Temporomandibular disorders and orofacial pain: study of quality of life measured by the Medical Outcomes Study 36 Item Short Form Health Survey*

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1 ORIGINAL ARTICLE Temporomandibular disorders and orofacial pain: study of quality of life measured by the Medical Outcomes Study 36 Item Short Form Health Survey* Desordens temporomandibulares e dor orofacial: estudo da qualidade de vida medida pelo Medical Outcomes Study 36 Item Short Form Health Survey Denis Noboru Kuroiwa 1, Juliano Gaspari Marinelli 1, Marta Solange Rampani 2, Wagner de Oliveira 2, Denise Nicodemo 3 *Received from the Social Dentistry and Children s Clinic Department and Occlusion and Temporomandibular Joint Center, School of Dentistry of São José dos Campos, São Paulo State University Julio de Mesquita Filho (COAT/UNESP). São José dos Campos, SP. FAPESP Scholarship granted Process 06/ Scientific Initiation SUMMARY 1. Dentists Graduated by the School of Dentistry of São José dos Campos, São Paulo State University Júlio de Mesquita Filho (UNESP). São José dos Campos, SP, Brazil. 2. Doctor Professors of the Occlusion and Temporomandibular Joint Center, School of Dentistry of São José dos Campos, São Paulo State University Júlio de Mesquita Filho (UNESP). São José dos Campos, SP, Brazil. 3. Doctor Professor, in charge of the Discipline of Psychology Applied to Dentistry, School of Dentistry of São José dos Campos, São Paulo State University Júlio de Mesquita Filho (UNESP). São José dos Campos, SP, Brazil. Correspondence to: Denise Nicodemo, MD Faculdade de Odontologia de São José dos Campos da UNESP Departamento de Odontologia Social e Clínica Infantil. Av. Engo Francisco José Longo, 777. Jardim São Dimas São José dos Campos, SP. Phone: (12) denise@fosjc.unesp.br c Sociedade Brasileira para o Estudo da Dor BACKGROUND AND OBJECTIVES: The understanding of quality of life (QL) indicators related to oral health is especially relevant for Dentistry, considering the impact that oral conditions may have in psychological and social well being. Studies on psychosocial aspects contribute for a better integration of clinical and assistance approach, which is a shared concern with health professionals. Integrating psychology and dentistry breaking interdisciplinary paradigms and the interest in knowing patients psychological aspects, have motivated this study. This study aimed at evaluating the QL of patients with temporomandibular dysfunction and / or orofacial pain. METHOD: The Generic Questionnaire to Evaluate Quality of Life Medical Outcomes Study 36 Item Short Health Survey (SF-36) was applied to 91 patients who looked for assistance due to signs and / or symptoms of temporomandibular dysfunction (TMD) and orofacial pain (OFP). SF-36 evaluates 8 domains: functional capacity (FC), physical aspects (FA), pain, general health status (GHS), mental health (MH), emotional aspects (EA), social aspects (AS) and vitality (V). RESULTS: Descriptive and inferential statistical analysis by Pearson s Correlation (p = 0.05) has shown, with the exception of functional capacity (73.2), mean values between 50 and 64 for remaining domains: PA 57.6; Pain 50; HGS 54.5; V 53.4; AS 63.6; EA 51.8; MH 58. Considering that grades go from zero to 100, that is, from the worst to the best health status, mean values were low. There has been correlation between FC and GHS (p = 0.01) and significance trend for Pain and GHS (p = 0.07). CONCLUSION: Pain and functional capacity interfere with general health status; patients with TMD and OFP suffered negative impact in quality of life due to impairment of physical and mental aspects. Keywords: Orofacial pain, Psychosocial impact, Quality of life. 93

2 Pucci, Teófilo, Aragão et al. RESUMO JUSTIFICATIVA E OBJETIVOS: O conhecimento de indicadores de qualidade de vida (QV) relacionados à saúde bucal é especialmente relevante para a Odontologia considerando o impacto que as condições bucais podem provocar no bem estar psicológico e social. Estudos sobre aspectos psicossociais contribuem para maior integração da conduta clínica e assistencial, preocupação compar tilhada com profissionais da saúde. Integrar as áreas de Psicologia e Odontologia quebrando paradigmas interdis ciplinares e o interesse em conhecer os aspectos psicoló gicos dos pacientes, motivou a realização deste estudo. O objetivo deste estudo foi avaliar a QV dos pacientes com disfunção temporomandibular e/ou dor orofacial. MÉTODO: Foi aplicado o Questionário Genérico de Avaliação de Qualidade de Vida Medical Outcomes Stu dy 36 Item Short Health Survey (SF-36) a 91 pacientes, que buscaram atendimento por apresentarem sinais e/ou sintomas de disfunção temporomandibular (DTM) e dor orofacial (DOF). O SF-36 avalia 8 domínios: capacidade funcional (CF), aspectos físicos (AF), dor, estado geral de saúde (EGS), saúde mental (SM), aspectos emocionais (AE), aspectos sociais (AS) e vitalidade (V). RESULTADOS: A análise estatística descritiva e inferen cial pela Correlação de Pearson (p-valor 0,05) demons trou, com exceção da capacidade funcional (73,2), valores médios entre 50 e 64 para os demais domínios: AF - 57,6; Dor - 50; EGS - 54,5; V - 53,4; AS - 63,6; AE - 51,8; SM Considerando-se que a pontuação varia de 0 a 100, ou seja, do pior para o melhor estado de saúde, os valores médios foram baixos. Verificou-se correlação entre CF e EGS (pvalor 0,01), tendência de significância para dor e EGS (p-valor 0,07). CONCLUSÃO: Os aspectos dor e capacidade funcional interferem no estado geral de saúde; os pacientes com DTM e DOF sofreram impacto negativo na qualidade de vida pelo prejuízo dos aspectos físicos e mentais. Descritores: Dor orofacial, Impacto psicossocial, Quali dade de vida. INTRODUCTION Being understood as a dual process, pain has two variants: perception, which consists in an anatomophysiologic process through which pain is received 94 and transmitted, and reaction, which is summarized in the manifestation of live beings perception of the phenomenon. Both facial and dental pain are the most frequently mentioned aspects among oral health indicators which impact quality of life (QL), followed by the loss of sleeping hours and masticatory problems 1. Orofacial pain may change QL more than other systemic conditions, such as diabetes, hypertension or ulcer. People with this condition suffer major changes in their daily lives, including loss of working days, lack of relationship with relatives and friends, dissatisfaction with their oral condition, drug ingestion and dietary changes 2. The American Academy of Orofacial Pain accepts that Temporomandibular Disorder is a collective term involving a number of signs and symptoms including joint noise, such as clicks and crepitation; masticatory muscles pain; limitation of mandibular movements; facial pain; headache and temporomandibular joint (TMJ) pain 3,4. The term is synonym to temporomandibular dysfunctions (TMD), which have been identified as the major reason for non-dental orofacial pain. For being still very controversial, a lot has been studied about TMD and OFP etiology, since in general diagnosis and treatment are multidisciplinary 5. Several factors are considered by the literature as causing or worsening TMD and OFP: occlusal disharmony, psychological profile, musculoskeletal injuries, parafunctional habits, emotional stress, connective tissue lassitude, trauma, anatomic and pathophysiological factors Bruxism is a strong increment for TMD installation since this habit acts intensively on the predisposition and susceptibility of patients with regard to TMD etiology and worsening 12. This inter-relation between bruxism and TMD may be illustrated by several studies These studies have stated that there is a direct relation between the incidence and prevalence of bruxism and TMD, although bruxism is a strong TMD worsening factor being able to increase pain symptoms in up to 40%. The first associations between TMD and psychological factors appeared after studies of a psychiatrist and a dentist working together 18. Among psychological factors associated to TMD etiology there were behavioral, cognitive and emotional or affective factors, such as anxiety, stress and depression. The Quality of Life group of the World Health Organization (WHO) has defined quality of life as the perception of one individual of his position in life

3 Pain in Hansen s disease patients Rev Dor. São Paulo, 2011 abr-jun;12(2):93-8 in the context of culture and of the value system in which he lives and with regard to his objectives, expectations, standards and concerns 19. QL indicators may be especially relevant for Dentistry, considering the importance of the face appearance for self-image and self-esteem and also the sometimes subtle impact that oral conditions may have on the well being and psychological functioning We hope, with this study, to contribute to increasingly integrated clinical approach and assistance directed to promote physical, psychic and social well being by applying scientific knowledge to the professional practice. So, this study aimed at evaluating QL of patients looking for a better oral health because they have TMD and / or orofacial pain. METHOD After the Ethics Committee, São Paulo State University Julio de Mesquita Filho, São José dos Campos approval, protocol 06/2005-PH/CEP, this study was carried out with 91 adult patients of both genders, to be treated by the Occlusion and Temporomandibular Joint Center (COAT) of the School of Dentistry of São José dos Campos, for having signs and / or symptoms of TMD and OFP, being these the inclusion criteria. When enrolling for