Systemic diseases and other painful conditions in patients with temporomandibular disorders and migraine

Abstract

Temporomandibular disorders (TMD) are a highly prevalent, painful musculoskeletal condition affecting the masticatory system, and are frequently associated with migraines (M) and other diseases. This study aimed to investigate the association between painful TMD and M with other painful conditions and systemic diseases, such as cervicalgia, body pain (BP), ear-nose-throat disorders, musculoskeletal disorders, diabetes, cardiopulmonary diseases and gastritis/peptic ulcer. Methods: This was a cross-sectional study conducted in a sample of 352 individuals. Participants were stratified into three groups according to the presence of painful TMD and M: controls [individuals free of TMD and any headache (HA)]; TMD only (presence of painful TMD, but free of any HA); and TMD+M (presence of painful TMD and M). TMD was classified according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) - Axis I. Nonspecific physical symptoms (NSPS) were assessed by RDC/TMD - Axis II. The International Classification of Headache Disorders - II criteria, second edition, were applied to identify and classify primary HA. Other painful conditions and systemic diseases were assessed by volunteers’ self-report. The prevalence of all assessed conditions was higher in the TMD+M group. Multiple regression models showed that cervicalgia was associated with the TMD only group (p<0.05), whereas gender (p<0.05), cervicalgia (p<0.05), BP (p<0.05) and NSPS (p<0.05) were significantly associated with the TMD+M group. Our results suggest that individuals with a comorbidity (TMD associated with M) have a more severe condition than those presenting only painful TMD.

Keywords:
Migraine Disorders; Temporomandibular Joint Disorders; Neck Pain; Headache; Comorbidity

Introduction

Temporomandibular disorders (TMD) are considered a type of functional pain syndrome (FPS) or idiopathic pain disorder (IPD), which also include conditions such as fibromyalgia, low back pain, irritable bowel syndrome, chronic headaches (HA), interstitial cystitis, chronic pelvic pain, chronic tinnitus, whiplash-associated disorders, and vulvar vestibulitis.¹ Whereas TMD is defined as a group of disorders involving the masticatory muscles, the temporomandibular joint (TMJ) and associated structures,² FPS, in general, is characterized by high levels of psychological distress (anxiety, health-seeking behavior and markers of somatization) and abnormalities in motor function, autonomic balance and sleep.^1,3 Although these disorders frequently occur concomitantly, the relationship among them remains unclear.³ Moreover, FPS typically does not respond well to conventional therapies, indicating that a better understanding of its etiology and mechanism should be highly relevant to the medical field.¹

A large proportion of patients with painful TMD also present a significant disability, with consequences that impact their lives. The simultaneous presence of pain in other body areas seems to increase the magnitude of the impact. Moreover, it has been demonstrated that painful TMD is strongly associated with other painful conditions,⁴ such as fibromyalgia,^5,6 widespread pain,^5,6 cervical spine dysfunction,⁷ neck pain, low back and joint pain⁸ and primary HA.^9,10,11,12

Among the comorbid conditions, some primary HA are more frequently associated with painful TMD.^{9,10,13,14,15,16} The magnitude of the association is higher for migraine (M), followed by tension-type headaches (TTH).^{10,11,12,13,14,15,16,17} Previous evidence has indicated that TMD is comorbid with M and a risk factor for M chronification.^9,11,12,13 Additionally, it has been demonstrated that the presence of a comorbidity negatively influences diagnostic tests for musculoskeletal pain.¹⁸

Although previous studies have shown an association between TMD and other painful conditions,^18,19 somatization, depression^5,18 and a reduced quality of life,²⁰ there is still a lack of information regarding the relationship between painful TMD (isolated or associated with M) and systemic diseases. Therefore, this study aimed to investigate the association between painful TMD and M with other painful conditions [such as cervicalgia, body pain (BP), musculoskeletal disorders (MED)] and systemic diseases [such as ear-nose-throat disorders (ENT), diabetes, cardiopulmonary diseases and gastritis/peptic ulcer]. We hypothesized that painful TMD was significantly associated with systemic diseases, and that the magnitude of the association would be greater in the case of painful TMD and M comorbidity, thus resulting in a higher burden of the disease.

Methods

Our sample was composed of 352 individuals. Of these, 305 were patients who sought care at the UNESP/Araraquara School of Dentistry, presenting with the chief complaint of orofacial pain, and 47 individuals (control group) were free of TMD, HA or any type of facial pain. The controls were selected among the patients seeking routine dental care treatment at the same university, or companions of patients. This group is relatively small, since finding individuals free of HA and TMD is not a simple task. We included individuals of both genders, aged between 18 and 65 years, presenting adequate bilateral occlusal contacts, and able to read and write. Exclusion criterion was the presence of any cognitive or communication impairment. The Research Ethics Committee of the Araraquara Dental School (UNESP - Universidade Estadual Paulista, Brazil), approved this study. Informed consent was obtained from each participant.

