Trauma, Emotional Control, Stress Coping Mechanisms, and Illness Acceptance in Individuals With Orofacial Pain, Headache, and Sleep Bruxism

ABSTRACT

Background

This cross‐sectional observational study aimed to assess the relationships between headache (HA), orofacial pain (OFP), sleep bruxism (SB), trauma, emotional control, stress management, and illness acceptance, as measured by scales.

Methods

Eligible patients underwent overnight videopolysomnography and completed validated questionnaires on pain, trauma, coping strategies, and illness acceptance; all data were analysed using TIBCO Statistica 13.

Results

The results showed a positive correlation between experienced trauma and pain (p = 0.001 for HIT 6, p = 0.002 for MIDAS, p = 0.002 for SF‐MPQ), as well as between pain and negative coping strategies such as denial (p = 0.020 for MIDAS, p = 0.038 for SF‐MPQ), venting (p = 0.020 for HIT‐6, p = 0.009 for MIDAS, p = 0.037 for SF‐MPQ), taking psychoactive substances (p = 0.009 for SF‐MPQ), behavioural disengagment (p = 0.007for HIT‐6, p = 0.039 for SF‐MPQ), and self—blame (p = 0.000 for HIT‐6, p = 0.001 for MIDAS, p = 0.000 for SF‐MPQ). The results also showed a correlation between lower illness acceptance and greater pain complaints (p = 0.000 for GCPS, p = 0.000 for HIT‐6, p = 0.000 for MIDAS, p = 0.000 for SF‐MPQ). We observed a significant negative relationship between self‐blame and the bruxism episode index (BEI) (p = 0.006) and between venting and BEI (p = 0.039).

Conclusions

Factors such as trauma, the use of negative coping strategies, and low levels of illness acceptance among patients with chronic orofacial pain can be associated with increased pain, which in turn compromises the effectiveness of treatment therapy. Self‐blame and emotional venting—showed significant negative correlations with BEI, indicating fewer SB episodes.

Trial Registration

www.ClinicalTrials.gov, “Relationship Between Selected Parameters and Bruxism”, identifier NCT04214561

Trauma, maladaptive coping strategies, and lower illness acceptance were associated with greater headache and orofacial pain burden in patients with orofacial pain. Self‐blame and emotional venting were negatively correlated with the bruxism episode index, suggesting fewer sleep bruxism episodes in these patients.

1. Introduction

According to the International Association for the Study of Pain (IASP), orofacial pain (OFP) represents a common category of pain localised to the facial region and/or the oral cavity, arising from pathological processes involving regional anatomical structures, dysfunctions of the nervous system, or as referred pain originating from distant sites [1]. In the classification of OFP, among others, such entities as OFP attributed to disorders of dentoalveolar and anatomically related structures, myofascial OFP, temporomandibular joint (TMJ) pain, OFP attributed to lesion or disease of the cranial nerves, OFP resembling presentations of primary headaches, idiopathic OFP, and psychosocial assessment of patients with OFP can be distinguished [2]. The OFP significantly affects patients' quality of life and their ability to engage in active social and professional activities. Treatment of OFP presents a considerable challenge for specialists, requiring, above all, accurate diagnosis and the selection of appropriate treatment methods, which may include both pharmacological and non‐pharmacological approaches [1, 3].

The biopsychosocial model, as outlined in the first edition of the International Classification of Orofacial Pain (ICOP‐1), integrates psychological and social factors with biomedical mechanisms to better explain pain conditions [1]. Psychological contributors include anxiety, depression, catastrophising, fear‐avoidance, and heightened symptom reporting, while social factors involve stigma, healthcare accessibility, and social support. Substantial evidence confirms the relevance of this model for understanding pain in general and OFP in particular [1, 4]. Research on biopsychosocial aspects of persistent OFP has focused primarily on temporomandibular disorders (TMD). Recognition of the biopsychosocial nature of TMD led to the development of the Research Diagnostic Criteria for TMD (RDC/TMD) by Dworkin and LeResche in 1992 [5], later revised as the Diagnostic Criteria for TMD (DC/TMD) [6].

Our research group has conducted multiple studies examining relationships between pain intensity, sleep quality, sleep bruxism (SB), psychoemotional state, personality traits, and general health in adults with TMD, including central sensitisation and somatisation [7, 8, 9]. We demonstrated that low emotional stability was strongly associated with greater pain severity, psychoemotional deterioration, functional impairment, and increased anxiety, depression, and stress, suggesting a more complex clinical course and reduced therapeutic responsiveness [7]. In another study, subjective sleep quality—but not objective polysomnographic measures—was significantly associated with OFP and headache intensity, as well as with depression, anxiety, and stress [8]. Additionally, somatisation was found to correlate with chronic masticatory muscle pain intensity, while women reported a higher somatic symptom burden than men [9].

Consistent with our findings, other authors report that OFP is rarely an isolated symptom and is frequently accompanied by sleep disturbances, bruxism, anxiety, chronic stress, and depressive symptoms [10, 11]. Psychoemotional status, coping strategies, and sleep quality have been repeatedly shown to influence pain perception and intensity [6, 11, 12, 13, 14, 15, 16].

Building on previous research, the present study aims to determine whether broader psychological processes—ranging from trauma exposure and coping strategies to illness acceptance and perceived health—may influence pain intensity and the severity of sleep bruxism, and whether such factors can inform early diagnostic and therapeutic decision‐making.

