Differences in personality, perceived stress and physical activity in women with burning mouth syndrome compared to controls

Elizabeth Jedel; Magnus L. Elfström; Catharina Hägglin

doi:10.1515/sjpain-2020-0110

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Differences in personality, perceived stress and physical activity in women with burning mouth syndrome compared to controls

Elizabeth Jedel , Magnus L. Elfström and Catharina Hägglin

Published/Copyright: October 28, 2020

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From the journal Scandinavian Journal of Pain Volume 21 Issue 1

Abstract

Objectives

Burning mouth syndrome (BMS) is a long-lasting pain condition which is commonly associated with anxiety symptoms and experience of adverse, stressful life events have been reported by those diagnosed with the syndrome. Stress-related biomarkers have been related to personality traits in BMS and a personality with high stress susceptibility and perceived stress may be of importance. Although biopsychosocial approaches are suggested to manage long-lasting orofacial pain, to date little is known about physical activity in women with BMS. The aim of this study was to investigate if personality, perceived stress and physical activity distinguish women with BMS from controls.

Methods

Fifty-six women with BMS and 56 controls matched on age and gender completed Swedish universities Scales of Personality (SSP), Perceived Stress Questionnaire (PSQ) and a general questionnaire with an item on weekly physical activity frequency. In addition, health-related quality of life was explored by additional questionnaires and reported in a companion article (Jedel et al. Scand J Pain. 2020. PubMed PMID: 32853174).

Results

SSP subscales Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Verbal Trait Aggression differed between women with BMS and controls and the personality factor scores for Neuroticism and Aggressiveness were higher. Perceived stress measured by PSQ index was higher for women with BMS compared to controls. Women with BMS reported lower physical activity frequency compared to controls and those reporting physical activity <4 days/week scored higher on PSQ compared to those with weekly physical activity ≥4 days/week.

Conclusions

Personality distinguished women with BMS from controls in this study. Perceived stress was higher and weekly physical activity was lower in women with BMS compared to controls. Our findings suggest physical activity should be more comprehensively measured in future BMS studies and, by extension, physical activity may be a treatment option for women with BMS. Pain management aiming to restore function and mobility with stress reduction should be considered in clinical decision making for women with BMS who have a personality with stress susceptibility, especially if reporting high perceived stress and insufficient physical activity.

Keywords: burning mouth syndrome; chronic pain; emotions; personality; physical activity; stress

Introduction

Burning mouth syndrome (BMS), a long-lasting pain condition, not better accounted for by another headache disorder, may be defined as an intraoral burning or dysesthetic sensation, recurring daily for more than 2 h per day over more than three months, without clinically evident causative lesions [1]. The pain is felt superficially in the oral mucosa and is usually located to the anterior part of the tongue. The pain intensity fluctuates and altered taste and dry mouth, i.e., xerostomia, are common findings in BMS, a syndrome associated with emotional distress [1].

The BMS prevalence increases with age and there is a strong dominance among women [2]. A Swedish study found a BMS prevalence of 12.2% in women and 3.6% in men 60–69 years [3].

Development and utilization of diagnostic methods have shown neuropathic involvement in BMS [4], with peripheral small fiber or trigeminal system damage, brainstem trigeminal system lesions and signs of decreased inhibition within the central nervous system [4], [5]. Peripheral and central neuropathic pain may overlap and the central type is suggested to have a common predisposition with psychological symptoms [4].

Psychological symptoms associated with BMS include anxiety [6], and experience of adverse, stressful life events have been reported by those affected [7], [8]. Stress, as a state of arousal in response to environmental stressors may be characterized by biopsychosocial changes with positive or negative consequences [9]. An individual’s personal distinctive, relatively enduring ways of thinking, feeling and acting, i.e., personality traits, may influence stress responses [10]. The personality characterized by a tendency to experience negative affect, neuroticism, has previously been linked to stress vulnerability [11]. In a study assessing patients with BMS by the use of structured psychiatric interviews and personality dimensions from the Big Five-theory, a personality profile with high neuroticism and low openness was observed [12]. The study showed that low openness was associated with stress-related markers in saliva [12]. To investigate this further, we hypothesize that BMS may be accompanied by a personality with high stress susceptibility and high perceived stress.

