Mindfulness Facets Associated with Orofacial Pain Outcomes

Abstract

Mindfulness can help improve chronic pain outcomes. This cross-sectional study is the first to test associations between specific mindfulness facets and pain-related outcomes (pain intensity, pain-related disability, anxiety, and depression) in individuals with chronic orofacial pain (N = 303). “Nonjudging” was associated with positive pain-related outcomes. “Observing” was associated with worse pain-related disability and anxiety outcomes. Multiple regressions revealed that “nonjudging” was the only facet independently associated with pain-related disability, anxiety, and depression beyond the other facets and clinical/demographic variables. Cultivating a nonjudgmental stance may facilitate positive orofacial pain outcomes.

Introduction

Chronic orofacial pain (pain in the face, mouth, or jaw for a minimum of 3 months and at least 1 day per month) is associated with emotional distress and disability.¹ Mindfulness, defined as paying attention on purpose, in the present moment, and nonjudgmentally,² is associated with improved pain-related and emotional outcomes in patients with chronic pain.³

Mindfulness, however, is not a uniform construct and is often described as consisting of separate facets, such as observing one's experiences, describing them, being nonreactive and nonjudgmental toward them, and acting with awareness.⁴ Accumulating evidence indicates that mindfulness facets can have distinct associations with clinical variables across patient populations. For example, unlike the rest of the facets, “observing” is often not correlated,^4,5 or inversely correlated,^4,6 with clinical outcomes across medical populations.

Among people with chronic pain, “observing” is similarly not associated with pain-related outcomes,⁷ or associated with worse pain intensity,⁸ while “nonjudgment” and “acting with awareness” are most often associated with positive pain outcomes.^7,9 To date, no studies directly tested these associations among patients with heterogeneous orofacial pain. Elucidating the relationship between mindfulness facets and pain-related outcomes can help inform how to teach mindfulness in interventions for this population to maximize positive outcomes.

The authors have previously shown that the total mindfulness score measured with the Five Facet Mindfulness Questionnaire¹⁰ (FFMQ-15) was associated with positive anxiety and depression outcomes but was not significantly associated with pain intensity and pain-related disability outcomes in patients with chronic heterogeneous orofacial pain.¹¹ In this study, the authors perform secondary analysis of these data, to test the associations between the Five Facet Mindfulness Questionnaire and the pain-related outcomes. They hypothesized that the “observing” facet would correlate with worse outcomes (i.e., greater anxiety, depression, pain intensity, and pain-related disability), whereas the other four facets of mindfulness would be associated with favorable outcomes. They further hypothesized that nonjudgment and acting with awareness would hold unique independent contributions to positive outcomes above and beyond the other mindfulness facets and relevant demographic and clinical variables.

Methods

Participants and procedures

In total, 303 participants with chronic heterogeneous oral-facial pain were recruited through an online newsletter sent to Facial Pain Association, an institution supporting people with orofacial pain. The recruitment period was March to June 2021, and inclusion criteria were being >18 years of age, self-reported English speaking and writing ability at a sixth grade level, experiencing orofacial pain that is nonmalignant for at least 3 months, and residing in the United States. Participants (Table 1 depicts demographic and clinical information) signed an online informed consent form and subsequently filled out the questionnaires on a secure online platform (REDCap). The Massachusetts General Hospital Institutional Review Board approved the study and its associated procedure. The authors classified reported diagnoses in line with the International Classification of Orofacial Pain (ICOP), first edition.¹²

Table 1.

Demographics and Clinical Characteristics of the Participants (Adapted from Greenberg et al.¹¹)

Variable
Age, M (SD)	59.11 (27.57)
Gender, n (%)
Male	42 (13.9)
Female	261 (86.1)
Education, n (%)
Less than high school	2 (0.7)
High school	31 (10.2)
Some college	80 (26.4)
4-year college	95 (31.4)
Graduate/professional	94 (31)
Preferred not to answer	1 (0.3)
Employment status, n (%)
Full time	82 (27.1)
Part time	35 (11.6)
Homemaker	12 (4)
Student	2 (0.7)
Retired	115 (38)
Unemployed	22 (7.3)
Other	31 (10.2)
Preferred not to answer	4 (1.3)
Marital status
Married	209 (69)
Single	29 (9.6)
Living w/significant other	17 (5.6)
Separated/divorced	32 (10.6)
Widowed	12 (4)
Preferred not to answer	4 (1.3)
Ethnicity, n (%)
Hispanic/Latino	16 (5.3)
Non-Hispanic/Latino	274 (90.4)
Preferred not to answer	13 (4.3)
Diagnosis, n (%)
Trigeminal neuralgia	156 (51.5)
TNP	22 (7.3)
TN2	22 (7.3)
PIFP	16 (5.3)
Multiple diagnoses	60 (19.8)
Other	14 (4.6)
None	13 (4.3)
Pain duration, n (%)
0–1 year	14 (4.6)
1–5 years	70 (23.1)
5–10 years	80 (26.4)
10+ years	139 (45.8)
Mental health history, n (%)
None	166 (54.8)
Depression	96 (31.7)
Anxiety	81 (26.7)
PTSD	29 (9.6)
Other	15 (5)
Using pain medications, n (%)	216 (71.3)
Using mood medications, n (%)	103 (34)