2. Materials and Methods

2.1. Participants

The study included 114 patients recruited between November 2019 and December 2020 from the Outpatient Clinic for Temporomandibular Disorders at Wroclaw Medical University. Individuals presented with pain localised to the face area, especially in masticatory muscles, temporomandibular joint (TMJ), or with headache complaints. All participants were examined by an experienced dentist with more than five years of clinical experience in managing OFP. A comprehensive clinical assessment was performed in accordance with the criteria of the 1st edition of ICOP [2]. The study group consisted of adult patients with OFP or primary headache. Primary headaches—defined as pain occurring in the absence of an underlying pathological process, disease, or trauma temporally related to symptom onset—comprised migraine, tension‐type headache, and trigeminal autonomic cephalalgias. Orofacial pain diagnoses included myofascial orofacial pain (pain localised to the masticatory muscles, with or without functional impairment), TMJ pain (pain localised to the TMJ, occurring at rest or during jaw movement or palpation), and orofacial pain mimicking primary headache phenotypes (pain in the orofacial region resembling primary headaches in character, duration, and intensity, with or without associated symptoms, but without concomitant headache).

Patients in whom the nature of the headache raised suspicion of a secondary aetiology—i.e., possibly related to an unidentified pathological process, disease, or trauma—were excluded and referred for neurological evaluation. Similarly, individuals whose orofacial pain could not be clearly classified as myofascial orofacial pain, TMJ pain, or orofacial pain resembling primary headache presentations were excluded from the study.

All eligible participants underwent video‐polysomnography (vPSG) at the Sleep Laboratory of the Clinical Department of Diabetology, Hypertension, and Internal Diseases at Wroclaw Medical University. Following polysomnographic assessment, participants completed a battery of validated questionnaires assessing pain intensity (Short Form McGill Pain Questionnaire (SF‐MPQ), Graded Chronic Pain Scale (GCPS), Headache Impact Test‐6 (HIT‐6), Migraine Disability Assessment (MIDAS), TMD pain screener) and four validated questionnaires to examine the entire psychological process: from trauma experience (Traumatic Experiences Checklist (TEC)) through coping mechanisms (Mini COPE, Courtauld Emotional Control Scale (CECS)) to acceptance and health (Acceptance of Illness Scale (AIS)).

The study protocol was approved by the Ethics Committee of Wroclaw Medical University (KB 175/2024). All participants were fully informed of the study aims, assured of confidentiality, and provided written informed consent. The study adhered to the ethical principles outlined in the World Medical Association Declaration of Helsinki. The clinical trial was registered at ClinicalTrials.gov (identifier: NCT04214561). This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Table S6) [17].

2.1.1. Inclusion Criteria

Participants were eligible for enrolment if they met the following conditions: they were at least 18 years old, provided written informed consent, and received a clinical diagnosis of OFP—specifically myofascial pain of the masticatory muscles, TMJ‐related pain, or OFP presenting with features similar to primary headaches according to the ICOP classification two and/or clinical diagnosis of primary headache disorders based on the 3rd edition of the International Classification of Headache Disorders (ICHD‐3) [18].

2.1.2. Exclusion Criteria

Participants were excluded if their symptoms were attributed to dentoalveolar pathology or abnormalities of adjacent anatomical structures. Additional exclusion factors encompassed dependency on alcohol or psychoactive substances, current use of medications that could substantially influence neuromuscular function, the presence of neoplastic disease, or severe systemic illnesses such as genetic syndromes, neurological conditions, active inflammatory or malignant processes, and major psychiatric disorders or significant intellectual impairment. Individuals who declined to participate, as well as pregnant or breastfeeding women, were excluded from the study.

2.2. Video‐Polysomnography Procedure

All participants underwent an overnight vPSG assessment in the Sleep Laboratory at Wroclaw Medical University, using the Nox A1s system (Nox Medical, Reykjavík, Iceland). Recordings were performed approximately between 22:00 and 06:00, with adjustments made to accommodate each patient's habitual sleep schedule.

The vPSG protocol incorporated electroencephalographic, electrocardiographic, electrooculographic, and electromyographic recordings, including signals from the chin region and bilateral masseter muscle measurements. Respiratory effort was monitored using thoracic and abdominal movement sensors, and additional parameters, including body position, audio, and video data, were collected. Oxygen saturation and pulse were registered using a NONIN 3150 WristOx 2 pulse oximeter (Nonin Medical Inc., Plymouth, USA). Data processing and scoring were performed using the Noxturnal software platform (Nox Medical), dedicated to polysomnographic analysis.

All vPSG recordings were scored and analysed in 30‐s epochs by a qualified and experienced physician (H.M.), in accordance with the American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events, Version 2.4 [19, 20].

Sleep bruxism (SB) was assessed using bilateral masseter EMG and audio–video evaluation during polysomnography. The Bruxism Episode Index (BEI) was scored according to the AASM guidelines [19]. The BEI quantifies the number of bruxism episodes per hour of sleep (< 2: Irrelevant SB; 2–4: Mild/moderate SB; > 4: Severe SB) [19].

2.3. Pain Assessment

2.3.1. Short Form McGill Pain Questionnaire (SF‐MPQ)

The SF‐MPQ comprises 78 descriptors characterising various dimensions of the pain experience. Total scores range from 0 (indicating the absence of pain) to 78 (reflecting very intense pain), with values above 5 considered clinically meaningful. In their foundational work, Melzack et al. confirmed that SF‐MPQ demonstrates strong reliability, validity, and internal consistency. The abbreviated version is particularly suited for research contexts [21].

