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Psychological Factors Associated With Development of TMD: The OPPERA Prospective Cohort Study
Open accessAbstract
Unlabelled Case-control studies have consistently associated psychological factors with chronic pain in general and with temporomandibular disorder (TMD) specifically. However, only a handful of prospective studies have explored whether preexisting psychological characteristics represent risk factors for first-onset TMD. The current findings derive from the prospective cohort study of the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) cooperative agreement. For this study, 3,263 TMD-free participants completed a battery of psychological instruments assessing general psychological adjustment and personality, affective distress, psychosocial stress, somatic symptoms, and pain coping and catastrophizing. Study participants were then followed prospectively for an average of 2.8 years to ascertain cases of first-onset of TMD, and 2,737 provided follow-up data and were considered in the analyses of TMD onset. In bivariate and demographically adjusted analyses, several psychological variables predicted increased risk of first-onset TMD, including reported somatic symptoms, psychosocial stress, and affective distress. Principal component analysis of 26 psychological scores was used to identify latent constructs, revealing 4 components: stress and negative affectivity, global psychological and somatic symptoms, passive pain coping, and active pain coping. In multivariable analyses, global psychological and somatic symptoms emerged as the most robust risk factor for incident TMD. These findings provide evidence that measures of psychological functioning can predict first onset of TMD. Future analyses in the OPPERA cohort will determine whether these psychological factors interact with other variables to increase risk for TMD onset and persistence.Perspective This article reports that several premorbid psychological variables predict first-onset TMD in the OPPERA study, a large prospective cohort study designed to discover causal determinants of TMD pain. Measures of somatic symptoms were most strongly associated with TMD onset, but perceived stress, previous life events, and negative affect also predicted TMD incidence.
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“Psychosocial distress is a risk factor for onset of acute- and chronic TMD, and can be a cause and a consequence of TMD (Fillingim et al., Citation2013, Citation2018).”
From The association between pain-related factors and psychological distress in patients with temporomandibular disorder. (2023) · cites this paper as Fillingim et al., 2013
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“Several studies found that patients reporting positive general social support but lacking solicitous responses to pain were less likely to develop persistent phantom limb pain post-amputation and report lower levels of physical dysfunction 85, 107, 109.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [109]
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Self-citationManagement of pain in patients with temporomandibular disorder (TMD): challenges and solutions
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ResultTemporomandibular Joint Disorders in Older Adults
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InfluentialSelf-citationAlessandro de, S. I. R. E., Marotta, N., Ferrillo, M., Agostini, F., Sconza, C., Lippi, L., Respizzi, S., Giudice, A., Invernizzi, M., & Ammendolia, A. (2022) · International Journal of Molecular Sciences · doi:10.3390/ijms23052528 · Cited by 120
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Is there a relationship between psychological factors and TMD?
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“Firstly, somatic symptoms could result from parafunctional behaviours such as bruxism or nail-biting or other behavioural changes such as sleep disturbance, and this can in turn increase the risk of TMD, thus exacerbating the symptoms of TMD including pain intensity (29).”
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Slade, G. D., Sanders, A. E., Ohrbach, R. K., Bair, E., Maixner, W. D., Greenspan, J. D., Fillingim, R. B., Smith, S. B., & Diatchenko, L. B. (2015) · Journal of Dental Research · doi:10.1177/0022034515595043 · Cited by 64
“…prospective studies confirmed the temporal sequence of this relationship, showing that increases in several dimensions of psychological distress predicted greater risk of TMD development (Slade et al. 2007; Aggarwal et al. 2010; Kindler et al. 2012; Fillingim et al. 2013; Sipila et al. 2013).”
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Self-citationPremorbid and concurrent predictors of TMD onset and persistence
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BackgroundMethodSelf-citationJivnani, H., Tripathi, S., Rai, R. S., Singh, B. P., Agrawal, K. K., & Singhal, R. (2017) · Journal of Prosthodontics · doi:10.1111/jopr.12704 · Cited by 49
Genome-wide association reveals contribution of MRAS to painful temporomandibular disorder in males
Smith, S. B., Parisien, M., Bair, E., Belfer, I., Chabot‐Doré, A., Gris, P., Khoury, S., Tansley, S. N., Torosyan, Y., Zaykin, D. V., et al. (2018) · Pain · doi:10.1097/j.pain.0000000000001438 · Cited by 56
Self-citationAdaptive Stress Coping in Awake Bruxism
Soto-Goñi, X., Alén, F., Buiza-González, L., Marcolino-Cruz, D., Sánchez, T. S., García, I. A., Aneiros-López, F., & Jiménez‐Ortega, L. (2020) · Frontiers in Neurology · doi:10.3389/fneur.2020.564431 · Cited by 49
“It is possible that awake bruxism could constitute a risk factor for TMD only when accompanied by maladaptive coping strategies and/or the lack of adaptive ones (positive reappraisal) that might increase perceived stress, which, in turn, has been described as the strongest psychological predictor of TMD (52).”
