Point-of-care diabetes testing in the dental setting: A national scope of practice survey.

OBJECTIVES: The aim of this study was to assess the knowledge of state dental directors regarding their state's professional practice act, specifically scope of practice laws regarding point-of-care chairside screening for diabetes. METHODS: A cross-sectional study design was used to examine the 50 state dental directors' knowledge of policy around point-of-care diabetes testing in their state. A five-item survey instrument was designed in a web-based platform and electronically distributed in 2022. RESULTS: Thirty-seven states (74%) responded to the survey. Regarding whether it was within the scope of practice for dentists to provide chairside point-of-care HbA1c screening, 17 states (46.0%) responded "yes," 5 states (13.5%) responded "no," and 15 states (40.5%) responded "don't know." Of the 17 states who provide diabetes testing, four states (23.5%) reported that dentists were reimbursed, nine states (53.0%) reported they were not reimbursed, and four states (23.5%) reported they did not know regarding reimbursement. CONCLUSIONS: There is significant state heterogeneity with regard to laws, regulations, and reimbursement for chairside diabetes testing in the United States. This is accompanied by vagueness and lack of specificity in the state education laws. For more widespread promotion and adoption of this evidence-based screening, the entire dental community including clinicians, educators, policymakers, payers, and professional organizations at all levels are encouraged to work together to advocate for clarification and specificity in the language of state education laws as well as reimbursement for this vital service.

Social support and oral health among working-age and older adults in the United States.

OBJECTIVES: The purpose of this study was to examine the association of social support with untreated dental caries and severe tooth loss in adults in the United States. METHODS: This cross-sectional study was conducted by analyzing data obtained from 5,447 individuals, 40 years of age and older, in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008 who had both a complete dental examination and social support index measures. Sample characteristics, overall and by social support level, were examined through descriptive statistical analyses. Logistic regression analyses were performed to estimate the association of social support with untreated dental caries and severe tooth loss. RESULTS: In this nationally representative sample (mean age 56.5 years) the prevalence of low social support was 27.5%. The prevalence of individuals with moderate-to-high social support increased with higher levels of educational attainment and income level. In fully adjusted models, relative to those who had moderate-high social support levels, individuals with low social support had 1.49 higher odds of untreated dental caries (95% CI, 1.17-1.90, p=0.002) and 1.23 higher odds of severe tooth loss (95% CI, 1.05-1.44, p=0.011). CONCLUSIONS: Higher odds of untreated dental caries and severe tooth loss were found among U.S. adults with low levels of social support compared to those with moderate-to-high levels of social support. Additional studies are warranted to provide a more current perspective on the impact of social support on oral health so that programs may be developed and tailored to reach these populations.

Bridging gaps in oral health education in a medical school in the United States: a pilot study.

BACKGROUND: Oral health is an important component of medical education given its connection to overall health and quality of life; however, oral health is infrequently incorporated into medical school curricula in the United States. The aim of this study was to pilot a novel oral health care clerkship for United States medical students that implemented the Smiles for Life (SFL) curriculum, in-person clinical activities, and pre and post curricula assessments to assess knowledge acquisition, attitude change, and clinical skill development. METHODS: Third year medical students at Albert Einstein College of Medicine, Bronx, New York, volunteered (n = 37) for a clerkship in oral health. Students completed the Smiles For Life National Oral Health Curriculum and participated in three half-day clinical sessions in a hospital-based dental clinic. The participants were evaluated on knowledge acquisition, attitude change, and clinical skill development through a pre and post clerkship assessment in order to assess the efficacy of the intervention. RESULTS: There was a 23.4% increase in oral health knowledge (p < 0.001) following participation in the online modules and clerkship. Additionally, attitudes in the following domains showed improved familiarity and proficiency: causes and prevention of dental caries (78.4%, p < 0.001) and periodontal disease (83.8%, p < 0.001), provision of oral health information to patients (67.6%, p < 0.001), and ability to conduct an oral examination (62.2%, p < 0.001). CONCLUSIONS: Third year medical students who participated in a novel oral health clerkship demonstrated significant increases in basic oral health knowledge and reported increased comfort in providing oral examinations and anticipatory guidance to patients. The results support the feasibility of this approach to incorporating oral health education into a medical school curriculum in the United States.