2.3.2. Graded Chronic Pain Scale (GCPS)

The GCPS evaluates chronic pain through three components: Chronic Pain Grade, Disability Score, and Disability Points. The grading system is structured as follows: Grade 0 denotes the absence of pain during the preceding six months; Grade I reflects low pain intensity (characteristic pain intensity < 50) combined with minimal disability (< 3 Disability Points); Grade II indicates high pain intensity (characteristic pain intensity > 50) but similarly low disability (< 3 Disability Points); Grade III is defined by moderate disability (3–4 Disability Points), which limits functioning, irrespective of pain intensity; Grade IV represents severe disability (5–6 Disability Points) with substantial functional restriction, again independent of pain intensity. Sharma et al. demonstrated that the 1‐month version of the GCPS performs as reliably as, or more reliably than, the 6‐month version across domains such as pain intensity, number of disability days, pain interference, chronic pain grade, and high‐impact pain. Their findings support the GCPS as a valid and dependable instrument for evaluating both pain severity and pain‐related functional impairment [22].

2.3.3. Headache Impact Test–6 (HIT‐6)

The HIT‐6 yields a total score ranging from 36 to 78. Scores ≤ 49 indicate no or minimal interference of headache with daily functioning; scores between 50 and 55 indicate a mild impact; scores ranging from 56 to 59 correspond to a substantial impact; scores ≥ 60 denote a severe disruption of everyday activities due to headache. Evidence from previous research demonstrates that HIT‐6 is a reliable and valid measure for assessing the burden of headaches in individuals with both episodic and chronic migraine. In the referenced study, the instrument showed strong internal consistency among migraine patients, with reliability coefficients ranging from 0.82 to 0.90 [23].

2.3.4. Migraine Disability Assessment (MIDAS)

The MIDAS questionnaire yields a score based on the sum of the days reported in items 1–5. Disability severity is categorised as follows: Grade I (minimal or no disability) for 0–5 days, Grade II (mild disability) for 6–10 days, Grade III (moderate disability) for 11–20 days, and Grade IV (severe disability) for more than 21 days. Stewart et al. demonstrated that the MIDAS instrument shows moderately strong test–retest reliability among individuals with headache disorders and aligns well with clinical evaluations of healthcare needs. The MIDAS total score is derived by summing the number of missed days at work or school, days on which household responsibilities were not performed, days of missed non‐work activities, and days during which productivity at work, school, or at home was reduced by 50% or more over three months. The study also reported a correlation coefficient of 0.63 between the MIDAS total score and an equivalent diary‐based measure, indicating that the questionnaire provides a valid approximation of more intensive daily tracking. Mean and median MIDAS scores obtained from a population‐based migraine cohort were comparable to those derived from diary methodologies [23].

2.3.5. Temporomandibular Disorder Pain Screening Tool (TMD Pain Screener)

A score of 3 or higher on the TMD Pain Screener (possible range: 0–7) indicates a positive screening result for painful temporomandibular disorders, as defined by DC/TMD. This threshold has been shown to predict the presence of pain‐related TMD reliably. The instrument demonstrates diagnostic performance, with very high sensitivity and specificity. In validation studies, the screener correctly identified individuals with painful TMD with 99% sensitivity and healthy controls with 97% specificity. Moreover, it effectively differentiated TMD‐related pain from other symptom conditions; specificity reached 95% for nonpainful TMJ conditions and 96% for headaches not associated with TMD [24].

2.4. Trauma Experience, Coping Mechanisms, and Acceptance of Illness

2.4.1. Traumatic Experiences Checklist (TEC)

The TEC involves 29 different traumatic experiences. It assesses five types of trauma and other problems, including emotional neglect, emotional abuse, body threat, sexual harassment, and sexual abuse, severe family problems, death or loss of a family member, body harm, and war experiences. Scoring includes computing two indexes (overall index of number of traumas experienced resulting from the sum of all items, and the total area of traumatic presence, which is the sum of the five traumatic experience areas); and three trauma severity indexes (determined by the impact of trauma and age when it occurred, and assembled into emotional, physical, and sexual trauma). The severity of total trauma can range from 0 to 13 (neglect and emotional abuse, physical abuse, and sexual harassment or abuse) or from 0 to 24 (body threat, pain, and bizarre/strange punishment). It is a powerful screening tool for correlational research on the impact of trauma. However, it should be noted that the scale relies entirely on self‐report and is therefore susceptible to memory bias and defence mechanisms (e.g., repression). Furthermore, different cultures and personalities may interpret what constitutes “traumatic” in different ways [25].

