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Liaison psychiatry and psychology in dentistry
Journal of PsychosomaticResearch, Vot. 43, No. 5, pp. 467476. 1997 Copyright © 1997 Elsevier Science Inc. All rights reserved. 0022-3999/97 $17.00 + .00
ELSEVIER
S0022-3999(97)00028-7
REVIEW
LIAISON P S Y C H I A T R Y A N D P S Y C H O L O G Y IN D E N T I S T R Y C. F E I N M A N N * and S H E E L A H H A R R I S O N ? Abstrael--Dentists are trained to provide treatment for patients with straightforward problems that respond to routine therapy and do not recur. However, patients may present to dentists and complain solely of physical symptoms such as toothache, headache, and facial pain: only after much inappropriate treatment these symptons are revealed to be due to emotional disturbance. The dentist may spend hours investigating such patients, in some of whom dental pathology may be present, but the symptoms and ensuing disability cannot be satisfactorily explained as a result. There are other patients who are preoccupied by physical symptoms or by their appearance. In others, anxiety may manifest itself as a phobia, or a dysmorphic concern about certain aspects of their appearance. This article reviewsthe role of liaison psychiatry and psychology in dentistry. © 1997 Elsevier Science Inc.
Keywords: Liaison;Pain; Anxiety. CLINICAL FEATURES OF CHRONIC IDIOPATHIC FACIAL PAIN Chronic idiopathic facial pain is a c o m m o n p r o b l e m worldwide and presents a clinical challenge for m a n y medical and dental specialists [1]. A n estimated five to seven million Americans suffer from chronic facial pain at a cost to society of over $4 billion per year [2]. Asberg and Carlsson [3] have suggested that 25-45% of the population are affected at some time in their lives, but there is no comparable epidemiological study for the United Kingdom. Magni et al. [4] estimate that prevalence of chronic pain is generally 15%. The age range for facial pain extends from childhood to late adult life, although the m e a n age for facial arthromyalgia is 30 and 55 years for atypical facial pain and its variants [5]. It is four to five times m o r e c o m m o n in females than males, although some claim that men are equally affected but m o r e w o m e n seek treatment [5]. At least four s y m p t o m complexes are recognizable: facial arthromyalgia (FAM) as a uni- or bilateral pain in the t e m p o r o m a n d i b u l a r joint (TMJ) and associated craniofacial musculature, and there m a y also be a sense of fullness, popping, or tinnitus in the ear. Atypical facial pain (AFP) (or idiopathic facial pain) is usually a continuous ache with intermittent excruciating episodes, localized to the nonmuscular, nonjoint areas of the face. The pain m a y be uni- or bilateral and may persist for months or years. Atypical odontalgia (AO), is the dental variant, which is diagnosed in the absence of detectable dental pathology. Oral dysesthesia includes a burning discom* Joint Department of Maxillofacial Surgery, Eastman Dental Hospital, London, UK. t Academic Department of Psychiatry, University College London Hospital, London, UK. Address correspondence to: Dr. Charlotte Feinmann, Joint Department of Maxillofacial Surgery, Eastman Dental Hospital, 256 Grays Inn Road, London WC1X 8LD, UK. Tel: 44 171 915 1051; Fax: 44 171 915 1259.
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fort in the tongue (glossopyrosis), gingiva, or lips; a persistently dry mouth in the presence of saliva; a disturbance of taste; denture intolerance; or a persistently uncomfortable occlusion (phantom bite or occlusal hyperawareness). Although perceived to be separate conditions, AFP and AO often coexist or occur sequentially in the same patient. Furthermore, they are associated with other chronic pains such as headache, neck and back pain including fibromyalgia and myofascial pain, pruritus, abdominal pain (irritable bowel), pelvic pain often diagnosed as endometriosis, which as dysfunctional uterine bleeding invariably leads to early hysterectomy. There is also an association with myalgic encephalomyelitis and posttraumatic stress disorder [6]. The overview creates a picture of a pain-vulnerable person or a whole body pain syndrome [7].
ETIOLOGY These conditions are idiopathic. Despite enthusiastic dental support malocclusion has never been substantiated as a cause by any controlled trial [8, 9]. An explanation of bruxism producing muscle cramp and overloading of the joint is also difficult to sustain without any pathophysiological evidence, especially when compared with a greater percentage of asymptomatic bruxers. The equally enigmatic tension headache has also been shown to be unrelated to muscle tension [10]. Facial pain patients appear to be psychosocially and biochemically vulnerable. The psychosocial features of clinical significance include an unstable or inadequate parental background, poor adaptation to school or work, marital and financial difficulties, chronic illness in the family, and bereavement [5, 11]. Marbach et al. [12], however, did not find any difference between patients' and controls' experience of adverse life events, but found that they had fewer sources of emotional support and therefore did not cope as well; Southwell et al. obtained similar results [13]. We have shown that 43% of such patients were psychiatrically normal, 35% had a depressive illness, and 22% were diagnosed as mixed neurosis cases. A small number can be identified as having a personality disorder with marked somatization or psychosis [5]. The question is how to explain the nature and relationship of the painful peripheral experience in terms of a central psychological disturbance. A biochemical basis for chronic facial pain has been suggested by its association with depression and patients' response to tricyclic antidepressants. Magni [4] found a high percentage of emotional disorder in first degree relatives of chronic pain patients. However, the relief of pain by tricyclic antidepressants occurs just as effectively in nondepressed, psychiatrically normal patients. The precise mode of action is not known but may be the result of increasing the concentration of analgesic monoamines in the midbrain. Evidence of higher cerebral involvement has been revealed by positron emission tomography (PET) [14], which has shown that patients with AFP had increased contralateral cingulate cortex activity in response to both heat and nociceptive heat. This suggests an enhanced alerting mechanism in response to peripheral stimuli which could therefore be perceived as pain. In summary, a credible hypothesis for idiopathic facial pain is that emotional strain together with local physical stress in a biochemically and psychologically vul-
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nerable subject promotes the release of neuropeptides in the "target tissues" such as the joint capsule, muscles, periodontal membrane, or dental pulp.