Periodontal disease and incident prediabetes and diabetes: The Hispanic Community Health Study/Study of Latinos.

AIM: To examine whether baseline periodontal disease is independently associated with incident prediabetes and incident diabetes in Hispanics/Latinos in the United States. MATERIALS AND METHODS: This study examined 7827 individuals, 18-74 years of age without diabetes, from the Hispanic Community Health Study/Study of Latinos. Participants received a full-mouth periodontal examination at baseline (2008-2011), and the disease was classified using the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions. At Visit 2 (2014-2017), incident prediabetes and diabetes were assessed using multiple standard procedures including blood tests. Multivariable survey Poisson regressions estimated the rate ratio (RR) and 95% confidence intervals (CIs) of incident prediabetes and incident diabetes associated with periodontal disease severity. RESULTS: Among the individuals without prediabetes or diabetes at baseline, 38.8% (n = 1553) had developed prediabetes and 2.2% (n = 87) had developed diabetes after 6 years. Nineteen percent (n = 727) of individuals with prediabetes at baseline developed diabetes after 6 years. Adjusting for all potential confounders, no significant association was found between periodontal disease severity and either incident prediabetes (RR: 0.93; 95% CI: 0.82-1.06) or incident diabetes (RR: 0.99; 95% CI: 0.80-1.22). CONCLUSIONS: Our findings suggest that among a diverse cohort of Hispanic/Latino individuals living in the United States, there was no association between periodontal disease severity and the development of either prediabetes or diabetes during a 6-year follow-up period.

The use of dental radiographs for age estimation of unaccompanied migrant minors: Scientific and ethical concerns.

Unaccompanied migrant minors are increasingly seeking asylum status in the United States (U.S.) where guidelines for age assessment call for the use of multiple forms of evidence. A commonly used approach in the U.S. is dental radiographs to assess the root development of third molars. Not only has research shown this methodology to be unreliable and imprecise, but the evidence has shown significant variability in dental development by chronologic age, race/ethnicity, sex, socioeconomic status, systemic disease, nutritional health, and other environmental factors. Misclassification of minors as adults based upon the imprecise tool of dental age assessment can have serious and harmful consequences. In the U.S., this misclassification has resulted in the housing of minors with adults in Immigrant and Custom Enforcement (ICE) operated jails. In addition, there are significant ethical concerns with regard to the use of radiographs for purposes that are neither diagnostic nor therapeutic and the lack of informed consent. In this commentary we review the (1) inadequacy of dental radiographs as a means of chronologic age assessment for minors, and (2) the ethical implications of implementing this flawed and inappropriate assessment on a highly vulnerable population.

Identifying the Utility of Dental Providers in Human Papillomavirus Prevention Efforts: Results From the National Health and Nutrition Examination Survey 2015-2018.

PURPOSE: The aim of this study is to (1) examine the prevalence of human papillomavirus (HPV) vaccination in adolescents and young adults in the U.S., including those who had a dental visit in the last year but not a medical visit and (2) to determine an association between last visit to the dentist and HPV vaccination status. METHODS: We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey from 2015 to 2018, including participants 9-26 years. Descriptive statistical analyses were conducted to characterize the study population and calculate the prevalence of HPV vaccination in adolescents and young adults, including those who had a dental visit in the last year but not a medical visit. Logistic regression analyses were performed to examine the association between last visit to the dentist and HPV vaccination status. RESULTS: In total, 38.6% of participants were vaccinated for HPV, with higher prevalence of vaccination in those with the following characteristics: female, older age, higher income, higher education level, and having medical insurance. Participants who had a dental visit in the last year had an HPV vaccination rate of 40.8%. Of those who had a dental visit and were not vaccinated for HPV, 12.5% did not have a medical visit. Having a dental visit in the last year increased the odds of being vaccinated for HPV (odds ratio 1.69, confidence interval 1.26-2.28). CONCLUSIONS: Dentists see a significant number of adolescents and young adults who are unvaccinated for HPV in a given year and could serve as an access point for HPV vaccine delivery in the future.

Chairside Diabetes Screening: A Survey of Dental Providers at the Largest Municipal Healthcare System in the United States.