With physical and associated psychological symptoms BMS has a potentially disabling nature, thus to develop treatment methods is important [13]. Galli and Pravettoni [14] suggest addressing interventions according to the patient needs, beliefs, preferences and personality. Randomized controlled trials for BMS have evaluated mainly pharmaceuticals [13], with some positive results. Importantly, central neuropathic pain, which may be part of the BMS pathophysiology, does not respond to treatments such as topical clonazepam [4]. In addition, pharmacological interventions have side-effects, including causing xerostomia. Current psychological interventions for long-lasting orofacial pain are underpinned by a biopsychosocial understanding [15], and more BMS specific knowledge of psychological factors is needed.

Although biopsychosocial approaches are suggested to manage long-lasting orofacial pain [15], and physical activity can activate pain inhibitory systems [16] to reduce pain severity in long-lasting pain conditions [17], to date little is known about physical activity in women with BMS. Physical activity is defined as bodily movements resulting in energy expenditure while physical exercise is a subcategory of physical activity that is planned, structured, repetitive for the purpose of maintaining or improve physical fitness [18].

BMS may be associated with deficit inhibitory conditioned pain modulation [5], and physical activity treatments to manage other neuropathic conditions [19] can hypothetically reduce pain in BMS. Another important aspect is that regular physical activity and personality are central traits, i.e., recurring ways of reacting and being, and both may be involved in activation of the neuromodulatory endocannabinoid system to varying degrees [20]. The endocannabinoid system may be supported by physical activity and by its action modulate anxiety and stress [20].

The aim of this study was to investigate if personality, perceived stress and physical activity distinguish women with BMS from controls.

Methods

Design and participants

Recruitment for this case-control study started at a Clinic of Oral Medicine, Institute of Odontology, Sahlgrenska Academy, Gothenburg, Sweden in 2011. One hundred and four patients previously diagnosed with BMS in accordance with International Classification of Headache Disorders [1] were considered for the study. There were three men in the patient registry and to avoid analytical bias a decision was made to include women only in the study. Therefore, inclusion criteria were women with BMS. Exclusion criteria were women with anemia, ongoing infection and/or an increased number of opportunistic microorganisms on the tongue and/or clinically visible oral changes.

The invitation was sent by mail and 30 women replied they wanted to take part in the study.

To exclude women not fulfilling the criteria, blood samples were taken at the Sahlgrenska University Hospital, and scraping samples from the tongue were obtained at the Department of Oral Microbiology, Institute of Odontology, Sahlgrenska Academy, Gothenburg University.

From the initial recruitment, 26 women agreed with verbal and written consent to participate in the study. Between 2012 and 2014 an ongoing recruitment resulted in an additional 30 women with BMS being eligible, thus 56 women were included.

Controls, to be matched by age (±3 years) and gender, were recruited between 2012 and 2015.

The recruitment of controls included patients from private and public dental clinics, dental assistants from the Clinic of Oral Medicine and office and laboratory staff from the Institute of Odontology. Inclusion criteria for controls were women without BMS diagnosis or a history of intraoral pain. To confirm control status, the examinations prior to inclusion included blood samples and scraping samples from the tongue. Excluded were women with anemia, ongoing infection, increased opportunistic microorganisms on the tongue, clinically visible oral changes, history of systemic disease, rheumatoid arthritis and/or other serious disease.