TREATMENT
Unfortunately the chronicity of these pains and their unrecognized psychogenic features invariably lead to many patients being referred elsewhere or abandoned. This is reflected in a formal audit of 813 new referrals to this department over an 18-month period. Their mean pain duration was 4.2 years (median 1-2 years) despite having been seen by an average of two consultants. Hence, 25% were tertiary referrals. This reflects a major expenditure to the Health Service as well as lost work time. In a double-blind controlled trial, the tricyclic antidepressant, dothiepin, was highly effective in 71% of patients over a 9-week period, but pain also remitted in 46% of the placebo group [15]. The high placebo response accounts for the putative success of any form of uncontrolled therapy. In this study, a soft bite guard did not confer any advantage and compliance was poor. It was also evident that the relapse rate was high when medication was discontinued before 6 months. Our department is now comparing cognitive therapy with antidepressant drug therapy, and splint therapy with antidepressant drug therapy (the most common form of dental treatment). A study comparing relaxation with hypnosis is also being completed. Preliminary results suggested that the combination of drug and cognitive therapy is effective [16], as is hypnosis, which is often welcomed by patients who not wish to undertake drug therapy. General practitioners and restorative specialists may elect to prescribe an occlusal splint (maxillary stabilization appliance) which provides simultaneous points of contact with smooth lateral guidance to be worn at night. Some patients gain relief from constant wear. The reason for success is unexplained and is probably a placebo effect [17]; however, such treatment should not persist beyond 3 months in the absence of pain relief. There is no evidence that occlusal adjustment is more effective than any other placebo and, more importantly, it may create a state of occlusal hyperawareness (phantom bite) in certain patients. Failure to respond to dental treatment, severe prolonged pain, or emotional disturbance are indications for medical therapy with a tricyclic antidepressant such as nortriptyline. It is essential to explain to the patient that this works as a centrally acting analgesic "which relaxes muscles and painful blood vessels in nondepressed patients." Drowsiness and xerostomia are overcome by slowly increasing the dose and reassurance, but weight gain and constipation trouble some patients. These problems may be avoided with serotonin reuptake inhibitors such as ftuoxetine (20-40 mg per day). However, medication should never be prescribed alone, and the patient must be counseled about their lifestyle and supported in any emotional crisis. Those with complex emotional history, depression, or agitated or psychotic states should be treated by a liaison psychiatrist or a psychologist. This is best done within the context of a joint clinic to avoid the perceived stigma of a psychiatric diagnosis. It is also important that surgeons, psychiatrists, and psychologists develop shared models of care, so therefore a close working environment is important. It is essential
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that the referral is handled sensitively, and the patient does not feel abandoned by the referring consultant. Failure to provide patients an adequate explanation about referral will cause unnecessary hostility and anxiety for the patient and for the psychiatrist or psychologist. MANAGEMENT PROBLEMS Seventy percent of patients respond to appropriate history taking and medication. Difficulties arise with an inadequate history where important medical, personal, family, or social factors are not elicited or even concealed by the patient. Reluctance by the patient to take medication for what has previously been "diagnosed" as a dental problem and reluctance to prescribe adequate medication by a timid clinician unfamiliar with the natural history of the condition prevent appropriate treatment. PROGNOSIS Many patients respond well to the aforementioned protocol. However, the evidence of both a biochemical and psychological trait basis explains the chronicity of the syndrome and the need for continued care as in cases of migraine or trigeminal neuralgia. Many dental practitioners do not take a full medical history and are unsure when prescribing psychotropic medication. Knowledge of drug dosages and possible side-effects is essential, as is clinical stamina in difficult cases. For this reason, a liaison psychiatrist or psychologist with an interest in psychosomatic medicine is required for unresponsive or emotionally disturbed patients. BODY DYSMORPHIC DISORDER (BDD) The surgical ability to alter facial appearance is dramatic. Frequently, in addition to an improved physical appearance, a favorable psychological result is achieved. BDD is the belief in a cosmetic defect in a person of normal appearance. The complaint may range from mild unattractiveness to ugliness and, frequently, the patient seeks treatment to correct the supposed deformity. Not surprisingly, the face and its components (the teeth, nose, mouth, ears, eyes, and chin) make up a large percentage of structures for which patients seek and undergo cosmetic surgery. These patients often have bizarre complaints about their profile or their smile. The disorder is in fact not a phobia at all but rather an obsession, or a delusion. Dissatisfaction with ethnic features, "ethnic dysphoria," is used to describe patients who desire a change from an Oriental or Negro to a Caucasian appearance. Frequently, the complaint is first vocalized in early adolescence and the patients may report being teased at school about their appearance. Sexual or gender dysphoria is an obsessional need to change gender. This complex problem may present the maxillofacial surgeon with the task of reducing the masculine features of a male transsexual. Such cases should only be treated in collaboration with a unit specializing in the appropriate psychiatric, hormonal, and surgical sexual realignment. Morselli [18], who first described dysmorphophobia, emphasized that a patient
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could be perfectly healthy, perhaps emotionally rather sensitive, and then suddenly develop the complaint and become preoccupied by it. Patients tend to be socially isolated, sensitive, introverted individuals with no sexual experience. Environmental stresses such as employment problems, difficulties in personal relationships, or acute events such as bereavements, are liable to concentrate attention on facial appearance. A morbid affective state such as depression may also make the patient more likely to express dissatisfaction. BDD is a rare symptom in isolation, and a necessary psychiatric evaluation of such patients requesting cosmetic surgery is not always possible. Few psychiatrists understand the nature and scope of cosmetic surgery and many patients refuse to see psychiatrists. The problem is whether to do what the patient wants, what the patient needs, or nothing. The outcome of surgery is usually unsatisfactory, except where some recognizable deformity has been carefully corrected. Reich [19], who examined 3000 patients, suggested that surgery should proceed if the patient's expectations are realistic and the patient appears able to withstand an imperfect result. But, with no deformity or minimal deformity and inappropriate concern the prognosis is poor. Psychiatric management may be very difficult because of poor drug compliance and a tendency toward "surgeon shopping" (seeking numerous surgical opinions). The relationship between the surgeon and patient is a vital factor in achieving good results and a psychiatrist should be included in clinical management. It is essential to have several meetings preoperatively so that mutual trust can be established. Detailed discussions about possible surgery and close follow-up after surgery are all necessary if the patient is to be satisfied. Repeat surgery is invariably unsuccessful. There is also evidence that BDD patients respond well to Fluoxetine, both alone and in combination with cognitive therapy. [20]. Joint treatment by a surgeon and a psychiatrist may be most optimal.
ORAL ULCERATION
Aphthous ulcers This troublesome condition of shallow, painful oral ulcers varies in incidence from sporadic single lesions to recurrent crops. The exact etiology is unknown although the condition often has the features of an autoimmune disturbance. Despite this, many patients are aware that emotional problems may precipitate their lesions. For this reason, it is useful, where patients complain of recurrent crops of painful ulcers, to obtain a full and careful history, including social and emotional factors. This should be followed-up by an ulcer diary, where the patient notes the number of ulcers present in the mouth and any associated factors on a day-to-day basis. Mild sedation or a tricyclic antidepressant will often produce a marked reduction in the number, frequency, and duration of the ulcers, making them more amenable to topical steroid therapy.
