Influence of craniomandibular and cervical pain on the activity of masticatory muscles in individuals with Temporomandibular Disorder

Purpose:This study aimed to establish the prevalence of pain in the craniomandibular and cervical spine region in individuals with Temporomandibular Disorders (TMD) and to analyze the effects of these disorders on the bilateral activation of anterior temporalis (AT) and masseter (MA) muscles during the masticatory cycle.Methods:The participants were 55 female volunteers aged 18–30 years. The presence of TMD and craniomandibular and cervical spine pain was evaluated by applying the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) questionnaire and using a combination of tests for the cervical region. The muscle activity of AT and MA during the masticatory cycle was assessed using the symmetry and antero-posterior coefficient indices.Results:The AT activity during the masticatory cycle is more asymmetric in individuals with TMD. The craniomandibular pain, more prevalent in these individuals, influenced these results.Conclusion:Individuals with TMD showed changes in the pattern activity of AT. The craniomandibular nociceptive inputs can influence the increase in asymmetry of the activation of this muscle.

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Associação entre a sintomatologia dolorosa e a disfunção temporomandibular

ARCHIVES OF HEALTH INVESTIGATION ◽

10.21270/archi.v9i1.4667 ◽

2020 ◽

Vol 9 (1) ◽

Author(s):

Wyllka Cyntya Galvão da Silva ◽

Karolinne Domingos Medeiros ◽

Eloisa Cesário Fernandes ◽

Sandja Gabriela Oliveira ◽

Caio Rodrigues Maia ◽

...

Keyword(s):

