Relationships Between Temporomandibular Disorders, MSD Conditions, and Mental Health Comorbidities: Findings from the Veterans Musculoskeletal Disorders Cohort

Preliminary insights into the association between the well-being spectrum and temporomandibular disorders

OBJECTIVES

This Mendelian randomization (MR) study aims to explore the causal effect of well-being spectrum on temporomandibular disorders (TMDs).

MATERIALS AND METHODS

We employed the largest available summary-level data from genome-wide association studies on the well-being spectrum and its four dimensions-life satisfaction, positive affect, neuroticism and depressive symptoms-along with data on TMDs. Univariable and multivariable MR analyses were used to assess causal effects and their independence from socioeconomic factors, including income, education, and occupation. Additionally, 125 potential mediators were examined for their role in the well-being spectrum-TMDs relationships using two-step MR.

RESULTS

A higher well-being spectrum was causally linked to a reduced risk of TMDs, independent of income (OR: 3.39, 95% CI: 1.78-6.43, p < 0.001), education (OR: 3.52, 95% CI: 1.68-7.33, p = 0.001), and occupation (OR: 3.74, 95% CI: 2.12-6.53, p < 0.001). Similar patterns were observed for life satisfaction, positive affect, neuroticism and depressive symptoms. Daily smoking (mediation proportion: 12.9%) and HDL-C (1.8%) were identified as significant mediators. No evidence of pleiotropy was detected (p > 0.05).

CONCLUSIONS

A higher well-being spectrum has a protective effect against TMDs, partially mediated by daily smoking and lipid metabolism.

CLINICAL RELEVANCE

These findings underscore the critical role of well-being spectrum in the management of TMDs. Among individuals with lower well-being, smokers and those with low HDL-C levels may be at an increased risk for TMDs, warranting focused monitoring and personalized preventive strategies.

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

Genetic evidence strengthens the connection between emotional disorders and TMD-related pain: A two-sample Mendelian randomization study

OBJECTIVES

This study aims to evaluate the genetic association between emotional disorders and TMD-related pain through two-sample Mendelian randomization analysis.

DESIGN

Single-nucleotide polymorphisms (SNPs) related to emotional disorders (worry, nerves, or depression) were selected from genome-wide association studies (GWAS) from UK Biobank consortia, and related these to SNPs from FinnGen consortia. The inverse-variance weighted (IVW) was used as the primary effect estimate between emotional disorders and TMD-related pain, and various methods were applied to test the reliability and stability of the results, namely MR-Egger and weighted median.

RESULTS

The Mendelian randomization analysis showed that there was a positive correlation between emotional disorders and TMD-related pain, including worry group (IVW odds ratio (OR) = 3.86, 95 % confidence interval (CI) = 1.67-8.91), nerves group (IVW OR = 11.20, 95 % CI=2.04-61.64) and depression group (IVW OR = 3.32, 95 % CI=1.24-8.90). MR-Egger intercept and MR-PRESSO global test did not suggest evidence of horizontal or directional pleiotropy. Cochran's Q test showed that there was no heterogeneity between instrumental variables.

CONCLUSIONS

This study provides genetic evidence that strengthens the connection between emotional disorders and TMD-related pain, which has important implications at the causal level as well as throughout the treatment process of TMD-related pain.

Temporomandibular disorders in patients with HIV: a cross-sectional study

Untreated HIV infection leads to severe immunodeficiency and can be associated with an accelerated aging process and a higher prevalence of frailty. Systemic changes are known to cause greater oral manifestations and decreased orofacial function. However, there is no investigation on Temporomandibular Disorders (TMD) in this population. This study aims to assess the prevalence of TMD in individuals living with HIV/AIDS. This cross-sectional study included HIV patients, with undetectable plasma viral load, under follow-up in the infectious disease's outpatient clinic at the Federal University of Bahia hospital. We recorded socio-demographic data, Fried's frailty criteria, Research Diagnostic Criteria for Temporomandibular Disorder, and Beck's Depression Inventory (BDI) through the application of structured questionnaires and extra-oral examination findings. Data analysis was conducted on SPSS-v18. The sample consisted of 198 patients. The prevalence of TMD was (33.8 %), most affecting females (46.6 %). Difficulty in opening the mouth and parafunctional habits were the main symptoms of the disease, as well as functional limitations. The mean of the BDI score was higher in TMD group than in those without TMD (11.01 ± 8.61 vs. 7.60 ± 7.52 valor de p = 0.004). Logistic regression showed an association between sex (OR=2.305, 95 % CI 1.243‒4.275) and depression (OR = 1.045, 95 % CI 1.005‒1.087) and TMD in HIV patients. The present study observed the prevalence of symptoms associated with TMD as difficulty opening the mouth, muscle fatigue, and joint noises in patients with chronic HIV and associated with depression. Highlights the importance of a broader view of the health of individuals living with HIV.