Factitious ulceration (stomatitis artifacta) Factitious ulceration is the intraoral counterpart of the well-recognized dermatitis artifacta [21]. The lesions vary in their appearance according to the manner in which they are created. The most common and least troublesome lesion is due to
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cheek chewing. Here, usually a young, anxious, individual continually chews the buccal mucosa producing wide areas of peeling, macerated, hyperkeratinized epidermis. It is usually bilateral and painless and may be associated with facial arthromyalgia with facial arthromyalgia. Similarly, lip biting may produce fissures, white areas of hyperkeratosis or a mucus extravasation cyst. In the older, anxious or agitated patient, lip chewing produces varicosities so that the vermilion border becomes curiously cyanotic in appearance. Greater difficulty may be experienced in recognizing the discrete lesion that local abrasion with a finger nail or sharp instrument may produce. Occasionally, caustic agents such as tablets or undiluted antiseptics may be used. The condition may mimic a natural lesion, particularly if the patient has some knowledge of dentistry or medicine and knows how to produce such a lesion. Unfortunately, there appears to be no age, intellectual, or professional barriers to this problem, although women seem to be more prone than men. The history of this problem is characteristically vague and the lesion either persists longer or recurs more frequently than one would expect. It is often associated with one of the pain syndromes, and the patient appears to produce the lesion to validate an organic diagnosis for their pain. Sneddon [21] describes three groups of definatitis artifacta: 1. True malingerers, where the injury is consciously aggravated for monetary gain or the avoidance of some responsibility. 2. Munchausen's syndrome, which is a persistent, incurable psychopathic way of life that offers no obvious advantage other than requiring medical and nursing care. 3. Part of an emotional instability, such as a personality disorder, where the underlying problem is a disturbance in personal relationships. It is rare to obtain an acknowledgment or an explanation as to how the lesions are produced, and it is often difficult to get the patient or his/her family to agree to psychiatric help---nevertheless, this is important to protect the patient from inappropriate investigations and treatment.
Anorexia nervosa and bulimia Anorexia nervosa is a pathological avoidance of food in which the subject has a delusional body image. Despite emaciation, they see themselves as being fat and, apart from limiting their food intake, there is often a covert practice of vomiting. The bulimic subject, by self-induced vomiting, maintains a normal weight despite indulging in eating binges. Both conditions eventually lead to erosion of the teeth and caries due to the constantly regurgitated gastric juice. Treatment requires the cooperation of the patient, a restorative dentist, and a psychiatrist. Presentation o f anxiety problems to the dentist Anxiety problems may vary from a simple overreaction to a dental procedure to more aggressive responses. Anxious, obsessional, or depressed patients may amplify pain or become agitated after what appears to the dentist to be a normal consultation. Similarly, an acute hypochondrial reaction may be precipitated by an innocent remark or trivial investigation.
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Dental phobia Anxiety provoked by dental treatment is a problem for both patients and dental practitioners. It is normal for individuals to feel some anxiety about dental treatment. Todd and Walker [22] interviewed 6000 British citizens and found that 43% of them avoided going to the dentist unless they were in trouble--an attitude that creates conflict for the dental surgeon who is trained to help the patients and relieve suffering, but is regarded by patients as someone who inflicts distress. Kent [23], in a survery of stresses encountered by dentists in practice found that the most significant and common problem included coping with difficult, anxious patients. The situation is complicated, anxious patients expect treatment to be painful, and their anxiety is not modified by a painless experience. Thus, coping with anxiety means that patients' preconceptions about treatment must be modified [24]. To prevent anxiety dentists should adopt more explicitly the role of dental health educator. Furthermore, if the dentist becomes responsible for the long-term dental health of the patient he will inspire greater confidence. A major obstacle to the enhancement of the dentist's role (identified by Bochier [24]) is the relative infrequency of visits. Bochier suggests that this might be overcome by interspersing conventional dental consultations with sessions devoted purely to educational aims, perhaps conducted in small groups.
Development of dental phobia It seems obvious that most people are anxious about dental treatment, because they are anticipating pain. Gale [25] demonstrated that the amount of fear could not be specified from knowledge of the situation alone and he concluded that a fair amount of dental anxiety was caused by uncertainty about particular treatments. Wardle [26] asked patients awaiting dental treatment how anxious they felt and how much pain they expected from several dental procedures. She found, not unexpectedly, that highly anxious patients were more fearful of pain. Undoubtedly, previous experience shapes a patient's response to treatment. Hallstrom and Halling [27] examined 784 women from a representative population sample in G0teborg, Sweden, and found a prevalence of severe dental anxiety/ dental phobia in 13.4% of the population studied. Previous studies have found a prevalence rate of between 8% and 15%. The prevalence was much greater in women with lower school education and those from the lower social classes. In 88%, the phobia onset occurred before age 20, but only 11% were aware of having been exposed to anxiety-provoking dental treatment prior to the development of phobias; the age of onset was similar to those in other studies, but the tack of a provoking factor is in contrast with other work [27]. All studies agree, however, that the disorder runs a chronic course. It seems that a number of factors contribute to dental anxiety. Uncertainty and fear result from previous learning that includes the dentist's behavior and a biological propensity to develop anxiety, which leads to the avoidance of dental treatment. Once this anxiety becomes too great, a phobia of dental treatment will develop and the patient will avoid all contact with the dentist.