Diagnostic Criteria ◽

Temporomandibular Disorders ◽

Temporomandibular Disorder ◽

Epidemiologic Study ◽

Masticatory Muscles ◽

Degenerative Disorders ◽

International Conference On Bioinformatics ◽

Research Diagnostic Criteria

Introdução: A Disfunção Temporomandibular (DTM) é um quadro patológico que afeta o sistema estomatognático e, frequentemente, acompanhada de dor. Objetivos: Aferir o nível de dor dos pacientes portadores de DTM e a prevalência de sintomatologia articular e muscular. Percebeu-se que a relação entre a origem da DTM e a sintomatologia dolorosa é pouco relatada na literatura. Materiais e Métodos: Trata-se de um estudo descritivo, observacional de corte transversal, desenvolvido com 30 pacientes com DTM, diagnosticado pelo Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). A amostra foi determinada pelas estimativas de atendimento. A associação entre a sintomatologia e a origem da DTM foram verificadas através do teste qui-quadrado, com intervalos de confiança (95%). Foi usada uma ficha clínica para a coleta de dados com idade, gênero e nível da dor, que foi aferido através da Escala Visual Analógica de dor. Resultados: Constatou-se que 26 pacientes eram do sexo feminino e 4 do sexo masculino. Quinze apresentaram idade inferior a 36,5 anos, e os outros uma idade superior a esta. Quanto a origem da DTM, 19 tinham desordem articular e 11 muscular. A categoria moderada foi o nível mais prevalente, seguida do intenso. Determinou-se que não houve associação estatisticamente significante entre as variáveis deste estudo com a DTM. Conclusão: Constatou-se que, os fatores etiológicos analisados isoladamente não influenciam de forma única no desenvolvimento da DTM, mas poderão atuar em conjunto com outros fatores, já que a sua causa é multifatorial.Descritores: Dimensão Vertical; Boca Edêntula; Dor Facial; Síndrome da Disfunção da Articulação Temporomandibular.ReferênciasDworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992;6(4):301-55.Gonçalves DAG, Bigal ME, Jales LCF, Camparis CM, Speciali JG. Headache and symptoms of temporomandibular disorders: an epidemiologic study. Headache. 2010;50(2):231-41.Piccin CF, Pozzebon D, Chiodelli L, Boufleus J, Pasinato F, Corrêa ECR. Aspectos clínicos e psicossociais avaliados por critérios de diagnóstico para disfunção temporomandibular. Revista Cefac. 2016;18(1):113-19.Winocur E, Emodi-Perlman A. Occlusion, orthodontic treatment and temporomandibular disorders: myths and scientific evidences. in: Orthodonthics-basis aspects and clinical considerations. In Tech. 2012.Jorge JMS, Dini C, Santos L, Camara de Bem SH, Custodio W. Associação entre dimensão vertical de oclusão e transtornos temporomandibulares. ClipeOdonto – UNITAU. 2016;8(1):44- 50.Bayma PTC, Feltrin PP, Dias CAS, Costa JF, Laganá DC, Inoue RT. Temporomandibular disorders in otolaryngology patients. RGO (Porto Alegre). 2010;58(3):313-17.Martinez JE, Grassi DC, Marques LG. Análise da aplicabilidade de três instrumentos de avaliação de dor em distintas unidades de atendimento: ambulatório, enfermaria e urgência. Rev Bras Reumatol. 2011;51(4):299-308.Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE et al. Painful temporomandibular disorder: decade of discovery from OPPERA studies. J Dental Res. 2016; 95(10):1084-92.Rauhala K., Oikarinen KS, Raustia AM. Role of temporomandibular disorders (TMD) in facial pain: occlusion, muscle and TMJ pain. Cranio. 1999;17(4):254-61.Manfredini D, Favero L, Gregorini G, Cocilovo F, Guarda-Nardini L. Natural course of temporomandibular disorders with low painrelated impairment: a 2-to-3-year follow-up study. J Oral Rehabil. 2013;40(6):436-42.Freitas LS. Associação da disfunção Temporomandibular com o polimorfismo 102T-C do gene receptor da serotonina HTR2A [tese]. São José do Rio Preto: Faculdade de Medicina do São José do Rio Preto – FAMERP; 2011.Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res. 2008;87(4):296-307.Lopes PRR, Campos PSF, Nascimento RJM. Dor e inflamação nas disfunções temporomandibulares: revisão de literatura dos últimos quatro anos. R Ci med biol. 2011;10(3):317-25.Wang X, Guo H, Wang Y, Yi X. The effects of estrogen on cytoplasmic ca2+ concentration of masticatory muscles myoblast in acid condition. 5th International Conference on Bioinformatics and Biomedical Engineering (iCBBE); 10-12 May 2011; Wuhan, China. Anais. Disponível em http://www.icbbe.org/2011/Proceeding2010.aspx.Cairns BE. Pathophysiology of TMD Pain—Basic Mechanisms and Their Implications for pharmacotherapy. J Oral Rehabil. 2010; 37(6):391-410.Portinho CP, Razera MV, Splitt BI, Gorgen ARH, Faller GJ, Collares MVM. Apresentação clínica inicial em pacientes com disfunção Temporomandibular. Rev Bras Cir Craniomaxilofac. 2012;15(3):109-12.

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Evaluation of pain threshold upon palpation of the masticatory muscles in women with temporomandibular disorder according to the Research Diagnostic Criteria of Temporomandibular Disorders

Revista CEFAC ◽

10.1590/1982-021620182028616 ◽

2018 ◽

Vol 20 (2) ◽

pp. 175-181 ◽

Cited By ~ 1

Author(s):

Carolina Marciela Herpich ◽

Fabiano Politti ◽

Cid Andre Fidelis de Paula Gomes ◽

Igor Phillip dos Santos Gloria ◽

Ana Paula Amaral ◽

...

Keyword(s):

Diagnostic Criteria ◽

Temporomandibular Disorders ◽

Pain Threshold ◽

Temporomandibular Disorder ◽

Cross Sectional Study ◽

Masticatory Muscles ◽

Cross Sectional ◽

Submandibular Region ◽

Mandibular Region ◽

Research Diagnostic Criteria

ABSTRACT Purpose: to evaluate the pain threshold upon palpation of the masticatory muscles in women with temporomandibular disorder (TMD) according to the Research Diagnostic Criteria of Temporomandibular Disorders (RDC/TMD). Methods: a cross-sectional study was conducted involving the evaluation of pain threshold upon palpation of the extraoral muscles (temporal, masseter, posterior mandibular region, submandibular region) and intraoral muscles (lateral pterygoid area and temporal tendon) in women using the RDC/TMD clinical examination. Results: 60 women were evaluated. Statistically significant differences were found among the muscles evaluated regarding the pain threshold. The lateral pterygoid area, bilaterally, had the lowest pain threshold, followed by the masseter and temporal muscles. Conclusion: this study suggests that the lateral pterygoid muscle, bilaterally, has the lowest pain threshold upon palpation among the masticatory muscles, followed by masseter and temporal muscles, in women with TMD, according to the RDC/TMD evaluation.

