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J Am Dent Assoc, Vol 136, No 4, 459-468.
© 2005 American Dental Association
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JADA Continuing Education

Are female patients with orofacial pain medically compromised?



RENY de LEEUW, D.D.S., Ph.D., GARY D. KLASSER, D.M.D. and ROMULO J.C. ALBUQUERQUE, D.D.S.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Chronic pain has been linked to various medical conditions. The authors assessed whether certain medical conditions are more prevalent in female patients with orofacial pain than in age-matched controls.

Methods. The study sample consisted of 87 female adult subjects from a university-based orofacial pain center (OPC) and 87 age-matched female subjects from a university-based undergraduate dental clinic (UDC). Subjects were evaluated between February 2003 and July 2003, and they completed a standardized, 78-question medical history questionnaire as part of routine clinical protocol. Using the subjects’ medical histories, the authors compared 11 major medical categories and 77 individual conditions for both groups. For statistical analyses, the authors used nonparametric Kolmogorov-Smirnov Z tests and {chi}2 tests and calculated odds ratios (ORs).

Results. The medical histories of subjects in the OPC group indicated a significantly greater number of medical conditions than did those of the subjects in the UDC group (Z = –4.411, P < .0001). Specifically, subjects in the OPC group reported having significantly more neurological (Z = –5.304, P < .0001), gastrointestinal (Z = –2.897, P = .004), pulmonary (Z = –2.298, P = .022), dermatologic (Z = –2.984, P = .003) and other conditions (Z = –2.885, P = .004) than did subjects in the UDC group. Subjects in the OPC group reported having 12 individual medical conditions significantly more often (P < .05, ORs ranged from 2.5 to 9.7) than did subjects in the UDC group.

Conclusions. Female patients with orofacial pain complaints appear to have more systemic problems than do female patients seeking routine dental care.

Clinical Implications. The presence of multiple medical conditions can influence orofacial pain management options and treatment outcomes. Patients with more medically complicated orofacial pain may require treatment on a multidisciplinary basis.

Key Words: Orofacial pain; medical conditions; health questionnaire; female

Pain is a common complaint. In 1985, the Nuprin Pain Study found that most Americans had experienced physical pain within the last 12 months and that they experienced an average of three to four different kinds of pain every year.1 The most frequently reported types were headache, backache, muscle, joint, stomach, menstrual and dental pain. Pain also has been found to be positively correlated with stress and daily "hassles."2 A survey of 45,711 American households found that nearly 22 percent of adults experienced at least one of five types of orofacial pain more than once during the past six months.3 The type of orofacial pain reported most often was toothache (12.2 percent), followed by oral sores (8.4 percent), temporomandibular joint (TMJ) pain (5.3 percent), face or cheek pain (1.4 percent) and burning mouth (0.7 percent).3 These studies indicated that pain in general and orofacial pain specifically are common and are experienced frequently.

Female patients with orofacial pain complaints appear to have more systemic problems than do female patients seeking routine dental care.

John and colleagues4 found that 76 percent of patients with temporomandibular disorder (TMD) who attended a primary care clinic reported pain outside the masticatory system. Other studies have reported an association between orofacial pain, general medical diseases or disorders5,6 and general pain conditions.7,8 Medical conditions that have suggested links with orofacial pain include cardiovascular disease9; headache10–12; ear, nose and throat symptoms13; neck pain14; gastrointestinal disorders15,16; musculoskeletal conditions such as fibromyalgia17,18; chronic fatigue syndrome and rheumatoid arthritis16; and psychological disturbances.19,20 The prevalence of comorbid conditions, other than some specific psychological disturbances and generalized musculoskeletal disorders, has been studied only loosely in orofacial pain populations.21–23 The presence of other medical conditions in a patient with orofacial pain may influence and limit the treatment options and compromise treatment outcomes.