Management of anxiety Once a patient becomes conditioned to be fearful of dentistry, the dentist must obviously attempt to allay such fears. Mild anxiety may be treated by reassurance,
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but if this fails, fear of pain can be appropriately treated by adequate pretreatment sensation and analgesia. Premedication with a mild tranquilizer such as diazepam has done for many years [28]. However, the dental practitioner is increasingly aware of the possibility of addiction with repeated use of such drugs. Pretreatment analgesia has been found to be an effective means of controlling pain. It has the advantage of not only pain reduction but the experience also becomes more reassuring for the patient. The use of various means of distraction such as listening to taped music or relaxation tapes (instructions for patients to contract and relax various muscle groups), have been found to be a useful way of alleviating anxiety and pain [29]. Additionally, giving the patient some control over their treatments such as raising an arm to stop drilling has been shown to be an effective way of reducing anxiety and pain [28]. Rankin and Harris [30] examined a large sample of 258 patients not receiving dental care and found that, although vicarious and personal experience made them fear dentistry, it was the fact that they felt unable to cope with the situation that prevented them from actually attending appointments--thus, helping patients to gain control of the situation is obviously an important part of treatment. Lindsey [31] estimated that six 1-hour sessions with a clinical psychologist would ensure less distress in anticipation of dental treatment and better attendance for dental care and improved dental health. He advises general dental practitioners to publicize the work of clinical psychologists in waiting rooms. He also suggested that services could be purchased in a block contract. INNOVATIONS IN THERAPY IN DENTAL CLINICS 1. Cognitive therapy with or without medication is being explored for chronic facial pain and has demonstrated significant success with a combination of medication and cognitive therapy [16]. Although the clinical psychologist has already established an invaluable role in the management of chronic disorders such as somatization. These skills need to be applied within the field of maxillofacial surgery and oral medicine [16]. Hypnosis is also a useful therapeutic tool and is presently under investigation. 2. The establishment of multidisciplinary facial pain clinics, especially in dental hospitals or departments of oral and maxillofacial surgery, is mandatory. Such groups would consist minimally of an oral physician or surgeon, a liaison psychiatrist, and a clinical psychologist. Furthermore, a network of such groups would facilitate the management of difficult cases and clinical research. 3. Pharmacotherapy. Serotonin uptake inhibitor antidepressants appear to have substantially fewer side-effects than tricyclics, and Fluoxetine is currently being investigated for its efficacy with chronic pain. 4. Training programs for medical and dental undergraduates and general practitioners. Although the identification of these patients may be carried out at both primary and secondary care levels, management training programs would provide a more efficient and cost-effective means of continuing care in general practice, as has been shown for depression [32, 33].
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. Anxiety management should be a larger part of undergraduate and postgraduate curricula, and much more treatment should be available for the phobic and anxious patient.
REFERENCES 1. Hunter S. The management of "psychogenic" orofacial pain. Br Med J 1992;304:329-330. 2. Bonica JJ. Pain research therapy. Past and current status and future needs. In: Ng LKY, Bonica JJ, eds. Pain, Discomfort and Humanitarian Care. Amsterdam: Elsevier 1980:1-46. 3. Asberg G, Carlsson GE. Functional disorders of the masticatory system: distribution of symptoms according to age and sex as judged from investigations by questionnaire. Acta Odont Scand 1972;30:597-613. 4. Magni G. On the relationship between chronic pain and depression when there is no organic lesion. Pain 1987;31:1-21. 5. Feinmann C, Harris M. Psychogenic facial pain. Part 1. The clinical presentation. Br Dent J 1984:156-168. 6. Aghabeigi B, Feinmann C, Harris M. Prevalence of post-traumatic stress disorder in patients with chronic idiopathic facial pain. Br J Oral Maxillofac Surg 1992;30:360-364. 7. Engel GL. Psychogenic pain and the pain-prone patient. Am J Med 1959;26:899-918. 8. Takenoshita Y, Ikebe T, Yamamoto M, Oka M. Occlusal contact area and temporomandibular joint symptons. Oral Surg Oral Med Oral Pathol 1991;72:388-394. 9. Pullinger AG, Seligman DA, Gonbein JA. A multiple logistic regression. Analysis of the risk and relative odds of TMJ disorders as a function of common occlusal features. J Dent Res 1993: 72:968-979. 10. Olesen J, Jensen R. Getting away from simple muscle contraction as a mechanism of tension-type headache. Pain 1991;46:123-124. 11. Speculand B, Hughes AO, Goss AN. The role of stressful life experience in the onset of temporomandibular joint dysfunction. Community Dent Oral Epidemiol 1984:197-202. 12. Marbach J J, Lennon MC, Dohrenwend BP. Candidate risk factors for temporomandibular pain and dysfunction syndome: Psychosocial, health behaviour, physical illness and injury. Pain 1988;34: 189-201. 13. Southwell J, Deary IJ, Geissler P. Personality and anxiety in temporomandibular joint syndrome patients. J Oral Rehabil 1990;17:239-243. 14. Derbyshire SWE, Jones AKP, Devani P, Friston K J, Feinmann C, Harris M, Pearce S, Watson JDG, Frackowiak RSJ. Cerebral responses to pain in patients with typical facial pain measured by postiron emission tomograghy. J Neurosurg Neuropsych 1994;57:116-117. 15. Feinmann C, Harris M. Psychogenic facial pain. Part 2. Management and prognosis. Br Dent J 1984b: 156-208. 16. Harrison S, Glover L, Maslin L, Feinmann C. Outcome of treatment of chronic idiopathic facial pain with anti-depressant medication and cognitive behavioural therapy. Congress of Pain. 1996;159:Aust no 163. 17. Dao TTT, Lavigue GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial. Pain 1994;56:85-94. 18. Morselli E. Sulla Tafefobia. Bulletin of Academic Medicine. Geneva VI. 1896:110-119. 19. Reich J. Factors influencing patient satisfaction with result of aesthetic plastic surgery. Plast Reconstr Surg 1975;13:55-58. 20. Phillips KA, McElroy SL, Keck PE et al. A comparison of delusional and nondelusional Body Dysmorphic Disorder in 100 cases. Pyschosoc Bull 1994;30:179-180. 21. Sneddon TB. Dermatitis artefacty. Proc RSM 1977;70:754-755. 22. Todd JE, Walker A. Adult dental health in England and Wales. London: HMSO 1980. 23. Kent G. The Psychology of Dental Care. Bristol, UK: John Wright & Sons 1984. 24. Bochier S. The Psychology of the Dentist-Patient Relationship. New York: Springer-Verlag 1988. 25. Gale EN. Fears of the Dental Situation. Dent Res 1972;51:964-966. 26. Wardle J. Fears of dentistry. Brit Med J 1982;55:119-126. 27. Hallstrom T, Hailing A. Prevalence of dentistry phobia and its relationship to missing teeth: alveolar bone loss and dental care habits in the urban community sample. Acta Psych Scand 1984; 70:438-446. 28. Pond D, Sutton M. Dentistry and psychiatry. Psychiatry in the General Hospital 1983.
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29. Coral NL, Gale EN, Illing SJ. The use of relaxation and distraction to reduce psychological stress during dental procedures. J Am Dent Assoc 1979;98:390-394. 30. Rankin JA, Harris MB. Dental Anxiety: The patient's point of view. J Am Dent Assoc 1984;109:43-47. 31. Lindsey S. One in 10 people avoid dentists through phobia. BMJ 1996;313:189. 32. Blank M, Nelles W. Education and training GPs in the management and treatment of drug users. Int J Drug Policy 1993;4:449-456. 33. Rutz W, von Knorring L, Walender J. Long term effects of an educational programme for general practitioner given by the Swedish Committee for the prevention and treatment of depression. Acta Psychiatrica Scand 1992;85:83.
