Psychosocial Scores and Jaw Muscle Activity in Women

Yoly M. Gonzalez, DDS, MS, MPH Aims: To test whether women with temporomandibular disorder (TMD)–related
Associate Professor pain showed higher psychosocial scores and higher awake- and sleep-time
Department of Oral Diagnostic Sciences jaw muscle activities (characterized by duty factors) compared to pain-free
School of Dental Medicine
State University of New York at Buffalo controls and whether psychosocial scores and the jaw muscle duty factors
Buffalo, New York, USA were associated. Methods: Subjects gave informed consent to participate.
The Diagnostic Criteria for TMD (DC/TMD) were used for diagnosis of TMD
Jeffrey C. Nickel, DMD, MSc, PhD
Associate Professor pain, and 31 and 36 women were included in the TMD-related pain and control
Department of Orthodontics groups, respectively. DC/TMD Axis II instruments were used to determine
School of Dentistry psychosocial scores. Subjects self-recorded masseter and anterior temporalis
Oregon Health & Science University electromyography (EMG) over 3 days and 3 nights. The duty factor (time of
Portland, Oregon, USA muscle activity/total recording time [%]) was quantified using subject-specific
JoAnna M. Scott, MS, PhD EMG/bite-force calibration via data recorded in the laboratory. Group differences
Assistant Professor (α = .05) were assessed for psychosocial scores and duty factors using chi-
Office of Research & Graduate Programs square and two-sample t tests. Linear regression assessed whether psychosocial
School of Dentistry
University of Missouri Kansas City scores were associated with duty factors. Results: Average duty factors
Kansas City, Missouri, USA were ≤ 2.4% for awake and sleep times in both muscles, and between-group
comparisons showed no significant differences. For physical symptom scores,
Hongzeng Liu, PhD
Senior Research Associate there were significantly fewer TMD-related pain subjects in the normal category
Department of Orthodontics and significantly more in the moderate-severe category (all P < .01) compared
School of Dentistry to controls. Subjects with elevated compared to normal psychosocial scores
Oregon Health & Science University showed significantly higher jaw muscle duty factors by ≥ 1.5-fold. Conclusion: A
Portland, Oregon, USA significantly larger proportion of TMD-related pain subjects compared to control
Laura R. Iwasaki, DDS, MSc, PhD subjects had moderate-severe physical symptom scores. Awake- and sleep-time
Associate Professor jaw muscle duty factors were not different between groups and were generally
Department of Orthodontics low among all subjects. Additionally, higher than normal psychosocial scores were
School of Dentistry
Oregon Health & Science University associated with significantly more low-magnitude jaw muscle activity. J Oral Facial
Portland, Oregon, USA Pain Headache 2018;32:381–388. doi: 10.11607/ofph.2133

Correspondence to: Keywords: bruxism, EMG, jaw muscle, pain, psychosocial factors, TMD
Dr Laura Iwasaki
2730 SW Moody Avenue, SDORTHO

P
Portland, OR 97201
Fax: 503-494-5777 arafunctional jaw muscle activity is regarded as both a cause and
Email: iwasaki@ohsu.edu a consequence of TMD-related pain.1,2 In addition, it is thought
that common mental health states such as somatization, anxi-
©2018 by Quintessence Publishing Co Inc. ety, and depression are associated with the onset and development
of chronic TMD-related pain.3,4 Previous pilot studies have shown in-
creased low-level awake-time jaw muscle activities in subjects with
TMD-related pain5 compared to subjects without TMD pain and in
subjects with self-reported somatic and depression symptoms6 com-
pared to subjects without these symptoms. Also, a recent systematic
review7 assessed the evidence for the association between psychoso-
cial states and development of TMD-related pain due to increased jaw
muscle activities. Although co-occurrence of these states with pain and
jaw muscle dysfunction was found, no clear suggestions about cau-
sality were possible due to the lack of quantitative data characterizing
muscle activities during the day and night, control groups, repeated
measures, and validation of instrument accuracy.
Quantitative analysis of polysomnography8,9 and ambulatory awake-
and sleep-time jaw muscle electromyography (EMG)10,11 showed that
jaw behaviors rarely produced large mandibular loads. For example,

