The European Journal of Stomatology, Oral and Facial Surgery

Research-Paper

Keywords: anxiety, depression, GAD-2, PHQ-2, temporomandibular disorders

Influence of a Diagnosis of Depression and/or Anxiety on Temporomandibular Joint Treatment -a Retrospective Study

David Faustino Ângelo,*,1,2,3ta Nunes Rodrigues,1Henrique José Cardoso

Maria Cristina de Faria ixeira1

 ,2and

1Faculdade de Medicina da Universidade de Lisboa, Portugal 2Instituto Português da Face, Lisboa, Portugal 3Centre for Rapid and Sustainable Product Development, Polytechnic Institute of Leiria, Portugal

*Author for correspondence. Email: david.angelo@ipface.pt

Abstract This cross-sectional retrospective study aimed to assess the depression and/or anxiety influence on temporomandibular disorders (TMD) diagnosis and treatment. The primary outcome was temporomandibular joint pain (VAS). The secondary outcomes were: 1) Health-related quality of life (VASLife); 2) Maximal Mouth Opening (MMO); 3) Myalgia degree. Patients were screened through PHQ-2 (depression) and GAD-2 (anxiety) validated questionnaires. A total of 247 patients (202 female), with mean age of 40.51 ± 17.04, were enrolled. 133 patients (53.8%, GAD-2 ≥3) and 91 patients (38.4%,

pre-treatment pain was 4.25 ± 2.62; VASLife was 6.60 ± 2.36; MMO 37.15 ± 9.50; myalgia PHQ-72 ≥2) were screened positive for anxiety and depression, respectively. The mean

degree was 2.22 ± 0.99. A higher psychological distress burden was significantly correlated with VASLife (p=0.040, PHQ-2 ≥2; p=0.025, GAD-2 ≥3) and myalgia levels (p=0.013, PHQ-2 ≥2; p=0.038, GAD-2 ≥3). Myalgia significantly subsisted post-

(OR=1.67; p=0.008) and, in anxious patients, post-treatment myalgia degree (OR=1.89; treatment in patients with anxiety (p=0.038, GAD-2 ≥3). The pre-treatment VASLife

p<0.001), were determinant factors for reintervention. Depression and/or anxiety were correlated with poor clinical outcomes, particularly in myogenous TMD. To implement multidisciplinary treatment programs for patients reporting a higher disease burden and refractory symptoms, awareness should be raised.

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1. Introduction

Temporomandibular disorders (TMD) are heterogeneous conditions related to functional and morphological deformities in the temporomandibular joint (TMJ) and associated structures [1]. TMD is the most common cause of non-dental chronic orofacial pain [2–4]. With an annual incidence rate of 2%, more than 50% of the population report symptoms related to TMD [1, 5], and its prevalence goes beyond 30% [1, 6, 7]. Two main subgroups are recognized: arthrogenous and myogenous TMD[1, 3, 8, 9].TMD subtypes have specific treatment protocols, starting with conservative options and progressing to other modalities, if required (Dimitroulis, 2013.. A change in paradigm advocates minimally invasive options as an early

iety disorders that trigger the biomechanical alterations in the TMJ are unsure. However, it is thought that depression and anxiety interact with pain-modulating networks and change the perception of pain, resulting in greater awareness of somatic and interoceptive cues. [1, 4, 11, 15, 17]. treatment for arthrogenous TMD [8, 10].

In multifactorial TMD etiopathogenesis, biopsychosocial factors play a dom-inant role. There is a consensual link between TMD and a higher psychopatho-logical burden, particularly for depression and anxiety [4, 5, 9, 11–14]. Stress and anxiety promote neuroendocrine modulation allowing physical and psychosocial adjustment [5, 15, 16]. The biomolecular mechanisms in depression and/or anx-

2 David Faustino Ângelo et al.

In 2019, Portugal was the European country with the highest prevalence of mental health disorders [18]. In the primary care setting, anxiety and depression prevalence range between 5.4-8.8% and 7.3-13.4%, respectively. In time-constrained clinical environments, brief screening tools such as PHQ-2 and GAD-2 allow timely and accu-rate screening of these prevalent comorbid mental health disorders [19–21]. Therefore, primarily aiming to assess the association between preexistent depression and/or anxiety and TMD, the following hypotheses were for-mulated: (1) Are PHQ-2 and GAD-2 scores negatively associated with TMD treatment outcomes? (2) Can some TMD subtypes possibly have a stronger association with depression and/or anxiety? (3) Does a higher psycholog-ical burden contribute to the need for intervention?

