How psychosocial and economic impacts of COVID-19 pandemic can interfere on bruxism and temporomandibular disorders?

In January 2020, a novel coronavirus has been announced as the etiologic pathogen of COVID-19 disease that had become a major epidemic threat in China. It has widely spread since December 2019 not only in China but also in many countries around the world, which became a major challenge for public health.¹ , ² World Health Organization (WHO) announced COVID-19 outbreak a pandemic in March 2020 and it constitutes a public health emergency of international concern.³ As of April 20, 2020, there have been more than 2.3 million confirmed cases and 157.000 deaths globally.⁴ COVID-19 consequences on the global economy and financial crisis are already tangible. Quarantines, disruptions of daily life, travel, work, school education and social isolation that occurred worldwide may have impacting consequences on mental health.⁵

Previous public health emergencies have demonstrated to have an influence on mental health.⁶ Literature shows that psychological reactions to previous epidemics and pandemics depend on individual vulnerability such as intolerance of uncertainty, perceived vulnerability to disease, and anxiety.⁶ In the current situation, there are many uncertainties concerning SARS-CoV-2 origin, nature, government capacity to prevent the spread of infection, and seriousness of the risk.⁷ Moreover, the lack of faith in the healthcare system to deal with new cases, worries about becoming infected, fear of death, increase in hygienic and avoidance behaviors, lack of information and misinformation fuel excessive fear and create an environment of anxiety and depression that interfere with basic daily activities, including sleep quality.⁷ , ⁸ , ⁹ In addition, people who are quarantined lose social connections and feelings of loneliness and anger may develop.¹⁰ , ¹¹ It has already been well documented the strong impact that COVID-19 is having on the psychological issues in China, where a significant portion of population has reported moderate-to-severe anxiety.¹² Medical health-care workers, mainly females, are also facing increased levels of anxiety and stress.⁹ , ¹³

It is well established the importance of psychosocial factors in development and maintenance of Temporomandibular Disorders (TMD) and the high prevalence of psychological disturbances in TMD patients, mainly in those who suffer from masticatory muscle disorders.¹⁴ - ¹⁶ Moreover, there is a significant relationship between painful TMD, depression, and anxiety.¹⁶ - ¹⁹ All psychological issues involved in emergency and threatening situations like the ones faced with COVID-19 pandemic are able to trigger a chain of events that culminate with higher levels of sympathetic activity and further release of adrenocortical steroids which lead to muscle vasoconstriction and increased peripheral vascular resistance. Feelings of warmth and cold, palpitations, tachycardia, nausea, abdominal pain, diarrhea, and constipation can all be the consequences of autonomic stress responses.²⁰ All these events are supposed to create/perpetuate a situation of system overloading, a common finding in TMD patients. The autonomic impairment may also lead to increased sympathetic drive and sensation of hyperarousal which create and perpetuate any sleep disturbance.²¹ If maintained, this cycle may play an important role in pain maintenance, especially in psychological vulnerable individuals. Hence, the occurrence of post-pandemic signs and symptoms of chronic orofacial pains, including TMD, is expected in a very similar pattern to well described posttraumatic stress syndrome.

The association between bruxism and psychological aspects has been documented,²² - ²⁷ although the intensity of sleep bruxism has not been associated to self-reported stress, depression, TMD or TMD-related pain.²² - ²⁴ A recent systematic review, however, reported that some specific symptoms of the anxiety disorders spectrum might have association to probable sleep bruxism.²⁵ Awake bruxism, in contrast, has psychosocial factors such as anxiety, stress and difficulty in identifying and describing feelings as important as somatic causes in its occurrence and maintenance.²⁶ Patients with high levels of stress are almost 6 times more likely to report awake bruxism.²⁷ Sustained muscle contraction of head and neck is also related to a required body posture associated to fight-or-flight response. Therefore, muscle contraction in awake bruxism could be part of the defense behavior associated with anxiety and stress.²⁸ The anxiety-related processes occur in the CNS and involves interactions among prefrontal cortex, limbic, paralimbic structures (amygdala, insula, anterior cingulate gyrus) and motor regions of the brain stem that leads to motor and physiological responses not only to stress, but also increased alertness and attention.²⁹ Under non-stress conditions, the prefrontal cortex (PFC) regions regulate behavior, thought and emotion, including inhibition of inappropriate motor responses. However, in stressful conditions, the amygdala activates pathways in the hypothalamus and brainstem and impairs PFC regulation.³⁰

Moreover, it is important to highlight that some other long-term effects of COVID-19 may be described in the future and deserve attention. Viral infections in the nervous system may lead to meningoencephalitis and neuropathies as seen for herpesviruses, Zika virus, and human immunodeficiency virus (HIV).³¹ , ³² , ³³ Since SARS-CoV-2 infection has caused central nervous system manifestations,³⁴ , ³⁵ possible consequences as neuropathic pain states may also be a possible long term manifestation of the pandemic.