BackgroundAltered levels of salivary and plasma pain related markers in temporomandibular disorders
Jasim, H., Ghafouri, B., Gerdle, B. U. C., Hedenberg‐Magnusson, B., & Ernberg, M. M. (2020) · The Journal of Headache and Pain · doi:10.1186/s10194-020-01160-z · Cited by 48
Connelly, S., Myung, J.-H., Gupta, R. J., Tartaglia, G. M., Gizdulich, A., Yang, J., & Silva, R. (2016) · International Journal of Oral and Maxillofacial Surgery · doi:10.1016/j.ijom.2016.11.004 · Cited by 47
Patient phenotyping in clinical trials of chronic pain treatments: IMMPACT recommendations
Edwards, R. R., Dworkin, R. H., Turk, D. C., Angst, M. S., Dionne, R. A., Freeman, R. L., Hansson, P. T., Haroutounian, S., Arendt‐Nielsen, L., Attal, N., et al. (2021) · PAIN Reports · doi:10.1097/pr9.0000000000000896 · Cited by 48
“of somatic focus (eg, the somatization subscale of the Symptom Checklist-90 and the Pennebaker Inventory of Limbic Languidness) are among the strongest psychosocial predictors of the subsequent development of TMD.(91) At present, there is a paucity September 2016·Volume 157·Number 9 www.”
BackgroundSelf-citationDopamine in plasma – a biomarker for myofascial TMD pain?
Dawson, A., Stensson, N., Ghafouri, B., Gerdle, B. U. C., List, T., Svensson, P. J., & Ernberg, M. M. (2016) · The Journal of Headache and Pain · doi:10.1186/s10194-016-0656-3 · Cited by 46
“, two factors that are reported to be risk factors for M-TMD pain [20, 36] with subsequent peripheral release of dopamine.”
BackgroundDifferential diagnosis of toothache to prevent erroneous and unnecessary dental treatment
Laat, A. D. (2020) · Journal of Oral Rehabilitation · doi:10.1111/joor.12946 · Cited by 44
Chung, M., Wang, S., Alshanqiti, I., Hu, J., & Ro, J. Y. (2023) · Frontiers in Pain Research · doi:10.3389/fpain.2023.1038808 · Cited by 44
Psychological aspects of temporomandibular disorders – literature review
Berger, M., Oleszek-Listopad, J., Marczak, M., & Szymańska, J. (2015) · Current Issues in Pharmacy and Medical Sciences · doi:10.1515/cipms-2015-0044 · Cited by 44
“Beyond this, it is also essential to realize that there are psychological factors associated with initial pain symptoms in TMD, as well as sociodemographic variables that contribute to the experience of craniofacial pain [8,10,11].”
BackgroundT. Jones, G. (2016) · Current Rheumatology Reviews · doi:10.2174/1573397112666151231113438 · Cited by 43
Winocur-Arias, O., Winocur, E., Shalev, T., Reiter, S., Levartovsky, S., Emodi‐Perlman, A., & Friedman-Rubin, P. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11030589 · Cited by 43
“Caregivers and dentists in particular should be aware and regularly monitor their patients for the possible existence and consequences of AB, OP, SB and TMDs especially in stressful times such as a pandemic, in order to prevent the possible harmful consequences of such behavior over time.”
BackgroundInfluentialPredictors of Long-Term Temporomandibular Disorder Pain Intensity: An 8-Year Cohort Study
Kapos, F. P., Look, J. O., Zhang, L., Hodges, J. S., & SCHIFFMAN, E. L. (2018) · Journal of Oral & Facial Pain and Headache · doi:10.11607/ofph.1819 · Cited by 43
Roithmann, C. C., da Silva, C. A. G., Pattussi, M. P., & Grossi, M. L. (2021) · Journal of Oral Rehabilitation · doi:10.1111/joor.13265 · Cited by 45
Pharmacological Management of Orofacial Pain
Romero‐Reyes, M., Arman, S., Teruel, A., Kumar, S., Hawkins, J. M., & Akerman, S. (2023) · Drugs · doi:10.1007/s40265-023-01927-z · Cited by 41
“Moreover, another layer of complexity is the psychological burden that these disorders inflict on the individual, which impact greatly on management [2, 9, 10].”