The recruitment period lasted between 2011 and 2015 and resulted in 56 women with BMS and a mean age of 67.8 (SD 8.9) years; and 56 controls with a mean age of 67.7 (SD 8.5) years. The participants age ranged from 43–84 years. For women with BMS the mean BMS debut age was 60 years (SD 9.37), the BMS duration ranged from 0.5–33 years (mean 7.75, SD 6.94) and the mean score for BMS-problem severity measured by visual analog scale (VAS) (0–100) was 68 (SD 19.21). All participants were Swedish residents, 41 (73.2%) women with BMS and 37 (61.1%) controls were married/cohabiting (p=0.538). Regarding employment status, 26 women with BMS (46.4%) and 33 controls (58.9%) reported they had been working during the past 10 years (p=0.071) and retirement were the main reason for not working in women with BMS and controls. Recruitment and examination processes have been further described by Acharya et al. [21], [22], [23], [24] in one survey [21] and three studies investigating saliva components [22], [23], [24]; and in our companion article Health-related quality of life in burning mouth syndrome- a case-control study [25]. The previous studies have different aims and statistical analysis methods, where case-control data were analyzed with unpaired tests [21], [22], [23], [24] or paired tests [25].

Procedure description

To investigate personality, perceived stress and physical activity frequency, questionnaires were distributed to and completed by all participants prior to examinations at the Department of Orofacial pain, Institute of Odontology, Sahlgrenska Academy, Gothenburg University. In addition, health-related quality of life was explored by additional questionnaires and reported in our companion article [25].

Description of measures

Swedish universities Scales of Personality

Swedish universities Scales of Personality (SSP) [26], [27] was derived from Karolinska Scales of Personality (KSP) [28] aiming to quantify important personality constructs used to explore and understand the complicated relationship between individual differences in behavior, affectivity and functioning in underlying biological substrates. KSP was not developed to cover the whole personality but aimed towards areas of importance for specific groups, among them patients suffering from depression and anxiety states [28]. SSP consist of 91 items divided into 13 subscales [26], [27]. There are seven items in each subscale and the response format for each item is on a four-point Likert scale ranging from does not apply at all to applies completely. Item ratings for each of the 13 groups are summed and divided by seven given a mean score 0–4 for each subscale. High scoring on SSP subscales can be described as follows: autonomic disturbances, restless, tense (Somatic Trait Anxiety); worrying, anticipating, lacking self-confidence (Psychic Trait Anxiety); easily fatigued, feeling uneasy when urged to speed up (Stress Susceptibility); lack ability to speak up and to be self-assertive in social situations (Lack of Assertiveness); acting on the spur of the moment, non-planning, impulsive (Impulsiveness); avoiding routine, need for change and action (Adventure Seeking); avoiding involvement in others, withdrawn, schizoid (Detachment); socially conforming, friendly, helpful (Social Desirability); unsatisfied, blaming and envying others (Embitterment); irritable, lacking patience (Trait Irritability); suspicious, distrusting peoples motives (Mistrust); getting into arguments, berating people when annoyed (Verbal Trait Aggression); and getting into fights, starts fights, hits back (Physical Trait Aggression). There are three personality factors tapped from the SSP subscales- Neuroticism, Aggressiveness and Extraversion [26], [27], as shown in Table 1. The internal consistency for SSP subscales in this study ranges from 0.73–0.86, except a value of 0.56 for Social Desirability, which is in line with the SSP developers who found lower consistency value for Social Desirability compared to the other subscales [26], [27].

Table 1:

Swedish universities Scales of Personality in women with burning mouth syndrome and controls.

Swedish universities Scales of Personality subscales	Women with burning mouth syndrome (n=56) Md (IQR, 25th percentile:75th percentile)	Controls (n=56) Md (IQR, 25th percentile:75th percentile)	Wilcoxon sign rank test p-Value	Effect size d_Cohen
Somatic Trait Anxiety^a	2.21 (1.86:2.57)	1.71 (1.43:2.14)	< 0.001	1.29
Psychic Trait Anxiety^a	2.21 (1.86:2.86)	2.00 (1.57:2.29)	0.002	0.90
Stress Susceptibility^a	2.14 (1.86:2.57)	1.86 (1.71:2.00)	0.001	1.05
Lack of Assertiveness^a	2.14 (1.71:2.71)	2.21 (1.86:2.43)	0.589	0.15
Impulsiveness^c	2.17 (1.83:2.50)	2.16 (2.00: 2.50)	0.389	0.23
Adventure Seeking^c	2.29 (1.86:2.86)	2.29 (2.00: 2.82)	0.384	0.23
Detachment^c	2.00 (1.71:2.16)	2.00 (1.84: 2.29)	0.626	0.13
Social Desirability^b	3.14 (2.86:3.29)	3.00 (2.71: 3.29)	0.040	0.57
Embitterment^a	1.71 (1.18:2.00)	1.57 (1.32:1.86)	0.430	0.21
Trait Irritability^b	2.36 (2.00:2.71)	2.07 (1.86:2.29)	0.076	0.49
Mistrust^a	2.00 (1.43:2.29)	1.86 (1.57:2.14)	0.608	0.14
Verbal Trait Aggression^b	1.86 (1.43:2.14)	1.43 (1.29:1.71)	0.001	0.94
Physical Trait Aggression^b	1.43 (1.29:1.96)	1.57 (1.29:2.00)	0.642	0.12