Assessments

Temporomandibular disorders and non-specific physical symptoms

Two trained researchers evaluated all the individuals, following a standardized orofacial pain clinic protocol, including an interview and a clinical exam. The chief complaint, characteristics of the pain (quality, duration, frequency, intensity, location, and exacerbating and alleviating factors), medical history and medication use were assessed. The TMD diagnosis and classification were made according to the diagnostic criteria of the American Academy of Orofacial Pain (AAOP)² and the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) - Axis I – Portuguese version, respectively.²² The RDC/TMD – Axis I allowed us to confirm the diagnosis of TMD and define its classification into muscle disorders (Group I), articular disorders (Group II and III), or both. Data analysis was performed by grouping the individuals according to the diagnosis of painful types of TMD, including those of muscular and/or articular origin. The nonspecific physical symptoms (NSPS) were assessed by the RDC/TMD - Axis II, item 2.3. According to this instrument, individuals were classified into two groups, those presenting or not presenting NSPS.

Painful conditions and systemic diseases

The presence of persistent painful conditions and systemic diseases in the last 6 months were assessed through the individuals’ report during the interview. We assessed the presence of cervicalgia, BP, musculoskeletal disorders (arthritis, fibromyalgia, back pain), ENT (otitis, sinusitis, rhinitis), diabetes, cardiorespiratory conditions (hypertension, heart disease, asthma, bronchitis), and gastritis/peptic ulcer.

Migraine

Migraine was clinically diagnosed by a researcher with specific training in HA medicine, using a structured questionnaire based on the International Classification for Headache Disorders, second edition (ICHD-II).²³ The questions collected information regarding HA features (frequency and duration of episodes, laterality, characteristics of pain, exacerbation with movement), and associated symptoms (aura, nausea, photophobia, phonophobia, autonomic symptoms). This questionnaire has been used in performing epidemiological and clinical research in Brazil,^{9,10,11,12,13} and can identify the existence of M, TTH, or primary HA. Only individuals free of any HA or presenting M were included in the sample.

Data Analysis

The presence of painful TMD only or TMD associated with M comprised the outcome variables. Gender, self-reported diseases, other painful conditions and presence of NSPS were considered predictor variables. The sample was stratified into three groups, according to the presence of painful TMD and M: control (free of TMD and any HA); TMD only group (individuals presenting painful TMD but free of any HA); TMD+M group (individuals presenting painful TMD and M).

Descriptive statistics and frequency counts were used to characterize the sample. Two logistic regression models were performed to investigate the association between the outcome variables. The first model was built to study what predictor variables were associated with the TMD only group, compared with the control group. The second model was performed to analyze what predictor variables were associated with the simultaneous presence of painful TMD and M (TMD+M group), compared with the control group. In both models, the variables showing significant association (p < 0.05) with the univariate analyses were included in the multiple logistic models. In the logistic regression model, the predictor variables with the weakest association to the outcome variable were removed. This procedure was repeated using a backward stepwise approach until all the variables retained in the model yielded p < 0.05. The p-to-exit is reported for each predictor variable removed. The data were checked for multicollinearity, using a tolerance value < 0.10 and a variance inflation factor > 10. All analyses were performed with the Statistical Package for the Social Sciences (SPSS) software, version 21.0 for Mac.

Results

Sample characterization

Initially, 507 volunteers were screened according to the protocol mentioned above. Of these, we excluded 93 individuals presenting other types of HA (no M), 21 presenting non-painful TMD, and 41 because of missing data regarding other diseases. The final sample consisted of 352 individuals stratified into three groups according to the presence of painful TMD and M (Figure). The descriptive data of the predictor variables stratified according to the three groups are shown in Table 1.

Figure 1
Participants flow diagram.

Table 1
Descriptive data of the predictor variables stratified according to the three groups.