2. Materials and Methods

2.1. Study Design

A cross-sectional retrospective study included patients treated for TMD from February 2018 to February 2022. The study was carried out on the STROBE guidelines. The study was approved by the ethics committee of Centro Académico de Medicina de Lisboa (CAML) (26.12.2022/311/22). According to current legislation, all enrolled patients were aware of its implications and gave their free terms of consent in writing.

The inclusion criteria were: (1) age >18 years 2) arthroge-nous and/or myogenous TMD; 3) conservative treatment without any improvement at least for three months; 4) Dimitroulis Classification between 1-4; 5) indication for one of the following TMD treatments: injection of bo-tulinum toxin; TMJ arthrocentesis; TMJ arthroscopy; TMJ open surgery without alloplastic material. The exclusion criteria were: 1) previous TMJ surgical intervention; 2) impaired cognitive capacity; 3) pregnant or breastfeeding women.

Before the intervention, all participants were exam-ined by the same TMJ surgeon. The variables measured throughout the study were obtained pre and post- treat-ment: 1) TMJ pain, with a Visual Analog Scale (VAS, 0-10, with 0 corresponding to the absence of pain and 10 max-imum insupportable pain); 2) Health-related quality of life (VASLife) through the question: "If you could give a life impact score to your TMJ problem in a 0 to 10 scale, where 0 means no impact and 10 means the maximum impact possible, what would be your score?"; 3) Maxi-mal Mouth Opening (MMO, mm) employing a certified ruler between the incisor’s teeth; 4) Myalgia degree (0-3), accordingly with pain intensity in each muscle: 0 = No Pain/Pressure Only; 1 = Mild Pain; 2 = Moderate Pain; 3 = Severe Pain [22]. Myogenous disease, including myalgia, was diagnosed according to a clinical history positive for 1) in the past 30 days, pain in the jaw, temple, in front of the ear, or the ear with examiner confirma-tion of pain location in the temporalis or masseter muscle and 2) pain modified with jaw movement, function or

parafunction and a favorable clinical evaluation for pal-pation pressure (5 seconds/1kg pressure) in masseter and temporalis muscles as defined in Diagnostic Criteria for Temporomandibular Disorders DC/TMD [23]. Arthral-gia was diagnosed through positive history for both cri-teria: 1) pain in TMJ, in the ear, or front of ear; 2) pain modified with jaw movement, function, or parafunction. Positive examination for arthralgia was reported if it was observed: pain location in the TMJ area and pain on pal-pation of the lateral pole or around the lateral pole or pain on maximum unassisted or assisted opening, right or left lateral movements, or protrusive movements. The final arthrogenous diagnosis was confirmed with MRI.

Each patient was further categorized, and the decision of which treatment to apply was based on Dimitroulis’TMJ Surgical Classification [24]: Category 1: patients without arthrogenous disease, with TMJ pain associated with myofascial pain. These patients were treated with botulinum toxin injections. Category 2: diagnosis of disc displacement with reduction (DDwR) with joint click-ing and intermittent pain or indication of inflammation with normal condyles. These patients were treated with arthrocentesis. Category 3: patients with long-standing closed lock (> 2 months), diagnosis of disc displacement without reduction (DDwoR), absence of clicks, arthroge-nous TMD, or synovial chondromatosis. These cases were treated with TMJ arthroscopy. Category 4: radio-logical signs of changes in condylar morphology such as osteophytes, small subchondral cysts, loss or thinning of cartilage layer, severe displaced and deformed articular discs, including disc perforation. When the disc was sal-vageable, the patients were treated with discopexy, and a discectomy was performed when unsalvageable.

Independently of the Dimitroulis category, all patients with myalgia grades 2 and 3 received a 155U or 195U bo-tulinum toxin injection in the masticatory muscles (mas-seter and temporal), respectively. This treatment was performed 10-15 days before the surgery.

