Neuropathic pain characteristics in patients with pain-related temporomandibular disorders

In orofacial pain patients, pain-related temporomandibular disorders (TMD) and neuropathic pain (NP) can both be present. The aim of this cross-sectional study was to examine whether in patients with orofacial pain, associations can be found between (subdiagnoses of) pain-related TMD and NP. Participants were asked to fill in the questionnaires of the Diagnostic Criteria for TMD (DC/TMD) and a screening questionnaire for NP, the Douleur Neuropathique 4 (DN4). Complete data sets were collected from 355 participants with an orofacial pain complaint. First, univariate analyses were used to pre-screen the independent variables. Subsequently, multivariate binary logistic regression analysis was used to further assess the association between the independent variables, which were significant in the univariate analyses, and the dependent variable NP. From all 355 participants, 274 (77.2%) had pain-related TMD. 72 participants (20.3%) had a DN4 score ≥4, suggesting the presence of NP. A DN4 score ≥4 occurred in 62 (22.6%) of the 274 cases with pain-related TMD. In the univariate analyses, NP was found to be significantly associated with the presence of pain-related TMD (χ2 = 4.088, p = 0.043), myalgia (χ2 = 6.916, p = 0.009), and headache attributed to TMD (χ2 = 13.366, p < 0.001). In the multivariate analysis, NP was only significantly associated with headache attributed to TMD (Odds Ratio = 2.37, 95% Confidence Interval: 1.30 to 4.34, p = 0.005). NP characteristics are associated with headache attributed to TMD. The results stress the need for including a NP assessment in diagnostic protocols for pain-related TMD.

Orofacial pain; Diagnostic criteria for temporomandibular disorders; Pain-related temporomandibular disorders; Douleur neuropathique 4; Neuropathic pain

[1] Leeuw Rd, Klasser GD. Diagnosis and management of TMD’s. In Leeuw Rd, Klasser GD (eds). Orofacial pain: guidelines for assessment, diagnosis, and management (pp.127–186). 5th edn. Quintessence Pub Co: Chicago. 2013.

[2] IASP update Fact Sheet. October 2022. Available at: https://www.iasp-pain.org/wp-content/uploads/2022/10/Orofacial_Pain.pdf (Accessed: 12 May 2024).

[3] International classification of orofacial pain, 1st edition (ICOP). Cephalalgia. 2020; 40: 129–221.

[4] Proença JDS, Baad-Hansen L, Braido GVDV, Mercante FG, Campi LB, Gonçalves DADG. Lack of correlation between central sensitization inventory and psychophysical measures of central sensitization in individuals with painful temporomandibular disorder. Archives of Oral Biology. 2021; 124: 105063.

[5] Dieleman JP, Kerklaan J, Huygen FJPM, Bouma PAD, Sturkenboom MCJM. Incidence rates and treatment of neuropathic pain conditions in the general population. Pain. 2008; 137: 681–688.

[6] Macfarlane TV, Glenny A, Worthington HV. Systematic review of population-based epidemiological studies of oro-facial pain. Journal of Dentistry. 2001; 29: 451–467.

[7] Okeson JP, de Leeuw R. Differential diagnosis of temporomandibular disorders and other orofacial pain disorders. Dental Clinics of North America. 2011; 55: 105–120.

[8] Simonek M, Türp JC, Bornstein MM, Dagassan-Berndt D. Prevalence and correlation with sex, age, and dental status of bone apposition at the mandibular angle and radiographic alterations of the temporomandibular joints: a retrospective observational study in an adult Swiss population. BMC Oral Health. 2024; 24: 193.

[9] Ferrillo M, Giudice A, Marotta N, Fortunato F, Di Venere D, Ammendolia A, et al. Pain management and rehabilitation for central sensitization in temporomandibular disorders: a comprehensive review. International Journal of Molecular Sciences. 2022; 23: 12164.

[10] Lövgren A, Visscher CM, Lobbezoo F, Yekkalam N, Vallin S, Wänman A, et al. The association between myofascial orofacial pain with and without referral and widespread pain. Acta Odontologica Scandinavica. 2022; 80: 481–486.

[11] Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet J, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortium network and orofacial pain special interest group. Journal of Oral & Facial Pain and Headache. 2014; 28: 6–27.

[12] Taxonomy ITFo. Part III: pain terms, a current list with definitions and notes on usage. Classification of Chronic Pain second edition (Revised) (pp. 209–214). IASP: Washington, DC. 2011.

[13] Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008; 70: 1630–1635.

[14] Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DLH, Bouhassira D, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain. 2016; 157: 1599–1606.

[15] Chen J, Weidner N, Puttagunta R. The impact of activity-based interventions on neuropathic pain in experimental spinal cord injury. Cells. 2022; 11: 3087.