Variable		Control	TMD only	TMD+M	Total
		47 (13.4)	41 (11.6)	264 (75)	352
Cervicalgia
	no	42 (38.5)	17 (15.6)	50 (45.9)	109 (100)
	yes	5 (2.1)	23 (9.6)	212 (88.3)	240 (100)
Body Pain
	no	43 (23)	23 (12.3)	121 (64.7)	187 (100)
	yes	4 (2.5)	17 (10.4)	142 (87.1)	163 (100)
MED
	no	32 (16.8)	23 (12.1)	135 (71.7)	190 (100)
	yes	15 (9.3)	18 (11.1)	129 (79.6)	162 (100)
ENT
	no	31 (17.8)	20 (11.5)	123 (70.7)	174 (100)
	yes	16 (9)	21 (11.8)	141 (79.2)	178 (100)
Diabetes
	no	44 (13.1)	36 (10.7)	255 (76.1)	335 (100)
	yes	3 (17.6)	5 (29.4)	9 (52.9)	17 (100)
Cardiopulmonary
	no	39 (14.8)	31 (11.7)	194 (73.5)	264 (100)
	yes	8 (9.1)	10 (11.4)	70 (79.5)	88 (100)
Gastritis/Peptic Ulcer
	no	41 (16.4)	28 (11.2)	181 (72.5)	250 (100)
	yes	6 (5.9)	13 (12.7)	83 (81.4)	102 (100)
NSPS
	no	34 (43)	19 (24.1)	26 (32.9)	79 (100)
	yes	13 (4.8)	22 (8.1)	238 (87.2)	273 (100)

• TMD: Temporomandibular disorders; M: Migraine; MED: Musculoskeletal disorders; ENT: Ear, nose and throat disorders; NSPS: Non-specific physical symptoms.

The majority of the sample were women (83.8%) (p < 0.001). Overall, the mean age was 37.7 ± 12.7, with no statistical difference among the groups (p > 0.05); 47 (13.4%) participants had no TMD or HA, and 305 (86.6%) presented painful TMD. Among the individuals with painful TMD, 264 also presented M. The prevalence of each painful condition and systemic disease, according to the three groups, are presented in Table 2. The prevalence of painful conditions, systemic diseases and NSPS was higher among individuals with painful TMD associated with M (TMD + M group), compared with the controls and the individuals presenting only painful TMD (TMD only group).

Table 2
Single and multiple logistic regression models for prediction of TMD only group versus the control group. The number of cases (n) included in the analysis is shown for each factor included in the single regression.

Predictor variables		n	Single regression			p -to-exit	Multiple regression
			p-value	OR	95%CI		p-value	OR	95%CI
Gender
	Men	34	–	–	–	–	–	–	–
	Women	54	0.036	2.6	1.07–6.41	0.163	–	–	–
Cervicalgia
	No	59	–	–	–	–	–	–	–
	Yes	28	0.000	11.3	3.71–34.81	–	0.000	10.0	3.24–31.30
Body Pain
	No	66	–	–	–	–	–	–	–
	Yes	21	0.001	7.9	2.39–26.41	0.340	–	–	–
MED
	No	55	–	–	–	–	–	–	–
	Yes	33	0.248	1.7	0.70–3.98	–	–	–	–
ENT
	No	51	–	–	–	–	–	–	–
	Yes	37	0.105	2.0	0.86–4.81	–	–	–	–
Diabetes
	No	80	–	–	–	–	–	–	–
	Yes	8	0.352	2.0	0.46–9.11	–	–	–	–
Cardiorespiratory conditions
	No	70	–	–	–	–	–	–	–
	Yes	18	0.395	1.6	0.55–4.46	–	–	–	–
Gastritis/Ulcer
	No	69	–	–	–	–	–	–	–
	Yes	19	0.036	3.2	1.08–9.34	0.312	–	–	–
NSPS
	No	53	–	–	–	–	–	–	–
	Yes	35	0.014	3.0	1.25–7.35	0.471	–	–	–

• TMD: Temporomandibular disorders; M: Migraine; MED: Musculoskeletal disorders; ENT: Ear, nose and throat disorders; NSPS: Non-specific physical symptoms.

The univariate analysis of the first regression model (TMD only compared with the control) showed that gender (p = 0.036), cervicalgia (p < 0.001), BP (p = 0.001), gastritis/peptic ulcer (p < 0.05) and NSPS (p < 0.05) were associated with the presence of painful TMD (Table 3). The multivariate analysis showed that the strongest predictor variable associated with the presence of TMD only was cervicalgia [odds ratio (OR): 10.0, 95%CI = 3.2–31.30].

Table 3
Single and multiple logistic regression models for prediction of the TMD+M versus the control group. The number of cases (n) included in the analysis is shown for each factor included in the single regression.