PURPOSE: To assess the knowledge and attitudes of dentists at the largest municipal healthcare system in the United States with regard to point-of-care chairside diabetes testing in the dental clinic. MATERIALS AND METHODS: A 29-item survey was designed in a web-based platform (Survey Monkey) and distributed in November 2020 to 264 dental providers (attending dentists and residents) within eleven dental departments of the New York City Health + Hospitals municipal healthcare system. The questionnaire included sections on demographics, current practices, level of diabetes training, scope of practice, and attitudes regarding chairside diabetes testing. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed, with statistical significance set at 0.05. RESULTS: Dentists' willingness to provide chairside HbA1c screening was positively associated with their agreement that this was part of their role (OR = 7.2, p = 0.001) and that screening has an impact on diabetes control (OR = 4.3, p = 0.04). The two most commonly reported barriers to willingness to provide chairside HbA1c screening were amount of time required to obtain and discuss a patient's test results (82.3%) and lack of reimbursement (70.6%). CONCLUSION: Among the largest municipal healthcare systems in the US, there is very limited integration of diabetes screening and management in the dental setting. Given the epidemic of diabetes among the vulnerable population that these hospitals serve, the dental setting is a critical but underutilized site for diabetes screening and medical referral. Increased efforts should be directed towards implementing workflows that incorporate auxiliary dental staff in order to address barriers to chairside screening.

Interprofessional Oral Health Collaboration: A Survey of Knowledge and Practice Behaviors of Hospital-Based Primary Care Medical Providers in New York City.

BACKGROUND: The siloed delivery of oral and medical health care in the United States has contributed to a lack of awareness of the consequences of poor oral health and has hampered effective interprofessional education and collaboration. The aim of this study was to assess the knowledge and practice behaviors of primary care medical providers in an urban safety-net hospital regarding collaboration with dentists and integration of oral health into overall health-care delivery. METHODS: A 36-item survey was designed in a web-based platform (Survey Monkey®) and electronically distributed in September 2020 to 181 primary care medical providers (physicians, nurses, physician assistants) within a municipal hospital in the Bronx, New York. The questionnaire included sections on demographics, current practices, oral health knowledge, and opinions regarding interprofessional collaboration. Descriptive statistics and bivariate analyses using the chi-square and Fisher's exact test were performed with a significance level of 0.05. RESULTS: The response rate was 66% (119 respondents). The vast majority (80%) reported little or no training in oral health and 85% reported no team experience with oral health professionals. Medical providers' confidence in examining the oral cavity was positively associated with previous additional training (p = 0.001) and with team experience (p = 0.005). The two most commonly reported barriers to willingness to collaborate were lack of formal relationships with dental providers (74%) and competing priorities (69%). CONCLUSION: Overall, there is very limited awareness and integration of oral health into the clinical practice of medical providers at this safety-net hospital. However, those providers with previous training and team experience had greater oral health confidence. Given the critical importance of oral health to overall health, increased efforts should be directed to further educate and train medical providers and address barriers to interprofessional care.

Dental access and expenditures for adults with intellectual and other disabilities.

OBJECTIVES: Individuals with disabilities experience greater barriers accessing health care services and have poorer oral health outcomes than those without disabilities. The aims of this study were to examine dental access, utilization, expenditures, and sources of payment between adults with intellectual disabilities (ID), other types of disabilities, and without disabilities. METHODS: Secondary analyses of data from the 2017 Medical Expenditure Panel Survey (MEPS) allowed examination of dental access (being able to get dental care and receiving necessary dental care without delay), dental utilization (having a dental visit in the past year), total dental expenditures, and associated sources of payment between three groups of adults based on disability status using descriptive, bivariate, and multivariable statistics. RESULTS: Adults with ID have 2.70 (95% CI: 2.03, 3.61) times the odds of being unable to get dental care and 2.88 (95% CI: 2.11, 3.94) times the odds of having to delay necessary dental care compared with adults without disabilities. No significant differences were observed in dental utilization or mean total dental expenditure between the three groups after adjusting for demographic and socioeconomic variables. Among adults who incurred a dental expenditure, adults with ID had a greater share of dental care paid for by Medicaid, and adults without disabilities had a greater share of dental care paid for by private insurance. CONCLUSIONS: Despite similar mean total dental expenditures, reduced dental access reported by adults with ID suggests that this population experiences significantly greater challenges obtaining dental care. Adults with ID rely more heavily on Medicaid to finance dental care.