Temporomandibular Joint Disorder Comorbidities

Comorbidity is a distinct additional condition that either existed or exists during the clinical course of a patient afflicted by the condition/entity in question. The clinician attempting to manage temporomandibular joint disorder (TMD) and TMD pain must realize that recognition and management of the comorbidities are essential to the successful management of the same with optimal pain control. When TMD presents with multiple comorbidities, the task for the clinician becomes more complex. It is the hope of the authors that this condensed version of TMD-associated comorbidities acts as a primer for understanding the significance of the same in pain management.

The Association Between Post-Traumatic Stress Disorder and Temporomandibular Disorders: A Systematic Review

The purpose of this systematic study was to discover a connection between temporomandibular joint disorders and post-traumatic stress disorder. A systematic review of observational studies on post-traumatic stress disorder and the incidence of temporomandibular joint disorders (TMD) was conducted. Electronic searches of PubMed, the Saudi Digital Library, Science Direct, the Virtual Health Library (VHL), Scopus, Web of Science, Sage, EBSCO Information Services, and Ovid were performed. There was a consensus among the reviewing examiners. Only studies with the following Medical Subject Headings (MeSH) terms were included: "Posttraumatic stress disorder" combined with "temporomandibular joint disorder," "myofascial pain," "orofacial pain," "internal derangement," "disc displacement with reduction," or "disc displacement without reduction." Only full-text studies in the English language published between 2010 and June 2020 were considered. Of a total of 381 articles meeting the initial screening criteria, only eight were included in the qualitative analysis. Overall, pain is exacerbated in patients with PTSD; that is, their TMD is heightened in all aspects of pain, chronicity, decreased response to conventional therapies, and the need for more potent treatment options as compared with patients with just TMD. The evidence, albeit weak, obtained from the studies included in this review suggests a relationship between PTSD and TMDs.

Temporomandibular Disorders as a Risk Factor for Suicidal Behavior: A Systematic Review

BACKGROUND

Temporomandibular disorders (TMD) are a group of common musculoskeletal dysfunctions that affect the temporomandibular joint or masticatory muscles and related structures or are expressed as a clinical combination of these two factors. The etiology of TMD is multifactorial and features related to anxiety, depression and mental disorders can contribute to the predisposition, onset and progression of TMD. The ability to adapt and develop coping attitudes was reduced in patients presenting with chronic pain, while suicidal behavior (suicidal ideation, suicide attempts, and suicide completion) was increased. The objective of this review was therefore to investigate suicidal behavior in relation to TMD.

METHODS

The review was performed according to the PRISMA 2020 guidelines. Six databases (PubMed, MEDLINE, EMBASE, Scopus, Ovid, and Google Scholar) were consulted through the use of keywords related to the review topic. The study is registered on PROSPERO (CRD42022320828).

RESULTS

The preliminary systematic search of the literature yielded 267 records. Excluding duplicates, 15 were considered potentially relevant and kept for title and abstract analysis. Only six articles were considered admissible reporting a single exposure factor, TMD and a single outcome, suicidal behavior, although these were evaluated through different assessment tools. We found a low association of TMD with suicidal behavior in observational studies, with estimates partly provided [prevalence ratio (PR) from 1.26 to 1.35, 95% confidence intervals (CI) from 1.15 to 1.19 (lower) and from 1.37 to 1.54 (higher); and odds ratios (OR) from 1.54 to 2.56, 95% CI from 1.014 to 1.157 (lower) and 2.051 to 6.484 (higher)], a relevant sample size (n = 44,645), but a few studies included (n = 6).

CONCLUSIONS

The results of the included studies showed that the prevalence data of suicidal behavior were more present in young adults with TMD, with a controversial association with gender. Suicidal behavior was also correlated and aggravated by the intensity of pain.

