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J Am Dent Assoc, Vol 132, No 1, 49-57.
© 2001 American Dental Association
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RESEARCH

JADA Continuing Education

Clinical implications of sex in acute temporomandibular disorders



JENNIFER M. PHILLIPS, Ph.D., ROBERT J. GATCHEL, Ph.D., A. LAVONNE WESLEY, Ph.D. and EDWARD ELLIS III, D.D.S.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 PROCEDURES
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Previous research on temporomandibular disorders, or TMDs, has been somewhat limited, with studies having low numbers of subjects, restricting the focus to women or looking at patients already diagnosed with chronic TMD. Because early intervention is beneficial, it is important to understand the symptoms that men and women have in the acute stage of TMD.

Methods. A total of 233 patients (161 women, 72 men) with acute TMD symptoms were assessed with a battery of biopsychosocial measures. Patients were diagnosed as having TMD on the basis of research diagnostic criteria, or RDC, for TMD. After six months, patients were reassessed to determine whether they continued to have pain, thus classifying them as having chronic TMD. The authors found that 153 patients (47 men, 106 women) had developed a chronic condition, while 80 patients (25 men, 55 women) no longer reported pain (nonchronic).

Results. Female and male patients who developed chronic TMD differed significantly from patients who had acute symptoms that subsided. Women who developed chronic TMD exhibited significantly more psychosocial distress and impairment than women who did not develop chronic TMD, in terms of Diagnostic and Statistical Manual, Fourth Edition, or DSM-IV, diagnoses; Beck Depression Inventory, or BDI, scores; Minnesota Multiphasic Personality Inventory scores; Multidimensional Pain Inventory, or MPI, scores; and physical and psychological measures assessed with the RDC for TMD. Men who developed chronic TMD differed significantly from men who did not develop chronic TMD, in that they exhibited more impairment in terms of DSM-IV diagnoses and BDI and RDC measures.

Conclusions. These findings provide evidence that significant differences exist between men and women in regard to acute TMD symptoms.

Clinical Implications. The biopsychosocial differences between men and women suggest that some treatments may be more beneficial for women than for men.

Temporomandibular disorder, or TMD, is an all-inclusive term referring to a heterogeneous group of psychophysiological disorders with the common characteristics of orofacial pain, masticatory dysfunction or both. The three primary symptoms of TMD are preauricular pain, limited mandibular functioning and joint sounds (such as clicking, popping or grinding).1–5 Epidemiologic research in this area has looked at sex differences, with authors repeatedly reporting that TMD is a female disease, with female-to-male ratios ranging from 3:1 to 6:1.3,6–8 Authors of other studies, however, argue that these ratios are seen only in people who actually seek treatment for TMD pain, not in the general population.9,10 The literature is unclear regarding possible reasons why women more often seek treatment of TMD symptoms than do men. The answer is likely a combination of biological, psychological and social variables, although many theories have been posited, with no definitive answers.

If differences between men and women exist in terms of temporo-mandibular disorders, it is important to study these differences to tailor treatment plans.

Commonly proposed explanations11–13 have been that women tend to seek care more often than do men because of psychophysiological stress. This may result from higher stress hormone levels11–13 and the presence of estrogen receptors14–17 that are absent in men. If differences between men and women do exist in terms of TMD, then it is important to study these differences to tailor treatment plans and target specific symptoms. One problem in much of the TMD literature, however, has been the sparse number of men in comparison with women who seek treatment, resulting in studies that have small numbers of men or studies that limit their investigations to women.