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Gonzalez et al

sleep-time recordings in women with and without disease, or with a history of trauma to or evidence of
temporomandibular joint (TMJ) disc displacement degenerative hard tissue changes in the TMJ were
and chronic pain showed that 95% of anterior tem- excluded. Chronic TMD-related pain was diagnosed
poralis–related clenches had a duration of < 4 sec- based on Axis I data that confirmed: (1) a history of
onds and were associated with bite forces < 10 N.11 facial pain within the past 30 days; (2) pain that was
However, in women with TMJ disc displacement and modified by function and/or parafunction; (3) pain
chronic pain, clench durations were 1.4-fold longer that was localized in the masticatory structures; and
and the anterior temporalis muscle duty factor for (4) pain that was familiar upon clinical provocation.
clenching (time of muscle activity during clenching/ Pains from masticatory structures were grouped be-
total recording time [%]) was, on average, 1.8-fold cause of growing evidence that chronic TMD-related
higher compared to healthy women. Nevertheless, pain is a central rather than a localized condition.19
total cumulative duration of these intermittent muscle Subjects made a minimum of three study visits to
activities lasted on average less than 5 minutes per perform previously described protocols.5,6,20 During
7-hour recording period, which suggests that other the first visit, a calibrated examiner reviewed the sub-
conditions may contribute to the presence or ab- ject’s medical history and performed the Axis I clin-
sence of chronic TMD-related pain. ical examination. The subject also completed Axis II
The current study was initiated to address the questionnaires and had cone beam CT images made.
identified needs7 noted above; namely, more quanti- At the second and third visits, bilateral surface EMG
tative data collected from case and control groups was recorded were made from the subject’s masse-
to characterize jaw muscle activity in natural environ- ter and anterior temporalis muscles during static and
ments during awake and sleep times and to charac- dynamic unilateral molar biting of low to medium ef-
terize psychosocial states using validated instruments fort on a calibrated bite-force transducer using es-
to test for associations. If verified, these associations tablished techniques.10 These laboratory recordings
could elucidate potential causal links between jaw were used to determine subject- and muscle-specific
muscle use and TMD-related pain for future investi- EMG/bite-force relations to calibrate the EMG re-
gations. As the incidence of TMD is higher for women corded by subjects in their natural environments. An
than for men,12 the focus of the present study was on investigator positioned the transducer between the
female subjects.12 Jaw muscle activity was quantified molars on the right and then the left side while the
using duty factors13–16 for comprehensive ranges of subject performed five static bites (holding the bite
magnitude and duration of muscle activity thresholds. force constant for about 3 seconds during each bite)
Therefore, this study aimed to test whether women and dynamic bites of varying effort at each of four
with TMD-related pain showed higher psychosocial different frequencies (0.5, 1.0, 1.5, 2.0 Hz) guided
scores and higher awake- and sleep-time jaw muscle by a digital metronome. No feedback regarding bite-
activities compared to pain-free controls, as well as force magnitude was provided to the subject. During
whether these psychosocial scores were associated the second visit, following the laboratory EMG and
with jaw muscle duty factors. bite-force recordings, the subject learned to use the
portable surface EMG equipment and supplies to
self-record from the masseter and anterior tempora-
Materials and Methods lis muscles on one side for at least 6 hours during
each of three awake and three sleep periods by us-
Subject Recruitment and Protocols ing previously described protocols.20 At the third vis-
This study was performed in accordance with guide- it, subjects returned EMG equipment and submitted
lines for strengthening the reporting of observa- data collected on storage cards and diary forms with
tional studies in epidemiology (STROBE). Adult notes about recordings.
subjects were recruited between 2011 and 2016 at
the University at Buffalo School of Dental Medicine Psychosocial Scores
and gave written informed consent to participate. Psychosocial data were collected via recognized, re-
Their rights were protected by two university institu- liable, and validated DC/TMD Axis II instruments and
tional review boards. The Diagnostic Criteria for TMD approaches.17 Subjects’ self-reports from the Patient
(DC/TMD)17 were applied using clinical examinations Health Questionnaire-15 (PHQ-15), Generalized
(Axis I) and computed tomography (CT) images of Anxiety Disorders 7-item scale (GAD-7), and PHQ-9
the head18 plus validated psychosocial instruments were used to quantitatively assess the severity of
(Axis II). A calibrated radiologist blinded to other study physical symptoms (somatization), anxiety symptoms,
data determined the presence or absence of osseous and depression symptoms, respectively. Based on
TMJ degeneration via the CT images. Women with- the responses and respective guidelines for the three
out teeth, with acute or chronic dental or periodontal instruments,21–23 a blinded investigator categorized