We conducted a study to compare the medical conditions that were self-reported on a standardized medical history questionnaire by female patients seen at the Orofacial Pain Center (OPC) of the College of Dentistry at the University of Kentucky, Lexington, with those self-reported by a similar population of patients seen for routine dental care at the undergraduate dental clinic (UDC) of the College of Dentistry at the University of Kentucky. We hypothesized that female patients receiving care for orofacial pain would report having more medical conditions than their age-matched counterparts who did not have orofacial pain. We limited our study sample to female patients because women comprise the majority of patients seeking treatment for orofacial pain (> 80 percent).24–26


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The study was approved by the institutional review board of the University of Kentucky.

Subjects. The study sample consisted of 174 age-matched female adult subjects who were evaluated between February 2003 and July 2003 at the OPC (87 women; mean age 41.2 ± 14.2 years standard deviation [SD]) and at the UDC (87 women; mean age 42.5 ± 15.3 years SD). The age group stratification is shown in Table 1Go. The most common primary diagnosis within the OPC population was muscle pain (n = 32, 36.8 percent), followed by TMJ pain (n = 24, 27.6 percent), neuropathic pain (n = 13, 14.9 percent) and primary headache (n = 3, 3.4 percent). Other diagnoses (for example, dental pain, sinus pain and earache) were made for 15 subjects (17.2 percent). This distribution of diagnoses was representative of the pain conditions seen at our multidisciplinary specialty clinic since 1999.


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  		TABLE 1 AGE GROUP STRATIFICATION.

 
Measures. As part of a routine practice, patients seen at the OPC and the UDC are required to fill out a standard medical history questionnaire before they are seen by a practitioner. This standardized questionnaire has been used by all departments at the University of Kentucky College of Dentistry since November 1996 and encompasses 77 common medical conditions in addition to the entry "Disease, Problem or Condition not listed" for which patients have the opportunity to report any additional medical conditions. The various medical conditions are grouped in categories according to the physiological system involved (that is, neurological, hematologic and so forth) (BoxGo). The subjects were instructed to check a box for any of the listed conditions that they had or had had in the past. In addition, there was an open entry, in which patients were to list any disease, problem or condition that was not included in the check-off sheet. One of the authors (G.D.K.) took the information recorded by the subjects directly from the questionnaires and collated it into a database for statistical analysis. The total number of medical problems reported in the questionnaires, as well as the number of complaints involving the particular systems and all of the medical conditions were variables for the statistical analysis. The author made group comparisons with regards to these variables between subjects in the OPC group and in the UDC group.


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  		BOX GENERAL MEDICAL HISTORY QUESTIONNAIRE CONDITIONS, BY SYSTEM.

 
Statistical analysis. We performed all statistical analyses using the software package Statistical Package for the Social Sciences, Release 11.5 (SPSS, Chicago), and we used nonparametric Kolmogorov-Smirnov Z tests to determine differences between the OPC group and the UDC group with regard to the total number of reported medical conditions and the system categories. We used {chi}2 tests to test differences with regard to the individual conditions. We calculated odds ratios (ORs) for individual conditions and set the level of significance at {alpha} = .05.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The 10 most commonly reported conditions were sinus trouble, use of tobacco, severe headaches, allergies or hives, earaches/ringing in ears, vision problems, high blood pressure, fainting/dizzy spells, panic attacks and use of alcohol (Table 2Go).


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  		TABLE 2 FREQUENCY DISTRIBUTION OF THE 10 MOST COMMONLY REPORTED CONDITIONS.

 
Subjects in the OPC group reported having more medical complaints compared with subjects in the UDC group (Z = –4.411, P < .0001) (Table 3Go, page 463). Specifically, subjects in the OPC group reported having significantly more neurological (Z = –5.304, P < .0001), gastrointestinal (Z = –2.897, P = .004), pulmonary (Z = –2.298, P = .022), dermatologic (Z = –2.984, P = .003) and other conditions (Z = –2.885, P = .004) than did subjects in the UDC group. Of the 77 medical conditions listed individually on the questionnaire, 12 were reported significantly more often by subjects in the OPC group than by subjects in the UDC group: earaches/ringing in ears, hearing loss, severe headaches, fainting/dizzy spells, psychiatric treatment, panic attacks, stomach/intestinal ulcers, persistent diarrhea, sinus trouble, skin rash, night sweats and frequent sore throats (FigureGo, page 464). In addition, the entry "Disease, Problem or Condition Not Listed" was reported significantly more often by subjects in the OPC group than by subjects in the UDC group. For each of these 12 conditions and the open entry Disease, Problem or Condition Not Listed, we calculated the OR as a means of displaying the greater likelihood of subjects in the OPC group to endorse these medical conditions (Table 4Go, page 465). None of the conditions was reported significantly more often by the subjects in the UDC group.