2.4.2. Mini‐COPE

Coping with stress, as assessed by the Mini‐COPE inventory, measures stress management. The questionnaire comprises 28 statements that represent 14 stress‐coping strategies. The range of results for each statement ranges from 0 to 3 points. The calculation of the results consists of adding together points for the answers regarding two theorems that make up the given scale and then dividing by 2. The strategies are: Active coping (taking direct action to remove or reduce the stressor), planning (thinking about how to confront the stressor and forming action strategies), positive reframing (attempting to see the stressor in a positive light or finding its benefits), acceptance (acknowledging the reality of the situation and coming to terms with it), humour (using humour to cope with the stressor), turning to religion (seeking comfort or help through religion or spiritual beliefs), emotional support (seeking sympathy, understanding, or encouragement from others), instrumental support (seeking advice, assistance, or information from others), self‐distraction (engaging in other activities to take one's mind off the stressor), denial (refusing to believe that the stressor exists or trying to ignore it), venting (expressing negative emotions and letting out feelings), substance use (using alcohol, drugs, or medications to reduce stress), behavioural disengagement (reducing efforts to deal with the stressor or giving up). Adaptive (Positive) coping strategies promote healthy stress management, facilitate emotional recovery, and reduce the risk of negative psychophysical consequences. These include active coping, planning, positive reframing, acceptance, humour, emotional support, and instrumental support. Maladaptive (Negative) coping strategies can worsen the situation or fail to resolve the problem, often exacerbating symptoms of stress and suffering. These include self‐distraction, denial, venting, substance use, behavioural disengagement, and self‐blame. A neutral or context‐dependent strategy is either adaptive or negative, depending on the personal and cultural context in which one turns to religion. It is a validated tool for research on adaptive and moderating mechanisms between stress and health. It allows us to see the profile of strategies—e.g., whether a person uses constructive or avoidant coping methods. However, the results are declarative—they describe beliefs about the way of coping, not actualbehaviour. Moreover, the tool may not capture changes in strategies over time (coping may change depending on the context) [26].

2.4.3. Courtauld Emotional Control Scale (CECS)

The CECS assesses emotional control. It consists of three subscales, each of which contains seven statements regarding the way of showing anger, depression, and anxiety. The scale is used to measure subjective control of anger, anxiety, and depression under challenging situations and is designed to examine adults (both healthy and ill). CECS is a tool of self‐description. Summing the scores of all three subscales yields the overall emotion control score. The examination aims to determine the degree to which an individual is subjectively convinced of their ability to control personal reactions when experiencing negative emotions. The overall indicator of emotion control is within the range of 21–84 points. The higher the score, the greater the suppression of negative emotions [27].

2.4.4. Acceptance of Illness Scale (AIS)

The AIS is used to assess the degree of disease acceptance. It contains eight statements describing the negative consequences of poor health. Each statement is scored from 1 to 5, where 1 means strongly agree, and 5 means strongly disagree. The scale has no standards. The obtained result is compared with the average result of one of eight clinical groups. The scale is used to measure the degree of disease acceptance. It can apply to any disease. The greater the acceptance of the disease, the better the adaptation and the less sense of mental discomfort [28].

2.5. Database

Information collected from participants' medical histories, completed questionnaires, and polysomnographic recordings was compiled into a dataset prepared using Microsoft Excel (Microsoft Office, USA). The resulting database served as the foundation for subsequent statistical analyses.

2.6. Statistical Analysis

All statistical computations were performed with TIBCO Statistica, version 13 (TIBCO Software Inc., 2017; http://statistica.io). Relationships between variables were evaluated using the nonparametric Kendall's Tau correlation coefficient, which was selected because the data were not normally distributed. A p below 0.05 was considered indicative of statistical significance. The required sample size was estimated based on power considerations using the cor function from the genefu package (https://rdrr.io/bioc/genefu/man/power.cor.html). The calculation assumed an expected Kendall correlation of 0.7 and a target confidence interval width of 0.05, yielding a minimum sample size of 22 participants. Thus, the final sample of 114 patients far exceeded the minimum threshold, ensuring adequate statistical power to detect meaningful associations between variables.

Given the exploratory aim of the study and the potential multicollinearity among psychological variables (including trauma exposure, coping strategies, and illness acceptance), the analysis was limited to bivariate correlations.

3. Results

3.1. Characteristics of the Study Population

The study included 114 adult participants (72 women and 42 men), all of Caucasian origin, aged 21–71 years. The mean age of the sample was 37.67 years.

3.2. The Relationship Between Traumatic Experiences and Pain Intensity

Among participants with greater trauma exposure, higher rates of reported pain were observed. This relationship was evident in three of the four questionnaires used to measure pain intensity. This aligns with the HIT‐6 (Ƭ = 0.219; p = 0.001), MIDAS (Ƭ = 0.212; p = 0.002), and SFM‐PQ (Ƭ = 0.204; p = 0.002). These relationships were directly proportional but not very strong. Nonetheless, it is clear that patients with more traumatic experiences in the past are more likely to report a greater impact of headaches on daily functioning, higher migraine‐related disability, and increased subjective pain intensity. However, no significant correlation was found between traumatic experiences and the degree of pain chronicity according to the GCPS classification, which may suggest that trauma influences pain perception and its functional effects more than its classification as chronic (Table 1).

TABLE 1.

Kendall tau correlations between the traumatic experiences checklist (TEC) and select pain measures: graded chronic pain scale (GCPS), headache impact test‐6 (HIT‐6), migraine disability assessment (MIDAS), and short‐form McGill pain questionnaire (SF‐MPQ).

Variables	n	Kendall tau	Z	p
TEC & GCPS	107	0.069	1.059	0.290
TEC & HIT‐6	105	0.219	3.317	0.001
TEC & MIDAS	98	0.212	3.087	0.002
TEC & SF‐MPQ	109	0.204	3.150	0.002

3.3. The Relationship Between Coping Strategies and Pain Intensity

We statistically analysed the relationship between 14 stress coping strategies and four pain assessment questionnaires: GCPS‐CPI, HIT‐6, MIDAS, and SF‐MPQ. Tau Kendall correlation coefficients were low, ranging from −0.13 to 0.25, indicating a weak correlation. Significant results (p < 0.05) were observed only for selected coping strategies—primarily those considered maladaptive (e.g., self‐blame, venting, disengagement).