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 Gonzalez et al

subjects according to recommended scoring as: nor- factor values were established from subjects who
mal (0–4); mild (5–9); or moderate-severe (≥ 10) for were placed into the normal category based on psy-
each psychosocial domain. chosocial scores of 0–4 on the PHQ-15, GAD-7, and
PHQ-9. Linear regression with generalized estimating
Masticatory Muscle Duty Factors equations to adjust for repeated measures was used
As previously described,20 EMG recorded by sub- to compare the combined effects of (1) compound
jects in their natural environments was calibrated psychosocial scores and (2) time period (day, night)
according to magnitude thresholds of average EMG on muscle duty factors. Fold increases in the slopes
activity for a selected, commonly used bite force of for all categories from the linear regression models
20 N (T20N), established from two laboratory visits to were calculated by dividing by the baseline duty fac-
determine jaw muscle activities via duty factors. The tor values. Fold increases in the confidence intervals
following equation was used to calculate duty factor (95% CI) were calculated similarly. Significance was
(DF) for a range of magnitudes (%T20N) and duration defined by α = .05 for all tests.
thresholds (seconds [s]):

Time of muscle activity at or above Results

given threshold (%T20N,s)
DF (%) = × 100
Total recording time Of the 242 individuals screened, 78 women qualified
and gave written consent to participate, and 67 of
[(# of windows) × 128 ms] at or these women completed the protocols. There were
above given threshold X%T20N,Y) 31 women included in the TMD pain group and 36
= × 100
Total recording time women in the control group, and the mean ± stan-
dard deviation (SD) ages were 35 ± 12 and 34 ± 13
. . . where: # of windows is the number of 128-­ years, respectively. Subjects produced 175 awake-
millisecond periods during a recording when EMG ac- and 183 sleep-time EMG recordings of mean ± SD
tivity was at the specified magnitude X% of T20N for durations of 6.9 ± 1.9 and 7.8 ± 1.7 hours, respec-
X = 5–9; 10–24; 25–49; 50–79; and ≥ 80%, and tively. Psychosocial scores were unequally distrib-
given duration Y = 0.5 to < 1; 1 to < 2; 2 to < 5; uted in the TMD pain vs control groups (Fig 1). For
5 to < 10; and ≥ 10 seconds. A 128-ms window was physical symptoms (somatization), there was a signif-
chosen to facilitate analysis of EMG signals as root icant difference in the number of TMD pain and con-
mean square (RMS) values because a sampling rate trol subjects across categories (P < .01); specifically,
of 2,000 Hz resulted in 256 data points per window. significantly more control vs TMD pain subjects were
The square root integer value of 16 ensured that there in the normal category, whereas significantly more
was no need to truncate decimal points, which may TMD pain vs control subjects were in the moder-
have produced errors in EMG RMS calculations. To ate-severe category (all P < .01; Fig 1a).
establish T20N for each subject and muscle, root mean Duty factors in the TMD pain and control groups
square muscle activities (RMS-EMG, mV) for a mus- were generally low, with a few exceptions. Duty fac-
cle and side were plotted vs bite force (N) for 25 biting tors for all EMG magnitude thresholds averaged over
tasks performed at each of two visits in the laboratory. all duration thresholds and sessions were ≤ 2.4% for
EMG activity for 20 N of bite force was calculated us- awake and sleep times in both muscles (Fig 2), and
ing linear regressions for each plot, then averaging for between-group comparisons showed no significant
the two sides and two visits for each subject and mus- differences. The highest values of these average
cle to determine T20N. Thus, a subject’s duty factors duty factors for both muscles during both awake and
for ranges of magnitude (5–9; 10–24; 25–49; 50–79; sleep times were for the lowest magnitude thresh-
≥ 80% T20N) and duration thresholds (0.5 to < 1; 1 to olds, 5–9% T20N and 10–24% T20N (Fig 2). As for the
< 2; 2 to < 5; 5 to < 10; ≥ 10 seconds) were calculat- exceptions, the highest single-session duty factors
ed for each muscle (masseter, anterior temporalis) and occurred for the masseter muscle in a control subject
time period (awake, sleep). (#002) at a magnitude threshold of 5–9% T20N and
were 65.4% for awake time at a duration threshold of
Statistical Analyses ≥ 10 seconds and 64.7% at a duration threshold of
TMD pain and control groups were compared for dif- 0.5 to < 1 second. The highest single-session anteri-
ferences within and across categories of psychoso- or temporalis duty factors were 28.9% for awake time
cial scores by using chi-square or Fisher exact and at 10–24% T20N and 1 to < 2 seconds and 13.7% for
one-sample binomial probability tests, respective- sleep time at ≥ 80% T20N and 0.5 to < 1 second in
ly. Between-group differences in duty factors were two TMD pain subjects (#114 and #087, respective-
compared using two-sample t tests. Baseline duty ly). For the largest magnitude threshold (≥ 80% T20N)