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Temporomandibular Disorders and Bruxism Prevalence in a Portuguese Sample

Medical Sciences Forum ◽

10.3390/msf2021005037 ◽

2021 ◽

Vol 5 (1) ◽

pp. 37

Author(s):

João Belo ◽

André Almeida ◽

Paula Moleirinho-Alves ◽

Catarina Godinho

Keyword(s):

Temporomandibular Joint ◽

Temporomandibular Disorders ◽

Temporomandibular Disorder ◽

Masticatory Muscles ◽

Diagnostic Aspects ◽

Relevant Role

Temporomandibular disorder (TMD) encompasses a set of disorders involving the masticatory muscles, the temporomandibular joint and associated structures. It is a complex biopsychosocial disorder with several triggering, predisposing and perpetuating factors. In the etiology of TMD, oral parafunctions, namely bruxism, play a relevant role. The study of bruxism is complicated by some taxonomic and diagnostic aspects that have prevented achieving an acceptable standardization of diagnosis. The aim of this study was to analyze the prevalence of temporomandibular disorders and bruxism in a Portuguese sample.

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Cervical spine dysfunction signs and symptoms in individuals with temporomandibular disorder

Jornal da Sociedade Brasileira de Fonoaudiologia ◽

10.1590/s2179-64912012000200008 ◽

2012 ◽

Vol 24 (2) ◽

pp. 134-139 ◽

Cited By ~ 16

Author(s):

Priscila Weber ◽

Eliane Castilhos Rodrigues Corrêa ◽

Fabiana dos Santos Ferreira ◽

Juliana Corrêa Soares ◽

Geovana de Paula Bolzan ◽

...

Keyword(s):

Cervical Spine ◽

Temporomandibular Disorder ◽

Signs And Symptoms ◽

Cervical Pain ◽

Pain Symptom ◽

Significant Difference ◽

The Common ◽

Cervical Spine Dysfunction ◽

Posture Assessment ◽

Craniocervical Dysfunction

PURPOSE: To study the frequency of cervical spine dysfunction (CCD) signs and symptoms in subjects with and without temporomandibular disorder (TMD) and to assess the craniocervical posture influence on TMD and CCD coexistence. METHODS: Participants were 71 women (19 to 35 years), assessed about TMD presence; 34 constituted the TMD group (G1) and 37 comprised the group without TMD (G2). The CCD was evaluated through the Craniocervical Dysfunction Index and the Cervical Mobility Index. Subjects were also questioned about cervical pain. Craniocervical posture was assessed by cephalometric analysis. RESULTS: There was no difference in the craniocervical posture between groups. G2 presented more mild CCD frequency and less moderate and severe CCD frequency (p=0.01). G1 presented higher percentage of pain during movements (p=0.03) and pain during cervical muscles palpation (p=0.01) compared to G2. Most of the TMD patients (88.24%) related cervical pain with significant difference when compared to G2 (p=0.00). CONCLUSION: Craniocervical posture assessment showed no difference between groups, suggesting that postural alterations could be more related to the CCD. Presence of TMD resulted in higher frequency of cervical pain symptom. Thus the coexistence of CCD and TMD signs and symptoms appear to be more related to the common innervations of the trigeminocervical complex and hyperalgesia of the TMD patients than to craniocervical posture deviations.

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Masticatory muscle activity during maximum voluntary clench in different research diagnostic criteria for temporomandibular disorders (RDC/TMD) groups

Manual Therapy ◽

10.1016/j.math.2007.05.011 ◽

2008 ◽

Vol 13 (5) ◽

pp. 434-440 ◽

Cited By ~ 59

Author(s):

Gianluca M. Tartaglia ◽

Marco Antonio Moreira Rodrigues da Silva ◽

Stefano Bottini ◽

Chiarella Sforza ◽

Virgilio F. Ferrario

Keyword(s):

Diagnostic Criteria ◽

Muscle Activity ◽

Temporomandibular Disorders ◽

Masticatory Muscle ◽

Masticatory Muscle Activity ◽

Research Diagnostic Criteria

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Wind Instrumentalists and Temporomandibular Disorder: From Diagnosis to Treatment

Dentistry Journal ◽

10.3390/dj6030041 ◽

2018 ◽

Vol 6 (3) ◽

pp. 41 ◽

Cited By ~ 5

Author(s):

Miguel Clemente ◽

Joaquim Mendes ◽

André Moreira ◽

Ricardo Vardasca ◽

Afonso Ferreira ◽

...

