471: Biopsychosocial phenotypes of TMD reveal distinct clinical profiles unrelated to cortisol imbalance

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic primary orofacial pain, Assessment and Measurement of Pain/Nociception

Background and Aims: Temporomandibular disorder (TMD) is a biopsychosocial condition that primarily affects women. It has a high rate of chronicity (49% after six months) and a worldwide prevalence of 34,1%, reaching 47% in South America.
Recent systematic reviews indicate that patients with TMD have higher salivary cortisol levels than healthy controls, that cortisol levels are higher in specific subtypes, and that cortisol levels decrease after intervention. However, the literature is still conflicting. Identifying psychosocial phenotypes while controlling for confounding factors, such as the use of medications that interfere with cortisol, may help clarify the role of hypothalamic-pituitary-adrenal axis dysregulation in chronic TMD.

Methods: This cross-sectional study included 78 women (≥18 years) with chronic TMD (≥3 months, pain≥4/10). Diagnoses utilized the whole DC/TMD; sleep was assessed by PSQI. Morning and evening salivary cortisol were analysed by electrochemiluminescence. Exclusion criteria comprised other orofacial pain, smoking, oral bleeding, adrenal gland diseases, pregnancy, lactation, and use of cortisol-affecting medications.
Biopsychosocial phenotypes were identified through hierarchical agglomerative clustering (Ward’s method) of psychosocial variables. Cluster number was determined by silhouette coefficient and dendrogram inspection. Inter-cluster comparisons of pain intensity, madibular disability and cortisol, levels employed Kruskal-Wallis tests and ε² effect sizes. TMD subtypes associations used Pearson’s chi-square.

Results: According to somatization, anxiety, depression, oral habits and sleep quality, two phenotypic groups were identified: Adaptive Profile (AP, 53.8%) and Vulnerability Profile (VP, 46.2%).
Between-cluster analyses identified: significantly higher VP mandibular disability (H= 5.84, p= 0.016, ε²= 0.064); pain intensity non-significant trend toward higher values in the VP (p= 0.060); no diferences for morning cortisol levels (p= 0.187) or cortisol diurnal variation (p= 0.189). Effect sizes for neuroendocrine variables were small, indicating limited biological distinction between phenotypes.
DC/TMD diagnoses did not differ significantly between clusters, indicating that phenotypic differentiation was driven primarily by psychosocial and behavioral variables rather than structural diagnosis.

Conclusions: These findings suggest that cross-sectionally measured salivary cortisol may lack sensitivity to discriminate chronic TMD phenotypes. Biological dysregulation may manifest through more complex dynamic patterns not captured by single-day sampling. Structural diagnostic classification alone fails to capture the patients´ multidimensional burden. VP represents a high-risk subgroup that may benefit most from interdisciplinary interventions, whereas AP demonstrates resilience despite persistent pain, suggesting protective coping mechanisms warranting further investigation.
Overall, this study supports a shift from anatomy-centered classification toward biopsychosocial stratification in chronic TMD. Integrating psychosocial screening into routine clinical evaluation may improve individualized treatment planning and optimize therapeutic outcomes.

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Presenting Author: Erika Brasil Cavalcante Citó
Submitting Author: Erika Citó

Senior Author: Mariana Lima Vale

IASP 2026 Global Year theme of Neuropathic Pain: No

• Mariana Lima Vale: PhD - Federal University of Ceara
• Delane Viana Gondim: PhD - Federal University of Ceara
• Letícia Ponte Soares: NA - Federal University of Ceara
• Erika Brasil Cavalcante Citó: MSc - Federal University of Ceara
• Ana Dhully da Silva Teixeira: DDS - Federal University of Ceara
• Érica Silva Mesquita: DDS - Federal University of Ceara