Sex differences in regard to levels of masticatory muscle tension and tolerance to pain also have been offered as possible explanations, suggesting that women are less tolerant of pain, exhibit lower pain thresholds or may be more sensitive to pain.7,8,18–20 TMD research also has noted sex differences in regard to the range of jaw opening and jaw excursions, vertical range of motion and range of protrusive opening.21 Other authors have found that women report more mandibular dysfunction; mandibular deflection; noise in the temporomandibular joint, or TMJ; pain on palpation of the TMJ and muscle; headache; impaired range of mandible movement; clicking; crepitus; and joint dysfunction than do men.8,22,23 Garofalo and colleagues24 found that a significant predictor of chronicity in patients with acute TMD was being a woman with a muscle disorder (myofascial pain), as diagnosed according to the research diagnostic criteria, or RDC, for TMD.5 These studies have shown that some physiological differences exist between men and women who report TMD symptoms, although specific findings vary by study.

Psychological testing has revealed significant differences between men and women who report experiencing pain. Depression in women was significantly related to their self-reported pain severity, while depression in men was related to inactivity, rather than to reports of pain.25 Moreover, men with chronic pain report more psychopathology than do women.26,27

Although this research has looked at chronic pain conditions in general, rather than focusing on TMD, it does raise the question of whether men and women with acute TMD symptoms are different from one another, not only across physiological measures, but across psychological and social measures as well. In addition, most studies have focused on examining differences between patients already diagnosed with chronic TMD.25,26,28,29 Because one goal in clinical settings is to prevent acute TMD symptoms from developing into chronic conditions, it is important to chronicle patients in the acute phase of TMD (that is, before chronicity develops). To overcome the aforementioned limitations, we designed the current study to examine the differences between men and women seeking treatment in the acute stage of TMD, using various biopsychosocial measures.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
PROCEDURES
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A total of 233 patients (161 women [69 percent], 72 men [31 percent]) initially classified with acute TMD, who participated in a larger ongoing TMD research project, were included in this study. In terms of demographic characteristics, including marital status, ethnicity, annual income, age and education, we found no significant differences between groups. We classified patients as having acute TMD if they had never been diagnosed as having TMD or had been diagnosed less than six months before this evaluation. This was determined to be the most objective and accurate method of classification, since memory of past symptoms is often inaccurate.

Patients were recruited in several ways, including referral by general dentists and oral surgeons practicing in the Dallas–Fort Worth area and by the Baylor College of Dentistry, Dallas; fliers posted on university campuses; and advertisements placed in Dallas-area newspapers. Inclusion criteria consisted of men and women ages 18 to 65 years, of various ethnic backgrounds and educational levels who reported the presence of current jaw or facial pain; clicking, popping or locking of the jaw; or both. In addition, only patients who were diagnosed as having TMD based on Axis I of the RDC for TMD5 were included. Patients were considered to have developed chronic TMD if they continued to report pain six months after the initial evaluation.


   PROCEDURES
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 PROCEDURES
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We gave each subject general information about the purpose and procedures of the research project. After providing informed consent, subjects were given a payment voucher ($20), as well as a general information questionnaire, the Beck Depression Inventory, or BDI,30 History Questionnaire of the RDC5 and Multidimensional Pain Inventory, or MPI,31 to fill out. After these questionnaires were completed, a clinical psychology graduate student who was trained by one of us (E.E.) performed the TMD examination, followed by the Structured Clinical Interview (SCID I and II) for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or DSM-IV.32,33 Finally, we administered the Minnesota Multiphasic Personality Inventory, or MMPI-2.34 The total assessment time was about two to three hours. The boxesGoGo "Research Diagnostic Criteria: Key Terms" and "Description of Psychological Measures" provide a description of the measures administered.


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  		RESEARCH DIAGNOSTIC CRITERIA: KEY TERMS.

 

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  		DESCRIPTION OF PSYCHOLOGICAL MEASURES.