BackgroundStocka, A., Kuć, J., Sierpińska, T., Gołębiewska, M., & Wieczorek, A. (2015) · BioMed Research International · doi:10.1155/2015/174013 · Cited by 41
Wu, Y., Lan, Y., Mao, J., Shen, J., Kang, T., & Xie, Z. (2023) · International Journal of Oral Science · doi:10.1038/s41368-023-00241-4 · Cited by 40
“Patients with painful TMD have been found that salivary levels of NGF and brain-derived neurotrophic factor (BDNF) are lower compared to healthy control subjects 211 NGF 212 and BDNF 213 are related to psychological impairment, which re fl ects a potential connection between an abnormal mental state and TMD.”
BackgroundSaini, R. S., Quadri, S. A., Mosaddad, S. A., & Heboyan, A. G. (2025) · Head & Face Medicine · doi:10.1186/s13005-025-00522-9 · Cited by 40
“Additional research [38] among adolescents with TMD revealed that the palpation index positively correlates with obsessive compulsiveness and anxiety in TMD following micro trauma.”
Interepisode Sleep Bruxism Intervals and Myofascial Face Pain
Muzalev, K., Lobbezoo, F., Janal, M. N., & Raphael, K. G. (2017) · SLEEP · doi:10.1093/sleep/zsx078 · Cited by 40
Rongo, R., Ekberg, E., Nilsson, I., Al‐Khotani, A., Alstergren, P. J., Conti, P. C. R., Durham, J., Goulet, J., Hirsch, C., Kalaykova, S., et al. (2021) · Journal of Oral Rehabilitation · doi:10.1111/joor.13301 · Cited by 45
Self-citationKnibbe, W., Lobbezoo, F., Voorendonk, E. M., Visscher, C. M., & de Jongh, A. (2022) · Journal of Oral Rehabilitation · doi:10.1111/joor.13367 · Cited by 39
Ekberg, E., Nilsson, I., Michelotti, A., Al‐Khotani, A., Alstergren, P. J., Conti, P. C. R., Durham, J., Goulet, J., Hirsch, C., Kalaykova, S., et al. (2023) · Journal of Oral Rehabilitation · doi:10.1111/joor.13488 · Cited by 44
“77,78 Similarly, use of screening instruments in Axis II can help clinicians to determine the impact of chronic pain on the lives of adolescents and how they have managed their pain.”
BackgroundMethodSelf-citationXu, L., Cai, B., Fan, S., Lu, S., & Dai, K. (2021) · Medical Science Monitor · doi:10.12659/msm.929985 · Cited by 38
“Psychological factors such as psychological distress, pain catastrophizing [26], fear-avoidance behaviors [27], depression and anxiety [28], and passive coping strategies [29] are associated with the increased pain and disability levels in patients with painful TMDs.”
BackgroundPsychologic Impact of Chronic Orofacial Pain: A Critical Review
Karamat, A., Smith, J., Melek, L. N. F., & Renton, T. F. (2022) · Journal of Oral & Facial Pain and Headache · doi:10.11607/ofph.3010 · Cited by 38
Causal Mediation in the Development of Painful Temporomandibular Disorder
Sanders, A. E., Akinkugbe, A. A., Fillingim, R. B., Ohrbach, R. K., Greenspan, J. D., Maixner, W. D., Bair, E., & Slade, G. D. (2016) · Journal of Pain · doi:10.1016/j.jpain.2016.12.003 · Cited by 40
Self-citationRisk factors for temporomandibular disorders: a systematic review of cohort studies
Da-Cas, C. D., Valesan, L. F., do Nascimento, L. P., Denardin, A. C. S., Januzzi, E., Fernandes, G., Stuginski‐Barbosa, J., & de Souza, B. D. M. (2024) · Oral Surgery Oral Medicine Oral Pathology and Oral Radiology · doi:10.1016/j.oooo.2024.06.007 · Cited by 36
Chronic Orofacial Pain: Burning Mouth Syndrome and Other Neuropathic Disorders
Tait, R. C., Ferguson, M. C., & Herndon, C. M. (2017) · Journal of Pain Management & Medicine · doi:10.35248/2684-1320.17.3.120 · Cited by 35
“Increased risk of TMD onset was associated with higher baseline levels of reported somatic symptoms, psychosocial stress, and affective distress [121,122].”