All patients were instructed to follow a soft diet for three days after surgery. In addition, five physiother-apy sessions and three speech therapy exercise sessions started 3-5 days after the intervention.

2.1.1. PHQ-2 GAD-2 questionnaires

For each patient, screening for depressive and/or anxiety disorder was assessed in the first consultation through validated PHQ-2 and GAD-2 questionnaires [25, 26](Kroenke et al., 2003, 2007).

of clinically significant depressive disorder, according to A PHQ-2 cutoff of ≥2 was considered likely to be

Levis et al. (2020). The authors established sensitivity and specificity of 0.91 and 0.67 for a PHQ-2 score ≥2 and 0.72 and 0.85 for a PHQ-2 score ≥3 20. Accordingly, a diag-nostic meta-analysis on PHQ-2 accuracy in the screening of MDD by Manea L. et al. [27] found similar operat-ing characteristics for this lower cutpoint (sensitivity of

The European Journal of Stomatology, Oral and Facial Surgery 3

Figure 1. STROBE- flow chart diagram reporting of participant enrolment. TMJ - temporomandibular joint.

0.91, specificity of 0.70) [27]. Bisby M.A. et al [21] also suggested a lower PHQ-2 cut point of ≥2 since it demon-strated optimal sensitivity and specificity. The higher sensitivity results in better case-finding ability, which comes at the expense of lower specificity. To account for the risk of a high rate of false positives and reduced clini-cal utility, a PHQ-2 score ≥2 should be implemented in settings with a high prevalence of the condition [21, 27]. Considering the high prevalence of depressive symptoms and disorders among the Portuguese population, a cutoff of ≥2 was adopted.

A GAD-2 cutoff of ≥3 suggested clinically significant anxiety disorder [26]. For a cutoff ≥3, GAD-2 has the following operating characteristics: sensitivity and speci-ficity of 86,0% and 83,0% in GAD screening; sensitivity and specificity of 65,0% and 88,0% in any anxiety dis-order screening [26]. Patients with a positive screening result for a depressive and/or anxiety disorder received advice on available resources for appropriate treatment and follow-up.

2.1.2. Statistical Analysis

A descriptive analysis of the study was performed through measures, absolute frequencies and mean. The mean was used as a location measure accompanied by its standard deviation (SD) as mean ± SD. The normality analysis was performed for all tests using the Kolmogorov-Smirnov test. Bivariate contingency tables containing the absolute frequency in each possible combination of categorical variables were created. The non-parametric Chi-square test (2) and Fisher’s exact test assessed associ-ations between these variables.

The Student T-test or non-parametric Mann-Whitney

U Test was used for continuous variables. Multivariable logistic regression analysis was used to assess the impact of depression and anxiety on reintervention treatment. Multivariable analysis was adjusted for: Pre-treatment VASLife; GAD-2; PHQ-2; Post-treatment Myalgia * GAD-2; Post-treatment Myalgia * PHQ-2. P-value <0.05 was considered statistically significant for all analyses. Data were analyzed using SPSS (v26) and graphical represen-tation through GraphPad Prism (v9) software.

3. Results

A total of 247 patients (202 female and 45 male) were enrolled (Figure 1), mean age of 40.51 ± 17.04 years, ranging from 14-88 years (Table 1). The clinical pre-treatment variables evaluated in the study are reported in Table 2. The mean pre-treatment VAS (0-10) was 4.25± 2.62, VASLife (0-10) was 6.60 ± 2.36, MMO was 37.15 ±9.50 (mm), and myalgia degree was 2.22 ± 0.99. The more frequent pre-treatment intra-articular diagnoses were: (1) DDwR (101 patients, 40.9%); (2) DDwoR (93 patients, 37.7%); (3) Osteoarthrosis (OA) (83 patients, 33.6%). Pre-treatment myalgia was identified in 222 (89.9%) patients: I – 24 (9.7%); II – 70 (28.3%); III – 128 (51.8%). One hun-dred fifty-five patients (37.2%) had arthralgia, and 144 (38.2%) had a disc displacement disorder with pain as-sociated. TMD severity, evaluated using the Dimitroulis Classification, was heterogeneous. Considering the Dim-itroulis Classification patients included were staged as following: 18 patients (19.4%) in category 1; 110 patients (44.5%) in category 2; 53 patients (21.5%) in category 3, and 36 patients (14.6%) in category 4. The mean follow-up period was 252.9 ± 278.8 days, ranging from 31 to 1224 days.