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  		TABLE 3 COMPARISON OF THE MAIN SYSTEM CATEGORIES BETWEEN THE OPC* AND UDC{dagger} GROUPS.

 


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  		Figure. Medical conditions reported by subjects at the Orofacial Pain Center (OPC) of the College of Dentistry at the University of Kentucky, Lexington, compared with subjects at the undergraduate dental clinic (UDC) of the College of Dentistry at the University of Kentucky, reaching statistical significance at {alpha} = .05 (*P ≤.01; {dagger}.01 < P ≤.05).

 

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  		TABLE 4 THE MEDICAL CONDITIONS OPC* SUBJECTS REPORTED SIGNIFICANTLY MORE OFTEN THAN UDC{dagger} SUBJECTS.{ddagger}

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Obtaining a medical history from each patient attending a health care facility should be a routine procedure. It gives the practitioner an insight into the past and present physical health of the person, and this information is of great importance in terms of diagnosis and overall treatment.27

Our study investigated whether a group of age-matched female patients seen at an OPC reported having a greater prevalence of medical conditions than did subjects seen at a UDC. The results of our study revealed that the subjects with orofacial pain reported having significantly more medical conditions than did subjects who sought routine care. They reported having pain significantly more often in the neurological, gastrointestinal, pulmonary and dermatologic categories. We found that 12 conditions—earaches/ringing in the ears, hearing loss, severe headaches, fainting/dizzy spells, psychiatric treatment, panic attacks, stomach/intestinal ulcers, persistent diarrhea, sinus trouble, skin rash, night sweats and frequent sore throats—in addition to the open entry Disease, Problem or Condition Not Listed were reported statistically significantly more often.

We will discuss each of the aforementioned conditions in light of the existing literature. We were unable to distill data for strictly female populations from the existing literature, because the vast majority of literature did not segregate outcome variables between sexes. Nevertheless, the TMD populations in these studies were 80 to 100 percent female, rendering our data sample comparable in composition.

Earaches/ringing in ears, hearing loss and fainting/dizzy spells. Earaches/ringing in ears, hearing loss and fainting/ dizzy spells were reported more often by subjects in the OPC group than by subjects in the UDC group. Tinnitus is a Latin word derived from the verb "tinnire," which is defined as to buzz, hum, jingle, peal, ring, sound, tinkle or whirr.28 Therefore, we use "tinnitus" interchangeably with "ringing in ears." A review of the literature identified a greater prevalence of otalgia (earache) (46–100 percent), tinnitus (44–64 percent), hearing loss (22–62 percent) and fainting/dizzy spells (33–70 percent) in TMD and orofacial pain populations compared with non-TMD populations.29–31 The high ORs for aural symptoms (otalgia, tinnitus, hearing loss, fainting/dizzy spells) in our study agree with those from the previously cited studies29–31 that reported an association between aural symptoms and orofacial pain. There are many hypotheses to explain this association, ranging from eustachian tube dysfunction to masticatory muscle dysfunction and reflex-sympathetic vasospasm of labyrinthine vessels secondary to abnormal stimulation of autonomic nerves of the TMJ32,33 to reflex disturbances of the tensor tympani and veli palatini muscles and the otomandibular ligaments.34 Other possibilities support the hypothesis of a neuromuscular interrelationship between the TMJ and the middle ear.35 In addition, a propensity of mutual referral patterns from these structures has been suggested.36,37 Earaches may present as TMJ pain or may be elicited on palpation of trigger points found in masticatory and cervical muscles.36,38 One limitation of our study was that the medical history questionnaire combined distinct entities such as earaches and ringing in ears into one category. This prevented us from determining precisely which medical condition the subjects meant to report.