BackgroundLi, Y., Fang, M., Niu, L., Fan, Y., Liu, Y., Long, Y., Liu, X., Tay, F. R., & Chen, J. (2019) · Canadian Medical Association Journal · doi:10.1503/cmaj.181535 · Cited by 37
Lötsch, J., Sipilä, R. M., Dimova, V., & Kalso, E. A. (2018) · British Journal of Anaesthesia · doi:10.1016/j.bja.2018.06.007 · Cited by 35
Strand, E. B., Mengshoel, A. M., Sandvik, L., Helland, I. B., Abraham, S., & Nes, L. S. (2018) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2018-0095 · Cited by 34
Bonafé, E., Rezende, M., Machado, M. M., Lima, S., Fernández, E., Baldani, M. M. P., Reis, A., Loguércio, A., & Bandeca, M. (2021) · BMC Oral Health · doi:10.1186/s12903-020-01370-6 · Cited by 30
Estrogen-dependent visceral hypersensitivity following stress in rats
Hubbard, C. S., Karpowicz, J., Furman, A. J., Silva, J. T. D., Seminowicz, D. A., & Traub, R. J. (2016) · Molecular Pain · doi:10.1177/1744806916654145 · Cited by 36
Quo Vadis Temporomandibular Disorders? By 2050, the Global Prevalence of TMD May Approach 44%
Zieliński, G. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14134414 · Cited by 44
“Psychosocial factors, including stress, anxiety, and depression, also play a significant role, as they can exacerbate muscle tension and pain symptoms [16,17].”
Pain Sensitivity Modifies Risk of Injury-Related Temporomandibular Disorder
Sharma, S., Ohrbach, R. K., Fillingim, R. B., Greenspan, J. D., & Slade, G. D. (2020) · Journal of Dental Research · doi:10.1177/0022034520913247 · Cited by 33
“2011), and coping (Coping Strategies Questionnaire–Revised; Riley and Robinson 1997); these variables are explained elsewhere (Fillingim et al. 2013).”
BackgroundSelf-citationInfluence of psychological factors on the prognosis of temporomandibular disorders pain
Jung, W. S., Lee, K., & Suh, B. (2020) · Journal of Dental Sciences · doi:10.1016/j.jds.2020.02.007 · Cited by 33
“Moreover, Fillingim et al.(7) analyzed the psychological characteristics of the patients who developed TMD, and showed using multivariate analysis that SOM score was a risk factor for TMD development.”
BackgroundAlajbeg, I. Z., Vrbanović, E., Lapić, I., Alajbeg, I., & Vuletić, L. (2020) · Scientific Reports · doi:10.1038/s41598-020-67383-x · Cited by 36
Metadata
- Authors
- Fillingim, R. B., Ohrbach, R., Greenspan, J. D., Knott, C., Diatchenko, L., Dubner, R., Bair, E., Baraian, C., Mack, N., Slade, G. D., & Maixner, W.
- Affiliations
- University of Florida Health (US)
- University at Buffalo, State University of New York (US)
- University of Maryland, Baltimore (US)
- Battelle (US)
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Fillingim, Roger B.
- ORCID
- Venue
- The Journal of Pain
- Publisher
- Elsevier BV
- Published
- 2013-12
- Volume
- 14
- Issue
- 12
- Pages
- T75-T90
- ISSN
- 1526-5900 (ISSN-L)
- PMC
- PMC3855656
- OpenAlex
- W2001391699
- Cited by
- 528
- References
- 93
- Citations by year
- 2026: 45 · 2025: 62 · 2024: 65 · 2023: 52 · 2022: 69 · 2021: 48 · 2020: 42 · 2019: 30 · 2018: 41 · 2017: 21 · 2016: 22 · 2015: 14 · 2014: 7 · 2013: 5
- FWCI
- 26.10
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion)
- UNC Libraries
- Funders
- National Institutes of Health
- University at Buffalo
- National Institute of Dental and Craniofacial Research (U01DE017018)
- Topics
- Health Sciences › Dentistry › Oral Surgery › Temporomandibular Joint Disorders
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Keywords
- temporomandibular disorders, psychological risk factors, somatic symptoms, psychosocial stress, emotional distress, negative affectivity, pain coping, pain catastrophizing, psychological adjustment, personality, orofacial pain
- MeSH terms
- Adolescent, Adult, Facial Pain, Female, Humans, Male, Prospective Studies, Surveys and Questionnaires, Risk Factors, Temporomandibular Joint Disorders
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