ELSEVIER
S0022-3999(97)00028-7
REVIEW
LIAISON P S Y C H I A T R Y A N D P S Y C H O L O G Y IN D E N T I S T R Y C. F E I N M A N N * and S H E E L A H H A R R I S O N ? Abstrael--Dentists are trained to provide treatment for patients with straightforward problems that respond to routine therapy and do not recur. However, patients may present to dentists and complain solely of physical symptoms such as toothache, headache, and facial pain: only after much inappropriate treatment these symptons are revealed to be due to emotional disturbance. The dentist may spend hours investigating such patients, in some of whom dental pathology may be present, but the symptoms and ensuing disability cannot be satisfactorily explained as a result. There are other patients who are preoccupied by physical symptoms or by their appearance. In others, anxiety may manifest itself as a phobia, or a dysmorphic concern about certain aspects of their appearance. This article reviewsthe role of liaison psychiatry and psychology in dentistry. © 1997 Elsevier Science Inc.
Keywords: Liaison;Pain; Anxiety. CLINICAL FEATURES OF CHRONIC IDIOPATHIC FACIAL PAIN Chronic idiopathic facial pain is a c o m m o n p r o b l e m worldwide and presents a clinical challenge for m a n y medical and dental specialists [1]. A n estimated five to seven million Americans suffer from chronic facial pain at a cost to society of over $4 billion per year [2]. Asberg and Carlsson [3] have suggested that 25-45% of the population are affected at some time in their lives, but there is no comparable epidemiological study for the United Kingdom. Magni et al. [4] estimate that prevalence of chronic pain is generally 15%. The age range for facial pain extends from childhood to late adult life, although the m e a n age for facial arthromyalgia is 30 and 55 years for atypical facial pain and its variants [5]. It is four to five times m o r e c o m m o n in females than males, although some claim that men are equally affected but m o r e w o m e n seek treatment [5]. At least four s y m p t o m complexes are recognizable: facial arthromyalgia (FAM) as a uni- or bilateral pain in the t e m p o r o m a n d i b u l a r joint (TMJ) and associated craniofacial musculature, and there m a y also be a sense of fullness, popping, or tinnitus in the ear. Atypical facial pain (AFP) (or idiopathic facial pain) is usually a continuous ache with intermittent excruciating episodes, localized to the nonmuscular, nonjoint areas of the face. The pain m a y be uni- or bilateral and may persist for months or years. Atypical odontalgia (AO), is the dental variant, which is diagnosed in the absence of detectable dental pathology. Oral dysesthesia includes a burning discom* Joint Department of Maxillofacial Surgery, Eastman Dental Hospital, London, UK. t Academic Department of Psychiatry, University College London Hospital, London, UK. Address correspondence to: Dr. Charlotte Feinmann, Joint Department of Maxillofacial Surgery, Eastman Dental Hospital, 256 Grays Inn Road, London WC1X 8LD, UK. Tel: 44 171 915 1051; Fax: 44 171 915 1259.
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fort in the tongue (glossopyrosis), gingiva, or lips; a persistently dry mouth in the presence of saliva; a disturbance of taste; denture intolerance; or a persistently uncomfortable occlusion (phantom bite or occlusal hyperawareness). Although perceived to be separate conditions, AFP and AO often coexist or occur sequentially in the same patient. Furthermore, they are associated with other chronic pains such as headache, neck and back pain including fibromyalgia and myofascial pain, pruritus, abdominal pain (irritable bowel), pelvic pain often diagnosed as endometriosis, which as dysfunctional uterine bleeding invariably leads to early hysterectomy. There is also an association with myalgic encephalomyelitis and posttraumatic stress disorder [6]. The overview creates a picture of a pain-vulnerable person or a whole body pain syndrome [7].
ETIOLOGY These conditions are idiopathic. Despite enthusiastic dental support malocclusion has never been substantiated as a cause by any controlled trial [8, 9]. An explanation of bruxism producing muscle cramp and overloading of the joint is also difficult to sustain without any pathophysiological evidence, especially when compared with a greater percentage of asymptomatic bruxers. The equally enigmatic tension headache has also been shown to be unrelated to muscle tension [10]. Facial pain patients appear to be psychosocially and biochemically vulnerable. The psychosocial features of clinical significance include an unstable or inadequate parental background, poor adaptation to school or work, marital and financial difficulties, chronic illness in the family, and bereavement [5, 11]. Marbach et al. [12], however, did not find any difference between patients' and controls' experience of adverse life events, but found that they had fewer sources of emotional support and therefore did not cope as well; Southwell et al. obtained similar results [13]. We have shown that 43% of such patients were psychiatrically normal, 35% had a depressive illness, and 22% were diagnosed as mixed neurosis cases. A small number can be identified as having a personality disorder with marked somatization or psychosis [5]. The question is how to explain the nature and relationship of the painful peripheral experience in terms of a central psychological disturbance. A biochemical basis for chronic facial pain has been suggested by its association with depression and patients' response to tricyclic antidepressants. Magni [4] found a high percentage of emotional disorder in first degree relatives of chronic pain patients. However, the relief of pain by tricyclic antidepressants occurs just as effectively in nondepressed, psychiatrically normal patients. The precise mode of action is not known but may be the result of increasing the concentration of analgesic monoamines in the midbrain. Evidence of higher cerebral involvement has been revealed by positron emission tomography (PET) [14], which has shown that patients with AFP had increased contralateral cingulate cortex activity in response to both heat and nociceptive heat. This suggests an enhanced alerting mechanism in response to peripheral stimuli which could therefore be perceived as pain. In summary, a credible hypothesis for idiopathic facial pain is that emotional strain together with local physical stress in a biochemically and psychologically vul-
Review
469
nerable subject promotes the release of neuropeptides in the "target tissues" such as the joint capsule, muscles, periodontal membrane, or dental pulp.
