Vol. 114 No.

5 November 2012

High prevalence of orofacial complaints in patients with

fibromyalgia: a case control study
Luciana A. da Silva,a Helena H. Kazyiama, MD,b Jose T. T. de Siqueira, DDS, PhD,c Manoel J. Teixeira, MD, PhD,d
and Silvia R. D. T. de Siqueira, DDS, PhD,e So Paulo, Brazil
University of So Paulo

Objective. The aim of this study was to investigate the orofacial complaints and characteristics of patients with fibromyalgia
syndrome (FS) compared with controls.
Study Design. We evaluated 25 patients diagnosed with FS compared with 25 gender- and age-matched controls by using a
detailed clinical protocol for orofacial pain diagnosis and dental examination.
Results. FS patients had a higher frequency of temporomandibular disorders (TMD), masticatory complaints, pain with
mandibular movements, and pain upon palpation of the head and neck area. There were no significant differences related to
the dental exam.
Conclusions. Orofacial complaints including TMD may be present either as symptoms of FS or as a comorbidity associated
with this condition. A comprehensive evaluation of patients with FS is necessary to identify the need for specific treatments
for orofacial complaints. Future studies, especially those with longitudinal design, should clarify whether a cause-effect
relationship exists between orofacial complaints and fibromyalgia. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:
e29-e34)

Fibromyalgia syndrome (FS) is characterized by chronic

generalized pain, sleep disturbance, fatigue, edema, paresthesia and dysesthesia,1 psychological distress, and
chronic headache2 that is sometimes associated with restless leg syndrome or irritable bowel syndrome.3 Diffuse
musculoskeletal pain and several areas of muscular hyperalgesia must be evidenced by the positive palpation of
at least 11 of 18 tender points4 in patients with FS. FS is
more prevalent in women5 and pathophysiological mechanisms include abnormal sensory processing leading to
central sensitization caused by temporal and spatial summation6-8; an increase in the levels of substance P, nerve
growth factor, and dynorphin in the cerebrospinal fluid
and blood serum; deficit of the descendent suppressing
pain system with an increase in the number of the brain
areas responsible for pain processing; and a decrease in
thalamic activity.9,10
a

Postgraduate Student, Neurology Department, Medical School, University of So Paulo, So Paulo, Brazil.
b
Member, Interdisciplinary Pain Center, Hospital das Clinicas, Neurology Department, Medical School, University of So Paulo, So
Paulo, Brazil.
c
Head, Orofacial Pain Team, Dentistry Division, Hospital das Clnicas, Medical School, University of So Paulo, So Paulo, Brazil.
d
Head, Interdisciplinary Pain Center, Hospital das Clinicas, and
Chairman of Neurosurgery, Neurology Department, Medical School,
University of So Paulo, So Paulo, Brazil.
e
Associate Professor, School of Arts, Science, and Humanities, University of So Paulo, So Paulo, Brazil.
Received for publication Aug 24, 2011; returned for revision Mar 19,
2012; accepted for publication Apr 2, 2012.
2012 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2012.04.001

Pain in the craniofacial area has not usually been

considered in the diagnosis of FS1,11; however, fibromyalgia patients often have orofacial pain including
temporomandibular disorders (TMD).12-15 It is not yet
clear whether these complaints are part of the symptoms of FS or whether they are comorbidities. Other
causes of orofacial pain such as dental infections, burning, and dry mouth10 also cause pain, which could
aggravate the symptoms of these patients and should be
correctly assessed together with the treatment for FS.
These patients are less tolerant of any discomfort10 and
abnormalities in the oral cavity are common.
Thus, the objective of this study was to investigate
the orofacial complaints and characteristics of patients
with FS compared with controls.

MATERIAL AND METHODS

Patients
We enrolled 25 consecutive patients with FS who had
been diagnosed at the Physical Medicine Division of
Trauma and Orthopedic Institute of Hospital das Clnicas, Medical School, University of So Paulo. The
diagnoses fulfilled the criteria of the American College

Statement of Clinical Relevance

Orofacial complaints are often not evaluated in fibromyalgia patients. This article shows evidence of
a high prevalence of musculoskeletal conditions in
these patients, which can be a comorbidity or an
associated symptom of fibromyalgia syndrome.