Diagnosis codes: TNP = other trigeminal neuropathic pain TN2 = classical trigeminal neuralgia with concomitant continuous pain. PIFP = Persistent Idiopathic Facial Pain. Unlisted diagnoses included under “multiple diagnoses” and “Other” include migraines (n = 8), myofascial orofacial pain (n = 2), temporomandibular disorders (n = 7), glossopharyngeal neuralgia (n = 10), hemicrania continua (n = 1), burning mouth syndrome (N = 4), occipital neuralgia (n = 8), and diagnoses not specified in the ICOP (n = 23).

ICOP, International Classification of Orofacial Pain.

Measures

Demographics and clinical characteristics

Participants reported demographic characteristics, including their age, gender, ethnicity, education level, employment, and marital status, as well as clinical characteristics such as their facial pain diagnosis, pain duration, mental health history, and pain or mood medication they are taking.

Mindfulness

The FFMQ-15 is a 15-item questionnaire assessing five facets of mindfulness: observing one's experiences, describing them, being nonreactive and nonjudgmental toward them, and acting with awareness.

Pain intensity and pain-related disability

Participants completed the Graded Chronic Pain Scale,¹³ which assesses pain intensity and pain-related disability on different subscales.

Depression

Participants completed the PROMIS depression scale version 108b, an 8-item questionnaire assessing the frequency and intensity of depression symptoms on a 1–5 Likert scale, and reported as a T score with a mean of 50 and a standard deviation of 10.¹⁴

Anxiety

Participants completed the PROMIS anxiety scale version 108a, an 8-item questionnaire assessing the frequency and intensity of anxiety symptoms on a 1–5 Likert scale, and reported as a T score with a mean of 50 and a standard deviation of 10.¹⁴

Analytic strategy

The authors conducted all analyses in SPSS 24. They first tested bivariate correlations between mindfulness facets and outcomes (anxiety, depression, pain intensity, and pain-related disability). They then conducted four two-step multiple regression models, one for each outcome, to assess whether and which mindfulness facets held unique, independent contributions to outcomes above and beyond other mindfulness facets and demographic and clinical variables. The first step included demographic and clinical variables (age, gender, education, employment, marital status, ethnicity, diagnosis, pain duration, and mental health history), and the second step included the five mindfulness facets.

The authors used the F statistic to assess model fit, and used R² to assess increase in variance accounted for. They measured effect size through squared semipartial correlations (sr²), representing the incremental variance added by each factor. Power analysis was calculated with the assumption of a small effect size. With power of 0.80 (α = 0.05) and 5 independent variables, a sample size of 250 would be required to detect a small effect size.¹⁵ In the case of missing data, the authors applied pairwise deletion, resulting in sample sizes ranging from 272 to 274 across analyses.

Results

Bivariate regressions

The “observing” facet significantly correlated with worse pain-related disability (r = 0.210, p < 0.001) and anxiety (r = 0.165, p = 0.033), and exhibited a nonsignificant correlations with worse depression (r = 0.133, p = 0.086) and pain intensity (r = 0.094, p = 0.148). “Nonjudging” was significantly associated with favorable outcomes on all measures (r = −0.567, p < 0.001 for anxiety, r = −0.563, p < 0.001 for depression, r = −0.165, p = 0.005 for pain intensity and r = −0.275, p < 0.001 for pain-related disability). “Acting with awareness” significantly correlated with lower anxiety (r = −0.323, p < 0.001), depression (r = −0.300, p < 0.001), and pain-related disability (r = −0.143, p = 0.014), and describing significantly correlated with lower anxiety (r = −0.205, p < 0.001) and depression (r = −0.230, p < 0.001).

Multiple regressions

The association between outcomes and demographic and clinical variables (step 1 of the regression models) is listed in Table 2 and discussed in the parent study.¹¹ In this study, the authors focus on associations of outcomes with mindfulness facets.

Table 2.