 
Patients classified with acute TMD during the initial evaluation were contacted by telephone by a clinical psychology graduate student three and six months after the first interview. Patients rated their current pain intensity, worst pain intensity and average pain intensity on a 0 to 10 scale since last contact. From this, the characteristic pain intensity, or CPI, was calculated at the point of transition from acute to chronic pain status (month 6). Patients with a CPI score of at least 15 at this point were considered to have a chronic condition. Of the 233 patients evaluated, 153 (66 percent) had developed chronic TMD (47 men and 106 women) and 80 (34 percent) no longer reported pain (25 men and 55 women). The percentage of men and women who were classified into either group was close (65.3 percent of men vs. 65.8 percent of women developing chronic TMD and 34.7 percent of men vs. 34.2 percent of women whose symptoms subsided), indicating that these groups were closely matched on this variable.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 PROCEDURES
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We found that men and women who went on to develop chronic TMD differed significantly on a variety of biopsychosocial measures at the initial evaluation from patients whose symptoms abated (that is, nonchronic TMD) (Tables 1Go and 2Go).


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  		TABLE 1 PSYCHOLOGICAL MEASURES FOR MEN AND WOMEN WITH ACUTE TMD LATER CLASSIFIED AS CHRONIC OR NONCHRONIC.*

 

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  		TABLE 2 BIOPSYCHOLOGICAL DIFFERENCES ON THE RDC FOR MEN AND WOMEN WITH ACUTE TMD LATER CLASSIFIED AS CHRONIC OR NONCHRONIC.*{dagger}

 
DSM-IV. Women who developed chronic TMD had significantly more anxiety disorders, current major depressive disorder, or MDD, and pain disorder than did women who did not develop chronic TMD. Women with chronic TMD also were significantly more likely to be diagnosed as having a borderline personality disorder.

Men who developed chronic TMD had a significantly higher prevalence of lifetime major depressive disorder than did men who did not develop chronic TMD. Men who developed chronic TMD also were significantly more likely to have received at least one personality disorder diagnosis than were men who did not develop chronic TMD.

BDI. Self-reported measures, including the BDI and MMPI-2, demonstrated findings that were similar to the DSM-IV results. Men and women who were classified as having a chronic condition had mean scores on the BDI that were significantly higher than those for patients who did not develop a chronic condition, indicating more symptoms of depression.

MMPI-2. Multivariate analysis of variance, or MANOVA, revealed a significant difference overall between MMPI-2 scales in women but not in men. Specifically, women who developed chronic TMD symptoms were found to have significantly higher mean T-scores on scales 1, 2 and 3 (that is, hypochondriasis, depression and hysteria, respectively) than women who did not develop chronic symptoms.

MPI. Women who developed chronic TMD were significantly more likely to have received an MPI coping style classification of "dysfunctional" or "interpersonally distressed," while women whose symptoms subsided were more likely to be classified as being adaptive copers. For men, MPI findings were not significant when we looked at each coping style separately, but when dysfunctional and interpersonally distressed styles were combined and compared with the adaptive coping style, men who developed chronic symptoms were significantly more likely to have one of these unhealthy diagnoses than were men whose symptoms subsided. In regard to overall differences between MPI scales, MANOVA results were significant for women but not for men. Specifically, we found that women who developed chronic TMD had significantly higher mean scores on scales 1, 2 and 10 (that is, pain severity, interference and outdoor work, respectively) than did women who did not develop chronic TMD.

Women who developed chronic temporobandibular disorder were significantly more likely to be diagnosed as having a muscle disorder than were women who did not develop chronic TMD.

RDC. Women who developed chronic TMD were significantly more likely to be diagnosed as having a muscle disorder (that is, myofascial pain, group 1 on Axis I of the RDC) than were women who did not develop chronic TMD. Men who did not develop chronic TMD were diagnosed significantly more often as having a joint disorder (group 3) than were men who developed chronic TMD.

On Axis II of the RDC, women who developed chronic TMD had significantly higher scores on graded chronic pain severity, or GCPS, indicating greater pain and disability; depression; and non-specific physical symptoms measures than did women who did not develop chronic symptoms. In addition, when looking at GCPS in terms of low (a score of 0 or 1), moderate (a score of 2) and high (3 or 4) scores, we found that women who developed chronic TMD had significantly fewer low scores than did women who did not develop chronic TMD, and significantly more moderate scores. Men who did not develop chronic TMD had significantly more low scores than did men who developed chronic TMD, and men who developed chronic TMD had significantly more high scores.