Keyword(s):

Performing Arts ◽

Temporomandibular Disorder ◽

Infrared Camera ◽

Masticatory Muscles ◽

Cervical Region ◽

Performing Arts Medicine ◽

Temporal Muscle ◽

Piezoresistive Sensors ◽

Professional Musician ◽

The Right

Introduction: Temporomandibular disorders (TMD) involve the presence of pain or dysfunction on certain areas of the Cranio-Cervico-Mandibular Complex (CCMC), such as the masticatory muscles, the temporomandibular joint (TMJ) and associated structures like the postural muscles of the cervical region, can be considered as a sub-group of musculoskeletal disorders. Wind instrument players, as a consequence of their musical performance and its relation with the CCMC, can develop a TMD associated to muscle hyperactivity of certain elevator muscles, or even an increase of the intra-articular pressure in the functioning of the TMJ throughout musical activity. Aim: The objective of this paper is to describe the necessary and elementary steps in the diagnoses and treatment of a wind instrumentalist with a temporomandibular disorder, with the introduction of infrared thermography during this procedure. This case study also has the purpose of presenting the usefulness of piezoresistive sensors in the analysis of the clarinettists’ embouchure. Methodology: A Caucasian, 30-year-old female clarinettist was assessed through a clinical examination following the Diagnostic Criteria for TMD (RDC/TMD), as a complementary tool of diagnosis, a thermal imaging infrared camera, Flir E60 (Wilsonville, OR, USA), was used in order to analyse the above referred articular and muscular regions. The complementary examination protocol implemented with this clarinet player also involved the analyses of the embouchure with the support of piezoresistive sensors. Results: The clinical outcomes resulting from this work were based on the RDC/TMD diagnoses indicated that the clarinet player had an internal derangement on both TMJ, with an osteoarthritis on the left TMJ and an anterior disc displacement with reduction on the right TMJ. The infrared thermograms that were analysed, verified the existence of a temperature differential of the anterior temporal muscle (0.1 °C), the TMJ (0.1 °C) and the masseter muscle (0.7 °C), and after the occlusal splint therapy the asymmetry related to the master muscle reduced to 0.3 °C. The high pitches can reach values of 379 g of force induced to the tooth 21 comparing to the 88 g of force applied on tooth 11. The embouchure force measurements consistently presented greater forces during the higher notes, followed by the medium notes and finally the low notes and this happened with higher pressures being transmitted always to tooth 21. Conclusion: Performing arts medicine should understand the major importance of the dentistry field in the daily life of a professional musician, and the significance of implementing routine screening procedures of dental examinations, with infrared thermograms examination of distinct areas of the CCMC, as well as the use of sensors on the analyses of an eventual asymmetrical embouchure. Employing these techniques in dentistry will create the chance of preventing the overuse of some anatomical structures, with an early diagnosis and the correct monitoring of these areas.

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Masticatory muscle Activity in Individuals with Temporomandibular Disorder

Acta Balneologica ◽

10.36740/abal202103109 ◽

2021 ◽

Vol 64 (3) ◽

pp. 179-182

Author(s):

Lyubov V. Smaglyuk ◽

Anastasiia V. Liakhovska

Keyword(s):