Multiple Regression Results

	B	SE	t	p	sr²
Pain intensity
Step 1
Gender	−0.351	3.603	−0.098	0.922	2.92
Education	−3.119	1.238	−2.502	0.012	0.02
Employment
Full time	1.642	3.029	0.542	0.588	0.00
Part time	1.013	4.154	0.244	0.807	0.00
Home maker	9.360	6.788	1.379	0.169	0.01
Student	9.722	14.790	0.657	0.511	0.00
Unemployed	3.634	4.903	0.741	0.459	0.00
Other	14.701	4.314	3.407	0.001	0.04
Diagnosis category
TN2	6.372	4.780	1.333	0.182	0.01
TNP	10.636	4.768	2.231	0.026	0.02
PIFP	7.637	5.574	1.370	0.171	0.01
Other	−3.696	5.947	−0.622	0.534	0.00
Multiple	7.674	3.203	2.396	0.017	0.02
None	−3.505	6.078	−0.577	0.564	0.00
Pain duration	−2.950	1.379	−2.139	0.033	0.01
Step 2
FFMQ observing	0.146	0.443	0.330	0.742	0.00
FFMQ describing	−0.119	0.538	−0.221	0.825	0.00
FFMQ acting with awareness	−0.206	0.552	0.373	0.710	0.00
FFMQ nonjudging	−0.727	0.500	−1.453	0.146	0.01
FFMQ nonreactivity	0.028	0.423	0.065	0.948	1.46
Pain disability
Step 1
Gender	4.811	5.156	0.933	0.351	0.00
Education	−2.148	1.771	−1.213	0.255	0.00
Employment
Full time	0.286	4.335	0.066	0.947	0.00
Part time	2.399	5.922	0.405	0.685	0.00
Homemaker	23.818	9.184	2.593	0.010	0.02
Student	10.448	21.182	0.493	0.622	0.00
Unemployed	17.592	7.015	2.508	0.012	0.02
Other	27.026	6.168	4.382	0.000	0.06
Diagnosis category
TN2	5.546	6.870	0.807	0.420	0.01
TNP	12.522	6.807	1.840	0.066	0.00
PIFP	1.413	7.951	0.178	0.859	0.00
Other	−16.681	8.647	−1.950	0.052	0.01
Multiple	8.308	4.553	1.825	0.068	0.01
None	−2.715	8.653	−0.314	0.754	0.00
Pain duration	−5.860	1.934	−3.029	0.002	0.03
Step 2
FFMQ observing	1.183	0.641	1.846	0.067	0.00
FFMQ describing	−0.077	0.739	−0.104	0.917	3.04
FFMQ acting with awareness	−0.073	0.774	−0.095	0.924	2.65
FFMQ nonjudging	−1.807	0.748	−2.415	0.017	0.02
FFMQ nonreactivity	−0.298	0.602	−0.495	0.621	0.00
Anxiety
Step 1
Gender	0.109	1.872	0.058	0.954	1.38
Education	−0.860	0.587	−1.466	0.143	0.01
Employment
Full time	1.322	1.416	0.933	0.351	0.00
Part time	1.651	2.050	0.805	0.421	0.00
Homemaker	10.190	2.989	3.410	0.001	0.04
Student	−5.300	11.348	−0.467	0.650	0.00
Unemployed	3.436	2.384	1.441	0.150	0.01
Other	2.387	2.014	1.185	0.236	0.00
Diagnosis category
TN2	0.055	2.651	0.021	0.983	1.79
TNP	4.199	2.295	1.830	0.068	0.01
PIFP	1.165	2.632	0.442	0.658	0.00
Other	0.859	2.783	0.309	0.758	0.00
Multiple	2.573	1.485	1.733	0.083	0.01
None	1.620	3.284	0.493	0.624	0.00
Pain duration	−2.156	0.673	−3.205	0.002	0.04
Step 2
FFMQ observing	0.207	0.220	0.939	0.360	0.00
FFMQ describing	−0.324	0.216	−1.500	0.135	0.01
FFMQ acting with awareness	−0.204	0.213	−0.959	0.338	0.00
FFMQ nonjudging	−1.677	0.208	−8.082	0.000	0.17
FFMQ nonreactivity	−0.190	0.171	−1.109	0.269	0.00
Depression
Step 1
Gender	−2.257	1.809	−1.248	0.213	0.01
Education	−1.116	0.616	−1.812	0.071	0.01
Employment
Full time	1.518	1.513	1.004	0.316	0.00
Part time	1.331	2.047	0.650	0.516	0.00
Homemaker	7.454	3.109	2.397	0.017	0.02
Student	23.318	8.369	2.786	0.008	0.03
Unemployed	5.691	3.019	1.885	0.071	0.02
Other	5.507	2.047	2.690	0.007	0.02
Diagnosis category
TN2	4.641	2.450	1.894	0.060	0.01
TNP	−1.382	2.749	−0.503	0.618	0.00
PIFP	2.385	2.675	0.891	0.373	0.00
Other	−0.410	2.837	−0.144	0.885	0.00
Multiple	4.200	1.572	2.672	0.008	0.02
None	4.881	3.702	1.319	0.199	0.01
Pain duration	−1.457	0.655	−2.223	0.026	0.02
Step 2
FFMQ observing	0.020	0.249	0.079	0.938	2.76
FFMQ describing	−0.209	0.233	−0.895	0.373	0.00
FFMQ acting with awareness	−0.258	0.217	−1.188	0.235	0.00
FFMQ nonjudging	−0.1.697	0.228	−7.445	0.000	0.17
FFMQ nonreactivity	−0.080	0.170	−0.469	0.639	0.00

For employment, all dummy coded variables represent comparisons against “retired status” as the most common category of employment. For diagnosis, all dummy coded variables represent comparisons against “trigeminal neuralgia” as the most common diagnostic category.

