Impact of Maternal Status on Dental Pain Perception in Adult Women: A Cross-sectional Study

1. INTRODUCTION

Pain is an inherently individualistic and subjective experience that presents challenges for researchers and clinicians. Its perception varies greatly among individuals and is influenced by the complex interplay of biological and psychosocial factors, including demographic charac-teristics, genetic, and psychosocial characteristics. These factors collectively yield a unique constellation of influ-ences on individual pain experiences [1]. Notably, sex, age, and ethnicity have been identified as significant determinants for chronic pain and responses to experi-mentally induced pain. Furthermore, genetic and psycho-social factors exert combined effects on clinical and experimental pain intensities.

Epidemiological evidence has consistently demons-trated a higher prevalence of chronic pain in women compared to men. For instance, a nationwide survey in the United States revealed that women reported experiencing any pain over the preceding 90 days more frequently than men, often describing their pain as persistent and dis-tressing [2]. Additionally, studies have identified distinct factors influencing pain quality between genders in conditions such as burning mouth syndrome, with dep-ression and alcohol consumption linked to pain quality in men, and educational level and marital status associated with pain experiences in women [3].

Age-related differences in pain perception have also been extensively studied, suggesting that older adults may exhibit decreased sensitivity to acute and superficial pain stimuli but increased sensitivity to prolonged deep-tissue pain [4].

Stress, defined as a state of disrupted homeostasis or harmony, plays a crucial role in pain perception. Both physical and psychological stressors trigger multifaceted responses involving neural, endocrine, and behavioral adaptations. This response is characterized by the acti-vation of the sympathetic nervous system and the Hypothalamic-Pituitary-Adrenal (HPA) axis, accompanied by changes in pain thresholds and various physiological and behavioral parameters [5, 6].

Research has shown that stress and anxiety can exacerbate pain by activating the hippocampus, sugges-ting strategies to mitigate pain by modulating hippo-campuscampal activity during potentially painful pro-cedures [7]. Individual personality traits, such as a propensity for catastrophizing, can influence the impact of stressors on emotional well-being. Although findings remain mixed, some studies have indicated a higher tendency among women to engage in catastrophizing [8].

Hormonal factors, such as estrogen levels, have been implicated in pain sensitivity and hormonal fluctuations linked to variations in pain perception and sex-specific responses to pain [9].

The perinatal period induces significant neuro-biological changes in women, enhancing susceptibility to stress and its effects on pain perception. Both historical and current stress can alter maternal brain function and affect circuits involved in stress regulation, empathy, and maternal motivation. Thus, interventions aimed at redu-cing stress in mothers could potentially mitigate adverse effects on the maternal brain and, by extension, pain perception [10, 11].

Changes in the HPA axis during pregnancy and the postpartum period aimed at adapting to maternal stress highlight a critical window of vulnerability and adapt-ability. Disruptions in this adaptive process owing to severe stress can lead to dysregulation and consequent mood disorders, further complicating the relationship between maternal status and pain perception [12].

Despite the extensive research on pain perception and its modulators, few studies have directly examined the influence of maternal status on dental pain perception in women. This study aimed to fill this gap by offering insights into how maternal status uniquely affects of experiences of dental pain in women.

2. MATERIALS AND METHODS

2.6. Pre-treatment Questions

This section included sociodemographic data (age, sex, nationality, occupation, education, and area of residence], and maternal history (number of children, and type of birth).

Anxiety was assessed using the Modified Dental Anxiety Scale (MDAS), which consists of five questions and summed together to produce a total score of 5–25. It can be integrated into everyday dental practice as a clinical aid and screen for dental anxiety and has shown high reliability and validity [13].

Participants rated their anticipated pain using the Wong-Baker Face Scale, the visual analogue scale, and the numerical pain scale (Figs. 1-3). The Wong-Baker Face Scale shows a series of faces ranging from a happy face at 0 (no pain), to a crying face at 10 “hurts like the worst pain imaginable” [14]. This scale is easy to use and comprehend and has high validity and reliability.

The Visual Analogue Scale (VAS) shows a straight line with the endpoints defining extreme as ‘no pain at all’ and ‘pain as bad as it could be.’ Participants were asked to mark their anticipated pain level between the two endpoints and the distance between ‘no pain at all’ and the mark was used to assess the level of pain [15]. This scale is one of the most frequently used scales in clinical settings and is valid and reliable.

The Numerical Pain Scale (NPS) shows a line with numbers marked from 0 (no pain) to 10 (hurts like the worst pain imaginable). Participants rated their anticipated pain [15]. Previous studies have found this scale to be valid and reliable.