[16] Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005; 114: 29–36.

[17] Rolke R, Baron R, Maier C, Tolle TR, Treede RD, Beyer A, et al. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain. 2006; 123: 231–243.

[18] Cayrol T, van den Broeke EN, Gerard E, Meeus M, Mouraux A, Roussel N, et al. Chronic temporomandibular disorders are associated with higher susceptibility to develop central sensitization: a case-control study. Pain. 2023; 164: e251–e258.

[19] Kothari SF, Baad-Hansen L, Oono Y, Svensson P. Somatosensory assessment and conditioned pain modulation in temporomandibular disorders pain patients. Pain. 2015; 156: 2545–2555.

[20] Zafereo J, Wang‐Price S, Kandil E. Quantitative sensory testing discriminates central sensitization inventory scores in participants with chronic musculoskeletal pain: an exploratory study. Pain Practice. 2021; 21: 547–556.

[21] Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007; 133: 581–624.

[22] DC/TMD Symptom Questionnaire (updated 05 December 2013). Available from: https://ubwp.buffalo.edu/rdc-tmdinternational/wp-content/uploads/sites/58/2017/01/DC-TMD_SQ_shortform_2013-05-12.pdf (Accessed: 12 May 2024).

[23] (IHS) HCCotIHS. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38: 1–211.

[24] Svensson P, Drangsholt M, Pfau DB, List T. Neurosensory testing of orofacial pain in the dental clinic. The Journal of the American Dental Association. 2012; 143: e37–e39.

[25] van der Meer HA, Calixtre LB, Engelbert RHH, Visscher CM, Nijhuis-van der Sanden MW, Speksnijder CM. Effects of physical therapy for temporomandibular disorders on headache pain intensity: a systematic review. Musculoskeletal Science and Practice. 2020; 50: 102277.

[26] Vale Braido GVD, Svensson P, Dos Santos Proença J, Mercante FG, Fernandes G, de Godoi Gonçalves DA. Are central sensitization symptoms and psychosocial alterations interfering in the association between painful TMD, migraine, and headache attributed to TMD? Clinical Oral Investigations. 2023; 27: 681–690.

[27] Shrivastava M, Battaglino R, Ye L. A comprehensive review on biomarkers associated with painful temporomandibular disorders. International Journal of Oral Science. 2021; 13: 23.

[28] Yang G, Baad-Hansen L, Wang K, Fu K, Xie Q, Svensson P. Somatosensory abnormalities in Chinese patients with painful temporomandibular disorders. The Journal of Headache and Pain. 2016; 17: 31.

[29] La Cesa S, Tamburin S, Tugnoli V, Sandrini G, Paolucci S, Lacerenza M, et al. How to diagnose neuropathic pain? The contribution from clinical examination, pain questionnaires and diagnostic tests. Neurological Sciences. 2015; 36: 2169–2175.

[30] Kleykamp BA, Ferguson MC, McNicol E, Bixho I, Arnold LM, Edwards RR, et al. The prevalence of comorbid chronic pain conditions among patients with temporomandibular disorders. The Journal of the American Dental Association. 2022; 153: 241–250.e10.

[31] Kleykamp BA, Ferguson MC, McNicol E, Bixho I, Arnold LM, Edwards RR, et al. The prevalence of psychiatric and chronic pain comorbidities in fibromyalgia: an ACTTION systematic review. Seminars in Arthritis and Rheumatism. 2021; 51: 166–174.

[32] Wang Y, Mo X, Zhang J, Fan Y, Wang K, Peter S. Quantitative sensory testing (QST) in the orofacial region of healthy Chinese: influence of site, gender and age. Acta Odontologica Scandinavica. 2018; 76: 58–63.

[33] Durham J, Breckons M, Araujo-Soares V, Exley C, Steele J, Vale L. Developing effective and efficient care pathways in chronic pain: DEEP study protocol. BMC Oral Health. 2014; 14: 6.

[34] Baggen JHM, Koevoets AC, Koutris M, Steegers MAH, Lobbezoo F. Chronic temporomandibular disorder pain patients with a history of neuropathic pain treatment: a narrative research on their diagnosis and treatment history. BMC Oral Health. 2024; 24: 22.

[35] Baron R. Mechanisms of disease: neuropathic pain—a clinical perspective. Nature Clinical Practice Neurology. 2006; 2: 95–106.

[36] Timmerman H, Wilder-Smith O, van Weel C, Wolff A, Vissers K. Detecting the neuropathic pain component in the clinical setting: a study protocol for validation of screening instruments for the presence of a neuropathic pain component. BMC Neurology. 2014; 14: 94.

[37] Kosek E, Cohen M, Baron R, Gebhart GF, Mico J, Rice ASC, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016; 157: 1382–1386.