In conclusion, COVID-19 outbreak may lead to major impacts in applied oral sciences for the next years. Remarkably, it could be expected that psychological factors associated to pandemic may lead to a greater risk of developing, worsening and perpetuating bruxism (mainly awake bruxism) and TMD. Orofacial pain specialists should be aware of this fact. Guidelines for patient’s education, self-management, home care and relaxations techniques are already available on the WEB and are useful tools in times of social isolation and pain.

References

• ¹ - Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. Erratum in: Lancet. 2020 Jan 30. doi: 10.1016/S0140-6736(20)30183-5
• ² - Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy [internet]. Fourthcoming 2020 [cited 2020 Feb 19]. Available from: https://doi.org/10.1111/all.14238 doi: doi: 10.1111/all.14238
  » https://doi.org/10.1111/all.14238
• ³ - World Health Organization - WHO. WHO announces COVID-19 outbreak a pandemic [internet]. Copenhagen: WHO; 2020 [cited 2020 Apr 19]. Available from: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/3/who-announces-covid-19-outbreak-a-pandemic
  » http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/3/who-announces-covid-19-outbreak-a-pandemic
• ⁴ - World Health Organization - WHO. Coronavirus disease 2019 (COVID-19): situation report – 91 [internet]. Copenhagen: WHO; 2020 [cited 2020 Apr 20]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200420-sitrep-91-covid-19.pdf?sfvrsn=fcf0670b_4
  » https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200420-sitrep-91-covid-19.pdf?sfvrsn=fcf0670b_4
• ⁵ - Ioannidis JP. Coronavirus disease 2019: the harms of exaggerated information and non-evidence-based measures. Eur J Clin Invest. 2020;50:13222. doi: 10.1111/eci.13223
• ⁶ - Taylor S. The psychology of pandemics: preparing for the next global outbreak of infectious disease. Cambridge: Cambridge Scholars Publishing; 2019.
• ⁷ - Qu X, Zhou XD. Psychological intervention in oral patients in novel coronavirus pneumonia outbreak period. Zhonghua Kou Qiang Yi Xue Za Zhi. 2020;55(0):E003. doi: 10.3760/cma.j.cn112144-20200213-00053
• ⁸ - Asmundson GJ, Taylor S. Coronaphobia: fear and the 2019-nCoV outbreak. J Anxiety Disord. 2020;70:102196. doi: 10.1016/j.janxdis.2020.102196
• ⁹ - Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 202022;395(10224):e37-8. doi: 10.1016/S0140-6736(20)30309-3
• ¹⁰ - Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-9. doi: 10.1016/S2215-0366(20)30046-8
• ¹¹ - Zandifar A, Badrfam R. Iranian mental health during the COVID-19 epidemic. Asian J Psychiatr. 2020;51:101990. doi: 10.1016/j.ajp.2020.101990
• ¹² - Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in china. Int J Environ Res Public Health. 2020;17(5):1729. doi: 10.3390/ijerph17051729
• ¹³ - Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2020;38(0):E001. doi: 10.3760/cma.j.cn121094-20200219-00063
• ¹⁴ - Manfredini D, Lombardo L, Siciliani G. Temporomandibular disorders and dental occlusion. A systematic review of association studies: end of an era? J Oral Rehabil. 2017;44(11):908-23. doi: 10.1111/joor.12531
• ¹⁵ - Manfredini D, Marini M, Pavan C, Pavan L, Guarda-Nardini L. Psychosocial profiles of painful TMD patients. J Oral Rehabil. 2009;36(3):193-8. doi: 10.1111/j.1365-2842.2008.01926.x
• ¹⁶ - De La Torre Canales G, Câmara-Souza MB, Muñoz Lora VR, Guarda-Nardini L, Conti PC, Rodrigues Garcia RM, et al. Prevalence of psychosocial impairment in temporomandibular disorder patients: a systematic review. J Oral Rehabil. 2018;45(11):881-9. doi: 10.1111/joor.12685
• ¹⁷ - Osiewicz M, Lobbezoo F, Ciapała B, Pytko-Polończyk J, Manfredini D. Pain predictors in a population of temporomandibular disorders patients. J Clin Med. 20206;9(2):452. doi: 10.3390/jcm9020452