4 David Faustino Ângelo et al.

Table 1. Demographic data.

Number of patients

247

Sex Female Male

Number of patients (%) 202 (81.8%) 45 (18.2%)
Age Mean ± SD (range)

40.51 ± 17.04 (18-88)

Table 2. Clinical evaluation.

Pre-treatment VAS (0-10) (mean ± SD)

4.25 ± 2.62
Pre-treatment VASLife (0-10) (mean ± SD)

6.60 ± 2.36

Pre-treatment MMO (mean ± SD)

37.15 ± 9.50
Pre-treatment Myalgia Degree (mean ± SD)

2.22 ± 0.99

Pre-treatment Intra-articular Diagnosis

 Number of patients (%)

DDwR

101 (40.9%)

DDwoR

93 (37.7%)

OA

83 (33.6%)

Pre-treatment Myalgia Diagnosis

 Number of patients (%)

Myalgia

222 (89.9%)

I

24 (9.7%)

II

70 (28.3%)

III

128 (51.8%)

Dimitroulis Classification

 Number of patients (%)

I

48 (19.4%)

II

110 (44.5%)

III

53 (21.5%)

IV

36 (14.6%)

Arthralgia diagnosis

155 (37.2%)

Disc displacement disorder with pain

144 (58.3%)

Follow-up period (days)

 252.9 ± 278.2 (31-1224)

The mean GAD-2 and PHQ-2 scores were 2.94 ± 1.78 and 1.33 ± 1.67 (Figures 2 and 3). One hundred thirty-three patients (53.8%, GAD-2 ≥3) screened positive for an anxiety disorder, and 91 patients (38.4%, PHQ-2 ≥2) for depression.

Table 3 summarizes the bivariate analysis of the so-ciodemographic variables associated with GAD-2 and PHQ-2 status. The mean age was significantly associated with the PHQ-2 rate (P=0.049). However, no significant association was found concerning patients’ sex.

The correlation of clinical variables (pre- and post-treatment) with GAD-2 and PHQ-2 status was analyzed (Table 4). There was a statistically positive association between PHQ-2 screening with the following clinical out-comes: pre-treatment VASLife (6.95±2.49; p=0.040), myal-gia (reported by 95,6% of the patients with a PHQ-2 score

For a positive GAD-2, there was a statistically signifi-≥2; p=0.011), and myalgia degree (2.43±0.83; p=0.013).

cant association with pre-treatment VASLife (6.92±2.37; p=0.025), myalgia degree (2.35 ± 0.91; p=0.038), and post-treatment myalgia degree (0.67 ± 1.08; p=0.036). For other

clinical variables (pre-treatment VAS, MMO and intra-articular diagnosis, post-treatment VAS and MMO, Dim-itroulis Classification, arthralgia diagnosis, and disc dis-placement disorder with pain), no statistically significant differences were found.

Forty patients (16.2%) required reintervention. A mul-tivariable logistic regression predicting patients requiring reintervention was adjusted for the screening measures status (GAD-2 and PHQ-2), pre-treatment VASLife, and post-treatment myalgia degree (Table 5). Although GAD-2 and PHQ-2 alone did not explain the profile of reinter-vened patients, significance was found for pre-treatment VASLife (odd ratio (OR)=1.67; p=0.008). In addition, the composed variable of post-treatment myalgia degree and GAD-2 status was also significant (OR=1.89; p<0.001).

4. Discussion

The association between psychological disorders, name-ly anxiety, and depression with TMD has been reported in several studies [11–13, 28, 29]. However, few stud-ies seem to have evaluated the preliminary diagnosis of anxiety and depression on the clinical outcomes of TMD patients and the need for surgical intervention.