Muscle Activity ◽

Clinical Symptoms ◽

Temporomandibular Disorder ◽

Normal Activity ◽

Masticatory Muscles ◽

Emg Activity ◽

Muscle Work ◽

Left And Right ◽

The Right ◽

Masseter Muscles

Aim: The aim of our study was to investigate features related to EMG-activity of masticatory muscles in subjects with TMD. materials and methods: The study comprised 22 patients with clinical symptoms of TMD. The average age of the subjects was 29.3 ± 4.4 years. Malocclusion was evaluated according to Angle classification, TMD – according to the Research Diagnostic Criteria (RDC/TMD). Registration of EMG-activity of masseter and anterior temporalis muscles was performed during maximum voluntary clenching, clenching on the right and left sides. Results: Normal activity of the masticatory muscles is characterized by symmetrical and EMG-activity of the masticatory muscles on the left and right sides. EMG-activity of masticatory muscles in subjects with TMD are characterized by: 1) increased values of EMG-activity of temporal and masseter muscles; 2) disproportional and asymmetric muscle work of the masticatory muscles on the right and left sides. Conclusions: Features of masticatory muscles activity in individuals with Angle Class I malocclusion and TMD were found.

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Biomarkers of Temporomandibular Disorders

SONDE (Sound of Dentistry) ◽

10.28932/sod.v3i1.1782 ◽

2019 ◽

Vol 3 (1) ◽

pp. 41-47

Author(s):

Dian Dominica ◽

Silvia Naliani ◽

Shelly Lelyana ◽

Ferry Sandra

Keyword(s):

Early Detection ◽

Temporomandibular Disorders ◽

Daily Activity ◽

Temporomandibular Disorder ◽

Masticatory Muscles ◽

Joint Function ◽

Monocyte Chemoattractant ◽

Temporomandibular Joints ◽

Myofacial Pain ◽

Potential Biomarkers

Temporomandibular disorder is a disorder that includes masticatory muscles or temporomandibular joints, unbalanced joint function or both. The disorders can disturb daily activity, cause by pain. The therapy consuming time and cost. Early detection of temporomandibular disorder is needed, as a prevention of more severe disorders. Increased cortisol can be found in myofacial pain and is not found in internal dearagement or osteoarthritis. Biomarkers of interleukin and monocyte chemoattractant proteins are only found in osteoarthritis. The use of biomarkers can be useful in detecting temporomandibular disorders. Biomarkers can be measured from blood, serum and saliva. Cortisol, dopamine and TAC are potential biomarkers in the temporomandibular disorder.

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Skeletal Divergence and Condylar Asymmetry in Patients with Temporomandibular Disorders (TMD): A Retrospective Study

BioMed Research International ◽

10.1155/2021/8042910 ◽

2021 ◽

Vol 2021 ◽

pp. 1-6

Author(s):

Maria Francesca Sfondrini ◽

Letizia Bolognesi ◽

Mario Bosco ◽

Paola Gandini ◽

Andrea Scribante

Keyword(s):

Retrospective Study ◽

Diagnostic Criteria ◽

Temporomandibular Disorders ◽

Temporomandibular Disorder ◽

Strong Association ◽

Joint Diseases ◽

Patients Âgés ◽

Effect Relationship ◽

Lateral Cephalograms ◽

Skeletal Pattern

Introduction. This study was aimed at evaluating the association between vertical skeletal patterns, condylar height symmetry, and temporomandibular disorders in adults. Methods. The study sample consisted of 200 patients (ages 18–30 years old) retrospectively recruited: 100 with temporomandibular disorders (TMD) and 100 without TMD (control), diagnosed by Diagnostic Criteria for the Temporomandibular Disorders (DC/TMD). For each subject, skeletal divergence was assessed on lateral cephalograms, and condylar height symmetry was evaluated by orthopantomography (Habets’ method). Results. Subjects with temporomandibular disorders showed a strong association with condylar asymmetry ( p < 0.0001 ) and, for the skeletal pattern variables, hyperdivergence ( p < 0.001 ). A correlation with the female sex was also found ( p < 0.04 ), while there was no difference in terms of age in the 2 groups ( p > 0.29 ). Conclusions. Although it does not imply a direct cause-and-effect relationship, the present study suggests condylar asymmetry and hyperdivergent skeletal pattern are more likely to be associated with a higher risk of temporomandibular disorder joint diseases in adult patients.