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ORAL MEDICINE
e30 Silva et al.

of Rheumatology for FS (chronic widespread pain and

11 of 18 possible tender points; widespread pain is
defined as pain in the axial plus upper and lower segments plus left- and right-side pain).1 Patients included
24 women and 1 man, and the mean age was 47.72
9.88 years old (mean SD). At the time of the study,
14 (56.0%) were taking a tricyclic antidepressant (amitriptyline), 5 (20.0%) were taking a tricyclic antidepressant and chlorpromazine, 3 (12.0%) were taking
opioids (morphine and oxycodone), and 3 (12.0%) were
taking an anticonvulsant (gabapentin). The patients
were directed to continue taking their medication during the period of the study. The mean duration of pain
was 7.32 3.94 years (mean SD), and the patients
had been taking the medications for at least the past 6
months prior to the study with no variation in doses.
In the control group, we included 25 healthy subjects
who had fewer than 5 tender points because no diagnostic criterion for FS should be fulfilled. None of the
evaluated subjects was excluded by this criterion. Controls included 24 women and 1 man, and their mean age
was 52.16 17.63 years old (mean SD). At the time
of the study, none of the controls was taking an analgesic medication nor had they done so for a period of 6
months prior to evaluation.
Exclusion criteria for both groups were systemic
medical conditions (except FS in the study group, e.g.,
diabetes mellitus, other chronic pain syndromes, neurological or other rheumatological conditions). All patients and controls were informed about the purposes of
the study, and all signed the informed consent. The
protocol had been approved by the local ethics committee.
Demographic data were compared using Pearsons 2 test
(SPSS 17.0; SPSS Inc., Chicago, IL, USA).
Investigation of tender points. The tender point exam
was performed on the day of the investigation in all
subjects by one observer (N.S.). A tender point was
counted as positive if the pressure pain threshold was
lower than 393 kPa (4 kg/cm2).1 An electronic pressure
algometer (Somedic, Horby, Sweden) with a probe area
of 1 cm2 pressed on the skin with a ramp rate of 50
kPa/s was used to determine pressure pain threshold
over the designated tender point areas. Tenderness in
any point was determined when some involuntary verbal or facial expression of pain occurred or withdrawal
was observed. All patients exhibited more than 11
tender points, fulfilling the American College of Rheumatology criteria.1 The controls were also evaluated
and all had fewer than 5 tender points.
Instruments for orofacial evaluation
The questionnaires and exams were performed by one
researcher only, who ensured the clear understanding of
the content by the participants before starting the pro-

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November 2012

tocol. Demographic data included gender, age, ethnicity, occupation, marital status, height, weight, and
smoking habits.
All subjects underwent a standardized protocol for
the evaluation of the orofacial region, including main
complaint, pain characteristics (location, quality, duration, descriptors, intensity by the visual analog scale,
causal, alleviation, and aggravation factors), medical
history and medications, earache, headache, generalized body pain, and sleep disturbances.16 Masticatory
complaints related to parafunctional habits, laterality,
and the quality of mastication were also investigated.
TMD was diagnosed according to the characteristics of
the pain and the previous history associated with the
clinical exam described below (American Academy of
Orofacial Pain criteria).17
Intraoral examination
The intraoral examination included the evaluation of
teeth, periodontal tissues, oral mucosa, tongue, lips and
facial skin, prostheses, occlusion, and functional aspects including mandibular movements (mouth opening, protrusion, laterality) and temporomandibular joint
evaluation (noises, spontaneous pain, or pain concomitant with movements). The muscular palpation of the
head and neck included the bilateral masseters, temporalis, digastrics, sternocleidomastoid, trapezius, splenius, and suboccipitals. The periodontal examination
including probing depths, and the diagnoses were determined in accordance with the criteria of the American Academy of Periodontology.18,19
Data analysis
The mean figures, standard deviations, and frequencies
were computed to summarize the distribution of numbers for each variable. After the initial descriptive evaluation, variables were tested in relation to the normal
distribution by the ShapiroWilk test and QQ plots,
and the quantitative salivary flow, which had normal
distribution, was analyzed by 1-factor analysis of variance. Nonparametric tests included Pearsons 2 and
Fishers exact test. The level of significance was 5%.

