Influence of the COVID-19 pandemic on pain and oral health-related quality of life in women with temporomandibular disorder

ABSTRACT Objective: This study aimed to evaluate and compare pain intensity and Oral Health-related Quality of Life (OHRQoL) in women with temporomandibular disorder (TMD) before (T1) and during (T2) COVID-19 pandemic. Materials and Methods: Sample was composed of forty-one female participants with painful TMD, who presented for TMD treatment. Subjects were asked to indicate their pain intensity and to answer the Oral Health Impact Profile-14 (OHIP-14). Participants data were collected twice: T1 (evaluation of medical records fulfilled before COVID-19 pandemic) and T2 (by means of an online form). Socio-demographic data were assessed in T1. Statistical analysis was performed with a significance level of 5% (Wilcoxon, chi-square or Fisher’s exact tests, multiple linear regressions). Results: No difference was found in pain intensity (p=0.26) and OHIP-14 global scores (p=0.53). Physical pain (p=0.03) and social disability (p=0.05) domains improved. In T1, subject’s occupation was associated with OHIP-14 global score, physical pain, and physical disability domains. In T2, age was associated with OHIP-14 global scores as well as physical pain, psychological discomfort, and psychological disability domains. Conclusion: COVID-19 pandemic did not worsen pain intensity and OHRQoL in women with painful TMD, and it is suggested that socio-demographic characteristics influenced TMD patients coping skills during pandemic.

On March 11, 2020, it reached the level of a pandemic, affecting countries across the world.¹ Due to its high contagion potential, 2 public health measures such as social isolation and quarantine were implemented to minimize the virus transmission. 3 While the scientific community is focusing mainly on COVID-19 prevention and treatment, 2,4 several psychological and emotional issues are being underestimated 1,4 and those may last longer than the disease itself. 2 Individual and community psychosocial impacts associated with a pandemic include fear, 5,6,7 anxiety, 4-11 depression, 5,[8][9][10][11] panic, 6,8,11 stress, 5,6,[9][10][11] and episodes of post-traumatic stress. 7,12 However, up to the date of this study, studies investigating the impact of the pandemic on quality of life are lacking. 13 Psychological factors are directly related to chronic painful conditions, and the COVID-19 pandemic has many characteristics that could potentially worsen these conditions. 5 Temporomandibular disorder (TMD) is a common musculoskeletal disorder resulting in pain and disability, and causes Mendonça AKR, Fontoura LPG, Rocha TD, Fontenele RC, Nunes TNB, Regis RR, Pinto-Fiamengui LMS Influence of the COVID-19 pandemic on pain and oral health-related quality of life in women with temporomandibular disorder 5 a significant impact on the individual as well as society, due to loss of productivity and increased number of consultations required for diagnosis and patient care. 14 TMD patients suffer from various types of psychosocial distress, such as anxiety, depression, and suicidal ideation. 15 Particularly in times of crisis, such as the COVID-19 pandemic, special attention must be given to vulnerable patient groupsnot only those susceptible to SARS-CoV-2, but also to those mentally unstable.
Individuals with TMD also present impaired oral health-related quality of life (OHRQoL). [16][17][18][19] OHRQoL is a conceptual model targeting the individual's perception of oral health. 18 It brings together the multidimensional character of symptoms, perceptions, and functional capacity. 16 The Oral Health Impact Profile (OHIP) is the most widely used instrument for measuring OHRQoL, 16 and when compared to healthy individuals, patients with TMD present worse scores related to physical pain, discomfort, and psychological disabilities. 18 Mental health can be defined by how individuals think and feel about themselves and their life, and it affects how an individual copes and manages in times of adversity. Physical and mental health are closely related, as they affect each other directly or indirectly. 20 Most mental health studies on COVID-19 Mendonça AKR, Fontoura LPG, Rocha TD, Fontenele RC, Nunes TNB, Regis RR, Pinto-Fiamengui LMS Influence of the COVID-19 pandemic on pain and oral health-related quality of life in women with temporomandibular disorder 6 focus on general population; 4,6,[8][9][10][11][12]13 however, psychological and behavioral changes due to the pandemic reveals the need for studies within specific populations, such as those with painful conditions. Therefore, due to the already established association between the COVID-19 pandemic and psychosocial impairment, 2,4,5,10,12 and the role of these in TMD worsening and perpetuation, [14][15][16][17][18] this longitudinal study aimed to evaluate and compare pain intensity and OHRQoL of women with TMD before and during COVID-19 pandemic.  subjects were asked to answer how frequently they had adverse impacts caused by TMD during the previous month, according to a 5-point ordinal scale, being: 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, and 4 = very often. The obtained scores were used to calculate severity of OHRQoL impairment. 19 Severity was characterized by the OHIP-14 global score, with a potential range of 0 (no adverse impacts) to 56 (all 14 impacts experienced very often). OHIP-14 domains were calculated by summing the response scores for the two corresponding items. 18 Socio-demographic characteristics were assessed in T1 (age, ethnicity, marital status, educational level, family income, and occupation) and T2 (occupation during pandemic). Data from all subjects were collected in T1, and 41 completed the follow-up (T2) (67.2% response rate of online form). From those who did not complete the study, reasons were as follows:

