring treatment being 2-4%. It is four times more prevalent in women ^[6][6] Alkhudhairy MW, Al Ramel F, Al Jader G, Al Saegh L, Al Hadad A, Alalwan T, et al. A self-reported association between temporomandibular joint disorders, headaches, and stress. J Int Soc Prev Community Dent 2018; 8(4):371-80. https://doi.org/10.4103/jispcd.JISPCD_177_18
https://doi.org/10.4103/jispcd.JISPCD_17... .

The etiology of TMD is multifactorial, not having a single triggering factor but several contributing and perpetuating factors. Among TMD risk factors, biopsychosocial factors must be considered both in the etiology and in the triggering of signs and symptoms ^[7][7] Waked JP, Canuto MPLAM, Gueiros MCSN, Aroucha JM, Farias CG, Caldas AF. Model for predicting temporomandibular dysfunction: use of classification tree analysis. Braz Dent J 2020; 31(4):360-7. https://doi.org/10.1590/0103-6440202003279
https://doi.org/10.1590/0103-64402020032... ; these factors can cause the overactivity of the masticatory muscles, being one of the causes of myofascial pain ^[8][8] Maślak-Bereś M, Loster JE, Wieczorek A, Loster BW. Evaluation of the psychoemotional status of young adults with symptoms of temporomandibular disorders. Brain Behav 2019; 9(11):e01443. https://doi.org/10.1002/brb3.1443
https://doi.org/10.1002/brb3.1443... .

Psychological factors act on the hypothalamic Pituitary Adrenal axis (HPA), increasing the serum level of cortisol, and influencing the physiological behavior of the Stomatognathic System, highlighting the importance of these factors in triggering and perpetuating TMD ^[9][9] Jasim H, Louca S, Christidis N, Ernberg M. Salivary cortisol and psychological factors in women with chronic and acute oro-facial pain. J Oral Rehabil 2014; 41(2):122-32. https://doi.org/10.1111/joor.12118
https://doi.org/10.1111/joor.12118... . In addition, TMD patients demonstrate high levels of anxiety and depression, which highlights its importance in the etiology and interdisciplinary treatments ^[10][10] Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician 2015; 91(6):378-86..

The aim of this study is to assess the influence of the COVID-19 pandemic on levels of anxiety, stress and orofacial pain in individuals with and without TMD.

Material and Methods

Ethical Clearance

The present study was submitted to the Human Research Ethics Committee of the São José dos Campos Institute of Science and Technology - ICT-UNESP (CAAE n° 32339620.6.0000.0077). Participants were informed about the research objectives and procedures and authorized participation by text message.

Study Design, Sample and Selection Criteria

The research was a comparative cross-sectional study, with data obtained by telephone to complete a questionnaire. The sample size was estimated in the GPower program for a test power of 90% (alpha, type I error = 5%) and with the assumption “effect size” = 0.30. For this study, it was determined an “n” of 20. Research participants were divided into two groups: 1- experimental (EG), 10 patients with TMD and 2-control (CG), 10 individuals without TMD. The inclusion criteria: women over 18 years old. The non-inclusion criteria: male, patients with psychiatric disorders, pregnant and having been previously infected with COVID-19. Participants were excluded when the diagnoses of TMD could not be confirmed.

The EG participants were selected from the database of patients who looked for treatment in the Center of Occlusion and Temporomandibular Joint (COAT), ICT UNESP. The presence of TMD was confirmed using the RDC/TMD (Research Diagnostic Criteria / Temporomandibular Disorders) axis I, validated in Portuguese ^[11][11] Pereira Júnior FJ, Favilla EE, Dworkin S, Huggins K. Research diagnostic criteria for temporomandibular disorders (RDC/TMD): formal translation to portuguese. J Bras Clin Odontol Integr 2004; 8(47):384-95., in the year of 2018.

The CG were volunteers recruited from social media. In this group, due to social isolation, they could not be examined in person. Thus the reason we used the TMD pain screener by DC/TMD (Diagnostic Criteria Temporomandibular Disorders) ^[12][12] Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP et al. International RDC/TMD Consortium Network, International association for Dental Research; Orofacial Pain Special Interest Group, International Association for the Study of Pain. 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(1):6-27. https://doi.org/10.11607/jop.1151
https://doi.org/10.11607/jop.1151... . The purpose of this validated rapid test is to select in which patients the completed application should be followed. When the result of pre-screening is negative, the patients are supposedly with no TMD. The same researcher performed the telephone interview for both groups in May 2020. For the EG was applied the psychological tests. For the CG was first applied the TMD pain screener, and only for those without TMD, the psychological tests were carried out.