RESULTS
The demographic characteristics of the patients and
controls are displayed in Table I. The two groups did
not differ significantly with respect to any of the demographic factors. Table II shows a summary of the
pain characteristics of the 25 patients with FS. All
characteristics describe the complaints of the patients
on the day of the exam, and they are not historic. There
was high intensity of pain by using the visual analog
scale (8.78 1.60), which was often daily and spontaneous (21 patients-84.0%); the most common pain

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Volume 114, Number 5

ORIGINAL ARTICLE
Silva et al. e31

Table I. Comparison between the study and control groups with respect to general characteristics (n 50)
Fibromyalgia (n 25)

Controls (n 25)

P*

Gender
Age (years)
Ethnicity
Occupation

24 (96.0%) women
47.72 9.88 (27-73)
22 (88.0%) white, 2 (08.0%) black, 1 (4.0%) yellow
9 (36.0%) housekeeper, 4 (16.0%) retired, 4 (16.0%)
seller, 3 (12.0%) teacher, 3 (12.0%) secretary, 1 (4.0%)
unemployed, 1 (4.0%) biologist

0.755
0.061
0.359
0.095

Marital status

15 (60.0%) married, 7 (28.0%) single, 3 (12.0%) widowed

Height (m)
Weight (kg)
Comorbidities

1.60 0.90 (1.45-1.79)

70.76 18.17 (53-126)
7 (28.0%) hypertension, 11 (44.0%) depression, 9 (36.0%)
gastritis, 4 (16.0%) rhinitis, 4 (16.0%) hypothyroidism,
2 (8.0%) hepatitis, 1 (4.0%) cardiopathy, 1 (4.0%)
stroke, 1 (4.0%) bipolar disorder, 1 (4.0%) nephropathy

Smoking habit

22 (88.0%) nonsmoking

24 (96.0%) women
52.16 17.63 (19-74)
19 (76.0%) white, 3 (12.0%) black, 3 (12.0%) Asian
9 (36.0%) housekeeper, 3 (12.0%) retired, 3 (12.0%)
secretary, 3 (12.0%) student, 2 (8.0%) decorator,
1 (4.0%) seller, 1 (4.0%) physician, 1 (4.0%)
watchman, 1 (4.0%) electrician, 1 (4.0%) other
12 (48.0%) married, 6 (24.0%) single, 3 (12.0%)
widowed, 4 (16.0%) divorced
1.60 0.81 (1.43-1.73)
65.28 12.37 (45-87)
13 (52.0%) hypertension, 4 (16.0%) rhinitis,
3 (12.0%) depression, 3 (12.0%) gastritis,
2 (8.0%) cardiopathy, 1 (4.0%) hepatitis, 1 (4.0%)
diabetes, 1 (4.0%) stroke, 1 (4.0%)
hypothyroidism, 1 (4.0%) nephropathy
22 (88.0%) nonsmoking

0.353
0.299
0.534
0.280

0.666

*Pearsons 2; Fishers exact test.

