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The Case for Incorporating Biobehavioral Treatment Into TMD Management
T
he term "temporomandibular disorders," or "TMD," is generally understood to include a wide variety of subtypes of clinical disorders that affect the masticatory and orthognathic systems (just as "headache" is the scientifically accepted term used collectively to refer to pain arising in the head from muscle and/or vascular and/or neuropathic disorders).
. . nX _
The most common of these TMD subtypes are understood to include masticatory muscle disorders and temporomandibular joint disorders, the latter disorders primarily involving displacements of the
The Case for Incorporating Biobehavioral Treatment Into TMD Management SAMUEL F. DWORKIN, D.D.S., PH.D.
articular disk and degenerative diseases of TMJ bony components. The NIH Technology Assessment Conference report on behavioral and educational treatment modalities does not focus on etiologic aspects of TMD, which are widely acknowledged to be complex, poorly understood and the source of some controversy. Rather, it focuses on the scientific support for treatment of TMD with approaches that systematically incorporate behavioral and educational treatment modalities. BIOBEHAVIORAL TREATMENT OF TUVUD
The scientific and clinical literature indicates that the behavioral and educational modalities most commonly used in the management of TMD-collectively referred to as biobehavioral treatments-include electromyographic biofeedback from masticatory muscles, relaxation, hypnosis and patient education. They also include cognitive-behavioral interventions, such as stress management and modification of negative or maladaptive behavioral and emotional patterns for coping with persistent TMD. The prime scientific rationale for incorporating biobehavioral JADA, Vol. 127, November 1996 1607
COMMENTARY treatments into the management of TMD comes from two scientifically well-supported and repeatedly demonstrated findings: - TMD is a chronic pain condition. That is, whatever its etiology, whatever else may be entailed in its underlying physiological or psychological processes, TMD is associated with persistent painand pain represents, overwhelmingly, the reason TMD sufferers seek treatment. They seek treatment also because of concerns about noises or sounds in the TMJ, nonpainful locking or catching of the jaw and achiness or stiffness in the masticatory muscles. But together, these factors not primarily related to overt pain compose only a small fraction-perhaps 15 percent, from the best available evidence-of the reasons TMD patients seek treatment. The rest come for relief from persistent pain in the muscles of mastication, the TMJ and their surrounding structures. - Behavioral and emotional disturbance does exist in TMD clinic populations. In other words, without judging cause or effect, virtually every scientific investigation finds significant amounts of psychological and behavioral distress and dysfunction in TMD sufferers. This psychological or emotional 1608 JADA, Vol. 127, November 1996
_ Z~on
upset is reported as stress, anxiety, depression, somatization; the behavioral or psychosocial disturbance can show itself as social isolation and inability to carry on activities of daily living. These manifestations often are accompanied by increased reliance (even de-
pendence)
medicines and
height-
ened use
~~~~~~of both
traditional and alternative health care providers.
Again, without labeling such negative behavioral and emotional consequences as either causing or resulting from chronic TMD, the scientific finding is that TMD sufferers are indeed at risk of experiencing disturbances in how they think, feel and act that can be transient and minor, can be moderately distressing or (for a significant minority of TMD patients) can reach appreciably dysfunctional levels. Fortunately, the scientific data also show that most TMD patients are able to bear the burden of this painful and dysphoric condition without experiencing lasting psychological disturbance.
