The Impact of Dental and Facial Pain

D. LOCKER and M. GRUSHKA

Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, Ontario, Canada M5G I G6
This paper presents data from a mail survey on dental andfacial pain.
The survey was conducted in the City of Toronto in 1986. The aim of
the study was to obtain estimates of the prevalence of such pain and
its impact on daily life. A random sample of 1014 names was drawn
from the voters' list, and, as a result offour mailings, information
was obtained on 71.6% of the eligible sample. Of those returning
questionnaires, 39.7%o- reported dental or facial pain in the previous
four weeks. A psychological impact in the form of worry or concern
was reported by 70.3% of those experiencing pain, while 58.0% reported one or more behavioral impacts. The most common behavioral
impacts were consulting a dentist or doctor, avoiding certain foods,
taking medication, and disturbance of sleep. Severe behavioral impacts such as work disability, need for bed rest, and reduced social
contacts were also reported by some of those having pain. The results
suggest that dental and facial pain imposes a significant burden on
the community. Further research is indicated, with more sensitive
impact measures being used.

J Dent Res 66(9):1414-1417, September, 1987

Introduction.
Relatively little is known about the impact of dental and oral
disease on individuals and communities. While a large body
of research has documented the functional, social, and psychological outcomes of a wide variety of physical disorders,
only a few studies have addressed the consequences of oral
conditions (Smith and Sheiham, 1979; Reisine, 1984; Cushing
et a-l., 1985). This is reflected in current measures of oral
health status which are almost exclusively clinical indices confined to the assessment of the nature and extent of tissue pathology and needs for treatment. Dentistry has yet to develop
sociodental indicators able to quantify the extent to which oral
conditions are disabling or handicapping. Recently, a number
of authors have discussed the need for such indices and their
role in health care planning and evaluation (Cohen and Jago,
1976; Nikias et al., 1980; Reisine, 1981). A first step in the
development of these measures is to obtain data on the social
and psychological consequences of oral disease.
Davis (1976) has argued that the impact of dental and oral
conditions on daily living is minimal. Because these conditions
are widespread in the population, rarely life-threatening, and
frequently asymptomatic, they do not give rise to the changes
in role behaviors seen in relation to other diseases. This view
is clearly untenable, particularly so with respect to conditions
which give rise to pain. Pain is a common symptom of dental
and oral conditions and has an immediate and profound impact
on the quality of everyday life. It disrupts sleep, work, recreational and leisure activities, and relationships with others.
Studies of chronic pain resulting from diseases such as rheumatoid arthritis have shown that pain can be a cause of severe
disability and can have an adverse effect on long-term life
chances (Locker, 1983). The study described here used selfreport data to provide preliminary estimates of the prevalence
of oral and facial pain and its impact on various aspects of
daily life.
Received for publication December 10, 1986
Accepted for publication April 2, 1987

1414

Materials and methods.

A two-stage random sampling procedure
The sample.
used to select 1014 names from the voters' list covering
the City of Toronto. It has been estimated that this list covers
97% of persons of voting age. In April of 1986, these subjects
were sent a questionnaire, along with a covering letter and a
stamped/addressed return envelope. This mail survey followed
the procedures recommended by Dillman (1978). Two weeks
after the initial mailing, non-respondents were sent a reminder
letter, and, after four weeks, another questionnaire, letter, and
return envelope were sent to those who still had not replied.
Finally, eight weeks after the initial mailing, a random sample
of the non-responders were sent a short version of the questionnaire with a covering letter urging response.
The questionnaire was designed to
The questionnaire.
collect information on current and recent past experience of
oral and facial pain, its severity and impact. Items concerning
pain covered pain that would be characteristic of disorders of
the teeth, jaws, oral mucosa, temporomandibular joints, and
trigeminal nerves. In order to test the validity of the questionnaire, we administered it to 30 patients attending clinics at the
Faculty of Dentistry, University of Toronto. Answers to the
questions concerning pain were compared with self-report and
clinical data collected during a subsequent oral examination.
In 85.0% of cases there was agreement between the responses
to the questionnaire and the clinical examination. We ascertained the reliability of the questionnaire by asking 50 of the
respondents to the first mailing to complete a second copy of
the questionnaire approximately one week later. A comparison
of the two questionnaires showed high levels of agreement for
each response. The Kappa value, which is used to determine
levels of agreement corrected for chance (Fleiss, 1981), was
0.65 or above for 14 of the 15 items examined and 0.80 or
above for eight, indicating good reliability.
All questions concerning pain reVariables employed.
ferred to the four weeks prior to the completion of the questionnaire. A short recall period was used to minimize bias due
to lapses in memory. The exacting wording of the eight items
about pain is given in Table 1. Eight questions were asked
concerning the impact of pain. Two items, seeking treatment
and taking medication, referred to the impact of pain in terms
of health-related behaviors. Six items, including work loss,
sleep disturbance, and bed rest, were concerned with the social
impact of pain, while the final item, worry or concern, addressed its psychological impact. In the analysis, these items
were examined individually and in combination.
was

TABLE 1
PAIN ITEMS
1.
2.
3.
4.
5.
6.
7.
8.