National Trends and Characteristics in Emergency Department Visits for Nontraumatic Dental Conditions Among Pediatric Patients.

Purpose: The purpose of this study was to examine trends and characteristics of pediatric nontraumatic dental condition (NTDC) visits to emergency departments (EDs) in the United States from 2010 to 2017. Methods: The 2010 to 2017 Nationwide Emergency Department Sample (NEDS) was analyzed for NTDC visits to EDs for children (zero to 20 years old). NTDC visits were identified based on ICD-9 and ICD-10 codes. Patient characteristics analyzed included age, sex, primary payor, county population, day of discharge, and household income. Descriptive statistics and a logistic regression analysis for 2016 and 2017 were completed. Results: Pediatric NTDC visits to EDs decreased from 103.1 to 89.3 per 10,000 ED visits between 2010 and 2017. Pediatric NTDC ED visits by Medicaid enrollees increased from 51 percent to 65.3 percent from 2010 to 2017. This was followed by a corresponding decrease among uninsured pediatric patients with NTDC visits to EDs. The odds of NTDC visits to EDs were higher among Medicaid enrollees, 15- to 20-year-olds, and the uninsured but were lower among those in wealthier zip codes. Conclusions: Emergency department visits for nontraumatic dental condition visits by pediatric patients decreased over time following the implementation of the Affordable Care Act. Despite this decrease, low socioeconomic status children continue to utilize emergency departments for dental conditions at higher rates than their peers.

Social support and dental caries experience: Findings from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study.

OBJECTIVE: To examine the association of social support with dental caries experience in Hispanics/Latinos living in the United States (US) and to assess whether the relationship is modified by nativity status. METHODS: This cross-sectional study analysed data for 4459 dentate men and women aged 18-74 years in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study. At baseline (2008-2011), dentists quantified dental caries experience as the number of decayed, missing, and filled permanent tooth surfaces (DMFS) for all teeth excluding third molars. Social support was assessed according to measures of structural support (Social Network Index) and functional support (Interpersonal Support Evaluation List). Covariate-adjusted multiple linear regression estimated the relationship between social support and dental caries experience and tested whether the association was modified by nativity status (born within the 50 US states, foreign-born <10 years in the United States, foreign-born >10 years or more in the United States). RESULTS: In covariate-adjusted models, each additional role in the social network was associated with 1.39 fewer DMF tooth surfaces (95% CI: -2.21, -0.58) among foreign-born Hispanics/Latinos with fewer than 10 years lived in the US. For foreign-born Hispanics/Latinos with 10 years or more in the United States, each additional social network role was associated with 0.57 fewer DMF tooth surfaces (95% CI: -1.19, 0.04). No association was observed between functional social support and dental caries experience regardless of nativity status. CONCLUSIONS: Our findings suggest that structural social support is protective against dental caries experience among recent immigrants of Hispanic/Latino background. This association may reflect the importance of social support to integration into the medical and dental infrastructure and thus receipt of dental care. Future research that examines the behavioural and cultural factors that moderate the relationship between social support and dental caries experience will inform development of culturally sensitive dental caries prevention programs for Hispanics/Latinos in the United States.

Prescribing Analgesics for Postoperative Dental Pain.

It is well-known that there is an opioid crisis in the United States. Prescription opioid analgesics contribute to this crisis; in 2012, dentists ranked second to family care physicians as the top prescribers. The medical and dental literature demonstrates that dental prescribing practices have been excessive, resulting in leftover medication that could then be diverted, misused, or abused. A multimodal analgesic approach is highly valuable in targeting pain along various points on the peripheral and central pain pathways and includes the use of long-acting local anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids, the last of which are generally reserved for the most severe pain only. The Dental Impaction Pain Model demonstrates that NSAIDs are the frontline drugs for postoperative dental pain. Opioids have their role in postoperative analgesia but should be reserved for severe breakthrough pain or in situations where NSAIDs may be contraindicated.