Table II. Patients pain characteristics (n 25)

Fibromyalgia (n 25)
Main complaint
Duration (years)
Periods of pain
Main descriptors
Intensity (visual analog scale)
Factors of worsening
Factors of alleviation
Causal factor
Treatments

12 (48.0%) generalized pain, 12 (48.0%) unilateral pain, 1 (4.0%) numbness and pain
7.3 3.9 (1-15)
21 (84.0%) daily and spontaneous, 2 (8.0%) provoked, 2 (8.0%) night
12 (48.0%) throbbing, 12 (48.0%) burning, 8 (32.0%) jumping, 7 (28.0%) heavy, 5 (20.0%) shock-like,
2 (8.0%) tight, 1 (4.0%) tiring, 1 (8.0%) pricking
8.78 1.60 (5-10)
10 (40.0%) physical activity, 7 (28.0%) emotional stress, 5 (20.0%) cold weather, 2 (8.0%) walking,
1 (4.0%) moving, 1 (4.0%) working, 1 (4.0%) hot weather
9 (36.0%) medication, 5 (20.0%) resting, 2 (8.0%) warm, 3 (12.0%) massage, 3 (12.0%) spirituality, 1 (4.0%)
distracting, 1 (04.0%) sleep, 1 (4.0%) cold
16 (64.0%) spontaneous start, 3 (12.0%) trauma/surgery, 3 (12.0%) emotional stress, 1 (4.0%) after football
game, 1 (4.0%) sun exposure, 1 (4.0%) too much work
14 (56.0%) tricyclic antidepressants, 11 (44.0%) physical therapy, 8 (32.0%) acupuncture, 5 (20.0%) tricyclic
antidepressants and chlorpromazine, 3 (12.0%) opioids (morphine and oxycodone), 3 (12.0%) gabapentin,
2 (8.0%) lidocaine anesthetic block, 1 (4.0%) surgery

descriptors were throbbing (12 patients-48.0%) and

burning (12 patients-48.0%), physical activity was
the most common worsening factor (10 patients40.0%), medication was the most common alleviating
factor (9 patients-36.0%), and pain usually had a spontaneous start (16 patients-64.0%). The pain descriptions
in Table II correspond with the general complaints of
the patients.
The FS group of patients exhibited a higher frequency of TMD (P 0.001), a higher frequency of
generalized pain upon awakening (P 0.001), more
fatigue complaints in the orofacial region (P 0.002),
more pain caused by mandibular movements (P
0.023), a higher number of painful areas upon palpation
of the head and neck (P 0.001), and more complaints
of earache (P 0.038), headache (P 0.004), and
sleep disturbances (P 0.001) than the control group
(Table III).

The dental and intraoral exams did not show any

significant differences between the groups (Table IV);
however, mastication complaints were more frequent in
FS patients (P 0.008). The prevalence of pain with
mouth opening was also higher in these patients (P
0.001).

DISCUSSION
This study demonstrated a higher prevalence of orofacial complaints (including a higher frequency of generalized pain upon awakening, more fatigue complaints
in the orofacial region, more pain caused by mandibular
movements, and a higher number of painful areas upon
palpation of the head and neck), as well as TMD, in
patients with FS than in controls. In this study, the
patients who had these orofacial complaints were also
those found to have TMD. Previous studies support
these findings.12-15,20-22

ORAL MEDICINE
e32 Silva et al.

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November 2012

Table III. General and orofacial complaints (n 50)

Fibromyalgia (n 25)
Parafunctional habits

7 (28.0%) bruxism, 8 (32.0%) biting tongue/

lips, 3 (12.0%) dont know
Laterality of mastication
11 (44.0%) bilateral, 8 (32.0%) right,
6 (24.0%) left
Quality of mastication
12 (48.0%) good, 5 (20.0%) bad, 6 (24.0%)
terrible, 1 (4.0%) painful
Pain upon awakening
16 (64.0%) body, 5 (20.0%) head, face, and
body, 2 (8.0%) neck and body, 1 (4.0%)
head and body, 1 (4.0%) superior limbs
Fatigue in the orofacial region 6 (24.0%) constant, 4 (16.0%) upon
awakening, 4 (16.0%) all the time,
2 (8.0%) while talking, 1 (4.0%) at work,
1 (4.0%) while chewing
Pain in mandibular movements 12 (48.0%) mouth opening, 2 (8.0%) all
movements, 1 (4.0%) opening and
laterality
Articular noises
4 (16.0%) bilateral click, 3 (12.0%) left click,
1 (4.0%) right click, 3 (12.0%) bilateral
crepitus, 3 (12.0%) right crepitus
Temporomandibular disorders 22 (88.0%)
Pain upon head/neck muscular 9 (36.0%) masseter, temporalis, and digastric,
palpation
8 (32.0%) masseter, temporalis, digastric,
sternocleidomastoid, and trapezius,
5 (20.0%) masseter and temporalis,
2 (8.0%) masseter
Earache
6 (24.0%) left, 6 (24.0%) right
Headache
8 (32.0%) frontotemporal, 6 (24.0%)
holocranial, 5 (20.0%) occipital, 3 (12.0%)
temporal and occipital, 1 (4.0%) temporal
Sleep complaints
3 (12.0%) good, 4 (16.0%) somewhat
compromised, 2 (8.0%) moderate,
7 (28.0%) very difficult, 8 (32.0%)
extremely difficult