Adaptive coping strategies showed little or no significant association with pain questionnaire scores. A correlation was observed between the strategy of seeking instrumental or emotional support and subjective pain intensity (SF‐MPQ): Instrumental support (τ = 0.197, p = 0.002); emotional support (τ = 0.149, p = 0.023). Active coping, positive reframing, and turning to religion did not show significant correlations with pain. However, the planning strategy and sense of humour showed slight correlations with SF‐MPQ: Planning (τ = 0.134, p = 0.039); humour (τ = 0.130, p = 0.047). Acceptance showed a slight inverse relationship with the GCPS score (τ = −0.166, p = 0.012).

Among the negative coping strategies, the strongest association with pain was found in the self‐blame strategy (HIT‐6: τ = 0.256, p = 0.000; MIDAS: τ = 0.228, p = 0.001; SF‐MPQ: τ = 0.255, p = 0.000), which shows that people who blame themselves more often experience more bothersome and intense pain. The venting/emotional discharge strategy was weakly positively correlated with pain (HIT‐6: τ = 0.155, p = 0.020; MIDAS: τ = 0.179, p = 0.009; SF‐MPQ: τ = 0.136, p = 0.037), indicating that patients who respond with emotional discharge tend to experience more severe and bothersome pain symptoms. The behavioural disengagement strategy was also positively correlated with pain (HIT‐6: τ = 0.178, p = 0.007; SF‐MPQ: τ = 0.134, p = 0.039). Weaker correlations with the intensity of pain were also visible for other negative pain coping strategies: Self‐distraction (HIT‐6 τ = 0,132, p = 0.048; SF‐MPQ τ = 0,138, p = 0.034); denial (MIDAS τ = 0,159, p = 0.02; SF‐MPQ τ = 0,136, p = 0.038), substance use (SF‐MPQ τ = 0,169, p = 0.009). All results are presented in Table 2.

TABLE 2.

Kendall tau correlations between coping strategies (mini COPE) and select pain measures: graded chronic pain scale (GCPS), headache impact test‐6 (HIT‐6), migraine disability assessment (MIDAS), and short‐form McGill pain questionnaire (SF‐MPQ).

Variables	n	Kendall tau	Z	p
Active coping & GCPS‐CPI	106	0.0181	0.276	0.782
Active coping & HIT‐6	104	−0.037	−0.561	0.575
Active coping & MIDAS	99	0.007	0.098	0.922
Active coping & SF‐MPQ total	108	0.045	0.691	0.490
Planning & GCPS‐CPI	106	−0.031	−0.476	0.634
Planning & HIT‐6	104	−0.019	−0.287	0.774
Planning & MIDAS	99	0.063	0.919	0.358
Planning & SF‐MPQ total	108	0.134	2.061	0.039
Positive reframing & GCPS‐CPI	106	−0.110	−1.673	0.094
Positive reframing & HIT‐6	104	−0.126	−1.898	0.058
Positive reframing & MIDAS	99	−0.064	−0.938	0.348
Positive reframing & SF‐MPQ total	108	0.003	0.041	0.967
Acceptance & GCPS‐CPI	106	−0.166	−2.515	0.012
Acceptance & HIT‐6	104	−0,082	−1.230	0.219
Acceptance & MIDAS	99	−0.053	−0.777	0.437
Acceptance & SF‐MPQ total	108	−0.011	−0.163	0.871
Humour & GCPS‐CPI	106	0.021	0.319	0.750
Humour & HIT‐6	104	0.064	0.958	0.338
Humour & MIDAS	99	0.111	1.630	0.103
Humour & SF‐MPQ total	108	0.130	1.990	0.047
Turning to religion & GCPS‐CPI	106	0.064	0.973	0.330
Turning to religion & HIT‐6	104	0.003	0.038	0.970
Turning to religion & MIDAS	99	−0.031	−0.454	0.650
Turning to religion & SF‐MPQ total	108	−0.047	−0.720	0.471
Emotional support & GCPS‐CPI	106	0.011	0.164	0.869
Emotional support & HIT‐6	104	−0.069	−1.031	0.302
Emotional support & MIDAS	99	−0.100	−1.470	0.142
Emotional support & SF‐MPQ total	108	0.149	2.279	0.023
Instrumental support & GCPS‐CPI	106	0.050	0.752	0.452
Instrumental support & HIT‐6	104	0.014	0.205	0.838
Instrumental support & MIDAS	99	−0.003	−0.037	0.971
Instrumental support & SF‐MPQ total	108	0.197	3.027	0.002
Self‐distraction & GCPS‐CPI	106	0.017	0.254	0.799
Self‐distraction & HIT‐6	104	0.132	1.989	0.048
Self‐distraction & MIDAS	99	0.092	1.355	0.175
Self‐distraction & SF‐MPQ total	108	0.138	2.120	0.034
Denial & GCPS‐CPI	105	0.029	0.446	0.656
Denial & HIT‐6	103	0.091	1.356	0.175
Denial & MIDAS	98	0.159	2.324	0.020
Denial & SF‐MPQ total	107	0.136	2.074	0.038
Venting & GCPS‐CPI	106	0.025	0.374	0.708
Venting & HIT‐6	104	0.155	2.325	0.020
Venting & MIDAS	99	0.179	2.620	0.009
Venting & SF‐MPQ total	108	0.136	2.088	0.037
Substance use & GCPS‐CPI	106	0.062	0.935	0.350
Substance use & HIT‐6	104	0.049	0.742	0.458
Substance use & MIDAS	99	0.105	1.542	0.123
Substance use & SF‐MPQ total	108	0.169	2.596	0.009
Behavioural disengagement & GCPS‐CPI	106	0.080	1.210	0.226
Behavioural disengagement & HIT‐6	104	0.178	2.679	0.007
Behavioural disengagement & MIDAS	99	0.118	1.736	0.083
Behavioural disengagement & SF‐MPQ total	108	0.134	2.060	0.039
Self‐blame & GCPS‐CPI	106	0.072	1.093	0.275
Self‐blame & HIT‐6	104	0.250	3.758	0.000
Self‐blame & MIDAS	99	0.228	3.347	0.001
Self‐blame & SF‐MPQ total	108	0.255	3.909	0.000