Scales Applied in the Study

In the present study, the BAI and PSS-10 scales were applied. The Beck Anxiety Scale is composed of 21 multiple-choice questions describing anxiety symptoms. There are four answer options: a) no (score 0); b) soft, it doesn't bother me much (score 1); c) moderate, it is unpleasant, but I can bear it (score 2); d) severe, I can hardly bear it (score 3). The sum of the scores obtained corresponds to the degree of anxiety: 0 - 10 (minimum); 11 - 19 (light); 20-30 (moderate); and 31 - 63 (severe). A score > 11 shows a high probability of anxiety disorder ^[13][13] Cunha JA. Manual da Versão em Português das Escalas Beck. São Paulo: Casa do Psicólogo. 2001. [In Portuguese]..

The Stress Perception Scale ^[14][14] Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24(4):385-96. is a global measure that evaluates through the sum of 10 questions about life situations as stressful in the last month according to the description by Reis et al. ^[15][15] Reis RS, Hino AA, Añez CR. Perceived stress scale: reliability and validity study in Brazil. J Health Psychol 2010; 15(1):107-14. https://doi.org/10.1177/1359105309346343
https://doi.org/10.1177/1359105309346343... . An Oral Analogue Scale was applied to each individual to quantify orofacial pain, with 0 (zero) without pain and 10 (ten) being the worst pain ever felt. Symptomatic patients were asked whether the pandemic influenced orofacial pain symptoms, informing whether there was an improvement or worsening.

Statistical Analysis

The Bioestat Software, version 5.3, was used to perform statistical analyzes. Quantitative variables were described by means and standard deviations. The Shapiro-Wilk test was used to assess the normality of the frequency distributions into the groups. The comparison between groups was performed using the MannWhitney test. Logistic regression was used to verify TMD dependence in relation to BAI (Beck Anxiety Scale) and PSS-10 (Perceived Stress Scale). Quantitative variables were correlated with each other by Pearson's correlation coefficient. The level of significance considered for all tests was 5% (p-value ≤ 0.05).

Results

The experimental and control groups were composed of independent samples. This study consisted of 20 women (10 with TMD and 10 without TMD). The age varied between 21 and 76, and the mean was 52.6 years.

The BAI scale showed that the mean value of the experimental group was higher than that of the control group, 16,900 and 7,700, respectively. In the PSS test, the mean values were also higher in the experimental group with 19,900 and in the CG of 14,300 (Table 1). There were no statistically significant differences between the study groups (Figures 1 and 2).

Figure 1
Comparison between BAI control and experimental BAI groups.

Figure 2
Comparison between the control EPS and experimental EPS groups.

The logistic regression was used to verify TMD dependence in relation to BAI and PSS. The results of the BAI and PSS regression coefficients were higher than alpha (0.05), which indicates that the dependence is not significant (Table 2).

The association between variables was analyzed using Spearman's correlation. The BAI and PSS scores correlated in a statistically significant way (p≤0.05), direct and weak with TMD, so there is an association between the variables (Figure 3). In those subjects with facial pain, we found a mean value of 4.5 on the oral analog scale. Fifty percent of patients reported improvement in pain, while the other fifty percent reported worsening in the pandemic period.

Figure 3
Correlation between DTM, BAI and EPS.

Discussion

The pandemic caused by COVID-19 brought a global public health crisis; in addition to the growing number of cases, it also had a socio-economic, political and psychological impact ^[16][16] Banerjee D, Rai M. Social isolation in Covid-19: The impact of loneliness. Int J Soc Psychiatry 2020; 66(6):525-7. https://doi.org/10.1177/0020764020922269
https://doi.org/10.1177/0020764020922269... . The psychological impact of social isolation may be increased in patients with pathologies with psychological components involved ^[17][17] Oliveira SSI, Gonçalves SLM, Weig KM, Magalhães Filho TR, Martinez Oer, Kalil MTAC, et al. Temporomandibular disorders: guidelines and self-care for patients during COVID-19 pandemic. Braz Dent Sci 2020; 23(2, supl):1-8. https://doi.org/10.14295/bds.2020.v23i2.2255
https://doi.org/10.14295/bds.2020.v23i2.... .