Mental health disorders are a significant public health challenge. It has been estimated that almost 14% of Euro-peans were affected by mental health disorders in 2019. In Portugal, the estimates reach nearly 19%, thereby being the European country with the highest psychopathologi-cal burden [18]. Anxiety disorders were the most preva-lent (4.69%), followed by depressive disorders (3.79%) [18]. According to the Epidemiological National Men-tal Health Study (2008-2009), part of the World Mental Health Survey Initiative, in Portugal, anxiety and affec-tive disorders are the most prevalent psychiatric diag-noses, with a prevalence of 16.5% and 7.9%, respectively [30]. Self-reported depressive symptoms reach a 10% prevalence [30]. Vos T. et al [18] reported prevalence values of 8.8% and 4.8% for anxiety and depression, re-spectively, in the Portuguese population. In our study, 38.4% and 53.8% of the patients screened positive for depression and anxiety, respectively. In line with a pre-vious study in the Portuguese setting [31], the higher prevalence found potentially reflects the consensual as-sociation between TMD and psychological distress. A future comparative study using GAD-2 and PHQ-2 in a population not diagnosed with TMD will be required to confirm these data. Although GAD-2 and PHQ-2 are easy and reliable clinically validated screening tools, as brief screening measures, a positive result should be comple-mented with other discriminatory methods or a directed clinical interview [20, 21, 25–27]. In our study, the values obtained could be due to overdiagnosis, and confirmation through other tools is required. If a sequential diagno-sis based on PHQ-2 > PHQ-9 and GAD-2 > GAD-7 is implemented, a lower prevalence but a more accurate diagnosis will be obtained. Previous studies, including

The European Journal of Stomatology, Oral and Facial Surgery 5

Figure 2. GAD-2 distribution among patients. (A) GAD-2 mean and distribution by the different classifications. (B) Distribution of positive and negative GAD-2.

Figure 3. PHQ-2 distribution among patients. (A) PHQ-2 mean and distribution by the different classifications. (B) Distribution of positive and negative PHQ-2.

Table 3. Demographic characteristics according to GAD-2 and PHQ-2 status.

Variable

 GAD-2 PHQ-2

GAD-2 (0-2)

GAD-2 ≥3

 p-value or χ2; df; p-value PHQ-2 (0-1)

PHQ-2 ≥2

p-value or χ2; df; p-value

Sex

92 (80.7%)

0.166; 1; 0.684

 120 (82.2%)

0.344; 1; 0.558

F

110 (82.7%)

72 (79.1%)

M

22 (19.3%)

23 (17.3%)

 26 (17.8%)

19 (20.9%)

Age Mean (mean ± SD)

38.19 ± 24.02

40.71 ± 18.91

0.731

39.11 ± 17.48

43.32 ± 16.74

0.049

PHQ-9 and GAD-7 screening tools in patients with TMD or chronic orofacial pain, established depression and anxi-ety prevalence values of 17-21% (PHQ-9 ≥10) and 15-29% (GAD-7 ≥10)[28, 32, 33].

Psychological factors may be prominently relevant in myogenous disease and pain of muscle origin [4, 7, 11, 13]. Psychosocial factors (stressful life events, psychological

distress, and pathology) arouse the Central Nervous Sys-tem, promoting excessive muscle activity [15, 16, 34]. While multiple systems might be affected and influence myofascial pain, the limbic system (LS) and the neurolog-ically related periaqueductal gray are primarily involved in the adjustment of emotions, defensive conduct, and pain modulation [16, 35]. The dynamic motor systems

6 David Faustino Ângelo et al.

Table 4. Diagnosis and treatment outcomes according to GAD-2 and PHQ-2 status.

Variable

 GAD-2 PHQ-2

GAD-2 (0-2) GAD-2 ≥3 4.12 ± 2.38 4.37 ± 2.81

p-value or χ2; df; p-value PHQ-2 (0-1) PHQ-2 ≥2

0.335 4.06 ± 2.57 4.42 ± 2.68

 p-value or χ2; df; p-value

Pre-treatment VAS (0-10) (mean ± SD) Pre-treatment VASLife (0-10) (mean ± SD) Pre-treatment MMO (mean ± SD)