Headaches. Headaches were reported more often by the subjects in the OPC group than by subjects in the UDC group. This was not simply owing to the inclusion of subjects with a primary diagnosis of headache, as these subjects were only 3 percent of the entire patient sample. More than 40 percent of the subjects in the OPC group reported severe headaches on the medical history questionnaire compared with 14 percent of the subjects in the UDC group. Reports on the prevalence of headaches in TMD populations indicate a range of 48 to 77 percent, which is reported to be up to twice as high as the prevalence of headaches in control populations.10,12,39,40 Thus, the prevalence of headaches in both of our samples seems to be somewhat lower than that of the other studies. A possible explanation may be that our questionnaire elicited the prevalence of "severe headaches," whereas the other studies did not discriminate on headache intensity.

Data about the mechanism of how TMD signs and symptoms are related to headaches are unclear and conflicting. Local, systemic, endocrinological and psychological factors may be involved in triggering and perpetuating headache pain. Malocclusion, stress, psychological tension, muscle hyperactivity, abnormal posture of the head and neck, cervical and masticatory trigger points and referral patterns from these structures, the teeth, TMJs and local trauma have been implicated as etiologic factors and probably are involved in the multifactorial pathogenesis of headache.14,41–50 Vascular, muscular and neurogenic mechanisms also may be involved.12,51,52 Imbalances in pain-related neurotransmitters, central excitatory effects, deficiencies in the body’s antinociceptive system, enhancement of facilitatory mechanism and increased peripheral input also have been found to be relevant interrelated mechanisms.39,53–59

Psychiatric treatment. Our findings suggested a statistically significant relationship between psychiatric treatment and orofacial pain. Korszun and colleagues60 studied the comorbidity of TMD with depressive disorders. They found that 53 percent of the study patients fulfilled criteria for a diagnosis of major or minor depression and an additional 22 percent of these patients reported subsyndromal depressive symptoms. Other studies have shown agreement between the comorbidity of chronic facial pain and depression, fluctuating from 30 to 60 percent, depending on whether samples were taken from the community or tertiary pain clinics.61,62 Other studies found a high prevalence of anxiety disorders in orofacial pain populations.63–65 The fact that psychological factors are regarded as predisposing, etiologic or maintaining factors or as a consequence of TMD is indicative of the multifactorial nature and interactivity among these entities. Moreover, it seems likely that chronic pain such as orofacial pain and psychological conditions share a common pathophysiological basis, making the division of symptoms into psychological and physical components an artificial one.66

Many theories exist that try to explain the causative factors involved in depressive disorders. In trying to determine the causative factors involved in depressive disorders, one must consider biological, genetic and psychosocial reasons. Biological factors may be due to a dysregulation or an imbalance of the neural and hormonal systems. Genetic considerations are of importance, as clinicians have observed for many years that psychological conditions tend to have a familial disposition. Genetic factors may predispose certain people to a greater risk of experiencing depression after stressful life events.67 Psychosocial factors—including lifestyles, stress-related biochemical and muscular responses, family relations, sleep disturbances, personality and coping mechanisms—all may play a role in the pathogenesis and maintenance of orofacial pain.68