3. RESULTS

4. DISCUSSION

This cross-sectional study investigated the intriguing question of whether maternal status influences dental pain perception in women. Our findings provide compelling evidence that mothers reported significantly higher actual pain during dental procedures than women who had not given birth, highlighting a potential modulation of pain sensitivity associated with childbirth. These findings align with studies suggesting increased pain sensitivity in mothers due to neuroplastic changes during the perinatal period [17]. For instance, a study conducted by Barba-Müller et al. in 2019 demonstrated that pregnancy-induced adaptations in brain regions like the amygdala and hippocampus contributed to heightened sensitivity to nociceptive stimuli. Similarly, Dekel et al., in 2019, found that postpartum changes in the Hypothalamic-Pituitary-Adrenal (HPA) axis exacerbated stress responses, which could amplify pain perception in clinical settings. Thus, our study adds to this body of evidence by uniquely exploring dental pain as a specific modality [27].

Several potential mechanisms might explain the elevated pain sensitivity observed in mothers [18]. One possibility involves alterations in the HPA axis activity [19]. Pregnancy and postpartum periods are characterized by a physiological adaptation of the HPA axis, leading to a state of hypo-reactivity to stress [20]. However, adverse experiences during pregnancy or postpartum depression can disrupt this adaptive process, resulting in HPA axis dysregulation and increased sensitivity to pain stimuli [21]. Our study did not directly assess HPA axis function, but future research exploring this pathway could shed light on its role in modulating pain perception in mothers.

Another potential mechanism involves modifications to brain regions involved in pain processing. Pregnancy and motherhood are associated with structural and functional changes in brain regions such as the amygdala, hippo-campus, and anterior cingulate cortex [22]. These areas play crucial roles in pain modulation, emotional regu-lation, and stress responses. It is conceivable that these neuroplastic changes, while adaptive to maternal care-giving behaviors, may also lead to a heightened sensitivity to nociceptive input, as observed in our study. Similar findings were reported by Kim et al. in 2016 [23], who found that various conditions, such as extreme stress, trauma, and mental disorders, can disturb normative changes in the brain, making mothers more vulnerable. Due to the remarkable plasticity of the maternal brain, it may be more sensitive to both positive and negative experiences, such as stress and interventions, throughout pregnancy and in the early postpartum phase.

Our findings resonate with previous research sugg-esting that mothers exhibit increased sensitivity to threat-related stimuli and experience more negative effects than non-mothers [23]. This heightened emotional reactivity might amplify pain perception through descen-ding pain modulation pathways originating in the prefrontal cortex and limbic system [24]. Additionally, altered stress per-ception and processing capabilities in mothers could contribute to increased pain sensitivity via stress-induced activation of pain-promoting pathways in the brainstem and spinal cord [25].

It is important to note that our study did not find significant differences between mothers and non-mothers in terms of expected pain or pain that motivated them to visit the dentist. This suggests that the observed difference in actual pain perception was not likely due to preexisting biases or expectations regarding dental procedures. However, further research with larger sample sizes and longitudinal designs is required to confirm these findings and explore the underlying mechanisms in greater detail.

Although our study demonstrated heightened pain in mothers during dental procedures, further research is needed to explore the specificity and extent of this sensi-tization. Understanding the specificity of pain sensitization can inform targeted pain management strategies for mothers in various healthcare settings [26]. The clinical implications of this study are far-reaching, particularly in promoting patient-centered care in dental settings. Dentists must recognize that motherhood-related neuroplastic changes may predispose women to heightened sensitivity to dental stimuli. Accordingly, treatment plans should be individualized to account for this increased pain perception, ensuring that mothers receive adequate support before, during, and after procedures. Furthermore, integrating education on maternal pain sensitivity into dental training programs could prepare future practitioners to handle this unique patient demographic effectively. Therefore, further research should evaluate the association between child-bearing and generalized hyperalgesia across different modalities.

Our findings suggest a potential heterogeneity in pain responses among mothers. While childbirth appears to be a general sensitizing factor, individual differences in childbirth experiences (vaginal vs. cesarean, postpartum complications, emotional well-being) might further modu-late pain perception [27]. Additionally, pre-existing chronic pain conditions, genetic predispositions, and psychological factors like anxiety and depression could interact with childbirth-induced neuroplasticity, contributing to indi-vidual variations in pain sensitivity [28]. Future research investigating these interactions is crucial for personalized pain management approaches in mothers.

