Anxiety and depression levels in patients with chronic orofacial pain

Introduction: Orofacial pain can be highly distressing, affecting 10% of the population and is associated with psychological symptoms. This study aims to assess the frequency of such psychological symptoms in orofacial pain patients compared to a control group and how these symptoms change with treatment. The effect of social deprivation will also be explored. Method: We conducted a prospective study comparing 342 consecutive referrals to the pain clinic over a nine-year period with 100 controls. Exclusion criteria involved patients with dental/dentoalveolar pain or trigeminal neuralgia. The chronic faical pain patient’s data was collected from validated questionnaires completed at every consultation. The somatic diagnoses were based on a interview process with one consultant conducting the pain clinic. Results : The average age of patients and controls was 49.5 years. There was a statistically signifi cant difference (p = 0.032) between the anxiety and depression scores respectively of patients (average 8.6 & 6) and controls (6 & 2.1). The pre-treatment anxiety scores were statistically signifi cantly higher in improvers compared to non-improvers (p < 0.05) but not with the depression scores. Conclusion: Forty-two percent of patients reported improvement in their symptoms. A statistically signifi cant correlation was found between anxiety and improvement following treatment, however not in depression scores. It is evident that while pain is managed effectively and anxiety is successfully reduced, depression is not treated. Deprivation is not a confounding factor in the experience of pain, anxiety, depression or improvement in symptoms. Therefore, treatment can be benefi cial in reducing anxiety. However, this was not the case for depression scores and improvement following treatment and therefore it is unclear whether there was a psychological health benefi t to these patients following treatment. Observational Study Anxiety and depression levels in patients with chronic orofacial pain Naomi Rahman1*, Norma O’Connor2, Zaid Sadiq3 and Victor Lopes4 1BDS MFDS MOral Surg DClindent PgCAP AFHEA, Consultant in Oral Surgery, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH, United Kingdom 2BDS NUI, MFDS RCS Edin, M Clin Dent Oral Surg, M Oral Surg RCS Edin, FFD OS RCS Edin, Consultant in Oral Surgery, Edinburgh Dental Institute, Lauriston building, Lauriston Place, Edinburgh, EH9 3HA, UK 3Ph., D, B.D.S., M.B., Ch.B., F.R.C.S. Consultant in Oral & Maxillofacial Surgery, University College London Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK 4B.Sc., Ph., D, B.D.S., M.B., Ch.B., F.R.C.S., Consultant in Oral & Maxillofacial Surgery, Edinburgh Dental Institute, Lauriston building, Lauriston Place, Edinburgh, EH9 3HA, UK Received: 16 March, 2020 Accepted: 26 May, 2020 Published: 28 May, 2020 *Corresponding author: Dr, Naomi Rahman, Naomi Rahman, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH, UK, Tel: 07805264087; E-mail: https://www.peertechz.com


Introduction
For descriptive purposes we categorise pain into two groups: 1) Acute pain which acts physiologically to warn the body of an impending injury. 2) Chronic (pathological) pain which could be defi ned as pain which persists after the stimulus that induced it has resolved or pain which cannot be attributed to an obvious stimulus. Pain may be regarded as the sixth sense and it is widely accepted as the most common reason that patients seek healthcare advice. Chronic pain is widespread in the community and prevalence has been reported to range from 19% [1], to 53.8% [2], of the general population.
Orofacial pain represents a signifi cant proportion of all chronic pain [3]. A systematic review of population based epidemiological studies of orofacial pain reported the median prevalence of orofacial pain affecting the population to be 13% [4]. In 2001, it was reported that facial pain affects at least 10% of the adult population and 50% of the elderly population [5].
Citation: Rahman  Orofacial pain can be highly distressing and this is demonstrated by the model of the sensory homunculus, where a signifi cant proportion of the cerebral hemisphere is represented by the head and in particular the lips and oral cavity. Orofacial pain includes dental, musculoskeletal, neurological and vascular pain. The majority of orofacial pain patients however will have more than one pain diagnosis at any given time [6]. Females are affected more commonly than males and the majority of patients are between 40 and 60 years of age [2]. The somatic, emotional and social wellbeing of this patient group is signifi cantly affected by their chronic pain [2]. Depression rates of up to 50% and anxiety levels of 15% have been reported in this group of patients [7]. Pain therefore is a physiological sensation with components of emotional and psychological undertone. Psychosocial components of pain can either be an effect or driver of pain especially in the chronic pain state. An association between chronic orofacial pain and psychosomatic disorders including fi bromyalgia, chronic fatigue syndrome, poor sleep, irritable bowel syndrome, dysmenorrhea and chronic back pain has been well documented [5,7,8].
In light of these fi ndings the aims of this study were:  A total of 100 patients were in the control group. Institutional approval was given for recruitment of the control group under local procedures for the conduct of audit and service review.