Md, Median; IQR, Interquartile range.
p-Value of 0.004 was set for accepting statistical significance.
^aSubscale for the personality factor Neuroticism.
^bSubscale for the personality factor Aggressiveness.
^cSubscale for the personality factor Extraversion.

Perceived Stress Questionnaire

Perceived Stress Questionnaire (PSQ) was developed for psychosomatic research by Levenstein et al. [29] and translated into Swedish by Bergdahl et al. [30]. PSQ assess perceived stress responses and the experience of external stressors across situations. The measure has 30 items and is scored on a four-point Likert scale where 1 = almost never, 2 = sometimes, 3 = often, 4 = usually. A PSQ index varying from 0 (lowest level of perceived stress) to 1 (highest level of perceived stress) is computed as (total raw score-30)/90 [29]. Cut-off scores for a Swedish population have been calculated as follows; 0.34–0.46 = moderate and >0.46 = high [30]. The PSQ factor structure varies between populations [29], [30], [31], [32], [33]. PSQ comes in a General (one-year recall) and a Recent (one-month recall) version, the only difference being the time frame. For this study Recent PSQ test the hypothesis that BMS may be accompanied by high perceived stress. The internal consistency for the PSQ index in this study is 0.92.

Physical activity

A general questionnaire included items on previous BMS treatments and the following item on physical activity: How many days/week are you physically active for a total of 30 min (e.g. walking at a brisk pace)? The item is rated on a seven-point scale ranging from one day [1] to seven days [7]. A 30 min brisk walk for five days/week agrees with the Global recommendations of physical activity for adults [34].

Statistical analysis

IBM SPSS Statistics program for Windows version 25.0, Armonk, NY: IBM Corporation was used for the analyzes. The 19 missing values from SSP were handled in accordance with the SSP manual, where respondents were allowed one missing value for each subscale without being excluded from analysis. All values from item 57, belonging to the subscale for Impulsiveness, were missing due to technical errors. For PSQ, there were four missing values and they were replaced by imputation by the mean, where the group mean for the missing value substituted the missing value. The questionnaires internal consistency was evaluated using Cronbach’s alpha (α) coefficient [35]. Distribution statistics, i.e., data skewness, was not all within ±1 and descriptives are presented as percentages, median (Md) and interquartile range (IQR 25th percentile:75th percentile). Differences between women with BMS and controls were analyzed with Wilcoxon sign rank test. For within group analyzes Mann–Whitney U test were used. Wilcoxon sign rank test and Mann–Whitney U test were transformed into effect sizes by means of the calculator provided by Lenhard and Lenhard [36]. The effect size interpretation followed Cohen’s criteria (0 to <0.20 = trivial, 0.20 to <0.50 = small, 0.50 to <0.80 = moderate and ≥0.80 = large) [37]. Results in this study were considered statistically significant at p<0.05. To minimize type I error due to multiple comparisons we applied a Bonferroni correction [38] dividing 0.05 by the number of tests performed, when appropriate.