TMDs are a group of diseases that are influenced by the emotional state of patients ^[18][18] Qu X, Zhou XD. Psychological intervention for patients with oral disease during the pandemic period of COVID-19. Zhonghua Kou Qiang Yi Xue Za Zhi 2020; 55(4):235-40. https://doi.org/10.3760/cma.j.cn112144-20200213-00053
https://doi.org/10.3760/cma.j.cn112144-2... . This heterogeneous group of musculoskeletal and neuromuscular diseases involves the temporomandibular joint complex, musculature and adjacent components ^[19][19] De Leeuw R, Klasser GD. American Academy of Orofacial Pain: Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. 5th ed. Chicago: Quintessence Publishing; 2013.. The somatic symptom is the strongest psychosocial predictor of TMD incidence ^[20][20] Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE, et al. Painful temporomandibular disorder: decade of discovery from OPPERA studies. J Dent Res 2016; 95(10):1084-92. https://doi.org/10.1177/0022034516653743
https://doi.org/10.1177/0022034516653743... ; because of this, we decided to investigate this factor in this study.

The highest prevalence of TMD occurs in women, so we included only that gender in the study. Women are more susceptible to these disorders and are more likely to experience painful symptoms. This suggests a differentiation in the activation of the endogenous analgesia system and the central processing of nociceptive stimuli. Women activate autonomic and affective areas more in addition to having female sex hormones playing an important role in painful sensitivity ^[21][21] Ferreira CL, Silva MA, Felício CM. Signs and symptoms of temporomandibular disorders in women and men. Codas 2016; 28(1):17-21. https://doi.org/10.1590/2317-1782/20162014218
https://doi.org/10.1590/2317-1782/201620... .

The Beck Inventory (BAI) was used to assess anxiety symptoms in patients with TMD. In this study, the scores of patients in the experimental group (EG) were higher, with a maximum of 42; while in the control group (CG) it was 18. The means were also higher with 7.7 (CG) and 16.9 in (GE), although the groups have no statistically significant difference between them, as for the correlation test, it can be observed that the correlation of TMD and BAI was statistically significant. Suggesting that anxiety has some influence on temporomandibular disorders. Several studies have shown high levels of anxiety in these patients [⁸[8] Maślak-Bereś M, Loster JE, Wieczorek A, Loster BW. Evaluation of the psychoemotional status of young adults with symptoms of temporomandibular disorders. Brain Behav 2019; 9(11):e01443. https://doi.org/10.1002/brb3.1443
https://doi.org/10.1002/brb3.1443... ,²²[22] Manfredini D, Bandettini di Poggio A, Cantini E, DellÓsso L, Bosco M. Mood and anxiety psychopathology and temporomandibular disorder: a spectrum approach. J Oral Rehabil 2004; 31(10):933-40. https://doi.org/10.1111/j.1365-2842.2004.01335
https://doi.org/10.1111/j.1365-2842.2004... ,²³[23] Pallegama RW, Ranasinghe AW, Weerasinghe VS, Sitheeque MAM. Anxiety and personality traits in patients with muscle related temporomandibular disorders. J Oral Rehabil 2005; 32:701-7. https://doi.org/10.1111/j.1365-2842.2005.01503.x
https://doi.org/10.1111/j.1365-2842.2005... ].

Stress was analyzed using the perceived stress scale (PSS). Perceived stress is how much the person feels the situations in which they are inserted as stressful. In this research, the results showed that the group of patients with TMD had an average with higher TMD levels than the control group. Although the comparison between the groups was not statistically significant, and the logistic regression did not show dependence between TMD and EPS, the correlation between TMD and stress was statistically significant [¹⁴[14] Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24(4):385-96.,¹⁵[15] Reis RS, Hino AA, Añez CR. Perceived stress scale: reliability and validity study in Brazil. J Health Psychol 2010; 15(1):107-14. https://doi.org/10.1177/1359105309346343
https://doi.org/10.1177/1359105309346343... ].

A concern commonly associated with TMD and orofacial pain is the patients' psycho-emotional state ^[8][8] Maślak-Bereś M, Loster JE, Wieczorek A, Loster BW. Evaluation of the psychoemotional status of young adults with symptoms of temporomandibular disorders. Brain Behav 2019; 9(11):e01443. https://doi.org/10.1002/brb3.1443
https://doi.org/10.1002/brb3.1443... . Psychological, somatic and psychosocial complaints are often related to psychological distress, requiring careful assessment of the biopsychosocial factor ^[17][17] Oliveira SSI, Gonçalves SLM, Weig KM, Magalhães Filho TR, Martinez Oer, Kalil MTAC, et al. Temporomandibular disorders: guidelines and self-care for patients during COVID-19 pandemic. Braz Dent Sci 2020; 23(2, supl):1-8. https://doi.org/10.14295/bds.2020.v23i2.2255
https://doi.org/10.14295/bds.2020.v23i2.... .