Predictor variables		n	Single regression			p-to-exit	Multiple regression
			p-value	OR	95%CI		p-value	OR	95%CI
Gender
	Men	46	–	–	–	–	–	–	–
	Women	265	0.000	10.0	4.92–20.51	–	0.000	6.4	2.38–16.99
Cervicalgia
	No	92	–	–	–	–	–	–	–
	Yes	217	0.000	35.6	13.41–94.62	–	0.000	10.3	3.37–31.44
Body pain
	No	164	–	--	–	–	–	–	–
	Yes	146	0.000	12.6	4.40–36.15	–	0.041	3.8	1.06–13.53
MED
	No	167	–	–	–	–	–	–	–
	Yes	144	0.034	2.0	1.06–3.94	0.156	–	–	--
ENT
	No	154	–	–	–	–	–	–	–
	Yes	157	0.016	2.0	1.16–4.25	0.064	–	–	–
Diabetes
	No	299	–	–	–	–	–	–	–
	Yes	12	0.337	2.0	0.50–7.42	–	–	–	–
Cardiorespiratory conditions
	No	233	–	–	–	–	–	–	–
	Yes	78	0.171	1.8	0.78–3.94	–	–	–	–
Gastritis/Ulcer
	No	222	–	–	–	–	–	–	–
	Yes	89	0.012	3.1	1.28–7.67	0.274	–	–	–
NSPS
	No	60	–	–	–	–	–	–	–
	Yes	251	0.000	24.0	11.24–51.02	–	0.000	7.1	2.81–18.06

• TMD: Temporomandibular disorders; M: Migraine; MED: Musculoskeletal disorders; ENT: Ear, nose and throat disorders; NSPS: Non-specific physical symptoms.

In the second model (Table 4) (TMD+M vs. control), the univariate analyses indicated that gender (p < 0.001), cervicalgia (p < 0.001), BP (p < 0.001), MED (p = 0.034), ENT (p = 0.016), gastritis/peptic ulcer (p = 0.012) and NSPS (p < 0.001) were significantly associated with the presence of concomitant painful TMD and M. Multivariate analyses, in turn, showed that comorbidity (TMD+M group) was significantly associated with a wide variety of predictor variables, including gender [OR: 6.4 (95%CI = 2.38–16.99)], cervicalgia [OR: 10.0 (95%CI = 3.24–31.30)], BP [OR: 3.8 (95%CI = 1.06–13.53)], and NSPS [OR: 7.1 (95%CI = 2.81–18.06)].

Table 4
Single and multiple logistic regression models for prediction of TMD+M group versus TMD only group. The number of cases (n) included in the analysis is shown for each factor included in the single regression.

Predictor variables		n	Single regression			p-to-exit	Multiple regression
			p value	OR	95%CI		p-value	OR	95%CI
Gender
	Men	34	–	–	–	–	–	–	–
	Women	271	0.001	3.8	1.7–8.65	–	0.026	2.8	1.13–6.86
Cervicalgia
	No	67	–	–	–	–	–	–	–
	Yes	235	0.001	3.1	1.55–6.30	0.232	–	–	–
Body pain
	No	144	–	–	–	–	–	–	–
	Yes	159	0.178	1.6	0.81–3.11	–	–	–	–
MED
	No	158	–	–	–	–	–	–	–
	Yes	147	0.555	1.2	0.63–2.36	–	–	–	–
ENT
	No	143	–	–	–	–	–	–	–
	Yes	162	0.794	1.1	0.56–2.10	–	–	–	–
Diabetes
	No	291	–	–	–	–	–	–	–
	Yes	14	0.019	3.9	1.24–12.39		0.019	4.5	1.23–15.55
Cardiorespiratory conditions
	No	225	–	–	–	–	–	–	–
	Yes	80	0.774	1.1	0.52–2.40	–	–	–	–
Gastritis/Ulcer
	No	209	–	–	–	–	–	–	–
	Yes	96	0.973	1.01	0.49–2.05	–	–	–	–
NSPS
	No	45	–	–	–	–	–	–	–
	Yes	260	< 0.001	7.9	3.79–16.49	–	< 0.001	6.8	3.16–14.64

Finally, the last model compared the TMD only group with the TMD+M group (Table 5). According to the univariate analyses, gender (p = 0.001), cervicalgia (p = 0.001), diabetes (p = 0.019) and NSPS (p < 0.001) were significantly associated with individuals presenting the concomitant presence of painful TMD and M, compared with those presenting only painful TMD. Multivariate analysis indicated that gender [OR = 2.8 (CI = 1.13–6.86)], diabetes [OR = 4.5 (CI = 1.23–15.55)] and NSPS [OR = 6.8 (CI = 3.16–14.64)] were significantly associated with the presence of painful TMD and M. There were no signs of multicollinearity among the predictor variables.

Table 5
Single and multiple logistic regression models for prediction of TMD+M group versus TMD only group. The number of cases (n) included in the analysis is shown for each factor included in the single regression.