Sugar-sweetened beverage consumption and caries experience: An examination of children and adults in the United States, National Health and Nutrition Examination Survey 2011-2014.

BACKGROUND: The authors' aim was to examine the association between sugar-sweetened beverage (SSB) consumption and the prevalence and severity of the caries experience in children and adults in the United States. METHODS: The authors analyzed data obtained from 14,192 people aged 2 through 74 years, who participated in the National Health and Nutrition Examination Survey from 2011 through 2014. Using descriptive analyses, the authors assessed the distributions of sociodemographic characteristics overall and via SSB intake. The authors used multivariable logistic regression to estimate the association of untreated and severe untreated caries with SSB consumption in all age groups. RESULTS: Across all ages, male participants were more likely than female participants to consume SSBs, and consumption was higher in non-Hispanic black and Hispanic populations. Relative to those who did not consume SSBs, people aged 20 through 44 years who consumed SSBs had significantly higher odds of having untreated caries (adjusted odds ratio [AOR], 1.27; 95% confidence interval [CI], 1.04 to 1.55) and severe untreated caries (AOR, 1.36; 95% CI, 1.15 to 1.60). Adolescents aged 9 through 19 years had significantly higher odds of having untreated caries (AOR, 1.37; 95% CI, 1.05 to 1.80), and middle-aged adults (45-64 years) had significantly higher odds of severe untreated caries (AOR, 1.46; 95% CI, 1.10 to 1.92) relative to those who did not consume SSBs. CONCLUSIONS: Consumption of SSBs was associated with increased caries experience among young children and increased risk of developing untreated caries in all age groups of children and adults. Continued efforts by policy makers, public health leaders, and clinicians to reduce consumption of SSBs across the life span are paramount.

Diet quality and dental caries in the Hispanic Community Health Study/Study of Latinos.

OBJECTIVES: Fermentable carbohydrate is universally recognized as the major dietary risk factor for dental caries. We assessed the broader relationship between diet quality and dental caries in a diverse Latinx adult population. METHODS: In a cross-sectional probability sample, 14,517 dentate men and women in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) received a dental examination and completed two 24-hours dietary recalls and a food propensity questionnaire. The 2010 Alternative Healthy Eating Index (AHEI) assessed diet quality and the National Cancer Institute method predicted usual intake of the 11 dietary components that comprise the AHEI. Dental caries experience was quantified using the decayed, missing and filled surfaces (DMFS) index. Covariates included sociodemographic and anthropometric characteristics. Survey multivariable-adjusted linear regression models quantified the relationship of 2010 AHEI score, and its 11 components, with DMFS. RESULTS: In multivariable-adjusted models, each 10-unit increase in diet quality score was associated with 2.5 fewer (95% confidence interval: -3.4, -1.6) DMFS. The relationship was pronounced among foreign-born individuals, who comprised three-quarters of the sample, irrespective of their length of US residence, but was not apparent among U.S.-born individuals. Greater intake of sugar-sweetened beverage and fruit juice was positively associated with dental caries, whereas vegetables (excluding potatoes); whole grains; and omega-3 fats were inversely associated with dental caries, independent of covariates and the other dietary components (all P < 0.05). CONCLUSIONS: An association between diet quality and dental caries was restricted to foreign-born Latinix and was not limited to the adverse impact of sugar-sweetened drinks.

Social capital and periodontal disease in Hispanic/Latino adults in the United States: Results from the Hispanic Community Health Study/Study of Latinos.

AIMS: To examine the association of social capital with periodontal disease severity. MATERIALS AND METHODS: We analysed data obtained from 3,994 men and women aged 18-74 years in the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study (HCHS/SOL SCAS). From 2008 to 2011, dentists assessed periodontitis status with a full-mouth periodontal examination. Periodontitis was classified using standardized case definitions. Multivariable logistic regression estimated odds of moderate-severe periodontitis associated with two measures of social capital: structural support (Social Network Index) and functional support (Interpersonal Support Evaluation List). RESULTS: For US-born participants, for each additional person in their social network, the adjusted odds of moderate-severe periodontitis was reduced 17% (OR = 0.83, 95% CI = 0.71, 0.96). However, no association was found between functional support and periodontal disease severity. CONCLUSIONS: Greater structural social support was associated with a lower prevalence of moderate-severe periodontitis in US-born Hispanics/Latinos. These findings suggest that US-born Hispanics/Latinos with less social support represent a vulnerable segment of the population at high-risk group for periodontal disease.