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Gonzalez et al

TMD pain TMD pain TMD pain

Frequency within category (%)

Frequency within category (%)

Frequency within category (%)

Control Control Control
100 100 100
90 2 90 90
80 80 3 80 8 1
14 8
70 70 25 70 27
60 20 60 60
50 14 50 50
40 40 40 3
30 30 11 6 30 13
20 14 20 20
14 15
10 3 10 10
0 0 0
Normal* Mild Moderate- Normal Mild Moderate- Normal Mild Moderate-
a severe* b severe c severe

Fig 1 Frequency distributions (%) of normal, mild, and moderate-severe categories, as defined by scores of 0–4, 5–9, and ≥ 10, respec-
tively,16–18 for (a) physical, (b) anxiety, and (c) depression symptoms among women in the TMD pain and control groups. The numbers of
TMD pain and control subjects are shown within each bar. *P < .01 within and across categories.

9 TMD pain 9 TMD pain

Control Control
8 8
7 7
Duty factor (%)

Duty factor (%)

6 6
5 5
4 4
3 3
2 2
1 1
0 0
5–9 10–24 25–49 50–79 ≥ 80 5–9 10–24 25–49 50–79 ≥ 80
Magnitude threshold (%T20N) Magnitude threshold (%T20N)
a b

9 TMD pain 9 TMD pain

Control Control
8 8
7 7
Duty factor (%)

Duty factor (%)

6 6
5 5
4 4
3 3
2 2
1 1
0 0
5–9 10–24 25–49 50–79 ≥ 80 5–9 10–24 25–49 50–79 ≥ 80
Magnitude threshold (%T20N) Magnitude threshold (%T20N)
c d
Fig 2 Duty factors (%) at EMG magnitude thresholds of 5–9, 10–24, 25–49, 50–79, and ≥ 80% T20N averaged over duration thresholds
and up to three sessions for (a) awake time masseter, (b) awake time anterior temporalis, (c) sleep time masseter, and (d) sleep time
anterior temporalis muscles in women. Each vertical line shows 1 standard deviation above the average duty factor.

and duration of ≥ 2 seconds, the highest single-ses- tors at 5–9% T20N from both muscles and all durations
sion duty factors (Table 1) were 41.0% for the anteri- measured in subjects with normal psychosocial scores
or temporalis muscle during sleep time in a TMD pain for awake and sleep times. Compared to baseline, duty
subject (#087) and 14.3% for the masseter muscle factors in those subjects with mild or moderate-severe
during awake time in a control subject (#013). scores for physical symptoms were not significantly
Because duty factors were generally highest for different if scores for depression and anxiety symp-
the 5–9% T20N compared to other thresholds, baseline toms were normal, but they were significantly higher
duty factors were calculated by averaging the duty fac- by up to 3-fold if mild scores for depression or anxiety