Predictor variables		n	Single regression			p-to-exit	Multiple regression
			p-value	OR	95%CI		p-value	OR	95%CI
Gender
	Men	34	–	–	–	–	–	–	–
	Women	271	0.001	3.8	1.7–8.65	–	0.026	2.8	1.13–6.86
Cervicalgia
	No	67	–	–	–	–	–	–	–
	Yes	235	0.001	3.1	1.55–6.30	0.232	–	–	–
BP
	No	144	–	–	–	–	–	–	–
	Yes	159	0.178	1.6	0.81–3.11	–	–	–	–
MED
	No	158	–	–	–	–	–	–	–
	Yes	147	0.555	1.2	0.63–2.36	–	–	–	–
ENT
	No	143	–	–	–	–	–	–	–
	Yes	162	0.794	1.1	0.56–2.10	–	–	–	–
Diabetes
	No	291	–	–	–	–	–	–	–
	Yes	14	0.019	3.9	1.24–12.39	–	0.019	4.5	1.23–15.55
Cardiorespiratory conditions
	No	225	–	–	–	–	–	–	–
	Yes	80	0.774	1.1	0.52–2.40	–	–	–	–
Gastritis/Ulcer
	No	209	–	--	–	–	–	–	–
	Yes	96	0.973	1.01	0.49–2.05	–	–	–	–
NSPS
	No	45	–	–	–	–	–	–	–
	Yes	260	< 0.001	7.9	3.79–16.49	–	< 0.001	6.8	3.16–14.64

• TMD: Temporomandibular disorders; M: Migraine; MED: Musculoskeletal disorders; ENT: Ear, nose and throat disorders; NSPS: Non-specific physical symptoms.

Discussion

TMD has been included in a group of painful conditions named functional pain syndromes, or idiopathic pain disorders.¹ These conditions are associated with neurobiological, physiological and anatomical changes in the central nervous system.²⁴ It is also well established that there is a comorbid relationship between painful TMD and M.^10,13 Previous studies have demonstrated that TMD patients, as well as migraineurs, are more sensitive to pain and present multiple BP areas more frequently.^4,19,25 These characteristics point to a generalized dysfunction of the nociceptive system, and an upregulation of the nociceptive process.²⁶ Herein, we hypothesized that the presence of a comorbidity (painful TMD associated with M) could be associated with a higher prevalence of other painful conditions and systemic diseases.

Our most important findings were: a) individuals with painful TMD and M presented higher prevalence of all the painful conditions and systemic diseases investigated; b) cervicalgia was significantly associated with the presence of painful TMD, compared with the condition of the controls; c) gender, cervicalgia, BP and NSPS were significantly associated with the presence of a comorbidity (painful TMD+M), compared with the condition of the controls; d) when comparing individuals with TMD, the presence of M (comorbid group) was associated with gender, diabetes and NSPS.

In our results, the report of persistent cervicalgia figured as an important factor associated with TMD only or TMD+M. Previous studies have shown that cervicalgia is both associated with and a predictor of TMD,^8,27 as is M.²⁸ Among the hypotheses about the mechanisms related to these associations, the anatomical aspects seem to be particularly relevant. Muscles and ligaments of the cranial area are connected in the cervical region, possibly resulting in an interaction among such factors as neck muscle activity, head position, and mandibular function.²⁹ Moreover, there is a convergence of cervical and trigeminal inputs with the spinal trigeminal nucleus, resulting in referred pain.²

In the present study, both TMD and M were more prevalent among adult women than men. In the univariate regression, gender was significantly associated with both groups (TMD only and TMD+M), whereas in the multiple regressions, it figured as a significant predictor only for the comorbid group. Similar results were found by other authors with a higher prevalence in women^10,30 aged 20 to 40 years.³⁰ These differences may be attributed to the different activation of the endogenous analgesia system and the central processing of nociceptive stimuli between genders. Moreover, sexual hormones, especially estrogen, have been pointed out as playing an important role in sensitivity to pain, altering the pain threshold and tolerance according to the menstrual cycle phase. TMD onset tends to occur after puberty, and the increase in the severity of signs and symptoms generally reaches its peak during the reproductive age, with higher prevalence in young adult women.³⁰

In our sample, the presence of diffuse BP was significantly associated with comorbidity. It has been reported that multiple pain conditions elsewhere in the body could predict TMD onset,³¹ and influence its maintenance.³² Migraineurs are also more likely to report BP.²⁵ It is plausible to hypothesize that this association could be related to central sensitization and functional changes in genetically susceptible individuals.³³ Previous evidence supports the theory that the activation and sensitization of the trigeminovascular system may result in the impairment of diffuse noxious inhibitory control,³⁴ predisposing to a progressive development of cephalic and whole-body cutaneous allodynia.³⁵ This evidence is consistent with our findings, considering that the association between M and TMD may reflect a more severe state of sensitization.