Results

We analyzed personality in women with BMS and controls to test the hypothesis that BMS may be accompanied by a personality with high stress susceptibility. The SSP subscales Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Verbal Trait Aggression differed between women with BMS and controls (Table 1). The personality factor scores tapped from SSP showed Neuroticism and Aggressiveness were higher for women with BMS compared to controls (Table 2). For women with BMS there were no statistically significant differences on SSP subscales or personality factors when comparing those below/above Md age 68.5 years, Md BMS duration 6 years and Md BMS-problem severity VAS 70.

Table 2:

Personality factors from Swedish universities Scales of Personality in women with burning mouth syndrome and controls.

Personality factors from Swedish universities Scales of Personality	Women with burning mouth syndrome (n=56) Md (IQR, 25th percentile:75th percentile)	Controls (n=56) Md (IQR, 25th percentile:75th percentile)	Wilcoxon sign rank test p-Value	Effect size d_Cohen
Neuroticism	10.50 (9.00:12.11)	9.43 (8.21:10.39)	0.002	0.91
Aggressiveness	8.93 (7.89:9.57)	8.12 (7.71:8.71)	0.001	1.01
Extraversion	4.50 (3.87:5.19)	4.62 (4.00:5.11)	0.716	0.19

Md, Median; IQR, Interquartile range.
p-Value of 0.02 was set for accepting statistical significance.

To test the hypothesis that BMS may be accompanied by high perceived stress we used the PSQ index which was higher for women with BMS (Md 0.31; IQR 0.17:0.45) compared to controls (Md 0.14; IQR 0.10:0.26) (p<0.001, d_Cohen 1.42). PSQ index were higher for women with BMS<68.5 years compared to ≥68.5 years (Md 0.40; IQR 0.22:0.51 vs. Md 0.26; IQR 0.13:0.40) (p=0.045, d_Cohen 0.56), respectively. There were no statistically significant differences on PSQ index when comparing women with BMS below/above Md BMS duration and/or Md BMS-problem severity.

Ten women with BMS reported yes to previous BMS treatments, including pharmaceuticals (n=5), oral splints (n=4) and acupuncture (n=1). For our hypothesis on physical activity, i.e., that women with BMS may have a lower physical activity frequency compared to controls, we used an item on how many days a week participants were physically active. We found that women with BMS reported lower physical activity frequency (Md 4.00; IQR 3.00:6.00) compared to controls (Md 5.00; IQR 3.00:7.00)(p=0.045, d_Cohen 0.56). The global weekly physical activity recommendations for adults were reached by 42.9% (n=24) of women with BMS vs. 62.5% (n=35) of controls.

To investigate if personality and perceived stress differed between women with BMS and physical activity frequency <4 days/week (n=25) and physical activity frequency ≥4 days/week (n=31), we performed Md split. Women with BMS and physical activity frequency <4 days/week scored higher on the SSP subscales Somatic Trait Anxiety (Md 2.43; IQR 2.07:2.79 vs. Md 2.00; IQR 1.71:2.43, p=0.007, d_Cohen 0.78) and Stress Susceptibility (Md 2.43; IQR 2.07:2.79 vs. Md 2.14; IQR 1.71:2.28, p=0.007, d_Cohen 0.77), respectively. Women with BMS reporting physical activity <4 days/week scored higher on perceived stress measured by PSQ (Md 0.40; IQR 0.25:0.52) when compared to those with weekly physical activity ≥4 days/week (Md 0.26; IQR 0.13:0.41) (p=0.028, d_Cohen 0.62). There were no statistically significant differences on physical activity frequency when comparing those below/above Md age, BMS duration and/or BMS-problem severity.