• ¹⁸ - Kindler S, Samietz S, Houshmand M, Grabe HJ, Bernhardt O, Biffar R, et al. Depressive and anxiety symptoms as risk factors for temporomandibular joint pain: a prospective cohort study in the general population. J Pain. 2012;13(12):1188-97. doi: 10.1016/j.jpain.2012.09.004
• ¹⁹ - Boscato N, Almeida RC, Koller CD, Presta AA, Goettems ML. Influence of anxiety on temporomandibular disorders: an epidemiological survey with elders and adults in Southern Brazil. J Oral Rehabil. 2013;40(9):643-9. doi: 10.1111/joor.12076
• ²⁰ - Ziegler MG. Psychological stress and the autonomic nervous system. In: Robertson D, Biaggioni I, Burnstock G, Low PA, editors. Primer on the autonomic nervous system. 2nd ed. Cambridge: Academic Press; 2004. p. 189-90.
• ²¹ - Miglis MG. Autonomic dysfunction in primary sleep disorders. Sleep Med. 2016;19:40-9. doi: 10.1016/j.sleep.2015.10.001
• ²² - Smardz J, Martynowicz H, Wojakowska A, Michalek-Zrabkowska M, Mazur G, Wieckiewicz M. Correlation between sleep bruxism, stress, and depression-A polysomnographic study. J Clin Med. 2019;8(9):1344. doi: 10.3390/jcm8091344
• ²³ - Wieckiewicz M, Smardz J, Martynowicz H, Wojakowska A, Mazur G, Winocur E. Distribution of temporomandibular disorders among sleep bruxers and non-bruxers: a polysomnographic study. J Oral Rehabil. 2020;10.1111/joor.12955. doi: 10.1111/joor.1295
• ²⁴ - Smardz J, Martynowicz H, Michalek-Zrabkowska M, Wojakowska A, Mazur G, Winocur E, et al. Sleep bruxism and occurrence of temporomandibular disorders-related pain: a polysomnographic study. Front Neurol. 2019;10:168. doi: 10.3389/fneur.2019.0016
• ²⁵ - Polmann H, Domingos FL, Melo G, Stuginski-Barbosa J, Guerra EN, Porporatti AL, et al. Association between sleep bruxism and anxiety symptoms in adults: a systematic review. J Oral Rehabil. 2019;46(5):482-91. doi: 10.1111/joor.12785
• ²⁶ - Przystańska A, Jasielska A, Ziarko M, Pobudek-Radzikowska M, Maciejewska-Szaniec Z, Prylińska-Czyżewska A, et al. Psychosocial predictors of bruxism. Biomed Res Int. 2019;2019:2069716. doi: 10.1155/2019/2069716
• ²⁷ - Quadri MF, Mahnashi A, Al Almutahhir A, Tubayqi H, Hakami A, Arishi M, et al. Association of awake bruxism with khat, coffee, tobacco, and stress among Jazan University Students. Int J Dent. 2015;2015:842096. doi: 10.1155/2015/842096
• ²⁸ - Marker RJ, Campeau S, Maluf KS. Psychosocial stress alters the strength of reticulospinal input to the human upper trapezius. J Neurophysiol. 2017;117(1):457-66. doi: 10.1152/jn.00448.2016
• ²⁹ - Mayer EA, Naliboff BD, Craig AD. Neuroimaging of the brain-gut axis: from basic understanding to treatment of functional GI disorders. Gastroenterology. 2006;131(6):1925-42. doi: 10.1053/j.gastro.2006.10.026
• ³⁰ - Arnsten AF. Stress signalling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci. 2009;10(6):410-22. doi: 10.1038/nrn2648
• ³¹ - Mallick-Searle T, Snodgrass B, Brant JM. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. J Multidiscip Healthc. 2016;9:447-54. doi: 10.2147/JMDH.S106340
• ³² - Koike H. Zika Virus and Guillain-Barré Syndrome. Brain Nerve. 2018;70(2):113-20. doi: 10.11477/mf.1416200963
• ³³ - Brizzi KT, Lyons JL. Peripheral nervous system manifestations of infectious diseases. Neurohospitalist. 2014;4(4):230-40. doi: 10.1177/1941874414535215
• ³⁴ - Ye M, Ren Y, Lv T. Encephalitis as a clinical manifestation of COVID-19. Brain Behav Immun [Internet]. Forthcoming 2020 [cited 2020 Apr 27]. Available from: https://dx.doi.org/10.1016/j.bbi.2020.04.017 doi: 10.1016/j.bbi.2020.04.017
  » https://dx.doi.org/10.1016/j.bbi.2020.04.017
• ³⁵ - Asadi-Pooya AA, Simani L. Central nervous system manifestations of COVID-19: a systematic review. J Neurol Sci. 2020;413:116832. doi: 10.1016/j.jns.2020.116832

Publication Dates

• Publication in this collection
  11 May 2020
• Date of issue
  2020

History

• Received
  13 Apr 2020
• Reviewed
  22 Apr 2020
• Accepted
  27 Apr 2020