Although more studies are needed to improve the understanding of the mechanisms involved in comorbid conditions, our results are aligned with the evidence pointing to the relevant role of the central and peripheral nervous systems. Structural and functional aspects have to be considered, in addition to the influence of other aspects, such as genetics and psychosocial alterations.^1,28,37

We can conclude that individuals with a comorbidity (M associated with painful TMD) show a more severe condition, as evidenced by the higher number of predictor variables, compared with individuals with only painful TMD. This finding strongly entails impairment of the endogenous mechanisms of pain control, which should be considered in all processes, from diagnosis to treatment plan.

References

• ¹
  Diatchenko L, Nackley AG, Slade GD, Fillingim RB, Maixner W. Idiopathic pain disorders—pathways of vulnerability. Pain. 2006 Aug;123(3):226-30. https://doi.org/10.1016/j.pain.2006.04.015
  » https://doi.org/10.1016/j.pain.2006.04.015
• ²
  De Leeuw R, Klasser GD, editors. Orofacial pain: guidelines for assessment, diagnosis and management. 5th ed. Hanover Park: Quintessence; 2013.
• ³
  Aggarwal VR, Macfarlane GJ, McBeth J. A high tender point count is associated with the presence of multiple idiopathic pain disorders: results from a population study. Eur J Pain. 2012 Sep;16(8):1195-203. https://doi.org/10.1002/j.1532-2149.2012.00127.x
  » https://doi.org/10.1002/j.1532-2149.2012.00127.x
• ⁴
  Visscher CM, Wesemael-Suijkerbuijk EA, Lobbezoo F. Is the experience of pain in patients with temporomandibular disorder associated with the presence of comorbidity? Eur J Oral Sci. 2016 Oct;124(5):459-64. https://doi.org/10.1111/eos.12295
  » https://doi.org/10.1111/eos.12295
• ⁵
  Velly AM, Look JO, Schiffman E, Lenton PA, Kang W, Messner RP et al. The effect of fibromyalgia and widespread pain on the clinically significant temporomandibular muscle and joint pain disorders: a prospective 18-month cohort study. J Pain. 2010 Nov;11(11):1155-64. https://doi.org/10.1016/j.jpain.2010.02.009
  » https://doi.org/10.1016/j.jpain.2010.02.009
• ⁶
  Velly AM, Fricton J. The impact of comorbid conditions on treatment of temporomandibular disorders. J Am Dent Assoc. 2012;142(2):170-2. https://doi.org/10.14219/jada.archive.2011.0060
  » https://doi.org/10.14219/jada.archive.2011.0060
• ⁷
  Costa YM, Conti PC, Faria FA, Bonjardim LR. Temporomandibular disorders and painful comorbidities: clinical association and underlying mechanisms. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017 Mar;123(3):288-97. https://doi.org/10.1016/j.oooo.2016.12.005
  » https://doi.org/10.1016/j.oooo.2016.12.005
• ⁸
  Plesh O, Adams SH, Gansky SA. Temporomandibular joint and muscle disorder-type pain and comorbid pains in a national US sample. J Orofac Pain. 2011;25(3):190-8.
• ⁹
  Gonçalves DA, Speciali JG, Jales LC, Camparis CM, Bigal ME. Temporomandibular symptoms, migraine, and chronic daily headaches in the population. Neurology. 2009 Aug;73(8):645-6. https://doi.org/10.1212/WNL.0b013e3181b389c2
  » https://doi.org/10.1212/WNL.0b013e3181b389c2
• ¹⁰
  Gonçalves DA, Bigal ME, Jales LC, Camparis CM, Speciali JG. Headache and symptoms of temporomandibular disorder: an epidemiological study. Headache. 2010 Feb;50(2):231-41. https://doi.org/10.1111/j.1526-4610.2009.01511.x
  » https://doi.org/10.1111/j.1526-4610.2009.01511.x
• ¹¹
  Franco AL, Gonçalves DA, Castanharo SM, Speciali JG, Bigal ME, Camparis CM. Migraine is the most prevalent primary headache in individuals with temporomandibular disorders. J Orofac Pain. 2010;24(3):287-92.
• ¹²
  Goncalves DA, Camparis CM, Speciali JG, Castanharo SM, Ujikawa LT, Lipton RB et al. Treatment of comorbid migraine and temporomandibular disorders: a factorial, double-blind, randomized, placebo-controlled study. J Orofac Pain. 2013;27(4):325-35. https://doi.org/10.11607/jop.1096