0.233
6.25 ± 2.31 6.92 ± 2.37

0.025

 6.34 ± 2.26 6.95 ± 2.49

0.040

37.40 ± 9.87 36.93 ± 9.21 0.704

 37.16 ± 9.90 37.86 ± 8.93 0.589

Intra-articular diagnosis

 59 (40.4%)

35 (38.5%)

0.089; 1; 0.765

DDwR

50 (43.9%)

51 (38.3%)

0.772; 1; 0.380

DDwoR

44 (38.6%)

49 (36.8%)

0.080; 1; 0.777

 51 (54.2%)

37 (40.7%)

0.788; 1; 0.375

OA

40 (35.1%)

43 (32.3%)

0.209; 1; 0.647

 47 (32.2%)

34 (37.4%)

0.666; 1; 0.414

Myalgia

98 (86.7%)

123 (93.2%) 2.872; 1; 0.090

124 (84.9%) 87 (95.6%)

6.538; 1; 0.011

Myalgia degree (mean ± SD)

2.07 ± 1.06

2.35 ± 0.91

0.038

 2.07 ± 1.07

2.43 ± 0.83

0.013

Post-treatment VAS (0-10) (mean ± SD)

0.67 ± 1.59

1.07 ± 2.43

0.614

 0.75 ± 1.93

0.73 ± 1.90

0.679
Post-treatment myalgia degree (mean ± SD) 0.46 ± 0.78

0.67 ± 1.08

0.038

 0.53 ± 0.89

0.57 ± 0.97

0.957

Post-treatment MMO (mean ± SD)

41.00 ± 7.08 40.32 ± 4.67 0.447

40.90 ± 6.24 40.71 ± 5.32 0.836

Dimitroulis Classification

 18 (15.8%) 30 (25.8%)

3.36; 3; 0.340

 26 (17.8%) 22 (24.2%)

3.436; 3; 0.329

1

2

 55 (48.2%) 55 (41.4%) 72 (49.3%) 34 (37.4%)

3

 27 (23.7%) 26 (19.5%) 28 (19.2%) 21 (18.8%)

4

 14 (12.3%) 22 (16.5%) 20 (13.7%) 14 (15.4%)

Arthralgia diagnosis

 71 (62.3%) 84 (63.2%)

0.020; 1; 0.887

 91 (62.3%) 58 (63.7%)

0.048; 1; 0.827

Disc displacement disorder with pain

 30 (26.3%) 42 (31.6%)

0.823; 1; 0.364

 39 (26.7%) 32 (35.2%)

1.909; 1; 0.167

Table 5. Multivariable logistic regression predicting reinterven-

tion treatment adjusted for VASLife, GAD-2, PHQ-2, myofascial

pain diagnosis, and post-treatment MT degree.

Variable

 OR 95% CI p-value

Pre-treatment VASLife

 1.67 1.14-2.44 0.008

GAD-2

 0.93 0.60-1.46 0.759

PHQ-2

 0.76 0.42-1.39 0.379
Post-treatment myalgia degree * GAD-2 1.89 1.35-2.64 <0.001
Post-treatment myalgia degree * PHQ-2 0.747 0.49-1.15 0.181

orchestrate the LS response to the perceived environment. Hence, each specific emotion generates certain changes in the body – stress contributes to pain related to muscle tension and trigger point (TrP) formation and perpetu-ates the body response, causing more stress and pain (hyperalgesia) [6, 16]. Muscular TrP is the critical element of myofascial pain syndrome and is classified as active (ATrP) or latent (LTrP). The latter is defined as the focus of hyperirritability in a taut muscle band and is clinically as-sociated with a local twitch response, tenderness, and/or referred pain upon manual examination [36, 37]. It has been shown that a higher number of LTrP is associated with a higher frequency of depressive symptoms reported by healthy individuals [36]. Likewise, anxiety seems to increase the likelihood of muscle tenderness [38]. In pa-tients with tension-type headaches, the number of ATrPs was associated with the physical burden of headache and

trait anxiety levels [39]. Furthermore, the LS outputs also impact autonomic, endocrine, somatic, nociceptive, and immune systems [16]. The autonomic sympathetic nervous system is of primary relevance. A chronically activated fight or flight response leads to neuroendocrine disequilibrium, contributing to muscle hyperactivity and exacerbating perceived pain [16].