Controls (n 25)

P*

10 (40.0%) bruxism, 8 (32.0%) biting tongue/lips,

3 (12.0%) dont know
11 (44.0%) bilateral, 8 (32.0%) right, 6 (24.0%) left

0.277

21 (84.0%) good, 2 (8.0%) bad, 2 (8.0%) terrible

0.102

07 (28.0%) body, 3 (12.0%) inferior limbs, 1 (4.0%)

superior limbs, 1 (4.0%) neck

0.999

<0.001

1 (4.0%) when stressed, 1 (4.0%) when tired,

1 (4.0%) other

0.002

2 (8.0%) mouth opening

0.023

3 (12.0%) bilateral click, 2 (8.0%) right click,

2 (8.0%) bilateral crepitus, 1 (4.0%) right crepitus

0.238

5 (20.0%)
4 (16.0%) masseter, 4 (16.0%) masseter, temporalis,
and digastric

<0.001
<0.001

2 (8.0%) right, 1 (4.0%) left, 1 (4.0%) bilateral

4 (16.0%) frontotemporal, 2 (8.0%) temporal and
occipital, 1 (4.0%) hemicrania, 1 (4.0%) temporal

0.038
0.004

14 (56.0%) good, 8 (32.0%) somewhat compromised,

1 (4.0%) moderate, 1 (4.0%) difficult, 1 (4.0%)
extremely difficult

0.001

*Pearsons 2; Fishers exact test. Significant P values appear in bold print.

Table IV. Characteristics observed upon physical exam of the orofacial region (n 50)
Dental characteristics

Oral mucosa
Tongue
Periodontal tissues
Teeth
Wearing prostheses
Duration of wearing prostheses (yr)
Amplitude of mouth opening (mm)
Pain in mouth opening
Amplitude of protrusion (mm)
Amplitude of right laterality (mm)
Amplitude of left laterality (mm)
Mastication complaints

Fibromyalgia (n 25)

Controls (n 25)

4 (16.0%) deep biting, 3 (12.0%) loss in vertical

dimension, 1 (4.0%) crossbite, 7 (28.0%) total
edentulous
2 (8.0%) mucositis, 1 (4.0%) ulcer
5 (20.0%) fissured, 2 (8.0%) white coating,
2 (8.0%) dry
15 (60.0%) healthy, 2 (8.0%) mild periodontitis,
1 (4.0%) moderate periodontitis
1 (4.0%) decay
7 (28.0%) complete prostheses, 5 (20.0%)
removable partial prostheses
19.3 13.2 (2-40)
43.3 7.7 (30-66)
15 (60.0%)
6.1 2.2 (2-10)
7.3 2.6 (4-15)
7.9 2.5 (3-12)
4 (16.0%) pain, 3 (12.0%) old prosthesis,
2 (8.0%) undefined, 2 (8.0%) weakness,
1 (4.0%) tooth absence

4 (16.0%) deep biting, 3 (12.0%) loss in

vertical dimension, 3 (12.0%) total
edentulous, 1 (4.0%) open bite
25 (100%) healthy
4 (16.0%) fissured, 1 (4.0%) white coating,
1 (4.0%) fissured and white coating
19 (86.0%) healthy, 2 (8.0%) severe
periodontitis, 1 (4.0%) mild periodontitis
2 (8.0%) decays
10 (40.0%) removable partial prostheses,
5 (20.0%) complete prostheses
16.15 15.25 (0-40)
47.1 7.5 (30-60)
2 (8.0%)
6.3 2.4 (2-12)
8.9 3.4 (3-16)
8.3 3.9 (2-19)
3 (12.0%) old prosthesis, 1 (4.0%) pain

*Pearsons 2; Fishers exact test; 1-factor analysis of variance. Significant P values are in bold print.