This was a cross-sectional study approved by Ethics
loss of contact = 7; refused to participate = 8; agreed to participate, but did not answer the questionnaire = 6. Participants mean age (T1) was 26.83 ± 7.54 years. Most participants were aged less than 30 years, were white, single, with a high school educational formation, and no occupation during pandemic.
A detailed description of socio-demographic characteristics is presented in Table 1.  Mendonça AKR, Fontoura LPG, Rocha TD, Fontenele RC, Nunes TNB, Regis RR, Pinto-Fiamengui LMS Influence of the COVID-19 pandemic on pain and oral health-related quality of life in women with temporomandibular disorder    Reduced accessibility to regular medical care during the social isolation due to pandemic should also be pointed out as a risk factor for the worsening of painful disorders. 5 In the present study, however, conflicting results were found, since subject's pain intensity and OHRQoL were similar before and during pandemic, and scores of OHIP-14 physical pain domain improved. Findings presented here suggest substantial need to consider socio-demographic characteristics when dealing with TMD patients.
In the present study, all participants were engaged in a regular occupational activity before the COVID-19 pandemic. Workrelated factors, such as occupation 24,25 and working-hours 26 have been related to TMD. Professions such as computer office workers 24,25 and dentists 25 show increased risk of developing TMD. In a previous study, the risk of TMD was found to be higher among women working more than 60h per week than among those working less than 40h per week, after adjusting for the general characteristics and work-related factors. 26 Also, TMD prevalence rate was higher for workers who perceived stress a lot. 26 Long-working hours have also been related to anxiety and depression, 27 and it may be assumed that mental and physical stress arising from long working-hours may affect TMD patients. 26 During pandemic, most subjects (61%) were presenting no occupation. A nationwide survey of psychological distress among Italian people during the COVID-19 Mendonça AKR, Fontoura LPG, Rocha TD, Fontenele RC, Nunes TNB, Regis RR, Pinto-Fiamengui LMS Influence of the COVID-19 pandemic on pain and oral health-related quality of life in women with temporomandibular disorder 16 pandemic found, among other factors, higher levels of stress were associated with having to leave one's domicile for work. 9 Therefore, staying in a safe place, as home, may have been a protective factor for most subjects of the present study, since perceived stress is also a risk factor for TMD. 28 Perhaps, the reduction of occupational activity, and reduced need of being productive in the work place, may have improved physical pain and social disability domains, and prevented subjects from TMD worsening.
According to a systematic review, the most often-affected OHIP domains in TMD patients are those evaluating psychological discomfort and disability, while social disability and handicap are the least often affected. 16 Although social isolation and quarantine were considered to cause a negative impact on many aspects of people's lives, 9 in the present study, the social disability domain improved during pandemic. A previous study conducted among the general population living in Jinzhou, Lianing Province, China, found that during pandemic, the majority of participants reported receiving increased social support from family and friends and increased caring for family members, especially those aged between 18-40 years. 13 In the present study those variables were note analyzed, however, the quarantine and the pandemic itself may have given opportunity for people to support and care for each other.