Aims Many patients with Temporomandibular Disorders (TMDs) diagnosed via AAOP/DC criteria report severe pain despite normal imaging, implicating non-structural drivers such as stress. This study aimed to quantify the stress–pain relationship and compare real-world pharmacological outcomes in an Indian tertiary-care dental outpatient department (OPD). Methods We conducted a retrospective review of 150 consecutive adults (18–60 years) with chronic TMD pain (≥ 3 months) and normal panoramic/CT/MRI findings (January 2024–June 2025). Variables included demographics, diagnosis subtype, baseline and follow-up pain (VAS 0–10), self-reported stress (0–10), psychiatric comorbidity, pharmacological regimen, and follow-up interval. Statistical analyses included Pearson correlation, ANOVA with Tukey-HSD (or non-parametric equivalents) with effect sizes (η2, Cohen’s d), and multivariable linear regression (adjusting for sex, subtype, comorbidity). Results Mean age 35.4 ± 12.3 years; 68% female; myalgia 72%. High stress in 78%. Stress correlated with baseline pain (r = 0.62; 95% CI 0.52–0.70; p < 0.001). Baseline VAS by stress: high 7.2 ± 1.4, moderate 5.8 ± 1.2, low 4.1 ± 1.0 (ANOVA F(2,147) = 45.2; p < 0.001; η2 = 0.38). Median follow-up was 4 weeks (IQR 3–6). Mean ΔVAS overall was 2.9 ± 1.2 (d = 1.2). ΔVAS by regimen (ANOVA F(3,146) = 12.4; p < 0.001; η2 = 0.21): diclofenac–paracetamol 2.7 ± 0.9; chlorzoxazone 2.4 ± 1.0; low-dose amitriptyline 3.1 ± 1.1; combination (including tizanidine) 3.5 ± 1.3; combination was superior to single agents (Tukey p < 0.05; d = 0.8–1.1). Responders (≥ 2-point VAS reduction): 65% overall; 78% with combination vs 52–61% with single agents (χ2 = 14.2; p = 0.003). By stress: 58% responders in high-stress vs 91% in low/moderate groups (χ2 = 12.6; p < 0.001). In regression, stress independently predicted higher pain (β = 0.48; p < 0.001). Conclusions In imaging-normal TMD, psychological stress is a strong, independent correlate of pain severity. Multimodal pharmacotherapy improves short-term outcomes beyond monotherapy, particularly in high-stress/myalgia-predominant cases. OPD workflows should incorporate brief validated stress screening and clear referral pathways to operationalize biopsychosocial care.

Impact of Stress on Pharmacological Management of Chronic Pain in Imaging-Negative TMD

期刊论文
发表日期：

2026年1月20日

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Chandrashekhar Chattopadhyay,
Vikas Deo,
Charu Chouhan,
Mamta Patel,
Ayush Garg,
Priti Airun

摘要

Aims

Many patients with Temporomandibular Disorders (TMDs) diagnosed via AAOP/DC criteria report severe pain despite normal imaging, implicating non-structural drivers such as stress. This study aimed to quantify the stress–pain relationship and compare real-world pharmacological outcomes in an Indian tertiary-care dental outpatient department (OPD).

Methods

We conducted a retrospective review of 150 consecutive adults (18–60 years) with chronic TMD pain (≥ 3 months) and normal panoramic/CT/MRI findings (January 2024–June 2025). Variables included demographics, diagnosis subtype, baseline and follow-up pain (VAS 0–10), self-reported stress (0–10), psychiatric comorbidity, pharmacological regimen, and follow-up interval. Statistical analyses included Pearson correlation, ANOVA with Tukey-HSD (or non-parametric equivalents) with effect sizes (η², Cohen’s d), and multivariable linear regression (adjusting for sex, subtype, comorbidity).

Results

Mean age 35.4 ± 12.3 years; 68% female; myalgia 72%. High stress in 78%. Stress correlated with baseline pain (r = 0.62; 95% CI 0.52–0.70; p < 0.001). Baseline VAS by stress: high 7.2 ± 1.4, moderate 5.8 ± 1.2, low 4.1 ± 1.0 (ANOVA F(2,147) = 45.2; p < 0.001; η² = 0.38). Median follow-up was 4 weeks (IQR 3–6). Mean ΔVAS overall was 2.9 ± 1.2 (d = 1.2). ΔVAS by regimen (ANOVA F(3,146) = 12.4; p < 0.001; η² = 0.21): diclofenac–paracetamol 2.7 ± 0.9; chlorzoxazone 2.4 ± 1.0; low-dose amitriptyline 3.1 ± 1.1; combination (including tizanidine) 3.5 ± 1.3; combination was superior to single agents (Tukey p < 0.05; d = 0.8–1.1). Responders (≥ 2-point VAS reduction): 65% overall; 78% with combination vs 52–61% with single agents (χ² = 14.2; p = 0.003). By stress: 58% responders in high-stress vs 91% in low/moderate groups (χ² = 12.6; p < 0.001). In regression, stress independently predicted higher pain (β = 0.48; p < 0.001).

Conclusions

In imaging-normal TMD, psychological stress is a strong, independent correlate of pain severity. Multimodal pharmacotherapy improves short-term outcomes beyond monotherapy, particularly in high-stress/myalgia-predominant cases. OPD workflows should incorporate brief validated stress screening and clear referral pathways to operationalize biopsychosocial care.