TThese two factors-TMD as a chronic pain condition and TMD and psychological disturbance-are obviously related and are universal characteristics or
risks associated with every disorder or disease studied in which persistent pain is a prominent feature. (Such diseases range from overt disease processes such as cancer and rheumatoid arthritis to moredifficult-to-understand disorders such as back pain, headache, irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia.) Thus, to advocate incorporating biobehavioral methods into treatment of TMD is not equivalent to asserting that behavioral factors caused the TMD, or that TMD is somehow not a real condition, but only that the available evidence does support the potential effectiveness of behavioral approaches in treating TMD. Indeed, it cannot be overemphasized that biobehavioral treatments are the modal type of treatment for chronic pain in pain clinics around the world. The integration of such modalities is recommended in guidelines provided by the International Association for the Study of Pain, the world's leading scientific and professional organization in this area. It is not the intent of such guidelines to eliminate or replace biomedical treatments for these conditions, of which chronic pain is so prominent a feature. Instead, the guidelines aim to provide a complementary set of modalities that can be integrated into a comprehensive approach to the management of the patient with persistent pain, independent of the site of the pain. An NIH Technology and Assessment Conference held in October 1995 evaluated the integration of behavioral and relaxation approaches into the
COMMENTARY treatment of chronic pain and insomnia. The conference participants found the evidence strong for the use of relaxation methods in reducing chronic pain in a variety of medical conditions and came to the same conclusion about hypnosis with regard to cancer pain. They also found evidence to support the use of this modality for pain associated with oral mucositis, TMD and tension headaches.
fects from biobehavioral interventions may be long-lastingin some cases, more so than treatments involving only medications or treatments involving such devices as occlusal splints. The evidence for the use of education alone as a biobehavioral treatment method, although positive, cannot be considered conclusive because of the paucity of research with this method, especially in the area of TMD.
B] y and large, patients who received the multimodal treatments (such as cognitive restructuring, affect regulation, stress management, relaxation, biofeedback) that are generally lumped together as cognitive-behavioral therapies found significant benefit from these methods when applied to back, neck, dental, facial and joint pain. But the NIH review panel also concluded that no one component of the multimodal approachfor instance, stress
SELF-MANAGEMENT
management vs.
biofeedback i was more
effective than another for any given condition. By and large, it is fair to say that biobehavioral methods, taken together, are in widespread use in medical settings around the world. They are at least moderately effective. In addition, there appears to be growing evidence that ef-
Important characteristics associated with these biobehavioral modalities for TMD include safety, noninvasiveness, reversibility and, perhaps most important of all, emphasis on self-management. It is currently widely accepted that the most effective management of all forms of chronic illness, includ-
ing chronic pain conditions, must increasingly use the patient as a direct participant in long-term management of his or her chron-
disorder. Again, the principle of self-manageic
ment has been extended to allow biobehavioral clini-
cians, principally clinical
psychologists, to be employed in the rehabilitation of patients with conditions ranging from those requiring organ transplantation to rehabilitation from stroke, coronary and pulmonary disease, paraplegia and arthritis.
Especially critical to observe is the increased tendency among health care professionals to favor incorporating self-management of chronic illness as a responsibility of primary care medical practitioners. In this regard, the NIH report on TMD also recommended that the primary responsibility for managing the majority of TMD patients rests with the general dentist. Indeed, it is apparent from available studies that many of the so-called conservative therapies currently advocated as highly desirable in TMD management are in fact biobehavioral treatment methods that seek to change diet, exercise and general health behaviors-and dentists are delivering these treatments, albeit not in a systematic fashion. These behaviors include sleep and behavioral pathogens that have been directly implicated in the maintenance of TMD-related pain and mandibular dysfunction, such as bruxism and other destructive oral habits. SUIMMARY AND EPILOGUE
Obviously, much more research is needed before a reliable and valid assessment of these biobehavioral therapies can be accomplished-but the same caveat applies to all modalities for treating TMD. We have very few data based on randomized clinical trials that evaluate the long-term safety and effectiveness of such diverse treatments as occlusal splints or occlusal adjustments, physical therapy, arthroscopy and joint surgery. When seen in this context, it is encouraging that the available evidence, although not abundant, does support the effectiveness of beJADA, Vol. 127, November 1996 1609