Toothache
Pain in the teeth with hot or cold fluids
A prolonged burning sensation in tongue or other parts of mouth
Pain in the jaw joints
Pain in the jaw while chewing
Pain in the jaw joint while opening the mouth wide
Pain in the face just in front of the ear
Sharp shooting pains across the face or cheeks

Vol. 66 No. 9

IMPACT OF DENTAL AND FACIAL PAIN

Results.
Response to the survey. - Of the 1014 subjects sent questionnaires, 137 had died, moved, or could not be located by
the post office. Of the remaining 877 subjects, questionnaires
were returned by 628, representing a response rate of 71.6%.
The following analysis, however, is limited to the 594 subjects
who completed the long version of the questionnaire, representing 67.7% of the eligible sample.
Characteristics of the sample. - The age and sex distribution of the respondents is given in Table 2, along with the
corresponding distribution for the population of the City of
Toronto. The age distribution of the respondents matches that
of the city quite closely. However, females are over-represented and males under-represented, largely because the response rate was higher among females than among males.
Prevalence of pain. - Overall, 39.7% of the respondents
reported dental, oral, or facial pain in the four weeks prior to
the completion of the questionnaire. This estimate is high,
because pain with hot and cold fluids was included as one of
the items. This was reported by 28.8% of the sample. There
were no sex differences in the prevalence of reported pain,
although statistically significant differences were observed with
respect to age. Of those aged 18 to 24 years, 62.5% reported
pain, compared with 22.6% of those aged 65 years and over
(p < 0.0001). In terms of severity, 50.9% of those reporting
pain said it was moderately severe or severe.
Social and psychological impact. - Table 3 gives the percentage of those reporting pain who responded positively to
the individual impact items. The most common impact observed was psychological, with 70.3% reporting worry and

TABLE 2
AGE AND SEX DISTRIBUTION OF SUBJECTS AND STUDY
POPULATION (% ONLY)
City of Toronto
Subjects
Population*
Sex
Male
39.1
47.7
Female
58.9
52.3
Not known
2.0
18-24
Age
12.8
13.2
25-44
44.9
43.9
45-65
26.7
25.8
65 and over
14.6
16.2
Not known
1.9
*Obtained from 1981 Census data.
TABLE 3
NUMBER AND PERCENT RESPONDING POSITIVELY TO
INDIVIDUAL AND COMBINED IMPACT ITEMS
Pain
Total
Individual Impact Items:
N
Subgroup
Sample
I. Consulted dentist or doctor
102
44.0
17.2
2. Took medication
68
29.1
11.4
3. Took time off from work
10
4.2
1.7
4. Stayed in bed more than usual
9
4.1
1.5
5. Stayed home more than usual
12
2.0
5.2
6. Avoided family and friends
18
7.7
3.0
7. Experienced sleep disturbance
14.2
5.5
33
8. Avoided certain foods
71
11.9
30.6
27.6
9. Worried about dental health
164
70.3
Combined Behavioral Impact Items:
10. Health behavior (Items I and 2)
18.4
109
46.8
11. Social impact (Items 3-8)
86
36.9
14.5
12. Total impact (Items 1-8)
134
58.0
22.5