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 Gonzalez et al

Table 1 Highest Single-Session Duty Factors (%) Per Group and Muscle for the Largest Magnitude
Threshold (≥ 80% T20N) and Duration Threshold ≥ 2 s
Time, muscle TMD pain group (subject #) Control group (subject #)
Awake, masseter 7.2 (#008) 14.3 (#013)
Awake, anterior temporalis 9.5 (#087) 4.4 (#164)
Sleep, masseter 5.3 (#004) 4.4 (#002)
Sleep, anterior temporalis 41.0 (#087) 1.0 (#206)
(fold increase relative to baseline)

(fold increase relative to baseline)

5.0 5.0
P = .005 P = .006
4.5 4.5
4.0 4.0
3.5 3.5
3.0 3.0
Duty factor

Duty factor
2.5 P = .01 2.5 P = .001
2.0 2.0
1.5 1.5
1.0 1.0
0.5 0.5
0 0
PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15
Mild Mild Mod-sev Mod-sev Mild Mild Mod-sev Mod-sev
PHQ-9 PHQ-9 PHQ-9 PHQ-9 PHQ-9 PHQ-9 PHQ-9 PHQ-9
a Normal Mild Normal Mild b Normal Mild Normal Mild

P = .007
(fold increase relative to baseline)

(fold increase relative to baseline)

5.0 P = .003 5.0

4.5 4.5
4.0 4.0
3.5 3.5
3.0 3.0
Duty factor

Duty factor

2.5 P = .034 2.5

2.0 2.0 P = .019
1.5 1.5
1.0 1.0
0.5 0.5
0 0
PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15 PHQ-15
Mild Mild Mod-sev Mod-sev Mild Mild Mod-sev Mod-sev
GAD-7 GAD-7 GAD-7 GAD-7 GAD-7 GAD-7 GAD-7 GAD-7
c Normal Mild Normal Mild d Normal Mild Normal Mild

Fig 3 Duty factors expressed relative to baseline duty factors, calculated by averaging duty factors at 5–9% T20N from masseter and
anterior temporalis muscles and all durations measured in subjects with normal psychosocial scores for awake and sleep times vs
(a) awake time somatization (PHQ-15) and depression (PHQ-9) symptom scores, (b) sleep time somatization and depression symp-
tom scores, (c) awake time somatization and anxiety (GAD-7) symptom scores, (d) sleep time somatization and anxiety symptom
scores. Vertical lines indicate 95% confidence intervals. P values indicate significant differences relative to the baseline duty factors.
Mod-sev = moderate-severe category; PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder scale.

symptoms were also present (P ≤ .01; Fig 3). In addi- and these differences were significant for physical
tion, duty factors were higher in those subjects with symptoms. However, there were no significant dif-
moderate-severe compared to mild scores for physical ferences between masseter and anterior temporalis
symptoms (somatization) if mild scores for depression duty factors between the two groups for either mus-
or anxiety symptoms were also present (Fig 3). cle or time. Thus, the presence of pain was not as-
sociated with increased jaw muscle activities during
the day or night. Nevertheless, subjects with elevated
Discussion psychosocial scores compared to those with normal
psychosocial scores showed significantly higher jaw
More women in the TMD pain group than in the control muscle duty factors. Previously, a subset of the cur-
group had higher than normal psychosocial scores, rent sample population was analyzed for clenching