The prevalence of comorbid chronic pain conditions among patients with temporomandibular disorders: A systematic review

BACKGROUND

This systematic review was designed to evaluate the presence of comorbid conditions among patients with temporomandibular disorders (TMDs).

TYPES OF STUDIES REVIEWED

The authors reviewed studies that reported the prevalence or incidence of chronic pain conditions or psychiatric disorders (anxiety, mood, personality disorders) among patients with any type of TMD. The authors calculated sample size-weighted prevalence estimates when data were reported in 2 or more studies for the same comorbid condition.

RESULTS

A total of 9 prevalence studies and no incidence studies were eligible for review; 8 of the studies examined chronic pain comorbidities. Weighted estimates showed high prevalence of pain comorbidities across studies, including current chronic back pain (66%), myofascial syndrome (50%), chronic stomach pain (50%), chronic migraine headache (40%), irritable bowel syndrome (19%), and fibromyalgia (14%). A single study examined psychiatric disorders and found that current depression was the most prevalent disorder identified (17.5%).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

There is a high prevalence of comorbid chronic pain conditions among patients with TMDs, with more than 50% of patients reporting chronic back pain, myofascial syndrome, and chronic stomach pain. Psychiatric disorders among patients with different types of TMDs were studied less commonly in this pain population. Knowledge of the distribution of these and other comorbid disease conditions among patients with different types of TMDs can help dentists and other health care providers to identify personalized treatment strategies, including the coordination of care across medical specialties.

Women’s oral health-related quality of life as a risk factor for TMD symptoms. A case-control study

OBJECTIVE

To investigate the association between temporomandibular disorder (TMD) symptoms and women's oral health-related quality of life (OHRQoL).Methods: An observational case-control study was performed with 765 adult women aged 21.5 years on average. Oral Health Impact Profile (OHIP-14) assessed OHRQoL and determined the selection of cases and controls matched by age and marital status at a ratio of 1:4 (153 cases: 612 controls). American Academy of Orofacial Pain's self-explanatory questionnaire assessed the TMD symptoms. The TMD symptoms' impact on OHRQoL was analyzed, estimating the odds ratio with a 95% confidence interval.

RESULTS

Of the women, 86.9% in the case group, and 69.6% in the control group presented some TMD symptoms (p< 0.05). Women with an impacted OHRQoL are 2.95 (95% CI:1.79-4.86) times more likely to report some TMD symptoms (p< 0.05).

DISCUSSION

Women with a negative impact on OHRQoL are more likely to report TMD symptoms.

Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian: Algorithm Development and Validation

Background

It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models.

Objective

This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis.

Methods

We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model.

Results

The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows—year 2: 79.91%, 84.04%, 78.83%, 82.50%, and 81.47%; year 3: 76.23%, 80.61%, 73.51%, 79.84%, and 77.13%; year 4: 72.38%, 78.22%, 72.96%, 77.92%, and 72.65%; and year 5: 69.51%, 76.15%, 73.04%, 76.72%, and 69.99%, respectively. This demonstrates an overall 12.07% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network.

Conclusions

Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC.

Extracellular matrix turnover and inflammation in chemically-induced TMJ arthritis mouse models

The temporomandibular joint (TMJ) is a fibrocartilaginous tissue critical for chewing and speaking. In patients with temporomandibular disorders (TMDs), permanent tissue loss can occur. Recapitulating the complexity of TMDs in animal models is difficult, yet critical for the advent of new therapies. Synovial fluid from diseased human samples revealed elevated levels of tumor necrosis factor alpha (TNF-alpha). Here, we propose to recapitulate these findings in mice by subjecting murine TMJs with TNF-alpha or CFA (Complete Freund’s Adjuvant) in mandibular condyle explant cultures and by local delivery in vivo using TMJ intra-articular injections. Both TNF-alpha and CFA delivery to whole mandibular explants and in vivo increased extracellular matrix deposition and increased cartilage thickness, while TNF-alpha treated explants had increased expression of inflammatory cytokines and degradative enzymes. Moreover, the application of TNF-alpha or CFA in both models reduced cell number. CFA delivery in vivo caused soft tissue inflammation, including pannus formation. Our work provides two methods of chemically induced TMJ inflammatory arthritis through a condyle explant model and intra-articular injection model that replicate findings seen in synovial fluid of human patients, which can be used for further studies delineating the mechanisms underlying TMJ pathology.