treatment, patients are examined by a single examiner to confirm signs and symptoms related to orofacial pain and TMD. Those people wait on a list for TDM diagnosis and specific treatment and participants were recruited from this list for this study. Inclusion criteria were that patients should have at least one of the following signs or symptoms for a minimum period of three months: masticatory muscles pain, TMJ pain > 5 according to the visual analog scale (VAS), joint noise and functional limitation. Patients with systemic diseases which might affect the orofacial area or with cognitive incapacity to answer the SF-36 questionnaire were excluded from the sample. Patients volunteered for the research and gave their free and informed consent when presenting at COAT, after being enrolled and called by the Unit Screening Sector. Procedure The procedure consisted in the application of the Generic Questionnaire to Evaluate Quality of Life Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) 23. Questionnaire was collectively applied in an adequate place by the researcher in charge of the study. Tool SF-36 validated for Brazil 24 in 1999, consists in 11 closed questions and aims at evaluating eight domains divided in two groups: physical, involving functional capacity, physical aspects, pain and general health status; and mental, involving mental health, emotional and social aspects and vitality. Scores vary from zero to 100, that is from the worst to the best health status. The questionnaire emphasizes individual perception of his health in the last four weeks. A description of what is intended to be evaluated for each domain is given below: Functional capacity: evaluates how the individual has performed his normal daily tasks (10 items in question 3); Physical aspects: evaluates how physical health has interfered with normal domestic or professional activities (four items in question 4); Pain: evaluates pain intensity in the last four weeks and the limitations it has caused to his daily life (two items in questions 7 and 8); General health status: evaluates the perception the individual has of his own health and his expectations with regard to the future (five items in questions 1 and 11); Vitality: evaluates the level of energy and disposition of the individual to perform daily tasks (four items in question 9); Social aspects: evaluates the extent to which normal social activities were affected by his physical or emotional status (two items in questions 6 and 10); Emotional aspect: evaluates how the emotional status has interfered with daily domestic or professional activities (three items in question 5); Mental health: evaluates for how long the individual is feeling anxious and depressed or happy and relaxed in his daily life (five items in question 9). Descriptive and inferential statistical analysis was performed by the Pearson Linear Correlation coefficients considering 5% as significance level. RESULTS It was observed that among 91 patients looking for treatment at COAT, 73 were females (80.22%) and 18 were males (19.78%) (Graph 1). SF-36 results have shown, with the exception of functional capacity with mean of 73.57, mean values between 52 and approximately 64 for remaining domains, that is, low values, indicating QL impairment 95

4 Pucci, Teófilo, Aragão et al. Total Females Males % Graph 1 Number of treatments by gender. in such patients. Functional capacity and social aspects domains (73.57 and 64.55, respectively), which evaluate normal daily tasks such as climbing steps, stooping, standing up and walking short distances, as well as social activities were not significantly affected. However, pain, emotional aspect and vitality domains, which presented, respectively the lowest values (52.12; and 53.41) have proven that normal daily activities at home and at work were affected by emotional and physical impairment, showed by higher malaise, tiredness and fatigue. Physical aspects domain (58.32) has also shown the impairment of daily jobs and tasks (Table 1, Graph 2). DISCUSSION Our study results have shown significant predominance of female patients (80.22% versus 19.88% of males). This higher number had already been suggested in a study evidencing that females tend to have more precise pain perception than males 25. Similarly, other studies have proposed that TMDs are Table 1 Descriptive analysis of each domain evaluated by SF-36 SF-36 FC PA Pain GHS Vitality SA EA MH > Value < Value Mean 73,57 58,32* 52,12 54,78* 53,41 63,55 52,56 57,64 *correlation between domains (p-valor 0.01) FC = functional capacity; PA = physical aspects; GHS = general health status; SA = social aspects; EA = emotional aspects; MH = mental health Mean FC MH EA SA V GHS PAIN PA 0 Graph 2 Mean score for each SF-36 domain FC = functional capacity; MH = mental health; EA = emotional aspects; SA = social aspects; GHS = general health status; PA = physical aspects. 96