It is crucial to investigate the long-term consequences of childbirth-induced pain sensitization. Specifically, the duration of the effect and vulnerability to chronic pain development is worth exploring. Alternatively, the effects of specific interventions or lifestyle modifications on pro-moting neuroplastic changes that normalize pain response after childbirth need to be investigated. Investigating the reversibility and long-term trajectory of pain sensitization offers valuable insights into preventive strategies and rehabilitation programs for mothers with chronic pain.

This study highlights the need for tailored pain manage-ment strategies for mothers in dental settings. Therefore, dentists should consider a combination of pharmacological and non-pharmacological approaches. Pharmacological regimens might require adjustments based on individual pain profiles and potential interactions with breastfeeding or other maternal medications [29]. Non-pharmacological techniques such as cognitive-behavioral therapy, mind-fulness practices, and relaxation strategies can empower mothers to actively manage their pain and reduce reliance on medication [30]. Furthermore, fostering a patient-centered environment that acknowledges and validates the pain experiences of mothers is crucial for building trust and improving dental care outcomes [31].

The link between childbirth and pain sensitivity extends beyond the dental setting and highlights the importance of integrating pain management into broader maternal health care [32]. Prenatal and postpartum care should incorporate pain assessment and education as routine components. Additionally, healthcare providers across various specialties should be aware of the potential heightened pain sensitivity in mothers and adjust their diagnostic and treatment approaches accordingly. Holi-stically recognizing and addressing the pain experiences of mothers can significantly improve their overall well-being and quality of life.

While our study provides valuable insights into the link between maternal status and dental pain perception, it has some limitations that warrant further consideration.

The cross-sectional design precluded causal inferences regarding the impact of childbirth on pain sensitivity. We cannot definitively claim that childbirth causes heightened pain perception, but only that mothers reported expe-riencing more actual pain during dental procedures than non-mothers. Longitudinal studies that track pain per-ception before and after childbirth are necessary to establish causality. Additionally, the sample size of the present study was moderate, which potentially limited the generalisability of our findings. Large-scale studies with more diverse populations are required to confirm the observed associations and explore potential subgroup differences. Further, our study relied solely on self-reported pain scores that are inherently subjective and prone to bias. Factors such as anxiety, fear of dental procedures, and cultural influences can affect the manner in which individuals report pain. Incorporating objective pain measures such as functional Magnetic Resonance Imaging (fMRI) or Electroencephalography (EEG) could provide more objective data on pain processing differences between mothers and non-mothers.

Our study did not account for all other potential confounding factors that might influence pain perception, such as specific birth experiences, differences in delivery mode (vaginal vs. caesarean), presence of postpartum complications, or breastfeeding status. Chronic and preexisting chronic pain conditions may also interact with childbirth-induced neuroplasticity, thereby affecting pain perception. Psychological factors such as anxiety, dep-ression, or fear of dental procedures could influence pain reporting and perception. Socioeconomic factors, such as access to healthcare, education levels, and social support networks, can influence pain experiences and pain management strategies. Future research addressing these limitations will strengthen our understanding of the complex interplay between motherhood and pain perception.

Although our study explored dental pain as a model for nociceptive processing, it is unclear whether the observed sensitization is specific to dental stimuli or can be generalized to other types of pain. Further studies investi-gating pain sensitivity in mothers across different pain modalities are necessary to better understand the broad implications of childbirth-induced neuroplasticity. By acknowledging and addressing these limitations, we can interpret our findings with greater caution and pave the way for future research to refine our understanding of pain perception in mothers and optimize pain management strategies for this population.

CONCLUSION

In conclusion, the present study provides compelling evidence that mothers report significantly higher actual pain during dental procedures than women who have not given birth. These findings suggest that motherhood, potentially through childbirth-induced neuroplastic changes, may alter pain processing pathways, leading to increased pain sensitivity. Although the underlying mecha-nisms remain unclear, our findings have significant implications for both dental practitioners and maternal healthcare providers. Dentists should recognize increased pain sensitivity in mothers and adapt treatment protocols accordingly. Strategies include building trust through clear communication, using tailored local anesthetics, and employing nonpharmacological methods like cognitive-behavioral techniques and mindfulness. Pre-visit pain assessments can further enhance patient comfort and satisfaction. Holistically recognizing and addressing the pain experiences of mothers within a broader maternal healthcare framework is crucial to ensure their well-being and quality of life. This study also highlights the need for further research to investigate the specificity and long-term consequences of childbirth-induced pain sensiti-zation. Future research with longitudinal designs, objective pain measures, and consideration of individual differences and contributing factors could pave the way for personalized pain management strategies for mothers, empowering them to manage pain effectively and thrive throughout motherhood.

REFERENCES