TREATMENT
Unfortunately the chronicity of these pains and their unrecognized psychogenic features invariably lead to many patients being referred elsewhere or abandoned. This is reflected in a formal audit of 813 new referrals to this department over an 18-month period. Their mean pain duration was 4.2 years (median 1-2 years) despite having been seen by an average of two consultants. Hence, 25% were tertiary referrals. This reflects a major expenditure to the Health Service as well as lost work time. In a double-blind controlled trial, the tricyclic antidepressant, dothiepin, was highly effective in 71% of patients over a 9-week period, but pain also remitted in 46% of the placebo group [15]. The high placebo response accounts for the putative success of any form of uncontrolled therapy. In this study, a soft bite guard did not confer any advantage and compliance was poor. It was also evident that the relapse rate was high when medication was discontinued before 6 months. Our department is now comparing cognitive therapy with antidepressant drug therapy, and splint therapy with antidepressant drug therapy (the most common form of dental treatment). A study comparing relaxation with hypnosis is also being completed. Preliminary results suggested that the combination of drug and cognitive therapy is effective [16], as is hypnosis, which is often welcomed by patients who not wish to undertake drug therapy. General practitioners and restorative specialists may elect to prescribe an occlusal splint (maxillary stabilization appliance) which provides simultaneous points of contact with smooth lateral guidance to be worn at night. Some patients gain relief from constant wear. The reason for success is unexplained and is probably a placebo effect [17]; however, such treatment should not persist beyond 3 months in the absence of pain relief. There is no evidence that occlusal adjustment is more effective than any other placebo and, more importantly, it may create a state of occlusal hyperawareness (phantom bite) in certain patients. Failure to respond to dental treatment, severe prolonged pain, or emotional disturbance are indications for medical therapy with a tricyclic antidepressant such as nortriptyline. It is essential to explain to the patient that this works as a centrally acting analgesic "which relaxes muscles and painful blood vessels in nondepressed patients." Drowsiness and xerostomia are overcome by slowly increasing the dose and reassurance, but weight gain and constipation trouble some patients. These problems may be avoided with serotonin reuptake inhibitors such as ftuoxetine (20-40 mg per day). However, medication should never be prescribed alone, and the patient must be counseled about their lifestyle and supported in any emotional crisis. Those with complex emotional history, depression, or agitated or psychotic states should be treated by a liaison psychiatrist or a psychologist. This is best done within the context of a joint clinic to avoid the perceived stigma of a psychiatric diagnosis. It is also important that surgeons, psychiatrists, and psychologists develop shared models of care, so therefore a close working environment is important. It is essential
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that the referral is handled sensitively, and the patient does not feel abandoned by the referring consultant. Failure to provide patients an adequate explanation about referral will cause unnecessary hostility and anxiety for the patient and for the psychiatrist or psychologist. MANAGEMENT PROBLEMS Seventy percent of patients respond to appropriate history taking and medication. Difficulties arise with an inadequate history where important medical, personal, family, or social factors are not elicited or even concealed by the patient. Reluctance by the patient to take medication for what has previously been "diagnosed" as a dental problem and reluctance to prescribe adequate medication by a timid clinician unfamiliar with the natural history of the condition prevent appropriate treatment. PROGNOSIS Many patients respond well to the aforementioned protocol. However, the evidence of both a biochemical and psychological trait basis explains the chronicity of the syndrome and the need for continued care as in cases of migraine or trigeminal neuralgia. Many dental practitioners do not take a full medical history and are unsure when prescribing psychotropic medication. Knowledge of drug dosages and possible side-effects is essential, as is clinical stamina in difficult cases. For this reason, a liaison psychiatrist or psychologist with an interest in psychosomatic medicine is required for unresponsive or emotionally disturbed patients. BODY DYSMORPHIC DISORDER (BDD) The surgical ability to alter facial appearance is dramatic. Frequently, in addition to an improved physical appearance, a favorable psychological result is achieved. BDD is the belief in a cosmetic defect in a person of normal appearance. The complaint may range from mild unattractiveness to ugliness and, frequently, the patient seeks treatment to correct the supposed deformity. Not surprisingly, the face and its components (the teeth, nose, mouth, ears, eyes, and chin) make up a large percentage of structures for which patients seek and undergo cosmetic surgery. These patients often have bizarre complaints about their profile or their smile. The disorder is in fact not a phobia at all but rather an obsession, or a delusion. Dissatisfaction with ethnic features, "ethnic dysphoria," is used to describe patients who desire a change from an Oriental or Negro to a Caucasian appearance. Frequently, the complaint is first vocalized in early adolescence and the patients may report being teased at school about their appearance. Sexual or gender dysphoria is an obsessional need to change gender. This complex problem may present the maxillofacial surgeon with the task of reducing the masculine features of a male transsexual. Such cases should only be treated in collaboration with a unit specializing in the appropriate psychiatric, hormonal, and surgical sexual realignment. Morselli [18], who first described dysmorphophobia, emphasized that a patient
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could be perfectly healthy, perhaps emotionally rather sensitive, and then suddenly develop the complaint and become preoccupied by it. Patients tend to be socially isolated, sensitive, introverted individuals with no sexual experience. Environmental stresses such as employment problems, difficulties in personal relationships, or acute events such as bereavements, are liable to concentrate attention on facial appearance. A morbid affective state such as depression may also make the patient more likely to express dissatisfaction. BDD is a rare symptom in isolation, and a necessary psychiatric evaluation of such patients requesting cosmetic surgery is not always possible. Few psychiatrists understand the nature and scope of cosmetic surgery and many patients refuse to see psychiatrists. The problem is whether to do what the patient wants, what the patient needs, or nothing. The outcome of surgery is usually unsatisfactory, except where some recognizable deformity has been carefully corrected. Reich [19], who examined 3000 patients, suggested that surgery should proceed if the patient's expectations are realistic and the patient appears able to withstand an imperfect result. But, with no deformity or minimal deformity and inappropriate concern the prognosis is poor. Psychiatric management may be very difficult because of poor drug compliance and a tendency toward "surgeon shopping" (seeking numerous surgical opinions). The relationship between the surgeon and patient is a vital factor in achieving good results and a psychiatrist should be included in clinical management. It is essential to have several meetings preoperatively so that mutual trust can be established. Detailed discussions about possible surgery and close follow-up after surgery are all necessary if the patient is to be satisfied. Repeat surgery is invariably unsuccessful. There is also evidence that BDD patients respond well to Fluoxetine, both alone and in combination with cognitive therapy. [20]. Joint treatment by a surgeon and a psychiatrist may be most optimal.
ORAL ULCERATION
Aphthous ulcers This troublesome condition of shallow, painful oral ulcers varies in incidence from sporadic single lesions to recurrent crops. The exact etiology is unknown although the condition often has the features of an autoimmune disturbance. Despite this, many patients are aware that emotional problems may precipitate their lesions. For this reason, it is useful, where patients complain of recurrent crops of painful ulcers, to obtain a full and careful history, including social and emotional factors. This should be followed-up by an ulcer diary, where the patient notes the number of ulcers present in the mouth and any associated factors on a day-to-day basis. Mild sedation or a tricyclic antidepressant will often produce a marked reduction in the number, frequency, and duration of the ulcers, making them more amenable to topical steroid therapy.