COMMENTARY havioral and educational modalities. t seems important to note that in the past, psychologi-
cally based therapies for the medically ill have been met with resistance among some patients and some health care providers. The resistance to incorporating biobehavioral treatments seems to have been largely resolved by the medical profession, as evidenced by the large number of psychologists and behavioral medicine specialists employed in scientific research and rehabilitation of patients with stroke, cardiac conditions, cancer and other chronic diseases-including, as already noted, chronic pain patients treated in major multidisciplinary pain centers. No review of the efficacy of and potential role for biobehavioral
1610 JADA, Vol. 127, November 1996
interventions incorporated into the management of TMD would be complete withDr. Dworkin is a proout at least ac- fessor, Departments knowledging, of Oral Medicine Psychiatry and frankly, that re- and Behavioral sistance to such Sciences, University approaches re- of Washington, School of Dentistry, mains. Seattle, Wash. Clinicians 98198. Address reprint requests to may need to Dr. Dworkin. offer support and encouragement to patients when recommending treatments centered around behavioral change. Patient resistance still too often greets a recommendation of using a psychologically based treatment for TMD. Such recommendations seem to carry, for some patients, the negative and clearly undesirable implication that TMD
problems must be all in the head or somehow psychological, hence not "real." No such destructive implication is ever intended when behavioral medicine specialists advocate a biobehavioral treatment. It is destructive to dentist-patient relationships if the patient perceives the dentist to hold such a view. TMD-related pain and distress is as real as the distress associated with any other chronic condition, and people vary in their capacity to endure, let alone thrive, under such difficult physical conditions. It is unfortunate if unhealthy and unwarranted negative misapprehensions prevent any patient with TMD from being helped through the use of readily available, scientifically sound and safe methods that integrate biomedical and biobehavioral treatments. m
he term "temporomandibular disorders," or "TMD," is generally understood to include a wide variety of subtypes of clinical disorders that affect the masticatory and orthognathic systems (just as "headache" is the scientifically accepted term used collectively to refer to pain arising in the head from muscle and/or vascular and/or neuropathic disorders).
. . nX _
The most common of these TMD subtypes are understood to include masticatory muscle disorders and temporomandibular joint disorders, the latter disorders primarily involving displacements of the
The Case for Incorporating Biobehavioral Treatment Into TMD Management SAMUEL F. DWORKIN, D.D.S., PH.D.
articular disk and degenerative diseases of TMJ bony components. The NIH Technology Assessment Conference report on behavioral and educational treatment modalities does not focus on etiologic aspects of TMD, which are widely acknowledged to be complex, poorly understood and the source of some controversy. Rather, it focuses on the scientific support for treatment of TMD with approaches that systematically incorporate behavioral and educational treatment modalities. BIOBEHAVIORAL TREATMENT OF TUVUD
The scientific and clinical literature indicates that the behavioral and educational modalities most commonly used in the management of TMD-collectively referred to as biobehavioral treatments-include electromyographic biofeedback from masticatory muscles, relaxation, hypnosis and patient education. They also include cognitive-behavioral interventions, such as stress management and modification of negative or maladaptive behavioral and emotional patterns for coping with persistent TMD. The prime scientific rationale for incorporating biobehavioral JADA, Vol. 127, November 1996 1607
COMMENTARY treatments into the management of TMD comes from two scientifically well-supported and repeatedly demonstrated findings: - TMD is a chronic pain condition. That is, whatever its etiology, whatever else may be entailed in its underlying physiological or psychological processes, TMD is associated with persistent painand pain represents, overwhelmingly, the reason TMD sufferers seek treatment. They seek treatment also because of concerns about noises or sounds in the TMJ, nonpainful locking or catching of the jaw and achiness or stiffness in the masticatory muscles. But together, these factors not primarily related to overt pain compose only a small fraction-perhaps 15 percent, from the best available evidence-of the reasons TMD patients seek treatment. The rest come for relief from persistent pain in the muscles of mastication, the TMJ and their surrounding structures. - Behavioral and emotional disturbance does exist in TMD clinic populations. In other words, without judging cause or effect, virtually every scientific investigation finds significant amounts of psychological and behavioral distress and dysfunction in TMD sufferers. This psychological or emotional 1608 JADA, Vol. 127, November 1996
_ Z~on
upset is reported as stress, anxiety, depression, somatization; the behavioral or psychosocial disturbance can show itself as social isolation and inability to carry on activities of daily living. These manifestations often are accompanied by increased reliance (even de-
pendence)
medicines and
height-
ened use
~~~~~~of both
traditional and alternative health care providers.