Methods
Anxiety and depression levels were quantifi ed by the HAD (Hospital Anxiety and Depression) scale before treatment.
The scale involves a 14-item self-administered rating scale consisting of 2 subscales: seven items measuring anxiety and seven items measuring depression [9]. A score of greater than 8 identifi es possible and probable anxiety or depression with high sensitivity and specifi city [10]. Scores from 10-14 are said to represent moderate anxiety or depression and scores >15 have been reported to represent severe disease [11]. The maximum score is 21 in each domain. A review of the validity of the HAD scale conducted in 2002 concluded that the HAD questionnaire performs at least as well as more comprehensive instruments used for identifi cation of anxiety and depression [10]. The postcodes of the test group were analysed by means of SIMD deciles from 2012 to derive deprivation status and compared to controls. Deciles were compared between patients without anxiety to those with moderate anxiety and severe anxiety. Also we compared the SIMD deciles between patients with moderate and severe anxiety. The same tests were carried out for depression. Treatment of pain patients included

Results
Their symptoms were classed as: 1) Persistent facial pain-59% 2) Temporomandibular joint dysfunction (TMD)-35% 3) Burning mouth syndrome-6% At initial presentation, the mean anxiety score in pain patients was 8.5, with a range of zero to 21. The mean depression score for the pain group was 6.01, with a range of zero to 20 ( Figure 1). A total of 25% of the test group had an anxiety score of 10-14 (mild to moderate anxiety) and 14% of test group had an anxiety score of more than 15 (moderate to severe anxiety.) In relation to depression, 15% of the test group had a score of 10-14 (mild to moderate depression) and 7% had a depression score of greater than 15 (moderate to severe depression.) See summary in Table 2.
There were 100 controls which included 22 (22%) males and 78 (78%) females, with a mean age of 50 years ( Table 1). The mean anxiety score was 6 and the mean depression score was 2.1 ( Figure 1). There was a statistically signifi cant difference between the anxiety and depression scores in the pain group and the controls, with a p value = 0.032 for anxiety and also depression, which is highly signifi cant.
Treatment given to pain patients are summarised in Table   3.
In 42% (143) of pain patients there was a reported improvement in symptoms following treatment, 35% (118) did not report improvement following treatment and in 24% (81) of cases the result was unknown as patients did not return for follow up (Table 4). We also looked at the anxiety levels in males versus females, mean 8.76, median 8 and found that there was no statistically     The mean SIMD of patients attending the pain clinic was 6.53 (Table 5) and the mean SIMD of controls was 6.88, Mann-Whitney test showed that these two groups were not statistically signifi cantly different (p value = 0.32.) On comparison of SIMD deciles between patients without anxiety (mean 6.7, median 7) and those with moderate anxiety (mean 6.6, median 7) and severe anxiety (mean 6.3, median 7) as shown in Table 6, no statistical signifi cance was found (Table 7).
On comparison of SIMD deciles between patients without anxiety (mean 6.7, median 7) and those with moderate anxiety (mean 6.6, median 7) and severe anxiety (mean 6.3, median 7) as shown in Table 6, no statistical signifi cance was found (Table 7).
Similarly, no statistical signifi cance in SIMD was detected between patients without depression (mean 6.67, median 7) and those with moderate (mean 6.24, median 6) and severe depression (mean 6.25, median 8) and is shown in Table 8.