Discussion

The aim of this study was to investigate if personality, perceived stress and physical activity distinguished women with BMS from controls. To measure personality traits we used SSP subscales together with SSP personality factors and noted differences between women with BMS and controls on several subscales referring to anxiety which is in line with other studies [12], [39]. In addition to differences on subscales, the personality factor scores for Neuroticism and Aggressiveness distinguished women with BMS from controls. The personality factors in this study were those tapped from SSP by developers [26], [27]. Due to our relatively small number of participants we were not able to perform an evaluation of the SSP factor structure for women with BMS. Therefore, we need to be somewhat cautious with our interpretations regarding the personality factor scores for Neuroticism and Aggressiveness that distinguished women with BMS from controls. As seen in Table 1, the three subscales Somatic Trait Anxiety, Psychic Trait Anxiety and Stress Susceptibility, which refer to the factor Neuroticism, differed between women with BMS and controls while the two subscales Lack of Assertiveness and Mistrust did not show any statistically significant differences. For the factor Aggressiveness, it was Verbal Aggression that fell out, that is, was significant between women with BMS and controls. For the factor Extraversion, the three subscales did not show any differences between women with BMS and controls.

de Souza et al. [12] found personality traits of neuroticism in BMS, and a personality profile with neuroticism infer a tendency toward negative emotions. Although few studies on BMS have used pure personality scales, studies have measured negative emotional symptoms, e.g. symptoms of anxiety and depression, by Hospital Anxiety Depression Scale (HADS) [7], [40], [41], Montgomery–Åsberg Depression Rating Scale (MADRS) [42], Symptom Checklist-90-Revised (SCL-90-R) [43], Beck Anxiety Inventory (BAI) [44], Beck Depression Inventory (BDI) [45], [46], Cattels Anxiety Scale [47], and State and Trait Anxiety (STAI) [43], [45], [48]. Results from earlier studies show that the role of psychological factors in BMS are substantial. Galli and Pravettoni [14] suggest going beyond the study of cormobid associations of anxiety symptoms and mood disorders, as we do when studying personality.

Women with BMS in this study scored higher than controls on the SSP subscale Verbal Trait Aggression, and in agreement with our findings, high scores on neuroticism related scales have previously been suggested to be indirectly associated with higher scores on verbal aggression scales via increased long-term access to negative emotions such as anger [49]. Anger hostility differed between BMS and controls in the study by Al Quran [39], who utilized the personality scale Neuroticism Extraversion Openness Personality Inventory Revised (NEO-PI-R) [50] which is based on the Big Five-theory.

By utilizing SSP, a personality scale derived from a different theoretical framework than the known Big Five-theory previously used in BMS research by de Souza et al. [12] and Al Quran [39], our study validate the link between BMS and personality.

Women with BMS <68.5 years in this study did not score different from those ≥68.5 on SSP. Interestingly, personality research have provided support for the hypothesis that personality changes gradually throughout life, which can lead to personality in older age being quite different from personality in early age [51]. Whether personality changes over time in women with BMS remain to be elucidated. Earlier studies on BMS have suggested personality to be closely related to the pain experience [52], [53], thus would support a hypothesis that personality change over the years. In our study we did not find differences on SSP between those who reported high vs. low BMS-problem severity. Neither were there any differences on SSP between women with BMS duration <6 years and ≥6 years. Importantly, we did not follow the women with BMS over time.

One explanation as to why personality may change over time is that a long-lasting pain history may adjust personality profiles toward anxiety propensity with general tendencies to experience negative emotions in relation to uncontrollability of perceived stress. Anxiety and stress are closely related [54], and women with BMS in this study scored higher on SSP scales related to anxious personality and stress susceptibility. To measure perceived stress we used PSQ, which in a study by Bergdahl et al. [30] showed mean scores of 0.22 in Swedish adults as compared to an Italian based study with mean scores of 0.30 for the general population [55]. The later study observed perceived stress to be rising and falling over the lifetime [55]. A higher PSQ index for women with BMS compared to controls in this study may indicate an imbalance between demands encountered in daily living and the capability to respond. With an inability to influence events and outcomes in the environment there can be a sense of uncontrollability [54].