Factitious ulceration (stomatitis artifacta) Factitious ulceration is the intraoral counterpart of the well-recognized dermatitis artifacta [21]. The lesions vary in their appearance according to the manner in which they are created. The most common and least troublesome lesion is due to
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cheek chewing. Here, usually a young, anxious, individual continually chews the buccal mucosa producing wide areas of peeling, macerated, hyperkeratinized epidermis. It is usually bilateral and painless and may be associated with facial arthromyalgia with facial arthromyalgia. Similarly, lip biting may produce fissures, white areas of hyperkeratosis or a mucus extravasation cyst. In the older, anxious or agitated patient, lip chewing produces varicosities so that the vermilion border becomes curiously cyanotic in appearance. Greater difficulty may be experienced in recognizing the discrete lesion that local abrasion with a finger nail or sharp instrument may produce. Occasionally, caustic agents such as tablets or undiluted antiseptics may be used. The condition may mimic a natural lesion, particularly if the patient has some knowledge of dentistry or medicine and knows how to produce such a lesion. Unfortunately, there appears to be no age, intellectual, or professional barriers to this problem, although women seem to be more prone than men. The history of this problem is characteristically vague and the lesion either persists longer or recurs more frequently than one would expect. It is often associated with one of the pain syndromes, and the patient appears to produce the lesion to validate an organic diagnosis for their pain. Sneddon [21] describes three groups of definatitis artifacta: 1. True malingerers, where the injury is consciously aggravated for monetary gain or the avoidance of some responsibility. 2. Munchausen's syndrome, which is a persistent, incurable psychopathic way of life that offers no obvious advantage other than requiring medical and nursing care. 3. Part of an emotional instability, such as a personality disorder, where the underlying problem is a disturbance in personal relationships. It is rare to obtain an acknowledgment or an explanation as to how the lesions are produced, and it is often difficult to get the patient or his/her family to agree to psychiatric help---nevertheless, this is important to protect the patient from inappropriate investigations and treatment.
Anorexia nervosa and bulimia Anorexia nervosa is a pathological avoidance of food in which the subject has a delusional body image. Despite emaciation, they see themselves as being fat and, apart from limiting their food intake, there is often a covert practice of vomiting. The bulimic subject, by self-induced vomiting, maintains a normal weight despite indulging in eating binges. Both conditions eventually lead to erosion of the teeth and caries due to the constantly regurgitated gastric juice. Treatment requires the cooperation of the patient, a restorative dentist, and a psychiatrist. Presentation o f anxiety problems to the dentist Anxiety problems may vary from a simple overreaction to a dental procedure to more aggressive responses. Anxious, obsessional, or depressed patients may amplify pain or become agitated after what appears to the dentist to be a normal consultation. Similarly, an acute hypochondrial reaction may be precipitated by an innocent remark or trivial investigation.
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Dental phobia Anxiety provoked by dental treatment is a problem for both patients and dental practitioners. It is normal for individuals to feel some anxiety about dental treatment. Todd and Walker [22] interviewed 6000 British citizens and found that 43% of them avoided going to the dentist unless they were in trouble--an attitude that creates conflict for the dental surgeon who is trained to help the patients and relieve suffering, but is regarded by patients as someone who inflicts distress. Kent [23], in a survery of stresses encountered by dentists in practice found that the most significant and common problem included coping with difficult, anxious patients. The situation is complicated, anxious patients expect treatment to be painful, and their anxiety is not modified by a painless experience. Thus, coping with anxiety means that patients' preconceptions about treatment must be modified [24]. To prevent anxiety dentists should adopt more explicitly the role of dental health educator. Furthermore, if the dentist becomes responsible for the long-term dental health of the patient he will inspire greater confidence. A major obstacle to the enhancement of the dentist's role (identified by Bochier [24]) is the relative infrequency of visits. Bochier suggests that this might be overcome by interspersing conventional dental consultations with sessions devoted purely to educational aims, perhaps conducted in small groups.
Development of dental phobia It seems obvious that most people are anxious about dental treatment, because they are anticipating pain. Gale [25] demonstrated that the amount of fear could not be specified from knowledge of the situation alone and he concluded that a fair amount of dental anxiety was caused by uncertainty about particular treatments. Wardle [26] asked patients awaiting dental treatment how anxious they felt and how much pain they expected from several dental procedures. She found, not unexpectedly, that highly anxious patients were more fearful of pain. Undoubtedly, previous experience shapes a patient's response to treatment. Hallstrom and Halling [27] examined 784 women from a representative population sample in G0teborg, Sweden, and found a prevalence of severe dental anxiety/ dental phobia in 13.4% of the population studied. Previous studies have found a prevalence rate of between 8% and 15%. The prevalence was much greater in women with lower school education and those from the lower social classes. In 88%, the phobia onset occurred before age 20, but only 11% were aware of having been exposed to anxiety-provoking dental treatment prior to the development of phobias; the age of onset was similar to those in other studies, but the tack of a provoking factor is in contrast with other work [27]. All studies agree, however, that the disorder runs a chronic course. It seems that a number of factors contribute to dental anxiety. Uncertainty and fear result from previous learning that includes the dentist's behavior and a biological propensity to develop anxiety, which leads to the avoidance of dental treatment. Once this anxiety becomes too great, a phobia of dental treatment will develop and the patient will avoid all contact with the dentist.