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Gonzalez et al

behavior during ambulatory EMG recordings.11 These afferents in the trigeminal ganglia and secondary in-
results showed no significant differences between terneurons in the trigeminal subnucelus caudalis.32–34
diagnostic groups in number of clenching events, Further evidence for ANS dysregulation in TMD sub-
which averaged between seven and eight events per jects compared to control subjects has been shown
hour and were similar to previous polysomnography using pupillometry.35,36 The approach was based
findings.9 on detectable differences in pupil diameters mea-
As reported in previous studies,5,9,11,20 jaw muscle sured under different light conditions and the ef-
activities recorded in subjects’ natural environments fects of parasympathetic and sympathetic tones on
were generally low in duration and magnitude. Duty the control of pupil dilation and constriction. These
factors for all EMG magnitude thresholds averaged studies have shown differences between TMD and
over all duration thresholds and sessions were at control subjects in ANS behavior35 and in respons-
most 2.4% for awake and sleep times in both mus- es to transcutaneous electrical nerve stimulation.36
cles. For a 7-hour recording period, this was a total Possibly, subjects with TMD and ANS dysregulation
of 10 minutes of muscle activity and occurred at the self-report parafunctional activities because of cen-
lowest EMG magnitude of 5–9% T20N, which was trally mediated misinterpretation of afferent informa-
equivalent to a bite force of 1–2 N. There were a tion which, under normal conditions, would not be
few exceptions; for example, one control subject had interpreted as noxious or fatiguing.
awake-time masseter duty factors at low loading lev- A prospective study of 2,737 subjects without
els (5–9% T20N) and both short (0.5 to < 1 second) TMD who were followed for an average of 2.8 years
and long (≥ 10 seconds) durations of about 65%, to determine rates of first onset of TMD showed that
which was over 4.5 hours out of a 7-hour recording increased reports of somatic symptoms were a strong
period. For the largest EMG magnitude threshold of risk for TMD development, particularly in younger
≥ 80% T20N, which was equivalent to a bite force of age groups.3 Somatization has been correlated with
≥ 16 N, and for duration ≥ 2 seconds, one TMD pain decreased parasympathetic and increased sympa-
subject had a sleep-time anterior temporalis duty fac- thetic tones27; hence, the mechanism by which so-
tor of 41% and one control subject had an awake-time matization alters the processing of information by an
masseter duty factor of 14%. These were equivalent individual may be associated with dysregulated ANS
to approximately 3 hours and 1 hour, respectively, of function. Increased sympathetic tone is associated
total muscle activity during a 7-hour recording period. with increased excitability of masticatory motoneu-
The lack of significant differences in duty factors rons through dopamine and noradrenergic, enhanced
between the TMD pain and control groups and the responses of motoneurons to glutamate.24,37 These
findings that these duty factors were on average low phenomena may explain current and previous6,38 find-
and occurred at low magnitudes of jaw loading refute ings that physical and depression symptom scores
the theory that parafunctional jaw activity is a cause were correlated with jaw muscle duty factors at low
and consequence of TMD-related pain. The findings magnitudes of jaw loading.
of the current study are consistent with previous re- The current study had a number of limitations,
ports that high magnitudes of jaw loading were rare including the focus on women only, the unilater-
during recordings made in subjects’ natural environ- al ambulatory EMG recordings, and the unverified
ments20 and in sleep studies8 and that more frequent fidelity of the subjects to the self-recording proto-
muscle behaviors at low intensities were related to cols. Although good reliability of self-recorded EMG
psychosocial status.6 The association between high- from the masseter and anterior temporalis muscles
er than normal psychosocial scores and TMD-related has been shown,39 six recording sessions per sub-
pain may be due to autonomic nervous system (ANS) ject may be insufficient to represent actual jaw be-
dysregulation, which has been shown to increase haviors for a given subject’s life stage. Additionally,
motoneuron excitability24 and account for increased as has been pointed out previously,14 the laboratory
physical symptoms associated with variables such as EMG vs bite-force measurements used for calibra-
somatization.25 ANS dysregulation has been shown tion of ambulatory EMG recordings may have under-
to produce both central and peripheral neuroplastic estimated the activities required for similar forces at
changes via astroglia cells—particularly in the trigem- tooth-to-tooth contact40,41 because a gap of about
inal subnucleus caudalis—and peripheral trigeminal 8 mm was required for the bite-force transducer.
ganglia satellite glial cells, affecting non-nocicep- Sensitive, specific, and accurate computer-based
tive and nociceptive afferent processing.26–31 ANS algorithms are being developed and tested for tooth
dysregulation, with reduced parasympathetic and clenching detection11 and could be applied to im-
increased sympathetic spectral powers, promotes prove this in future studies. Future studies should
production of inflammatory cytokines from glial cells, include both sexes and improved technology for bi-
which in turn increases excitability of peripheral lateral EMG activity, as well as electrocardiography