P*
0.676

0.469
0.520
0.302
0.145
0.356
0.808
0.766
<0.001
0.656
0.316
0.149
0.008

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Volume 114, Number 5

Although palpation of the head and neck is not

included in the diagnostic criteria for FS,1,11 only 1
patient of the 25 with FS enrolled in this study did not
have head and neck pain when evaluated. Therefore,
the systematization of the assessment of craniofacial
areas should be considered in patients being evaluated
for FS.23-27 On the other hand, FS is characterized by
low pain thresholds associated with concurrent symptoms and signs such as irritable bowel syndrome, sleep
complaints, and musculoskeletal pain affecting areas
such as joints, muscles, and bones.2-4 Thus, TMD
should be included among the comorbidities of FS.
The association between TMD and FS has been
extensively discussed and, although other arthralgias or
myofascial pain syndromes are recognized as comorbidities of FS but not TMD, the latter seems to assume
a higher importance in the development of generalized
pain when FS is not yet present. Previous studies have
shown that TMD has a higher potential to trigger FS
than other musculoskeletal causes of pain.15 In 2007,
Balasubramaniam and colleagues12 observed that orofacial complaints may precede either generalized or
localized pain in other body regions. These complaints,
therefore, need careful assessment and treatment to
have their progression prevented, particularly in patients who have already had fatigue, taken medication
to sleep, or had anxiety episodes. The possible mechanism underlying the progression of TMD to FS is the
deregulation of autonomic and hypothalamicpituitaryadrenal axis functions.12
Therefore, because of the importance that TMD may
have in the onset of FS and its progression, further
longitudinal studies must be conducted to investigate
this potential cause effect relationship. Furthermore,
the inclusion of TMD and orofacial evaluation in the
criteria of FS is imperative.
To our knowledge, there has been no previous study
that investigates the presence of disease involving the
oral mucosa, tongue, teeth, and periodontal tissues in
patients with FS. Although the role of oral infections
and chronic inflammation in FS is not known, there is
evidence of activation of stress pathways in FS with
etiologic or pathophysiological implications, which can
also be triggered by chronic or acute infections including periodontal disease. However, this study found no
significant difference between patients and controls in
relation to those features.
Because this study was conducted in a reference
center such as a hospital, limitations included difficulty in enrolling study patients who had been newly
found to have FS and who were not currently receiving treatment. All patients with FS in this study were
being pharmacologically treated for FS. The medications used by study patients for the treatment of

ORIGINAL ARTICLE
Silva et al. e33

FS, particularly opioids (12% of patients), can interfere with oral health and decrease musculoskeletal
pain.20-22 However, we would expect that if these
patients were not receiving treatment with medications for FS, their pain assessments would have most
likely been higher than those reported in this study,
and the use of medications by the FS patients in this
study does not invalidate the observations and results
reported here.
In conclusion, this study found no difference in the
presence or severity of oral disease including periodontal disease, caries, and oral mucosal disease between
controls and patients with FS. Orofacial complaints
including TMD may either be present as symptoms of
FS or represent a comorbidity associated with this
condition. The cause effect relationship between FS
and TMD requires further investigation, and several
authors have also pointed in that direction.12,15 Therefore, a comprehensive evaluation of patients with FS is
necessary to identify the need for specific treatments for
orofacial complaints. Future studies, especially those
with longitudinal design, should help clarify the role of
orofacial complaints in fibromyalgia.
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