It is clear that patients who use maladaptive coping strategies may face a higher risk of experiencing more severe pain and worse functioning. The weak link between adaptive strategies and pain indicates that coping style alone might not be enough if the patient is going through significant emotional distress or trauma. The findings suggest that psychological treatments should aim to modify maladaptive strategies rather than just strengthening adaptive ones. The weak link between adaptive strategies and pain indicates that coping style alone might not be enough if the patient is going through significant emotional distress or trauma.

3.4. The Relationship Between Emotional Control and Pain Intensity

None of the correlations between the level of emotional control (CECS) and the scores on the pain questionnaires: GCPS, HIT‐6, MIDAS, and SF‐MPQ are statistically significant (all p's > 0.05). The Kendall Tau coefficient values are close to zero (ranging from −0.067 to 0.000), indicating a lack of a linear relationship between these variables. The results suggest that emotional control does not directly influence the level of pain experienced or its impact on daily life or disability. Emotionally inhibited control does not appear to be a factor related to pain intensity or its functional consequences. This may suggest that, in the studied patients, the tendency to suppress emotions alone does not translate into greater or lesser pain (Table 3).

TABLE 3.

Kendall tau correlations between courtland emotional control scale (CECS) and select pain measures: graded chronic pain scale (GCPS), headache impact test‐6 (HIT‐6), migraine disability assessment (MIDAS), and short‐form McGill pain questionnaire (SF‐MPQ).

Variables	n	Kendall tau	Z	p
CECS & GCPS CPI	110	−0.067	−1.045	0.296
CECS & HIT‐6	108	0.000	0.005	0.996
CECS & MIDAS	101	−0.011	−0.156	0.876
CECS & SF‐MPQ	114	−0.028	−0.444	0.657

3.5. The Relationship Between Acceptance of Illness and Pain Intensity

The study found statistically significant, moderately strong negative correlations between the level of illness acceptance, measured by the AIS, and four clinical indicators of pain and its functional consequences. These correlations were statistically significant for: GCPS‐CPI (τ = −0,257; p = 0,000); HIT‐6 (τ = −0,320; p = 0,000); MIDAS (τ = −0,307; p = 0,000); SF‐MPQ (τ = −0,300, p = 0,000).

This indicates a consistent association between higher levels of illness acceptance and lower scores on pain intensity, its impact on daily functioning, and disability. These correlations suggest that illness acceptance plays a significant protective role, potentially mitigating the subjective experience of pain and limiting its negative consequences. All results are summarised in Table 4.

TABLE 4.

Kendall tau correlations between acceptance illness scale (AIS) and select pain measures: graded chronic pain scale (GCPS), headache impact test‐6 (HIT‐6), migraine disability assessment (MIDAS), and short‐form McGill pain questionnaire (SF‐MPQ).

Variables	n	Kendall tau	Z	p
AIS & GCPS‐CPI	102	−0.257	−3.829	0.000
AIS & HIT‐6	100	−0.320	−4.711	0.000
AIS & MIDAS	97	−0.307	−4.449	0.000
AIS & SF‐MPQ	104	−0.300	−4.517	0.000

3.6. The Relationship Between Trauma, Coping Strategies, Emotional Control, Acceptance of Illness and Bruxism Episode Index (BEI)

Neither trauma, nor emotion control, nor illness acceptance showed a statistically significant relationship with BEI (p > 0.05 for all comparisons). However, analysis of the relationship between stress coping strategies and BEI revealed statistically significant correlations. We observed a significant negative relationship between self‐blame and BEI (τ = −0.189; p = 0.006). The negative correlation suggests that individuals who more frequently blame themselves have fewer SB episodes. We also observed a significant negative, albeit weaker, relationship between venting and BEI (τ = −0.142; p = 0.039). Individuals who more frequently vent their emotions (e.g., by screaming or crying) have fewer SB episodes. All results are summarised in Table 5.

TABLE 5.

Kendall tau correlations between traumatic experiences checklist (TEC), coping strategies (mini COPE), Courtauld emotional control scale (CECS), acceptance illness scale (AIS) and buxism episode index (BEI).