For the Limitations Related to Mandibular Functioning and CPI scores, both men and women who developed chronic TMD had significantly higher mean scores on these measures than did patients who did not develop chronic TMD.


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 PROCEDURES
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
The findings of this study show that people who develop chronic TMD display more psychosocial distress before development of the chronic disorder than do people who have acute symptoms that subside. Our analysis of self-reported symptoms demonstrated that men and women did not respond to biopsychosocial measures in the same way.

DSM-IV. Men who developed chronic TMD were found to have more personality disorders than women who developed chronic TMD, while women who developed chronic TMD had more somatization and anxiety diagnoses than men who developed chronic TMD. These are the first results to indicate that there are differences between men and women with regard to the type of psychopathology that makes them more prone to develop chronic TMD problems.

BDI. Men did not report the same degree of depressive symptoms as did women on the BDI, although DSM-IV findings indicated that men were as likely to receive a major depressive disorder diagnosis. The mean BDI score among women who developed chronic TMD fell in the mildly-to-moderately depressed range, while scores for women who did not develop chronic TMD fell in the normal range. Among men, even though mean scores were significantly different between the chronic and nonchronic groups, both scores fell in the normal range. This suggests that women may tend to express their psychological discomfort more than men, which could be a contributing factor to the increased number of women seeking treatment for TMD symptoms.

It appears that even when men who develop chronic TMD are significantly depressed, they minimize their symptoms on self-report measures. This could indicate that women are more aware of the symptoms of depression than are men, which has important implications in terms of treatment issues. While research has demonstrated the benefit of treatments such as cognitive-behavioral therapy and stress management for patients with TMD,35–39 it is likely that early interventions of this nature will not prove as fruitful for men as they will for women. Cognitive-behavioral therapy dictates that one must have awareness of mal-adaptive thoughts and behaviors before being able to learn the skills and techniques needed to change those thoughts and behaviors. By this standard, it appears that this approach will not work as well in men.

It appears that even when men who develop chronic temporomandibular disorder are significantly depressed, they minimize their symptoms on self-report measures.

MMPI-2. Overall, MMPI-2 scale differences between women in the chronic and nonchronic groups were significant, but they were not for the two groups of men. Even for women who developed chronic TMD, their higher scores on scales 1, 2 and 3 were not, on average, in the clinically significant range (above a T-score of 65). Perhaps these scores are consistent with the BDI findings, which indicated only mild-to-moderate depression in women, and few, if any, symptoms in men. These scores clearly are lower than those seen in studies of subjects who already have a chronic condition,25,28,29 indicating that the degree of psychopathology may be lower in patients with acute symptoms, which then increases after a chronic condition sets in.

MPI. The lack of a significant overall difference in MPI scale scores between men with and without chronic TMD suggests that pain is not as limiting in men across as many variables as it is in women, although men who develop chronic TMD still are not doing as well as men who do not develop chronic TMD (who more often were classified as adaptive copers).

RDC. Our muscle disorder findings are consistent with those of other studies attempting to predict chronicity in patients with acute TMD.24,40 Muscle disorders are more prevalent in patients who go on to develop chronic TMD, and being female with a muscle disorder is a specific predictor of chronicity. Another interesting finding was that men who went on to develop chronic TMD were less likely than men who did not develop chronic TMD to be diagnosed as having a joint disorder. Women who developed chronic TMD, however, were just as likely to be diagnosed as having a joint disorder as women who did not develop chronic TMD, although previous research has demonstrated that women with chronic TMD are more likely to have a joint disorder than women who do not develop chronic TMD.24 Our findings suggest that men who later develop chronicity are particularly unlikely to have a joint disorder diagnosis (other than disc displacements). This finding somehow may be tied to estrogen receptor research, which hypothesizes that these receptors may play a role in the development of joint disorders such as osteoarthrosis.16 If women have more of these receptors in the TMJ than men, then perhaps men are unlikely to develop joint disorders.