5 Pain in Hansen s disease patients Rev Dor. São Paulo, 2011 abr-jun;12(2):93-8 part of a spectrum of syndromes associated to stress and characterized by somatic and psychological changes, including fatigue, impairment of work and school activities, sleep and appetite / feeding disorders, anxiety and depression 26,27. Higher levels of pain and stress were found in TMD patients as compared to control group 26. Mental health domain, with low general mean (57.33), has shown low emotional control of patients, representing, for what is evaluated in this domain, higher anxiety, nervousness and depression. Patients believe that their health is poor and tends to worsen, fact proven by general health status domain mean (54.78). There was also correlation between Physical Aspects and General Health Status domains (p = 0.01) and a trend to statistical significance for Pain and General Health Status (p = 0.07). A study 28 has shown that oral health improvement may positively interfere with the physical condition perceived by a better performance of professional and daily activities. This negative interference of physical, functional, social, mental and psychological well being, observed as from the quality of life questionnaire SF-36, confirms the previously described assumption, stressing that health is not merely the absence of disease 1. It has once more been evidenced in this study via SF- 36 that TMD and OFP are disorders with multifactorial etiology and that a multidisciplinary approach is needed with different professionals, such as dentists, psychologists, speech therapists, physical therapists and neurologists, to provide the best treatment and as a consequence a better QL. However, these subjective indicators should not be used to diagnose diseases or to replace clinical evaluation because they do not provide objective signs of the disease. Such data should be used more as an evaluation tool, complementing clinical information and allowing the identification of people who need curative, preventive or educative actions. CONCLUSION Pain and functional capacity aspects have negatively interfered with general health status of TMD and OFP patients; TMD and OFP patients have suffered negative impact in their quality of life due to impaired physical and mental aspects. REFERENCES 1. Locker D, Grushka M. The impact of dental and facial pain. J Dent Res 1987;66(9): Biazevic MGH, Araújo ME, Michel-Crosato E. Indicadores de qualidade de vida relacionados com a saúde bucal: revisão sistemática. Rev Odontol 2002;4(1): Parker MW. A dynamic model of etiology in temporomandibular disorders. J Am Dent Assoc 1990;120(3): Bocchi EA, Kuhn AMB, Nascimento RSGF. Características psicológicas de pacientes com queixa de disfunção da articulação temporomandibular. Psikhe 2000;5(1): McNeill C. Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent 1997;77(5): Riolo ML, Brandt D, TenHave TR. Associations between occlusal characteristics and signs and symptoms of TMJ dysfunction in children and young adults. Am J Orthod Dentofacial Orthop 1987;92(6): Pullinger AG, Seligman DA. Trauma history in diagnostic groups of temporomandibular disorders. Oral Surg Oral Med Oral Pathol 1991;71(5): Henrikson T, Ekberg EC, Nilner M. Symptoms and signs of temporomandibular disorders in girls with normal occlusion and Class II malocclusion. Acta Odontol Scand 1997;55(4): Ruf S, Cecere F, Kupfer J, et al. Stress-induced changes in the functional electromyographic activity of the masticatory muscles. Acta Odontol Scand 1997;55(1): Steed PA. Etiological factors and temporomandibular treatment outcomes: the effects of trauma and psychological dysfunction. Funct Orthod 1997;14(4) Rauhala K, Oikarinen KS, Raustia AM. Role of temporomandibular disorders (TMD) in facial pain: occlusion, muscle and TMJ pain. Cranio 1999;17(4): Santos A, Bergantin A, Maekawa M, et al. Análise crítica da participação dos fatores odontológicos e psicológicos na etiologia do bruxismo. Rev Odontológica de Araçatuba 2007;28(2): Tsolka P, Walter JD, Wilson RF, et al. Occlusal variables, bruxism and temporomandibular disorders: a clinical and kinesiographic assessment. J Oral Rehabil 1995;22(12): Lobbezoo F, Lavigne GJ. Do bruxism and temporomandibular disorders have a cause- and-effect relationship? J Orofac Pain 1997;11(1): Molina OF, dos Santos Junior J, Nelson SJ, et al. A clinical study of specific signs and symptoms of CMD in bruxers classified by the degree of severity. Cranio 1999;17(4): Molina OF, Santos J, Mazzeto M, et al. Oral jaw behaviors in TMD and bruxism: a comparison study by severity of bruxism. Cranio 2001;19(2): Venâncio RA, Camparis CM. Estudo da relação entre 97

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