Variables	n	Kendall tau	Z	p
TEC & BEI	98	0.167	0.244	0.808
Active coping & BEI	98	0.0317	0.462	0.644
Planning & BEI	98	0.0149	0.218	0.827
Positive reframing & BEI	98	0.0762	1.112	0.266
Acceptance & BEI	98	0.009	0.130	0.897
Humour & BEI	98	−0.003	−0.050	0.960
Turning to religion & BEI	98	−0.053	−0.768	0.443
Emotional support & BEI	98	−0.120	−1.750	0.080
Instrumental support & BEI	98	−0.131	−1.911	0.056
Self‐distraction & BEI	98	−0.116	−1.690	0.091
Denial & BEI	97	−0.112	−1.623	0.105
Venting & BEI	98	−0.142	−2.069	0.039
Substance use & BEI	98	0.004	0.053	0.959
Behavioural disengagement & BEI	98	−0.086	−1.262	0.207
Self‐blame & BEI	98	−0.189	−2.762	0.006
CECS & BEI	101	−0.125	−1.846	0.065
AIS & BEI	94	0.013	0.185	0.853

4. Discussion

The literature consistently shows that psychoemotional state influences pain intensity and treatment outcomes [14, 29, 30, 31, 32], a finding supported by our previous studies [7, 8, 9]. We demonstrated that low emotional stability is strongly associated with greater pain severity, poorer psychoemotional health, functional impairment, and higher levels of anxiety, depression, and stress, potentially leading to more complex treatment courses and reduced therapeutic responsiveness [7]. Given the importance of psychoemotional factors in orofacial pain and primary headaches, the present study examines the relationships between pain intensity, coping strategies, emotional control, trauma exposure, and illness acceptance.

Analysis of the results showed that participants with a greater number of traumatic experiences in the past are more likely to experience a greater impact of headaches on life functioning, a higher level of migraine‐related disability, and a higher subjective pain intensity. However, no relationship between the trauma experienced and the increase in the intensity of SB was revealed. This is consistent with the findings of other studies. Al‐Khudhairy conducted a systematic review examining the association between posttraumatic stress disorder (PTSD) and TMD. Eight observational studies indicated that individuals with PTSD were more likely to suffer from TMD, experienced more severe OFP, had a low pain threshold, and responded less effectively to standard treatments. Biological mechanisms included impaired pain processing and increased stress‐induced muscle tension. The authors emphasised that TMD treatment should consider psychological aspects, including trauma presence [33]. Additionally, the findings of Bottiroli et al. provide strong evidence of a complex relationship between early‐life trauma, stress exposure, alexithymia, and chronic migraine with medication overuse. Patients with chronic migraine and medication overuse more often reported both emotional and physical childhood trauma, along with higher exposure to stressful life events in adulthood, compared to those with episodic migraine. These findings support the biopsychosocial model of chronic pain, highlighting the role of psychological and environmental factors in the development and persistence of pain conditions. Notably, alexithymia—especially difficulties in identifying feelings—was identified as a significant predictor of chronic migraine with medication overuse in this study. This suggests that emotional regulation deficits may increase vulnerability to chronic pain and contribute to maladaptive behaviours, such as medication overuse. It underscores the importance of assessing and addressing emotional processing issues as part of clinical care. The findings emphasise the need for integrated therapeutic approaches that include psychological assessment and support, especially for individuals with a trauma history or emotional dysregulation. Such strategies could improve treatment outcomes and help prevent the progression or relapse of chronic migraine with medication overuse [34]. Moreover, the study by Knibbe et al. offers new insights into how trauma‐focused therapy impacts oral health outcomes in patients with severe PTSD and chronic painful TMD. The results showed that intensive trauma treatment—targeting core PTSD symptoms—led to significant and sustained reductions in TMD pain, awake and sleep bruxism. These improvements closely matched the reduction in PTSD symptoms, highlighting a psychophysiological link between trauma and orofacial dysfunction [35]. The findings support the idea that chronic OFP and bruxism may be physical expressions of unresolved trauma. This underscores the need for a multidisciplinary approach in managing TMD, especially in patients with comorbid psychological trauma.

The results obtained in our study also show that maladaptive coping strategies can be associated with experiencing severe pain and reduced functioning. While adaptive strategies show only a weak link to pain relief, this suggests that coping strategies alone are not enough—especially in patients with emotional distress or trauma. Therefore, psychological interventions should prioritise reducing maladaptive coping rather than just enhancing adaptive strategies. Venting and self‐balance strategies were additionally associated with an increased frequency of bruxism. Greenberg et al. examined how coping strategies relate to pain‐related outcomes in individuals with chronic OFP. The researchers investigated three key coping mechanisms—pain catastrophising, kinesiophobia, and mindfulness—and their associations with pain intensity, pain‐related disability, depression, and anxiety. Findings showed that pain catastrophising was the strongest predictor of increased pain and disability, highlighting it as a primary intervention target. All three coping strategies were independently linked to psychological factors: Higher catastrophising and kinesiophobia predicted increased anxiety and depression, while greater mindfulness was associated with reduced emotional distress. Given the high prevalence of depression and anxiety in this population, the study emphasises the need for comprehensive psychological interventions that not only address catastrophic thinking but also incorporate strategies to manage movement‐related fear and promote mindfulness [36]. The authors' conclusions are consistent with our research. Our results show that patients who use maladaptive coping strategies may be at risk for more severe pain and poorer functioning. However, the weak correlation we found between adaptive strategies and pain suggests that coping style alone may not be sufficient if the patient is experiencing significant emotional stress or trauma.