  » https://doi.org/10.11607/jop.1096
• ¹³
  Gonçalves DA, Camparis CM, Speciali JG, Franco AL, Castanharo SM, Bigal ME. Temporomandibular disorders are differentially associated with headache diagnoses: a controlled study. Clin J Pain. 2011 Sep;27(7):611-5. https://doi.org/10.1097/AJP.0b013e31820e12f5
  » https://doi.org/10.1097/AJP.0b013e31820e12f5
• ¹⁴
  Ohrbach R, Fillingim RB, Mulkey F, Gonzalez Y, Gordon S, Gremillion H et al. Clinical findings and pain symptoms as potential risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study. J Pain. 2011;12(11):27-45. https://doi.org/10.1016/j.jpain.2011.09.001
  » https://doi.org/10.1016/j.jpain.2011.09.001
• ¹⁵
  Sagripanti M, Viti C. Primary headaches in patients with temporomandibular disorders: diagnosis and treatment of central sensitization pain. Cranio. 2017 Jul;28(7):1-9. https://doi.org/10.1080/08869634.2017.1359353
  » https://doi.org/10.1080/08869634.2017.1359353
• ¹⁶
  Di Paolo C, D'Urso A, Papi P, Di Sabato F, Rosella D, Pompa G et al. Temporomandibular disorders and headache: a retrospective analysis of 1198 patients. Pain Res Manag. 2017;2017:ID3203027. https://doi.org/10.1155/2017/3203027
  » https://doi.org/10.1155/2017/3203027
• ¹⁷
  Florencio LL, Oliveira AS, Carvalho GF, Dach F, Bigal ME, Fernández-de-Las-Peñas C,et al. Association between severity of temporomandibular disorders and the frequency of headache attacks in women with migraine: a cross-sectional study. J Manipulative Physiol Ther. 2017 May;40(4):250-4. https://doi.org/10.1016/j.jmpt.2017.02.006
  » https://doi.org/10.1016/j.jmpt.2017.02.006
• ¹⁸
  Koutris M, Visscher CM, Lobbezoo F, Naeije M. Comorbidity negatively influences the outcomes of diagnostic tests for musculoskeletal pain in the orofacial region. Pain. 2013 Jun;154(6):927-32. https://doi.org/10.1016/j.pain.2013.03.004
  » https://doi.org/10.1016/j.pain.2013.03.004
• ¹⁹
  Bonato LL, Quinelato V, De Felipe Cordeiro PC, De Sousa EB, Tesch R, Casado PL. Association between temporomandibular disorders and pain in other regions of the body. J Oral Rehabil. 2017 Jan;44(1):9-15. https://doi.org/10.1111/joor.12457
  » https://doi.org/10.1111/joor.12457
• ²⁰
  Tjakkes GH, Reinders JJ, Tenvergert EM, Stegenga B. TMD pain: the effect on health related quality of life and the influence of pain duration. Health Qual Life Outcomes. 2010 May;8(1):46. https://doi.org/10.1186/1477-7525-8-46
  » https://doi.org/10.1186/1477-7525-8-46
• ²¹
  Ligthart L, Visscher CM, Houtem CM, Geels LM, Vink JM, Jongh A et al. Comorbidity among multiple pain symptoms and anxious depression in a Dutch population sample. J Pain. 2014 Sep;15(9):945-55. https://doi.org/10.1016/j.jpain.2014.06.007
  » https://doi.org/10.1016/j.jpain.2014.06.007
• ²²
  Lucena LB, Kosminsky M, Costa LJ, Góes PS. Validation of the Portuguese version of the RDC/TMD Axis II questionnaire. Braz Oral Res. 2006 Oct-Dec;20(4):312-7. https://doi.org/10.1590/S1806-83242006000400006
  » https://doi.org/10.1590/S1806-83242006000400006
• ²³
  The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160.
• ²⁴
  Chen H, Nackley A, Miller V, Diatchenko L, Maixner W. Multisystem dysregulation in painful temporomandibular disorders. J Pain. 2013 Sep;14(9):983-96. https://doi.org/10.1016/j.jpain.2013.03.011
  » https://doi.org/10.1016/j.jpain.2013.03.011
• ²⁵
  Cuadrado ML, Young WB, Fernández-de-las-Peñas C, Arias JA, Pareja JA. Migrainous corpalgia: body pain and allodynia associated with migraine attacks. Cephalalgia. 2008 Jan;28(1):87-91. https://doi.org/10.1111/j.1468-2982.2007.01485.x
  » https://doi.org/10.1111/j.1468-2982.2007.01485.x
• ²⁶
  Sarlani E, Greenspan JD. Why look in the brain for answers to temporomandibular disorder pain? Cells Tissues Organs. 2005;180(1):69-75. https://doi.org/10.1159/000086200
