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Eur J Pain. 2019 Aug 17. doi: 10.1002/ejp.1472. [Epub ahead of print]

Premorbid and concurrent predictors of TMD onset and persistence.

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Department of Oral Diagnostic Sciences, University at Buffalo, Buffalo, New York.
Department of Dental Ecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Center for Pain Research and Innovation, University of North Carolina, Chapel Hill, North Carolina.
Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina.
Department of Endodontics, University of North Carolina, Chapel Hill, North Carolina.
Alan Edwards Centre for Research on Pain, McGill University, Montréal, QC, Canada.
Department of Neural and Pain Sciences, and Brotman Facial Pain Clinic, University of Maryland School of Dentistry, Baltimore, Maryland.
Department of Anesthesiology, Center for Translational Pain Medicine, Duke University, Durham, North Carolina.
Pain Research and Intervention Center of Excellence, Gainesville, Florida.



Multiple risk factors predict temporomandibular disorders (TMD) onset, but temporal changes in risk factors and their contribution to risk of TMD have not been evaluated. The study aims were to (a) describe changes occurring in premorbid TMD risk factors when re-measured at TMD onset and 6 months later, and (b) determine if measures of change improve accuracy in predicting TMD incidence compared to premorbid measures alone.


In this observational prospective cohort study at four university research clinics, 3,258 community-based, 18- to 44-year-olds without TMD were enrolled. During the 3-year median follow-up, 260 incident cases of first-onset TMD were identified, and 196 TMD-free subjects were selected as matched controls. Six-months later, 147 of 260 incident cases (56.6%) were re-examined revealing 72 (49%) with 'persistent TMD' and 75 (51%) whose condition had resolved ('transient TMD'). Virtually all (126) of the 127 re-examined controls remained without TMD. Questionnaires and clinical measurements evaluated risk factors from clinical, health, psychological and behavioural and neurosensory domains.


Most risk factors across all four domains increased with TMD onset, remained elevated in the persistent group and declined in the transient group (i.e., significant ANOVA interactions, p < .05). Accuracy in predicting first-onset TMD, quantified as area under the receiver operating characteristic curve was 0.71 (95% CL 0.68, 0.73) using only premorbid measures of risk factors, which increased to 0.91 (95% CL 0.89, 0.94) after addition of change measures.


TMD pain onset and persistence appear to be determined by enduring characteristics of the person as well as mutually interactive with temporally evolving variables.


TMD is known to be a complex disorder, in which onset and persistence are associated with disease-related variables in multiple domains, including environmental exposure, clinical, psychological, health status, and pain processing variables. Using a more dynamic approach in order to capture change across time, many aspects of those domains were found to worsen prior to the reporting of pain, with bidirectional influences between domains and pain emergence likely. TMD onset appears to represent the cumulative effect of multiple system dysregulation.


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