Women with BMS in this study reported differences in personality with stress susceptibility together with perceived stress and physical activity frequency compared to controls. Global recommendations of physical activity for adults include at least 150 min of moderate intensity throughout the week [34], a recommendation not reached by a large percentage of women with BMS in this study. This opens for issues on how those with BMS and perceived stress should think and what coping strategies are needed to change physical activity behavior to reach the global recommendations. Based on theory described by Chorpita and Barlow [54] our feelings range along a continuum from excitement to stress to anxiety to depression depending on sense of control and ability to cope. Some individuals use physical activity to cope with perceived stress [56] and expectation of personal efficacy will determine if coping will be initiated, how much effort will be expended and how long it will be sustained [57]. Although the reciprocal relationship between physical activity and perceived stress speaks for physical activity to reduce stress [58], it is important to acknowledge that for long-lasting pain conditions there might be biological and behavioral inhibition factors predicting less physical activity [59]. For example, in long-lasting pain populations, the pain reduction that occurs during and after physical exercise may be impaired, thus lead to pain exacerbation which can precipitate a cycle of physical inactivity [60].

There are important parallels between BMS and other long-lasting pain syndromes, where pain can be the sole or a leading complaint requiring special treatment and care [61]. Today, physical activity and physical exercise programs are increasingly being promoted and offered in health care for a variety of long-lasting pain conditions [62]. None of the women with BMS in this study reported they had been engaged in physical activity programs and/or physical exercise programs when asked of previous BMS treatments. This may be due to several reasons, one being that physical activity interventions may not have been considered a treatment option in BMS. Sustainability factors in BMS can result in consequences for individuals, their families and society in several ways and by promoting and offering physical activity, pain severity reduction may follow with improved overall physical and psychological health [62]. Our findings of high stress susceptibility, perceived stress together with insufficient physical activity frequency in women with BMS indicate an unmet need for treatment and we suggest biopsychosocial approaches to benefit those with long-lasting pain conditions. By addressing biopsychosocial models, individuals can be encouraged to daily physical activity, guided to understand their personal stress reaction and appreciate support to manage their pain and worries. For future improvements in BMS management, well-designed randomized controlled trials with thorough outcome protocols have been warranted [63].

Limitations of this study include measuring physical activity frequency by a single item and results are therefore preliminary. The physical activity item was rated from one to seven days a week, thus zero days a week were not an option which is a further study limitation. In future studies, it is important to collect data on how long the participants have been involved in physical activity and possible other treatments. We suggest upcoming assessments of physical activity in BMS should contain more extensive data on both physical activity and physical exercise. Sociodemographics, such as education level, housing and income should be considered in future studies. Another limitation factor is the number of participants. No power analysis preceded this study. In addition, SSP was assessed without personal interviews which is needed for a comprehensive assessment of personality. SSP and PSQ were completed by participants without follow-up and may therefore be interpreted from the participants subjective perception at one point only. Thus, no conclusions on causality can be drawn. Future experimental studies have potential to evaluate if BMS contribute to certain personality traits and perceived stress or vice versa. To evaluate physical activity as an intervention we suggest power-calculated randomized controlled trials with long-term follow-up, as suggested by Geneen et al. [62], to improve quality of studies on physical activity for long-lasting pain conditions.

Conclusion

Corresponding author: Elizabeth Jedel, Public Dental Service, Region Västra Götaland, Gothenburg, Sweden, E-mail: elizabethjedel@hotmail.com

Acknowledgments

We would like to thank Associate Professor Anette Carlén who initiated the research, Professor Emeritus Sven G. Carlsson for expert advice on questionnaires and Shikha Acharya, PhD for her research contribution.

Research funding: This work was supported by Tandläkarutbildningsavtalet (TUA) Research Funding, Sahlgrenska Academy, University of Gothenburg/Region Västra Götaland, Sweden (grant number TUAGBG-83061, 2018).
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: The authors state no conflict of interest.
Informed consent: All participants gave verbal and written consent to participate in this study.
Ethical approval: The study was approved by the Central Ethical Review Board at the University of Gothenburg (Day-book number 368-19).

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Received: 2020-07-05

Accepted: 2020-09-21

Published Online: 2020-10-28

Published in Print: 2021-01-27

Articles in the same Issue

https://doi.org/10.1515/sjpain-2020-0110

Keywords for this article

burning mouth syndrome; chronic pain; emotions; personality; physical activity; stress