  » https://doi.org/10.1159/000086200
• ²⁷
  Ohrbach R, Bair E, Fillingim RB, Gonzalez Y, Gordon SM, Lim PF et al. Clinical orofacial characteristics associated with risk of first-onset TMD: the OPPERA prospective cohort study. J Pain. 2013;14(12):33-50. https://doi.org/10.1016/j.jpain.2013.07.018
  » https://doi.org/10.1016/j.jpain.2013.07.018
• ²⁸
  Tosato JP, Gonzalez TO, Sampaio LMM, Corrêa JCF, Gonzalez DAB. Prevalência de sinais e sintomas de disfunção temporomandibular em mulheres com cervicalgia e lombalgia. Arq Med ABC. 2007;32(Supl 2):S20-2.
• ²⁹
  Woda A, Pionchon P, Palla S. Regulation of mandibular postures: mechanisms and clinical implications. Crit Rev Oral Biol Med. 2001;12(2):166-78. https://doi.org/10.1177/10454411010120020601
  » https://doi.org/10.1177/10454411010120020601
• ³⁰
  Ferreira CL, Silva MA, Felício CM. Signs and symptoms of temporomandibular disorders in women and men. CoDAS. 2016 Jan-Feb;28(1):17-21. https://doi.org/10.1590/2317-1782/20162014218
  » https://doi.org/10.1590/2317-1782/20162014218
• ³¹
  LeResche L, Mancl LA, Drangsholt MT, Huang G, Von Korff M. Predictors of onset of facial pain and temporomandibular disorders in early adolescence. Pain. 2007 Jun;129(3):269-78. https://doi.org/10.1016/j.pain.2006.10.012
  » https://doi.org/10.1016/j.pain.2006.10.012
• ³²
  Rammelsberg P, LeResche L, Dworkin S, Mancl L. Longitudinal outcome of temporomandibular disorders: a 5-year epidemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain. 2003;17(1):9-20.
• ³³
  Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar;152(3 Suppl):S2-15. https://doi.org/10.1016/j.pain.2010.09.030
  » https://doi.org/10.1016/j.pain.2010.09.030
• ³⁴
  Boyer N, Dallel R, Artola A, Monconduit L. General trigeminospinal central sensitization and impaired descending pain inhibitory controls contribute to migraine progression. Pain. 2014 Jul;155(7):1196-205. https://doi.org/10.1016/j.pain.2014.03.001
  » https://doi.org/10.1016/j.pain.2014.03.001
• ³⁵
  Noseda R, Burstein R. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, CSD, sensitization and modulation of pain. Pain. 2013 Dec;154 Suppl 1: https://doi.org/10.1016/j.pain.2013.07.021
  » https://doi.org/10.1016/j.pain.2013.07.021
• ³⁶
  McCracken LM, Faber SD, Janeck AS. Pain-related anxiety predicts non-specific physical complaints in persons with chronic pain. Behav Res Ther. 1998 Jun;36(6):621-30. https://doi.org/10.1016/S0005-7967(97)10039-0
  » https://doi.org/10.1016/S0005-7967(97)10039-0
• ³⁷
  Velly AM, Look JO, Carlson C, Lenton PA, Kang W, Holcroft CA et al. The effect of catastrophizing and depression on chronic pain—a prospective cohort study of temporomandibular muscle and joint pain disorders. Pain. 2011 Oct;152(10):2377-83. https://doi.org/10.1016/j.pain.2011.07.004
  » https://doi.org/10.1016/j.pain.2011.07.004
• ³⁸
  Kitsoulis P, Marini A, Iliou K, Galani V, Zimpis A, Kanavaros P et al. Signs and symptoms of temporomandibular joint disorders related to the degree of mouth opening and hearing loss. BMC Ear Nose Throat Disord. 2011 May;11(1):5. https://doi.org/10.1186/1472-6815-11-5
  » https://doi.org/10.1186/1472-6815-11-5
• ³⁹
  Leeuw R, Klasser GD, Albuquerque RJ. Are female patients with orofacial pain medically compromised? J Am Dent Assoc. 2005 Apr;136(4):459-68. https://doi.org/10.14219/jada.archive.2005.0201
  » https://doi.org/10.14219/jada.archive.2005.0201
• ⁴⁰
  Teixido M, Seymour P, Kung B, Lazar S, Sabra O. Otalgia associated with migraine. Otol Neurotol. 2011 Feb;32(2):322-5. https://doi.org/10.1097/MAO.0b013e318200a0c4
  » https://doi.org/10.1097/MAO.0b013e318200a0c4

Publication Dates

• Publication in this collection
  2018

History

• Received
  07 Oct 2017
• Accepted
  21 Feb 2018
• Reviewed
  04 June 2018