Discussion
Pre-treatment anxiety and depression scores observed in the cohort of patients presented here were 8.5 and 6.01 respectively. On comparison to other studies, slightly lower scores have been reported. In a study carried out by Giannakopoulos et al, the mean anxiety score in patients with TMD with or without chronic facial pain, was 5.6 and the mean depression score was 4 12 . A study of patients with chronic orofacial pain carried out by Galli et al in 2010, reported anxiety and depression scores at initial presentation of 7.76 and 5.72 respectively [19]. In our study, a statistically signifi cant difference was evident between anxiety and depression scores of pain patients and controls. However, the biological relevance of this difference is questionable as the scores for the pain patients were generally low, with the mean anxiety score just exceeding the caseness threshold and the mean depression score falling within a normal range.
Anxiety refers to a relatively permanent future-focused state of worry and nervousness characterized by physical symptoms and it is usually accompanied by compulsive behaviour or attacks of panic [11]. Depression on the other hand is an affective disorder characterised by a pessimistic sense of inadequacy and a despondent lack of activity [11]. Pain is recognised as a subjective feeling engaging emotional and affective components and is more complex than a mere physical sensation event signalling tissue damage [10]. Genetic predisposition, heightened anxiety and depression combined with certain environmental factors all play an important role in the development of chronic pain conditions [12]. In their article reclassifying myofascial pain as persistent orofacial muscle pain (POMP) the authors described 'a complex disease model' for chronic facial pain just like other persistent pain conditions [13]. It is well established that persistent pain may lead to neuroplastic changes within the peripheral and central nervous system [14], a process known as central sensitisation. Mounting evidence suggests that regional pain syndromes, including TMD, fi bromyalgia, irritable bowel syndrome,    Table 6: SIMD scores for patients without anxiety (HAD score <8), with moderate anxiety (HAD score [10][11][12][13][14], with severe anxiety (HAD score >15) and SIMD scores for patients without depression (HAD score <8), with moderate depression (HAD score [10][11][12][13][14] and severe depression (HAD score >15).   headaches, chronic lower back pain and chronic neck pain share this common pathological process [15]. This evidence is strengthened by the fact that these disorders often co-exist and also serve as risk factors for each other [12].

SIMD
With this in mind, the management of patients with chronic orofacial pain or POMP, it is important to address and minimise psychosocial elements or morbidities in an attempt to optimise treatment success. Mongini et al reported that anxiety increases the likelihood of muscle tenderness and facial pain [16]. Madland et al looked at patients with facial arthromyalgia and reported that increased levels of pain lead to elevated anxiety scores [17]. On the other hand, a recent study looking at patients with anxiety and depression demonstrated that patients with co-existing pain are more prone to chronic anxiety and/or depression and an overall poorer disease progression [18]. It recommended to pay more attention to pain in the management of these patients.
Optimal management of chronic orofacial pain patients involves input from a multidisciplinary team of healthcare workers [20,21]. Unfortunately, availability of this skill set within one team is rarely a reality. prevalence and intensity [6,24], in this study the SIMD did not demonstrate any statistical signifi cance between pain patients and controls and also between patients with varying degrees of anxiety and depression.

Conclusion
The patients investigated in this study experienced higher levels of anxiety and depression to other published studies.
There was a statistically signifi cant correlation between anxiety scores and improvement following treatment. Therefore, treatment can be benefi cial in reducing anxiety. However, this was not the case for depression scores and improvement following treatment and therefore it is unclear whether there was a psychological health benefi t to these patients following treatment. In accordance with current quality assurance standards, it would be desirable to follow-up this study with a health outcome based assessment to analyse the relevant effect of the current treatment regimens.

Informed consent
Verbal informed consent was obtained from all subjects before the study. Written informed consent was not obtained because the study was part of an ongoing service review.

Ethical approval
Ethical approval was not sought for the present study because the study was part of an ongoing service review.
However institutional approval was given for recruitment of the control group under local procedures for the conduct of audit and service review. This study was completed in accordance with the Helsinki Declaration as revised in 2013.