Our findings for the depression and nonspecific physical symptoms scores are consistent with the BDI and DSM-IV findings, suggesting that women who develop chronic TMD report higher levels of depressive symptoms than women who do not develop a chronic condition. In addition, men are not as open about reporting depressive symptoms, even though they are as likely to have a depressive disorder. The fact that women who develop chronic TMD are more likely than men who develop chronic TMD to score in the moderate and severe range, in terms of non-specific physical symptoms, is consistent with our findings from the DSM-IV data that women have more somatization disorders (that is, pain disorder) than do men.

Taken as a whole, the above results suggest that finding and implementing the correct intervention in a timely manner may reduce the risk of developing chronic TMD. For example, participation in cognitive-behavioral therapy has proved more effective in women than in men for managing TMD, because such treatment requires the understanding of underlying dysfunctional thinking.41 Because men do not admit to experiencing depression as frequently as do women, biofeedback or physical treatments may prove more effective for them.


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 PROCEDURES
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The primary purpose of this study was to distinguish between men and women in terms of TMD, and to examine the differences between patients who developed chronic TMD and those who did not. The results of the study replicated findings of previous studies that found many biopsychosocial differences between patients with TMD who developed a chronic condition and those whose symptoms subsided. This was found for both men and women. However, we also discovered that, while some variables were similar for men and women, others were markedly different.

Specifically, it appears that findings for women in this study are fairly similar to previous research findings. However, men did not demonstrate differences among the expected biopsychosocial variables as frequently as did women in regard to predicting whether chronicity will develop. This result is expected, given that most subjects in previous studies were women, so the results most likely will be representative of female patients with TMD. This study highlights the fact that men and women are not homogeneous, which has important implications for future research, as well as for clinical applications.

One important finding with treatment implications is that men who developed a chronic condition were more likely to demonstrate personality disorders, while women demonstrated a significant degree of a major form of psychopathology. Previous research has examined the potential effectiveness of interventions such as cognitive-behavioral therapy in the treatment of chronic TMD. However, patients with personality disorders typically are less amenable to such interventions. In addition, as noted above, the finding that men do not admit depressive symptoms as frequently as do women suggests that they might be less able to effectively participate in a cognitive-behavioral therapeutic protocol. Alternative techniques (such as biofeedback or physical treatments) might prove more successful in men. On the other hand, our findings support the likelihood that women will benefit from psychological treatments of TMD, such as cognitive-behavioral therapy.

Finding and implementing the correct intervention in a timely manner is important. Early intervention may prevent the suffering that results from a chronic pain condition, prevent further increase in psychopathology and impairment, and save the health care industry a great deal of time and expense. Thus, dentists may want to use psychological tests to evaluate patients, or refer patients for psychological testing, if the pain appears to be unmanageable with procedures they have been trained to provide.


   FOOTNOTES
 

Dr. Gatchel is a professor of psychiatry and Elizabeth H. Penn Professor of Clinical Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, Texas 75390-9044, e-mail "robert.gatchel{at}utsouthwestern.edu". Address reprint requests to Dr. Gatchel.


Dr. Phillips is a postdoctoral psychology fellow, Southwest Autism Research Center, Phoenix, and Department of Family Resources and Human Development, Arizona State University, Tempe.


Dr. Wesley is a clinical assistant professor, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas.


Dr. Ellis is a professor, Department of Oral Surgery, University of Texas Southwestern Medical Center at Dallas.


This research was supported by National Institutes of Health grants R01 DE10713 and KO2 MH01107 awarded to Dr. Gatchel.


   REFERENCES
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 PROCEDURES
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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