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Temporomandibular Joint Dysfunction and Posttraumatic Stress Disorder

Discussion in 'News, Politics & Debates' started by anthony, Dec 25, 2006.

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  1. anthony

    anthony Silently Watching Founder

    Over the last few years I’ve had the privilege of visiting Croatia several times. I was one of the first Western academics to go back there to teach after the war, and I’ve made many good friends. It is a beautiful country with lovely people and it is a terrible shame what happened there.

    One of the big problems that remain is the incredible number of people suffering from posttraumatic stress disorder (PTSD). There continues to be some debate about whether PTSD can only occur in response to one major traumatic event in which a person feels that their life is in danger, or whether it can also occur as a result of repeated less serious traumata. We have discussed the relationships between PTSD, resilience and neurological dysfunction, and of the association between PTSD and laterality.

    There has also been at least one report of an association between PTSD and atypical facial pain.

    A new paper from colleagues in Croatia has clarified this association by showing that people with PTSD are at increased risk of temporomandibular muscle and joint disorder, or TMJD, which used to be known simply as temporomandibular joint (TMJ) dysfunction. This is intuitively obvious, but it is an important finding. The main complaint was of headache, and it is important not to dismiss these headaches as migraine, tension headaches or as some kind of somatization.

    There is currently an $8 million project underway to establish valid and reliable TMJD diagnostic criteria. It is to be hoped that the results of the study will advance the field of TMJD research and aid clinicians in their practices. At a meeting of the American Association of Dental Research in Orlando, Florida in March, Richard Ohrbach from the University of Buffalo presented data from the study indicating that 82% of People whose recurrent headaches have been diagnosed as tension-related actually had TMJD.

    In April of this year, we had the first meeting of the National Institutes of Health Pain Consortium. There’s a good report in Clinical Psychiatry News about ongoing studies from the University of Washington in Seattle. Niloofar Afari presented data that confirms the findings in the Croatian study. And provides yet more useful information.

    The investigators used state records to identify twins and surveyed more than 1,700 female twins by mail and by telephone. The results so far indicate that the association between PTSD and TMJD is real and that there may be a genetic predisposition to the association.

    It is important not to miss this possible association. Misdiagnosis can cause a lot of needless suffering.

    Source: Richard G Petty
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  3. Roerich

    Roerich M.D.

    1: Mil Med. 2006 Nov;171(11):1147-9. Related Articles, Links

    The prevalence of temporomandibular disorders in war veterans with post-traumatic stress disorder.

    Uhac I, Kovac Z, Muhvic-Urek M, Kovacevic D, Franciskovic T, Simunovic-Soskic M.

    Department of Prosthodontics, Faculty of Medicine, University of Rijeka, Rijeka, HR-51000 Kresimirova 40, Croatia.

    The purposes of this study were to assess the prevalence of temporomandibular disorders in Croatian war veterans suffering from post-traumatic stress disorder (PTSD) and to analyze the impact of the disease on mandibular function. One hundred eighty-two male subjects participated in the study. The examined group consisted of 94 subjects who had taken part in the war in Croatia and for whom PTSD had previously been diagnosed. Patients were compared with an age- and gender-matched group of subjects who had not taken part in the war and for whom PTSD was excluded by means of a psychiatric examination. The study used a clinical examination and standard questionnaire. Statistically significant differences were found in almost all measured parameters. With regard to restricted movements, overbite, and overjet, the differences obtained did not have clinical significance. The most significant differences were found in the parameters of pain. Headache was experienced by 63.83% of the subjects with PTSD, facial pain by 12.77%, and pain in the region of the jaw by 10.64%. Headache was the most intense pain, with an average intensity of 4.92 on a scale of 0 to 10. Pain on loading, temporomandibular joint clicking, and intrameatal tenderness were more prevalent in the PTSD group than in the healthy control group. The study supports the concept that PTSD patients are at increased risk for the development of temporomandibular disorder symptoms.

    PMID: 17153558 [PubMed - in process]
  4. Roerich

    Roerich M.D.

    PTSD Linked to TMJ Dysfunction

    PTSD Linked to TMJ Dysfunction
    return to Article Outline

    The first-ever study to examine in a cohort of twins the previously identified relationship between temporomandibular joint dysfunction and posttraumatic stress disorder has found a possibly confounding genetic influence, Niloofar Afari, Ph.D., reported in a poster presentation at a meeting sponsored by the National Institutes of Health's Pain Consortium.

    Moreover, the study found that the relationship between the two disorders is not attributable to cooccurring chronic widespread pain (CWP).

    Dr. Afari, of the University of Washington, Seattle, and her coinvestigators used state records to identify twins and surveyed more than 1,700 female twins by mail and by telephone. They asked about the respondents' zygosity status, administered questions used in prior studies to assess CWP and PTSD, and asked respondents whether they had experienced temporomandibular joint dysfunction (TMJD) pain in the last 3 months.