1415

concern about their oral or dental health. The most common

behavioral impacts reported were consulting a dentist or doctor
(44.0%), avoiding certain foods (30.6%), taking medication
(29.1%), and sleep disturbance (14.2%). The more severe behavioral impacts, such as work disability, bed rest, and reduced social contacts, were also reported, albeit by less than
10% of those who had experienced pain.
The eight questions which refer to the behavioral consequences of pain were used to create three summary variables:
The first consists of the two health impact items, the second
of the six social impact items, and the third of all eight items.
Table 3 shows that 46.8% reported an impact on health behavior, while some social impact was reported by 36.9% of
those having pain. The total-impact variable revealed that pain
affected the daily lives of 58.0% of these respondents.
In order to provide estimates of the burden on the community as a whole, we have expressed the numbers reporting one
or more impacts because of pain as a percentage of the 594
subjects returning completed questionnaires. These percentages are listed in the right-hand column of Table 3. They range
from a low of 1.7% to a high of 27.6% for the individual
items. Approximately five percent, for example, reported sleep
disturbance due to pain. The combined items show that, in the
four weeks prior to completion of the questionnaire, the daily
lives of over one-fifth of the respondents were disrupted in
some way because of dental or facial pain.
Analysis by independent variables. - Five independent variables were used to explore variations in the social and psychological impact of pain. These variables were sex, age, place
of birth, type of pain, and severity of the pain. Place of birth
was included since almost two-fifths of the population of the
City of Toronto was born outside Canada.
Although women were more likely to respond positively to
all impact items, none of the differences between men and
women was statistically- significant. Nor were there any significant sex differences on any of the three summary variables.
Older respondents were more likely than younger respondents to report behavioral impacts. However, the differences
were significant with respect to only one item. More than half
of those aged 45 years and over had consulted a doctor or
dentist because of the pain, compared with one-third of those
aged 44 and under (p < 0.05). Similarly, place of birth was
associated with only one impact item, with those born outside
Canada being more likely to have sought professional advice
than native-born Canadians (56.1% vs. 38.3%, p < 0.05).
Because diagnoses cannot be inferred from self-report data,
analysis was undertaken of variations in impact by type of pain
reported. For this analysis, those reporting pain were divided
into three groups: (1) those reporting pain in the teeth with hot
and cold foods only; (2) those reporting toothache, alone or in
combination with other types of pain; and (3) all others. Those
with toothaches were the most likely to report impacts and
those with pain with hot and cold the least likely. Differences
were statistically significant for three of the individual impact
items - sleep disturbance (p < 0.05), taking medication (p
< 0.05), and avoiding certain foods (p < 0.001) - and for
all summary impact variables (p < 0.001)). For example, 75.0%
of those with toothache reported one or more behavioral impacts, compared with 40.0% of those reporting pain with hot
and cold foods.
The variable most consistently associated with social and
psychological impacts was severity of the pain. As expected,
the more severe the pain, the more likely that daily life was
disrupted in some way. The association was statistically significant at the 5% level for all individual impact items, except
consulting a doctor or dentist and taking time off from work,
and for all three summary impact variables.

J Dent Res September 1987

LOCKER & GRUSHKA

1416

In order to assess the magnitude of the relationship between

type and severity of pain and social functioning, we undertook
analysis using the social impact variable. This was obtained
by a simple count of the number of such impacts reported by
each respondent. The mean number of social impacts reported
by those with toothache was 0.96, compared with 0.39 for
those with other types of pain (t test: p < 0.001). The mean
number of impacts reported by those with moderate or severe
pain was 1.1, compared with 0.44 for those with mild pain (t
test: p < 0.001).
A binary regression analysis with dummy variables was undertaken to confirm that these effects remained while controlling for the effects of all other independent variables. Each
categorical independent variable was reduced to a dichotomous
variable in which one category was coded 1 and the other, the
reference category, was coded 0. Following conventional practice, the reference category was the most frequent with respect
to each variable. The variables used in the analysis, along with
their codes, are given in Table 4.
The results of the regression analysis are summarized in
Table 5. The regression coefficients represent the mean difference in the dependent variable between the category coded
1 and the reference category, coded 0 (Polissar and Diehr,
1982). For example, the coefficient for severity of the pain
was -0.55, indicating that those with mild pain reported a
mean of 0.55 fewer social impacts than did the reference category, those with moderate or severe pain, after the effects of
all other variables were controlled for. This analysis confirms
that those with moderate or severe pain and those with toothache are more likely to experience an impact on social functioning.

Discussion.
Data have been presented on the prevalence of dental and
facial pain and its impact on daily life. Pain was reported by
TABLE 4
VARIABLES USED IN THE REGRESSION ANALYSIS

Dependent variable
Social impact
Independent variables
Sex

Age
Place of birth

Type of pain

Severity of pain

Males

Females
45 years and over
44 years and under
Born outside Canada
Born in Canada
Toothache
Other
Mild
Moderate or

severe

TABLE 5
RESULTS OF THE REGRESSION ANALYSIS
Regression
Variable
Coefficient
Significance
Sex
-0.24061
0.1530
0.25199
0.1615
Age
Place of birth
0.8536
-0.03253
0.42169
0.0113
Type of pain
0.0011
-0.54659
Severity of pain
0.2191.
R2 =
p < 0.001.