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CONTRIBUIÇÕES DA TERAPIA COGNITIVO-COMPORTAMENTAL NO TRATAMENTO DA DISFUNÇÃO TEMPOROMANDIBULAR (DTM)

polemica ◽

10.12957/polemica.2021.64134 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Hellorainy Rangel Rodrigues Souza ◽

Ana Lúcia Novais Carvalho

Keyword(s):

Cognitive Behavioral Therapy ◽

Cognitive Therapy ◽

Temporomandibular Disorders ◽

Behavioral Interventions ◽

Relaxation Training ◽

Behavioral Therapy ◽

Temporomandibular Disorder ◽

Multidisciplinary Treatment ◽

Masticatory Muscles ◽

Cognitive Behavioral

Resumo: A Disfunção Temporomandibular (DTM) é um distúrbio que afeta as articulações temporomandibulares e os músculos mastigatórios, entre outras estruturas da face. Os sintomas podem gerar dores nessas articulações e músculos, bem como dores na cabeça, orelha, ruídos nas articulações, zumbidos, dores no ouvido, limitação na abertura da boca, entre outros. Sua etiologia é multifatorial. Entre os fatores que podem influenciar a DTM encontram-se os psicológicos. Assim, este estudo teve como objetivo identificar as principais estratégias da terapia cognitivo-comportamental (TCC) utilizadas para o tratamento de indivíduos diagnosticados com DTM. Por método, adotou-se a revisão da literatura. Os bancos de dados utilizados foram PePSIC, SCIELO, PubMed e BVS, em inglês e português. Os descritores utilizados em todos os bancos foram: DTM e terapia cognitiva-comportamental; Disfunção temporomandibular e terapia-cognitiva comportamental, Disfunção temporomandibular e terapia-cognitiva, TMD and cognitive behavioral therapy; Temporomandibular disorder and cognitive behavioral therapy, Temporomandibular disorder and cognitive therapy. Os filtros utilizados para inclusão dos estudos foram artigos sobre intervenções em TCC, em português e/ou inglês e com datas de publicação dos últimos três anos. Seis artigos foram analisados, após a passagem dos filtros. Os resultados apontam que as principais estratégias de TCC utilizadas no tratamento da DTM são a restruturação cognitiva, a autogestão, a psicoeducação e o relaxamento. Sugerem, também, que a TCC pode trazer contribuições positivas para os casos de DTM, porém a amostra deste estudo foi pequena. Os artigos analisados apontam que o tratamento multidisciplinar deve incluir intervenções cognitivas e comportamentais. Sendo assim, fica evidenciada a necessidade de realização de mais pesquisas com o objetivo de verificar os efeitos da TCC em pacientes com DTM, principalmente, estudos com ensaios clínicos.Palavras-chave: Terapia cognitiva-comportamental. Disfunção temporomandibular. DTM. Estresse. Ansiedade. Abstract: Temporomandibular Disorder (TMD) is a disorder that affects the temporomandibular joints and masticatory muscles, among other facial structures. Symptoms can generate pain in these joints and muscles, as well as pain in the head, ear, noise in the joints, tinnitus, ear pain, limitation in opening the mouth, among others. Its etiology has multifactorial causes. Among the factors that can influence TMD are psychological. Objective: This study aimed to identify cognitive behavioral therapy (CBT) strategies used to treat individuals diagnosed with TMD. Method: Literature review. The databases used were PePSIC, SCIELO, PubMed and BVS, in English and Portuguese. The descriptors used in databases were: TMD and cognitive-behavioral therapy; Temporomandibular disorders and cognitive behavioral therapy, Temporomandibular disorders and cognitive therapy, TMD and cognitive behavioral therapy; Temporomandibular disorder and cognitive behavioral therapy, Temporomandibular disorder and cognitive therapy. The filters used to include the studies were: articles on CBT interventions, articles in Portuguese and/or English and with publication dates in the last three years. Results: Six articles were analyzed, after passing the filters. Discussion: The results show that the main CBT guidelines used in the treatment of TMD are: cognitive restructuring, self-management, psychoeducation and relaxation training. They also suggest that a CBT can bring positive contributions to TMD cases, but the sample in this study was small. The articles point out that multidisciplinary treatment must include cognitive and behavioral interventions. Thus, the need for further research to verify the effects of CBT in patients with TMD is evidenced, especially, studies with clinical trials.Keywords: Cognitive behavioral therapy. Temporomandibular disorder. TMD. Stress. Anxiety.

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