Trends in non-traumatic dental emergency department use in New York and New Jersey: a look at Medicaid expansion from both sides of the Hudson River.

OBJECTIVE: The aim of this study was to examine the effect of Medicaid expansion on non-traumatic dental condition (NTDC) emergency department visits in New York (NY) and New Jersey (NJ). METHODS: The 2010-2014 State Emergency Department Databases for NY and NJ were analyzed. NTDCs were defined as ICD-9-CM codes 520.0-529.9. Primary payers for ED discharges and patient's race were considered. RESULTS: In NY, from 2010 to 2011, there was a 51 percent decrease in private insurance and a 91 percent increase in Medicaid for NTDCs. In NJ, with the 2014 expansion, NTDCs fell 35 percent for uninsured and rose 57 percent for Medicaid. Black individuals have by far the highest population rates of NTDC ED visits, particularly in NJ. CONCLUSIONS: The experiences in NY and NJ suggest that the timing of expansion had significant effects on payer distribution for NTDCs. Racial disparities continue exist with black individuals disproportionately accessing EDs for NTDCs.

Mother's Caries Experience as a Risk Factor for Child's Oral Health: An Analysis of a High-Risk Population in the Bronx, New York.

Purpose: The purposes of this study were to: (1) assess the prevalence of dental caries experience in a sample of 543 low-income children, ages six months to 17 years, in the Bronx, New York; and (2) determine the existence of any association between maternal active decay and child's caries experience. Methods: Caries risk assessment forms completed in the pediatric clinic of an urban safety-net hospital in the Bronx were analyzed. Descriptive statistics and multiple logistic regression models assessed associations between maternal active decay and child's caries experience. Results: Active decay in the past 12 months was seen in 43.8 percent of mothers or primary caregivers. Prevalence of white spots and obvious decay and presence of restorations in their children were 26.5 percent, 23.8 percent, and 16.4 percent, respectively. Children of mothers or primary caregivers who had active decay in the past 12 months had more than double the odds (odds ratio equals 2.18; 95 percent confidence interval equals 1.53 to 3.09) of experiencing dental caries (P<0.0001). Conclusions: This study highlights the significant impact that a mother's oral health has on a child's risk of experiencing dental caries. Incorporating oral health risk assessments in adult and pediatric primary care is strongly recommended.

Genome-wide association reveals contribution of MRAS to painful temporomandibular disorder in males.

Painful temporomandibular disorders (TMDs) are the leading cause of chronic orofacial pain, but its underlying molecular mechanisms remain obscure. Although many environmental factors have been associated with higher risk of developing painful TMD, family and twin studies support a heritable genetic component as well. We performed a genome-wide association study assuming an additive genetic model of TMD in a discovery cohort of 999 cases and 2031 TMD-free controls from the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study. Using logistic models adjusted for sex, age, enrollment site, and race, we identified 3 distinct loci that were significant in combined or sex-segregated analyses. A single-nucleotide polymorphism on chromosome 3 (rs13078961) was significantly associated with TMD in males only (odds ratio = 2.9, 95% confidence interval: 2.02-4.27, P = 2.2 × 10). This association was nominally replicated in a meta-analysis of 7 independent orofacial pain cohorts including 160,194 participants (odds ratio = 1.16, 95% confidence interval: 1.0-1.35, P = 2.3 × 10). Functional analysis in human dorsal root ganglia and blood indicated this variant is an expression quantitative trait locus, with the minor allele associated with decreased expression of the nearby muscle RAS oncogene homolog (MRAS) gene (beta = -0.51, P = 2.43 × 10). Male mice, but not female mice, with a null mutation of Mras displayed persistent mechanical allodynia in a model of inflammatory pain. Genetic and behavioral evidence support a novel mechanism by which genetically determined MRAS expression moderates the resiliency to chronic pain. This effect is male-specific and may contribute to the lower rates of painful TMD in men.