39.7% of the sample, and, of those with pain, 58.0% reported

a behavioral impact and 70.3% a psychological impact. Those
reporting these impacts represent 22.0% and 27.0% of the
sample as a whole.
Although most of the impacts reported involved relatively
minor changes in normal activities, in a small percentage of
cases dental and facial pain had a more profound impact, affecting social roles and social interaction. Since all data refer
to a four-week recall period, it is clear that, over time, oral
disease giving rise to pain does represent a significant burden
on the community. Extrapolating from the data given here
suggests that approximately 20.0% of the population may be
subject to work or bed disability over the course of a year as
a result of such pain.
The association between type and severity of pain and social
impact was to be expected. However, the lack of a consistent
association with age, sex, and place of birth is somewhat surprising, although Cushing et al. (1985) found relatively few
differences between men and women in terms of the impact
of dental problems. There were, however, differences in seeking professional advice by age and place of birth, a factor
which deserves further consideration. The latter suggests that
these are cultural differences in the seeking of treatment for
pain, a view supported by early work on cultural differences
in responses to pain (Zborowski, 1952). Given that only 44%
of those reporting pain had visited a dentist or doctor, the
whole issue of treatment-seeking is being explored further and
will be the subject of a later paper.
Clinical data were not available in this study to allow for
analysis of impact by diagnosis. The work of Cushing et al.
(1985) indicates that clinical indices such as DMFT, periodontal indices, and prosthetic needs are not consistently associated with psychological and social impacts. Nevertheless,
clinical data on diagnosis would be a useful addition to studies
of the consequences of pain. Further work is being planned,
to provide such data.
The prevalence of impacts observed in this study was consistent with that reported by Reisine (1985) and Cushing et al.
(1985). Reisine reported that, during a study year, 25.0% of
a sample of employed adults experienced work loss as a result
of dental visits or the symptoms associated with those visits,
with a mean loss of 1.26 hours per person over the sample as
a whole. While the average amount of work loss is small, its
overall economic impact in terms of lost productivity is likely
to be considerable. Cushing et al. (1985) developed a measure
of social impact based on eating restrictions, communication
restrictions, pain, discomfort, and aesthetic dissatisfaction. This
was used in a survey of employed adults, 71.0% of whom
reported one or more impacts. These studies, like the study
described here, used fairly crude indicators of impact and ignored the many more subtle social and psychological consequences of dental and oral conditions. Work loss, for example,
does not take into account reduced performance while at work
and is, therefore, lacking in sensitivity (Reisine, 1985). The
data presented here suggest that comprehensive and sensitive
measures such as the Sickness Impact Profile (Bergner et al.,
1981), based on 136 statements about the behavioral consequences of illness, are not only applicable to oral disease but
are also essential for full documentation of the impact of such
disease on social functioning and quality of life. Such measures, or comparable ones tailored to the specific characteristics of oral conditions, would almost certainly increase these
estimates of the prevalence of social and psychological impacts
and would more clearly demonstrate that these conditions are
not as minor as has often been thought.

Vol. 66 No. 9

IMPACT OF DENTAL AND FACIAL PAIN

REFERENCES
BERGNER, M.; BOBBITT, R.; CARTER, W.; and GILSON, B.
(1981): The Sickness Impact Profile: Development and Final Revision of a Health Status Measure, Med Care 27:787-806.
COHEN, L. and JAGO, J. (1976): Toward the Formulation of Sociodental Indicators, Int J Health Serv 6:681-687.
CUSHING, A.; SHEIHAM, A.; and MAIZELS, J. (1985): Developing Sociodental Indicators The Social Impact of Dental Disease, Community Dent Health 3:3-17.
DAVIS, P. (1976): Compliance Structures and the Delivery of Health
Care: The Case of Dentistry, Soc Sci and Med 10:329-334.
DILLMAN, D. (1978): Mail and Telephone Surveys: The Total
Design Method. New York: John Wiley and Sons.
FLEISS, J. (1981): Statistical Methods for Rates and Proportions.
New York: John Wiley and Sons.
LOCKER, D. (1983): Disability and Disadvantage. London: Tavistock Publications Ltd.

1417

NIKIAS, M.; BAILIT, H.; BECK, J.; COHEN, L.; CONRAD, D.;
GIDDON, D.; REISINE, S.; and SHEIHAM, A. (1980): Progress
Report of the Committee on Sociodental Indicators of the Behavioral Science Group of IADR to WHO/Oral Research Advisory
Group (unpublished).
POLISSAR, L. and DIEHR, P. (1982): Regression Analysis in Health
Services Research: The Use of Dummy Variables, Med Care 20:959966.
REISINE, S. (1981): Theoretical Considerations in Formulating Sociodental Indicators, Soc Sci and Med 15(A):745-750.
REISINE, S. (1984): Dental Disease and Work Loss, J Dent Res
63:1158-1161.
REISINE, S. (1985): A Longitudinal Study of Work Loss Related to
Dental Diseases, Soc Sci and Med 25:1309-1314.
SMITH, J. and SHEIHAM, A. (1979): How Dental Conditions Handicap the Elderly, Community Dent Oral Epidemiol 7:305-310.
ZBOROWSKI, M. (1952): Cultural Components in Responses to Pain,
J Soc Issues 8:16-30.