In the studied groups, we found higher mean values in the PSS of individuals with TMD. Our results are in accordance with a study that evaluated the prevalence of TMD and its association with perceived stress and common mental disorders in 586 students, and significant correlations were observed between TMD and perceived stress ^[24][24] Augusto VG, Perina KCB, Penha DSG, Dos Santos DCA, Oliveira VAS. Temporomandibular dysfunction, stress and common mental disorder in University students. Acta Ortoped Bras 2016; 24(6):330-3. https://doi.org/10.1590/1413-785220162406162873
https://doi.org/10.1590/1413-78522016240... .

The COMT genotype (catechol O - methyltransferase gene) was associated with TMD. COMT has the function of regulating the catabolism of the neurotransmitter catechol, an essential process in the stress response ^[20][20] Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE, et al. Painful temporomandibular disorder: decade of discovery from OPPERA studies. J Dent Res 2016; 95(10):1084-92. https://doi.org/10.1177/0022034516653743
https://doi.org/10.1177/0022034516653743... . Therefore, the COVID-19 pandemic and the need for social isolation, can generate psychological impact, and mainly affect patients with TMD and bruxism ^[17][17] Oliveira SSI, Gonçalves SLM, Weig KM, Magalhães Filho TR, Martinez Oer, Kalil MTAC, et al. Temporomandibular disorders: guidelines and self-care for patients during COVID-19 pandemic. Braz Dent Sci 2020; 23(2, supl):1-8. https://doi.org/10.14295/bds.2020.v23i2.2255
https://doi.org/10.14295/bds.2020.v23i2.... , as there is an increased risk of these patients developing global psychological problems ^[20][20] Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE, et al. Painful temporomandibular disorder: decade of discovery from OPPERA studies. J Dent Res 2016; 95(10):1084-92. https://doi.org/10.1177/0022034516653743
https://doi.org/10.1177/0022034516653743... .

The rules during the pandemic have profoundly changed lifestyles and social relationships, which are likely to generate deep anxiety levels. Thus, psychological conditions may be compromised during the COVID-19 outbreak ^[25][25] Wang C, Tee M, Roy AE, Fardin MA, Srichokchatchawan W, Habib HA, et al. The impact of COVID-19 pandemic on physical and mental health of Asians: a study of seven middle-income countries in Asia. PLoS One 2021; 16(2):e0246824. https://doi.org/10.1371/journal.pone.0246824
https://doi.org/10.1371/journal.pone.024... . Although these social isolation measures are important to reduce the outbreak of COVID-19, it creates psychological distress for the population. The quality of sleep and anxiety symptoms in people who have gone through post-traumatic events have been reflected in negative aspects of general health. Studies carried out in the Chinese and Italian population during the pandemic showed a relationship between anxiety, depression, distress, sleep disorders and post-traumatic stress disorders, not only due to the impact of the infection but also by the isolation measures to control the coronavirus outbreak [²⁶[26] Casagrande M, Favieri F, Tambelli R, Forte G. The enemy who sealed the world: effects quarantine due to the COVID-19 on sleep quality, anxiety, and psychological distress in the Italian population. Sleep Med 2020; 75:12-20. https://doi.org/10.1016/j.sleep.2020.05.011
https://doi.org/10.1016/j.sleep.2020.05.... ,²⁷[27] Xiao H, Zhang Y, Kong D, Li S, Yang N. The Effects of Social Support on Sleep Quality of Medical Staff Treating Patients with Coronavirus Disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit 2020; 26:e923549. https://doi.org/10.12659/MSM.923549
https://doi.org/10.12659/MSM.923549... ].

Conclusion

Although the COVID 19 Pandemic has had a psychological impact on the general population, TMD patients had higher levels of anxiety and stress than the control group, suggesting the psychological component as a risk factor for TMD. In addition, half of TMD patients reported worsening orofacial pain, and half improved.

Acknowledgements

I would like to thank Adriano Bressane, José Wilson, e Regina El Dib for assistance in the execution this article.

References

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