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 Gonzalez et al

to determine ANS tone. Given the reported findings 7. Wieckiewicz M, Zietek M, Smardz J, Zenczak-Wieckiewicz
of psychosocial state as a risk factor for onset of D, Grychowska N. Mental status as a common factor for
TMD-related pain,3 future research should also focus masticatory muscle pain: A systematic review. Front Psychol
2017;8:646.
on longitudinal analyses of day- and sleep-time ANS 8. Raphael KG, Janal MN, Sirois DA, et al. Masticatory muscle
dysregulation and jaw muscle use. These data could sleep background electromyographic activity is elevated in my-
be used to test whether jaw muscle activities at low ofascial temporomandibular disorder patients. J Oral Rehabil
intensities are suitable biomarkers for ANS function 2013;40:883–891.
and to determine the cut-off point of ANS dysregula- 9. Raphael KG, Sirois DA, Janal MN, et al. Sleep bruxism
and myofascial temporomandibular disorders: A laborato-
tion for onset of chronic TMD-related pain. ry-based polysomnographic investigation. J Am Dent Assoc
2012;143:1223–1231.
10. Iwasaki LR, Gonzalez YM, Liu Y, et al. Mechanobehavioral
Conclusions scores in women with and without TMJ disc displacement.
J Dent Res 2017;96:895–901.
11. Wei F, Van Horn MH, Coombs MC, et al. A pilot study of noc-
The results of this study showed that the proportion turnal temporalis muscle activity in TMD diagnostic groups of
of women with higher than normal physical symp- women. J Oral Rehabil 2017;44:517–525.
tom scores was significantly larger in the TMD pain 12. Slade GD, Ohrbach R, Greenspan JD, et al. Painful temporo-
group compared to the control group. Awake- and mandibular disorder: Decade of discovery from OPPERA
studies. J Dent Res 2016;95:1084–1092.
sleep-time jaw muscle duty factors were general-
13. Grünheid T, Langenbach GE, Zentner A, Van Eijden TM. Duty
ly low and not different between groups. However, time of rabbit jaw muscles varies with the number of activity
higher than normal psychosocial scores were associ- bursts. J Dent Res 2006;85:1112–1117.
ated with significantly more low-magnitude jaw mus- 14. Iwasaki LR, Gonzalez YM, Liu Y, et al. Mechanobehavioral
cle activity. scores in women with and without TMJ disc displacement.
J Dent Res 2017;96:895–901.
15. Kawai N, Tanaka E, Langenbach GE, et al. Jaw-muscle activ-
ity changes after the induction of osteoarthrosis in the tem-
Acknowledgments poromandibular joint by mechanical loading. J Orofac Pain
2008;22:153–162.
The authors thank the subjects for their participation. This re- 16. Nickel JC, Weber AL, Covington Riddle P, Liu Y, Liu H, Iwasaki
search was supported by the National Institute of Dental and LR. Mechanobehaviour in dolichofacial and brachyfacial ado-
Craniofacial Research (R01 2DE016417, JN-PI). The authors de- lescents. Orthod Craniofac Res 2017;20(suppl):s139–s144.
clare no conflicts of interest with respect to the authorship and/or 17. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria
publication of this article. for Temporomandibular Disorders (DC/TMD) for clinical and
research applications: Recommendations of the International
RDC/TMD Consortium Network and Orofacial Pain Special
Interest Group. J Oral Facial Pain Headache 2014;28:6–27.
18. Ahmad M, Hollender L, Anderson Q, et al. Research
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388 Volume 32, Number 4, 2018

© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.