In their study, Saczuk et al. also reached conclusions consistent with those presented here. They surveyed 1018 medical university students during the COVID‐19 lockdown to assess symptoms of TMD, bruxism, stress levels, and coping strategies. Results showed that 77% of students reported TMD symptoms, and over half experienced bruxism. Those with TMD or bruxism had significantly higher perceived stress. Mostly maladaptive, emotion‐focused coping strategies were chosen by study subjects experiencing high stress levels. Using self‐blame as a coping strategy was the strongest predictor of perceived stress. However, our results indicate an inverse relationship between coping strategies considered maladaptive, such as venting or self‐blame, and bruxism severity. Although these strategies are typically linked to poorer mental health, our study found a negative association with bruxism severity, which contradicts Saczuk et al. [37]. The weak strength of the correlations and the study's correlational design do not allow for causal conclusions or determination of the direction of the relationships. It cannot be ruled out that other intervening variables may influence these relationships. Therefore, the results should be interpreted with caution and serve as a basis for further research, including longer‐term observation of patients with bruxism.

Our study results show a consistent link between higher levels of illness acceptance and lower scores in pain intensity, impact on daily functioning, and disability. Acceptance plays a crucial role in how people respond to and adapt to pain, a finding that has been repeatedly confirmed by other researchers who studied participants with rheumatoid arthritis (RA) [38, 39]. Costa et al. reported that high pain levels in people with RA were linked to low pain acceptance [39]. Pinto‐Gouveia found similar results in their studies on RA [38]. Additionally, Dogan et al. examined the relationship between pain acceptance and illness acceptance in 123 RA patients. Their results indicated that higher pain acceptance was associated with lower pain intensity and greater acceptance of the illness. Patients with higher education, employment, and better income levels scored significantly higher in both pain and illness acceptance. Furthermore, lower acceptance levels were linked to worse physical function and higher disease activity [40].

Researchers examining pain in patients with TMD have also aimed to understand whether acceptance of the condition and understanding of it are linked to perceived symptom levels. Evidence shows that chronic pain can drain self‐regulatory resources, making it hard for patients to control thoughts and emotions. In TMD patients, pain acceptance—defined as both a willingness to experience pain without trying to control it and ongoing engagement in valued activities—has been associated with improved psychological outcomes [41]. A study by Eisenlohr‐Moul et al. found that higher pain willingness correlates with less psychological distress and lower self‐regulatory fatigue, especially in those with long‐term pain. Additionally, the buffering effect of pain willingness on distress was mediated by decreased self‐regulatory fatigue. These results underscore the potential of acceptance‐based therapies to strengthen emotional resilience in chronic orofacial pain [41]. This aligns with our findings, which reveal a link between higher levels of illness acceptance and lower scores on pain intensity, its effects on daily activities, and disability. Illness acceptance serves a crucial protective role, potentially reducing the subjective experience of pain and mitigating its negative impacts. It is also worth mentioning here that an interesting direction of research is the connection between TMD and infectious diseases, which was recently discussed by the team of Osiewicz et al., which may be another clue in this complicated way of diagnosing and treating patients with TMD [42, 43].

4.1. Study Limitations

The main limitations include the absence of a healthy control group and reliance on self‐reported measures of pain, which may limit diagnostic precision. An important limitation of the present study is the lack of standardised DC/TMD Axis I diagnostic criteria. Although clinical diagnoses were established using ICOP‐1 criteria and an experienced clinician's clinical examination, the lack of a widely accepted, standardised diagnostic framework may affect the consistency and reproducibility of TMD classification. This limitation should be considered when comparing the present findings with studies based on DC/TMD criteria. Gender differences were notanalysed, and psychiatric assessments conducted by multiple researchers may have introduced variability. Polysomnography was limited to a single night in a laboratory setting, potentially affecting sleep quality due to the first‐night effect. Another limitation of the present study is that the sample was recruited from a single clinical centre, which may limit the generalisability of the findings to broader or more diverse populations. A further limitation of the present study is the absence of multivariate analyses, which would allow for assessment of the independent contribution of individual psychological factors. Potential sources of bias include the single‐centre design, reliance on a self‐reported questionnaire, and the cross‐sectional nature of the study. Despite these limitations, the study is strengthened by the use of vPSG as an objective tool for assessing sleep bruxism, a relatively large sample size (n = 114), and comprehensive psychological assessment using validated questionnaires, supporting the study's clinical relevance.

5. Conclusions

Our results indicate that the psychoemotional state of patients with chronic orofacial pain is closely associated with condition severity and treatment outcomes. Factors like trauma, negative coping strategies, and low levels of illness acceptance were linked to higher pain intensity, which may be related to reduced treatment effectiveness. Patients with impaired emotional processing and maladaptive coping styles tended to report more severe symptoms and lower quality of life, including limited social and professional functioning. These findings highlight the importance of a comprehensive therapeutic approach that includes psychological support for disease acceptance and targeted interventions to eliminate negative coping strategies. Stress coping strategies, but not trauma, emotion regulation, or illness acceptance, were associated with BEI, with higher self‐blame and venting linked to fewer bruxism episodes.

Author Contributions

Anna Wojakowska: investigation, data curation. Helena Martynowicz: conceptualization, methodology, investigation, writing – review and editing, formal analysis, data curation. Wojciech Bombala: software, formal analysis, data curation. Joanna Smardz: investigation, writing – review and editing, data curation. Mieszko Wieckiewicz: conceptualization, investigation, funding acquisition, writing – review and editing, methodology, project administration, supervision, resources. Sylwia Orzeszek: investigation, writing – original draft, methodology, data curation, project administration, funding acquisition, validation, visualization, conceptualization.

Funding

This work was supported by Uniwersytet Medyczny im. Piastow Slaskich we Wroclawiu, SUBK.B160.24.030.

Ethics Statement

The study protocol was approved by the Ethical Committee of Wroclaw Medical University (approval No. KB 175/2024).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Supporting Information.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.