Highlights
- •People with poor sleep quality reported worsening of perceived stress.
- •Poor sleep increased risk for temporomandibular disorder (TMD) directly and indirectly via perceived stress.
- •A third of the effect of poor sleep quality on TMD was mediated by perceived stress.
Abstract
We explored causal mediation of sleep quality and perceived stress in development
of painful temporomandibular disorder (TMD). Sleep quality and perceived stress were
assessed at baseline and quarterly intervals thereafter in 2,737 initially TMD-free
adults in the Orofacial Pain Prospective Evaluation and Risk Assessment study (OPPERA)
prospective cohort study. During follow-up, incident TMD cases were classified using
research diagnostic criteria. Mediation analysis was conducted using a weighted Cox
proportional hazards regression model that estimated hazard ratios (HRs) and 95% confidence
limits (CL) of first-onset TMD. Models determined whether: 1) poor sleep quality during
follow-up mediated the effect of baseline perceived stress on first-onset TMD, and
2) perceived stress during follow-up mediated the effect of baseline poor sleep quality
on first-onset TMD. In both analyses, the total effect was decomposed into natural
direct and indirect effects. Poor baseline sleep quality led to heightened perceived
stress that then contributed to TMD development. When the total effect of poor sleep
quality (HR = 2.10, CL = 1.76, 2.50) was decomposed, 34% of its effect was mediated
by perceived stress (indirect effect HR = 1.29, CL = 1.06, 1.58). The effect of perceived
stress on first-onset TMD was not mediated by sleep quality. Improving sleep may avert
escalation of stress, limiting effects of both factors on TMD development.
Perspective
Causal mediation analysis highlights mechanisms by which poor sleep quality promotes
development of TMD. First, poor sleep quality exerts a direct effect on pain. Second,
it triggers a heightened perception of stress, which acts as an intermediate factor
in the causal pathway between poor sleep quality and first-onset TMD pain.
Key words
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Article info
Publication history
Published online: December 17, 2016
Accepted:
December 6,
2016
Received in revised form:
November 18,
2016
Received:
September 9,
2016
Footnotes
This work was supported by the National Institutes of Health and National Institute of Dental and Cranial Research (grant numbers U01-DE17018 and R03-DE022595).
Roger B. Fillingim is a consultant and equity stock holder, and William Maixner is a founder and equity stock holder in Algynomics, a company providing research services in personalized pain medication and diagnostics. The remaining authors have no conflicts of interest to declare.
Identification
Copyright
© 2016 by the American Pain Society