Management of anxiety Once a patient becomes conditioned to be fearful of dentistry, the dentist must obviously attempt to allay such fears. Mild anxiety may be treated by reassurance,
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but if this fails, fear of pain can be appropriately treated by adequate pretreatment sensation and analgesia. Premedication with a mild tranquilizer such as diazepam has done for many years [28]. However, the dental practitioner is increasingly aware of the possibility of addiction with repeated use of such drugs. Pretreatment analgesia has been found to be an effective means of controlling pain. It has the advantage of not only pain reduction but the experience also becomes more reassuring for the patient. The use of various means of distraction such as listening to taped music or relaxation tapes (instructions for patients to contract and relax various muscle groups), have been found to be a useful way of alleviating anxiety and pain [29]. Additionally, giving the patient some control over their treatments such as raising an arm to stop drilling has been shown to be an effective way of reducing anxiety and pain [28]. Rankin and Harris [30] examined a large sample of 258 patients not receiving dental care and found that, although vicarious and personal experience made them fear dentistry, it was the fact that they felt unable to cope with the situation that prevented them from actually attending appointments--thus, helping patients to gain control of the situation is obviously an important part of treatment. Lindsey [31] estimated that six 1-hour sessions with a clinical psychologist would ensure less distress in anticipation of dental treatment and better attendance for dental care and improved dental health. He advises general dental practitioners to publicize the work of clinical psychologists in waiting rooms. He also suggested that services could be purchased in a block contract. INNOVATIONS IN THERAPY IN DENTAL CLINICS 1. Cognitive therapy with or without medication is being explored for chronic facial pain and has demonstrated significant success with a combination of medication and cognitive therapy [16]. Although the clinical psychologist has already established an invaluable role in the management of chronic disorders such as somatization. These skills need to be applied within the field of maxillofacial surgery and oral medicine [16]. Hypnosis is also a useful therapeutic tool and is presently under investigation. 2. The establishment of multidisciplinary facial pain clinics, especially in dental hospitals or departments of oral and maxillofacial surgery, is mandatory. Such groups would consist minimally of an oral physician or surgeon, a liaison psychiatrist, and a clinical psychologist. Furthermore, a network of such groups would facilitate the management of difficult cases and clinical research. 3. Pharmacotherapy. Serotonin uptake inhibitor antidepressants appear to have substantially fewer side-effects than tricyclics, and Fluoxetine is currently being investigated for its efficacy with chronic pain. 4. Training programs for medical and dental undergraduates and general practitioners. Although the identification of these patients may be carried out at both primary and secondary care levels, management training programs would provide a more efficient and cost-effective means of continuing care in general practice, as has been shown for depression [32, 33].
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. Anxiety management should be a larger part of undergraduate and postgraduate curricula, and much more treatment should be available for the phobic and anxious patient.
REFERENCES 1. Hunter S. The management of "psychogenic" orofacial pain. Br Med J 1992;304:329-330. 2. Bonica JJ. Pain research therapy. Past and current status and future needs. In: Ng LKY, Bonica JJ, eds. Pain, Discomfort and Humanitarian Care. Amsterdam: Elsevier 1980:1-46. 3. Asberg G, Carlsson GE. Functional disorders of the masticatory system: distribution of symptoms according to age and sex as judged from investigations by questionnaire. Acta Odont Scand 1972;30:597-613. 4. Magni G. On the relationship between chronic pain and depression when there is no organic lesion. Pain 1987;31:1-21. 5. Feinmann C, Harris M. Psychogenic facial pain. Part 1. The clinical presentation. Br Dent J 1984:156-168. 6. Aghabeigi B, Feinmann C, Harris M. Prevalence of post-traumatic stress disorder in patients with chronic idiopathic facial pain. Br J Oral Maxillofac Surg 1992;30:360-364. 7. Engel GL. Psychogenic pain and the pain-prone patient. Am J Med 1959;26:899-918. 8. Takenoshita Y, Ikebe T, Yamamoto M, Oka M. Occlusal contact area and temporomandibular joint symptons. Oral Surg Oral Med Oral Pathol 1991;72:388-394. 9. Pullinger AG, Seligman DA, Gonbein JA. A multiple logistic regression. Analysis of the risk and relative odds of TMJ disorders as a function of common occlusal features. J Dent Res 1993: 72:968-979. 10. Olesen J, Jensen R. Getting away from simple muscle contraction as a mechanism of tension-type headache. Pain 1991;46:123-124. 11. Speculand B, Hughes AO, Goss AN. The role of stressful life experience in the onset of temporomandibular joint dysfunction. Community Dent Oral Epidemiol 1984:197-202. 12. Marbach J J, Lennon MC, Dohrenwend BP. Candidate risk factors for temporomandibular pain and dysfunction syndome: Psychosocial, health behaviour, physical illness and injury. Pain 1988;34: 189-201. 13. Southwell J, Deary IJ, Geissler P. Personality and anxiety in temporomandibular joint syndrome patients. J Oral Rehabil 1990;17:239-243. 14. Derbyshire SWE, Jones AKP, Devani P, Friston K J, Feinmann C, Harris M, Pearce S, Watson JDG, Frackowiak RSJ. Cerebral responses to pain in patients with typical facial pain measured by postiron emission tomograghy. J Neurosurg Neuropsych 1994;57:116-117. 15. Feinmann C, Harris M. Psychogenic facial pain. Part 2. Management and prognosis. Br Dent J 1984b: 156-208. 16. Harrison S, Glover L, Maslin L, Feinmann C. Outcome of treatment of chronic idiopathic facial pain with anti-depressant medication and cognitive behavioural therapy. Congress of Pain. 1996;159:Aust no 163. 17. Dao TTT, Lavigue GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial. Pain 1994;56:85-94. 18. Morselli E. Sulla Tafefobia. Bulletin of Academic Medicine. Geneva VI. 1896:110-119. 19. Reich J. Factors influencing patient satisfaction with result of aesthetic plastic surgery. Plast Reconstr Surg 1975;13:55-58. 20. Phillips KA, McElroy SL, Keck PE et al. A comparison of delusional and nondelusional Body Dysmorphic Disorder in 100 cases. Pyschosoc Bull 1994;30:179-180. 21. Sneddon TB. Dermatitis artefacty. Proc RSM 1977;70:754-755. 22. Todd JE, Walker A. Adult dental health in England and Wales. London: HMSO 1980. 23. Kent G. The Psychology of Dental Care. Bristol, UK: John Wright & Sons 1984. 24. Bochier S. The Psychology of the Dentist-Patient Relationship. New York: Springer-Verlag 1988. 25. Gale EN. Fears of the Dental Situation. Dent Res 1972;51:964-966. 26. Wardle J. Fears of dentistry. Brit Med J 1982;55:119-126. 27. Hallstrom T, Hailing A. Prevalence of dentistry phobia and its relationship to missing teeth: alveolar bone loss and dental care habits in the urban community sample. Acta Psych Scand 1984; 70:438-446. 28. Pond D, Sutton M. Dentistry and psychiatry. Psychiatry in the General Hospital 1983.
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29. Coral NL, Gale EN, Illing SJ. The use of relaxation and distraction to reduce psychological stress during dental procedures. J Am Dent Assoc 1979;98:390-394. 30. Rankin JA, Harris MB. Dental Anxiety: The patient's point of view. J Am Dent Assoc 1984;109:43-47. 31. Lindsey S. One in 10 people avoid dentists through phobia. BMJ 1996;313:189. 32. Blank M, Nelles W. Education and training GPs in the management and treatment of drug users. Int J Drug Policy 1993;4:449-456. 33. Rutz W, von Knorring L, Walender J. Long term effects of an educational programme for general practitioner given by the Swedish Committee for the prevention and treatment of depression. Acta Psychiatrica Scand 1992;85:83.