Panic attacks. Subjects in the OPC group in our study also reported having statistically significantly more panic attacks than did subjects in the UDC group. A panic attack is a discrete period in which there is a sudden onset of intense apprehension, fearfulness or terror that often is associated with feeling of impending doom.69 During a panic attack, at least four of 13 somatic or cognitive symptoms must develop abruptly and reach a peak within 10 minutes. The 13 symptoms are palpitations, sweating, sensations of shortness of breath or smothering, choking sensations, trembling or shaking, chest pain or discomfort, nausea or abdominal distress, dizziness or lightheadedness, derealization or depersonalization, fear of losing control or "going crazy," fear of dying, paresthesias (numbness or tingling sensations) and chills or hot flushes.69 Repeated panic attacks are the basic symptom of panic disorder. Kuch and colleagues70 found that almost 40 percent of patients with panic disorder reported that they were "bothered by persistent pain" and that their pain had started more than six months ago (chronic pain). They also found that subsets of these patients (that is, those with chronic pain) are particularly prone to somatization and hypochondriasis. In a more recent study, Schmidt and colleagues71 looked at 139 patients who met the criteria for panic disorder in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, fourth edition.69 They concluded that 71 percent of the patients endorsed pain in at least one of the four pain domains studied, suggesting that these patients had a wide range of pain experiences. Although an association between pain and panic disorder exists, the underlying mechanisms for this linkage have not been well-explored. A possible explanation for the link between pain and panic disorder may be that panic disorder exists comorbidly with other anxiety and depressive disorders. Studies have suggested that these conditions share a common underlying pathophysiology, which manifests with the same pathogenetic features, one of which may be an increased sensitivity to pain.71–73

Night sweats. There appears to be a link between panic attacks and night sweats. After controlling for other variables, Mold and colleagues74 determined that the only variable associated with panic attacks was in fact night sweats. This association is plausible, given that both may be produced by a surge of activity in the autonomic nervous system.75 Interestingly, both panic attacks and night sweats were reported more often by the subjects with orofacial pain in our study.

Gastrointestinal disorders. In our study, subjects in the OPC group reported having more gastrointestinal problems than did subjects in the UDC group. Functional gastrointestinal disorders are a persistent or recurrent pain or discomfort centered in the upper abdomen without evidence of organic disease likely to explain the symptoms. Visceral hypersensitivity, motor dysfunction and impaired gastric accommodation are found in some patients, and psychological factors seem to play a role in the symptom formation.

Psychological distress may influence digestive secretion, motility and vascularity, thereby inducing dyspepsia and pain through autonomic arousal. Visceral hyperalgesia mediated by autonomic and emotional arousal may exacerbate the perception of pain. Alternatively, psychologically distressed people may be more vulnerable to experience somatization symptoms.76 The literature also suggests that biopsychosocial factors can exert a great influence on gastric ulceration. Finally, there seems to be an overlap between gastrointestinal disorders and nonspecific symptoms like headache, fatigue, muscle pain and sleep disturbances.77–80 Perhaps, not surprisingly, the subjects with orofacial pain in our study also reported having a greater number of gastrointestinal conditions (stomach/intestinal ulcers and persistent diarrhea).

Sinus troubles. In our study, subjects in the OPC group reported having had more sinus trouble than did subjects in the UDC group. In a study by Lindahl and colleagues,81 one of five patients with suspected recurrent or chronic sinusitis did not have sinusitis, but had dysfunction or infection in the masticatory system. The signs and symptoms of TMD and maxillary sinusitis are not always specific and localized. Patients with sinus trouble frequently describe facial pain and headache as "sinus-related" pains.82–84 Often, owing to the proximity of the maxillary teeth to the maxillary sinus, an acute or chronic episode of sinusitis may be felt as a constant, dull, aching pressure or discomfort in these teeth.85 Another confounding factor is that signs and symptoms of myofascial pain may mimic sinusitis.36,38 Hence, while some of the subjects with orofacial pain in our study may have had true sinus trouble, others may have mistaken their orofacial pain for sinus-related disease.

Sore throats. In our study, subjects with orofacial pain reported having more frequent sore throats than did subjects in the UDC group. Norton and colleagues78 reported that 39.6 percent of first-year university psychology students indicated that they experienced functional esophageal disorders of at least three months’ duration with some of the most common specific disorders being functional chest pain of presumed esophageal origin (18.1 percent) and globus (12.6 percent). Globus hystericus is the sensation of a lump in the throat or a choking sensation. The exact etiology of this condition has not been established definitely; however, investigators have proposed that reflux may be an important underlying factor.86 Globus has been associated with panic disorder and depression. Affective disorders, generalized anxiety and somatization disorders are largely responsible for disturbances in esophageal motility.87,88 Since our population of subjects with orofacial pain seemed to report a greater number of these disorders, it appears that this may be a reason for subjects’ reporting having frequent sore throats.