Our study has diagnosed many patients with myo-genous TMD (89.9%). Depression was significantly as-sociated with myalgia and myalgia degree. The rela-tionship was even more consistent for anxiety, where a significant association was shown for myalgia and post-treatment myalgia degrees. Vedolin G.M. et al [5] have also shown that individuals with myofascial pain TMD reported higher anxiety levels than healthy people. The positive correlation between TMD and psychological fac-tors would anticipate that higher levels of anxiety and depression would lead to a more significant number of tender points, lower MMO, and reduced functionality [5, 11, 13, 14]. However, no significant differences were found for the more objective clinical variables. Changes in the most subjective physical examination variables (e.g., muscle and joint palpation pain) seem to have the most robust relationship to changes in pain [40]. Stress and anxiety contribute to parafunctional oral habits and influence muscle pressure pain threshold (PPT) and pain. It has been shown that the masticatory muscles PPT of subjects with myofascial pain are markedly lower during stressful events, demonstrating an interaction with stress and anxiety levels [5]. Masticatory muscles may be ex-

The European Journal of Stomatology, Oral and Facial Surgery 7

ceptionally responsive to stressful conditions of personal value [5].

Chronic TMD patients are more frequently diagnosed with muscular TMD and suffer more psychological dis-tress baseline [17, 40]. In our subset of patients requiring reintervention, higher pre-treatment perceived impact on health-related quality of life attributed to TMD (VASLife) and the composed variable of post-treatment myalgia degree and GAD-2 status were predictors of the need for reintervention. Hence, awareness should be raised to identify patients reporting a higher disease burden and whose symptoms subsist after treatment.

Physicians should educate patients on good oral habits and screen and treat underlying associated anxiety and depression. Cognitive behavioral therapy has been proven effective in TMD, particularly of muscular origin, and of-fers an integrated approach to psychological symptoms [4, 13]. The ultimate objective is to assess further how spe-cific areas of psychological dysfunction influence distinct subtypes of TMD patients to tailor more efficient early intervention and pain management programs [4, 11].

The study’s main limitations were the following: (1) not implementing a sequential depression and/or anxiety screening methodology - specificity could be improved by sequentially applying GAD-7 and PHQ-9; (2) were not used tools to make definitive diagnosis according to DSM-5 criteria; (3) the small subset of reintervened patients limited the multivariable prediction model for reintervention; (4) the follow-up period was different between patients; (5) retrospective nature, which intro-duces potential biases such as establishing causality. This study’s retrospective design and single-center data col-lection introduce several potential biases. Selection bias is a concern, as the sample may not fully represent the broader population of patients with TMD, limiting the generalizability of the findings to other populations or settings. Recall bias is another issue, particularly in how patients reported their symptoms or treatment responses. Additionally, the reliance on self-reported questionnaires like PHQ-2 and GAD-2, despite their validation, may lead to measurement bias if patients underreport or overre-port their psychological distress. Although multivariable regression was used to control for some confounding factors, unmeasured confounders may still influence the observed association between psychological distress and TMD outcomes.

The generalizability of the study’s findings may be limited by the specific characteristics of the study sample and setting. The predominantly Portuguese patient pop-ulation, known for a high prevalence of mental health disorders, might influence the applicability of the results to populations with different psychological profiles or healthcare systems. The fact that all patients were treated by the same surgeon in a single institution suggests that the outcomes may reflect practices specific to that clinical setting, which may not be replicated in other centers with different protocols or patient demographics. Further-

more, the study’s focus on particular treatment modali-ties and specific subtypes of TMD, such as myogenous and arthrogenous conditions, may restrict the generaliz-ability of the findings to other forms of TMD or different treatment approaches not covered in this study.

More studies are required to characterize these and other patient-related variables that may influence treat-ment outcomes and further enhance the profiling of rein-tervened patients.

5. Conclusion

Despite its limitations, the study established that pre-treatment depression and/or anxiety influence TMD treat-ment outcomes, particularly in myogenous TMD, and contribute to reintervention. The presence of comorbid mental health disorders should warn the physician/ sur-geon to manage treatment strategies promptly and effi-ciently in a holistic treatment protocol.

Funding: This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing Interests: None

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