FFMQ-15, Five Facet Mindfulness Questionnaire.

No mindfulness facets held unique independent associations with pain intensity, above and beyond the other facets and covariates. Nonjudging was the only mindfulness facet significantly and independently associated with pain-related disability (B = −1.807, SE = 0.748, p = 0.017, sr² = 0.02 adding a 2% incremental variance to the model), anxiety (B = −1.677, SE = 0.208, p < 0.001, sr² = 0.02 adding a 17% incremental variance), and depression (B = −1.697, SE = 0.228, p < 0.001, sr² = 0.02 adding a 17% incremental variance; Table 2).

Discussion

This study is the first to test the relationship between facets of mindfulness and chronic orofacial pain-related outcomes. Broadly consistent with the authors' first hypothesis, bivariate correlations revealed that the “observing” facet significantly correlated with worse pain-related disability and anxiety and showed similar nonsignificant trends for worse outcomes on depression and pain intensity. “Nonjudging” was significantly associated with favorable outcomes on all measures. “Describing” and “acting with awareness” correlated with lower anxiety and depression, with the latter also correlating with lower pain-related disability.

These results raise the possibility that while most mindfulness facets have potential to improve orofacial pain outcomes, this may not be the case for “observing,” which may possibly have opposite effects. Merely increasing one's attention to their immediate experiences, if aversive, as common in individuals with chronic orofacial pain, may increase distress, amplify pain, or elicit rumination. While observing one's experience is an important facet of mindfulness,^2,4 it is important to complement it with the other mindfulness facets, which may help mitigate such negative effects and facilitate positive pain-related outcomes.^7,9 Of note, individuals with little or no mindfulness practice may report “observing” in a way that is not consistent with mindfulness.¹⁰ Varying levels of mindfulness practice, as well as factors such as a tendency for fear avoidance may have influenced the relationship between “observing” and these pain-related outcomes.

The authors' second hypothesis was partially supported, with “nonjudging” (but not “acting with awareness”) holding independent contributions to pain-related disability, anxiety, and depression beyond the other factors and relevant clinical and demographic variables. This supports findings from other pain populations about the centrality of nonjudging,⁷ and highlights the potential of interventions for this population aimed at cultivating a nonjudgmental attitude, such as mindfulness-based and compassion-based programs, to improve pain-related outcomes.¹⁶ Such programs may further ease distress, the tendency to be overly critical, and promote change in one's relationship with these pain and negative experiences.¹⁶

Limitations of this study include the cross-sectional design, which prevents the authors from establishing causality. Furthermore, most participants indicated trigeminal neuralgia as their primary orofacial pain diagnosis, which may limit generalizability to other populations. Nevertheless, results from the multiple regression models showed results are evident above and beyond specific diagnoses, supporting wider applicability. Finally, as mentioned earlier, the relationship between pain-related outcomes and mindfulness facets may be influenced by factors not accounted for in this study, including fear-avoidance beliefs and one's level of experience with mindfulness practices. Considering these factors is, therefore, important in interpreting the associations between mindfulness facets and pain-related outcomes.

In conclusion, mindfulness holds promise for promoting positive pain-related outcomes among individuals with chronic orofacial pain. Cultivating a nonjudgmental stance, for example, through mindfulness and compassion-based programs¹⁶ holds potential to facilitate positive orofacial pain outcomes, and may be particularly important to emphasize while observing adverse or painful experiences associated with orofacial pain. Future longitudinal research testing mindfulness-based interventions for this population and taking other potentially related factors into account is needed to further establish the role of mindfulness facets in orofacial pain outcomes.

Footnotes

Acknowledgment

The authors would like to thank the Facial Pain Association for their contribution to data collection in this study.

Authors' Contributions

J.G. co-conceptualized the design of the study, led data acquisition, interpreted data, and drafted the article. D.C.S. co-drafted the article. J.B. led data analysis and interpretation and provided meaningful revisions and commentary on the article. A.M.V. co-conceptualized the design of the study, provided meaningful revisions and commentary on the article, and provided oversight.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by a K23 grant from the National Center for Complementary and Integrative Health (NCCIH; 1K23AT010653-01A1) to the first author, and a K24 grant from NCCIH (1K24AT011760-01) to the senior author.

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