Skin rashes and disease, problem or condition not listed. Widespread and general complaints of pain outside of the masticatory system in patients with TMD are commonly observed and reported.4,8,89 Somatization disorder is a pattern of recurring, multiple, clinically significant somatic complaints. A somatic complaint is considered clinically significant if it results in medical treatment or causes impairment in social, occupational or other important areas of functioning. The multiple somatic complaints cannot be explained fully by any known general medical condition or the direct effects of a substance.90 This may be an explanation for the greater reporting of skin rashes, as well as several other medical conditions, in the subjects in the OPC group in our study.

Methodological considerations. A couple of methodological considerations about our study deserve attention. First, this study cannot be generalized to the general population because we restricted the study sample to female patients. We did this based on clinical experience and epidemiology studies. A review study has found that chronic pain is more prevalent in women than in men in the general population at a ratio of 2:1.91 This ratio is larger when female-to-male pain prevalence is observed within orofacial pain clinic populations. Bush and colleagues92 reported a range of female-to-male ratios of 5:1 to 9:1. Also, women report using health care services more than men do for a variety of health problems.93,94 Von Korff and colleagues,95 however, found that the increased utilization of health care for painful symptoms could not be assumed to be due to sex differences in propensity to seek treatment but rather to differences in symptom prevalence or severity.

Secondly, as is the case with many self-report instruments, the medical history questionnaire may have generated inaccuracies. All subjects were asked to check a box on the questionnaire for any condition that they had at the time they filled out the questionnaire or had had in the past. Many subjects may not have had their conditions diagnosed by a health care practitioner but rather may have made assumptions as to what medical conditions they "felt" they had. This could have led to erroneous or inaccurate self-reporting. Further, the subcategories used in the medical history questionnaire may have been too broad or too vague to ascertain accurately the exact nature of the medical condition. The fact that the medical history questionnaire inquired about and expected the reporting of both past and present medical conditions created a potential problem for recall bias, which may have led to both over- and underreporting of certain conditions. For both clinical and research methods, future questionnaires will have to be more specific as to what medical conditions are to be identified, whether they are past or current conditions and whether any diagnosis was made by a medical professional. Notwithstanding these critiques, and given the fact that both groups used identical questionnaires, the potential inaccuracies may be expected to be similar in both groups.


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Our study provided evidence that female patients seen at an OPC reported having significantly more medical conditions than did female patients in the control group, which consisted of a sample of patients from a UDC. A possible hypothesis for this finding may be that orofacial pain shares a pathophysiology with more systemic functional and generalized musculoskeletal disorders. It also is possible that the manifestations of these systemic disorders initially will be felt in the orofacial region, thus manifesting as precursors to more generalized conditions such as fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome.

In the future, prospective studies investigating similarities in reported medical conditions between patients with orofacial pain and patients with generalized musculoskeletal systemic disorders may strengthen the premise that these conditions share common pathophysiological mechanisms and lead to an improved method of medical management. Until a common pathophysiology has been established, treatment of patients with orofacial pain with complex medical histories should be directed toward both the orofacial pain complaint, as well as the concomitant medical conditions. However, all treatment plans should be designed so that the minimal amount of interventions would be rendered toward the management of all conditions. This entails comprehensive communication between all health care professionals involved.


   FOOTNOTES
 

Dr. de Leeuw is an assistant professor, Orofacial Pain Center, University of Kentucky, College of Dentistry, Chandler Medical Center D530, 800 Rose St., Lexington, Ky. 40536-0297, e-mail "rdele0{at}email.uky.edu". Address reprint requests to Dr. de Leeuw.


Dr. Klasser is a resident, Orofacial Pain Center, University of Kentucky, College of Dentistry, Chandler Medical Center, Lexington.


Dr. Albuquerque is a resident, Orofacial Pain Center, University of Kentucky, College of Dentistry, Chandler Medical Center, Lexington.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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