    Nearly 15% of the female twins reported having TMJD pain in the preceding 3-month period. These women had higher mean PTSD scores than did those without TMJD pain (26 vs. 18, respectively). They were also younger, had less education, and had experienced more depression and CWP. The researchers noted that the association between TMJD and PTSD persisted even after adjustment for CWP, depression, and demographic factors.

    However, adjustment for familial and genetic factors did indeed affect the relationship between PTSD and TMJD—and notably, the association within pairs of monozygotic twins was more attenuated than it was within dizygotic pairs. These results led the investigators to conclude that the relationship “may be partially due to confounding by genetic influences.”

    The findings “strongly support” the need to assess and treat for both disorders when symptoms of one are present, Dr. Afari and her colleagues concluded.
  5. Roerich

    Roerich M.D.

    Prevalence of post-traumatic stress disorder symptoms on orofacial pain patients

    de Leeuw R, Bertoli E et al Oral Surg 2005; 99: 558-568

    Post-traumatic stress disorder (PTSD) may occur in 1/6 of patients with chronic orofacial pain, and has relevance to temporomandibular disorders.

    Over a 5 year period, 1,478 patients were seen in a Kentucky orofacial pain clinic and diagnosed with masticatory /cervical muscle pain or TMJ pain. PTSD is diagnosed according to DSM-IV in relation to significant life-threatening traumatic exposures which are identified as stressors. On the basis of psychometric questionnaires, a PTSD-positive group (P+) of 218 was identified, and also a PTSD-negative group (P−) of 551 patients, with a stressor but without the disorder. The remaining 709 patients had no stressors (S−).

    There were significant differences between the 3 groups (P < 0.01) on 8 of 12 scales of the Multidimensional Pain Inventory. In relation to primary oral diagnoses, 76% of P+ subjects had muscle pain, and 24% had TMJ pain; respective percentages for P- were 66 and 34, and for S−, 61 and 39 (P < 0.001). More dysfunctional, and fewer adaptive coping and anomalous, profiles occurred in the P+ group than in P− and S− groups. Psychological distress was higher in all respects in the P+ group. The authors conclude that P− patients with TMJ disorders show low levels of distress, and that such distress is a likely indicator of PTSD.
  6. Roerich

    Roerich M.D.

    Chronic pain and PTSD

    The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers and Patients

    There are many forms of chronic pain, including: pain felt in the low back (most pervasive or common), the cervical area, the mouth and face, the temporomandibular joint (TMJ), the pelvis, or the head (e.g., tension and migraine headaches); complex regional pain syndrome (formally reflex sympathetic nerve dystrophy (RSD)); fibromyalgia; and cancer-related pain. Of course, each type of condition results in different experiences of pain. But, as an example, chronic low back pain (CLBP) is known to result in severe disability and limitation of movement. In its most severe forms, CLBP may cause paralysis and numbness, loss of gross motor control, loss of bowel and bladder control, loss of reflexes in lower limbs, spasticity, and nerve degeneration.

    What is the experience of chronic pain like psychologically?

    Chronic pain often results in disability, and with this comes a cognitive reevaluation and reintegration of one's belief systems, values, emotions, and feelings of self-worth (Miller, 1990). Numerous studies have indicated that many patients who experience chronic pain (up to 100%) tend to also be clinically depressed (e.g. Turk, 1994; Lindal, 1990; Schuster & Smith, 1994). In fact, depression is the most common psychiatric diagnosis in patients with chronic pain (Fishbain, Goldberg, Meagher, & Rosomoff, 1986). The experience of progressive, consistent chronic pain and disability also translates to many individuals having thoughts of suicide as a means of ending their pain and frustration (Fisher, Haythornthwaite, & Heinberg, 2001).

    The prevalence of posttraumatic stress disorder (PTSD) is also substantially elevated in patients with chronic pain (15-35%), compared to those who do not have chronic pain (2%; Asmundson, Bonin, Frombach, & Norton, 2000). For example, in a study of patients with chronic low back pain, 51% of the patients evidenced significant PTSD symptoms (DeCarvalho, 2003).

    In a study of patients who experienced chronic pain following a motor vehicle accident, researchers found that 50% of the patients developed PTSD (Hickling & Blanchard, 1992). As stated above, some people's chronic pain stems from a traumatic event, such as a physical or sexual assault, a motor vehicle accident, or some type of disaster. Under these circumstances the person may experience both chronic pain and posttraumatic stress disorder. One symptom of PTSD is that the person becomes emotionally or physically upset when reminded of the traumatic event. For people with chronic pain, the pain may actually serve as a reminder of the traumatic event, which will tend to exacerbate the PTSD.
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