Again, without labeling such negative behavioral and emotional consequences as either causing or resulting from chronic TMD, the scientific finding is that TMD sufferers are indeed at risk of experiencing disturbances in how they think, feel and act that can be transient and minor, can be moderately distressing or (for a significant minority of TMD patients) can reach appreciably dysfunctional levels. Fortunately, the scientific data also show that most TMD patients are able to bear the burden of this painful and dysphoric condition without experiencing lasting psychological disturbance.
TThese two factors-TMD as a chronic pain condition and TMD and psychological disturbance-are obviously related and are universal characteristics or
risks associated with every disorder or disease studied in which persistent pain is a prominent feature. (Such diseases range from overt disease processes such as cancer and rheumatoid arthritis to moredifficult-to-understand disorders such as back pain, headache, irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia.) Thus, to advocate incorporating biobehavioral methods into treatment of TMD is not equivalent to asserting that behavioral factors caused the TMD, or that TMD is somehow not a real condition, but only that the available evidence does support the potential effectiveness of behavioral approaches in treating TMD. Indeed, it cannot be overemphasized that biobehavioral treatments are the modal type of treatment for chronic pain in pain clinics around the world. The integration of such modalities is recommended in guidelines provided by the International Association for the Study of Pain, the world's leading scientific and professional organization in this area. It is not the intent of such guidelines to eliminate or replace biomedical treatments for these conditions, of which chronic pain is so prominent a feature. Instead, the guidelines aim to provide a complementary set of modalities that can be integrated into a comprehensive approach to the management of the patient with persistent pain, independent of the site of the pain. An NIH Technology and Assessment Conference held in October 1995 evaluated the integration of behavioral and relaxation approaches into the
COMMENTARY treatment of chronic pain and insomnia. The conference participants found the evidence strong for the use of relaxation methods in reducing chronic pain in a variety of medical conditions and came to the same conclusion about hypnosis with regard to cancer pain. They also found evidence to support the use of this modality for pain associated with oral mucositis, TMD and tension headaches.
fects from biobehavioral interventions may be long-lastingin some cases, more so than treatments involving only medications or treatments involving such devices as occlusal splints. The evidence for the use of education alone as a biobehavioral treatment method, although positive, cannot be considered conclusive because of the paucity of research with this method, especially in the area of TMD.
B] y and large, patients who received the multimodal treatments (such as cognitive restructuring, affect regulation, stress management, relaxation, biofeedback) that are generally lumped together as cognitive-behavioral therapies found significant benefit from these methods when applied to back, neck, dental, facial and joint pain. But the NIH review panel also concluded that no one component of the multimodal approachfor instance, stress
SELF-MANAGEMENT
management vs.
biofeedback i was more
effective than another for any given condition. By and large, it is fair to say that biobehavioral methods, taken together, are in widespread use in medical settings around the world. They are at least moderately effective. In addition, there appears to be growing evidence that ef-
Important characteristics associated with these biobehavioral modalities for TMD include safety, noninvasiveness, reversibility and, perhaps most important of all, emphasis on self-management. It is currently widely accepted that the most effective management of all forms of chronic illness, includ-
ing chronic pain conditions, must increasingly use the patient as a direct participant in long-term management of his or her chron-
disorder. Again, the principle of self-manageic
ment has been extended to allow biobehavioral clini-
cians, principally clinical
psychologists, to be employed in the rehabilitation of patients with conditions ranging from those requiring organ transplantation to rehabilitation from stroke, coronary and pulmonary disease, paraplegia and arthritis.
Especially critical to observe is the increased tendency among health care professionals to favor incorporating self-management of chronic illness as a responsibility of primary care medical practitioners. In this regard, the NIH report on TMD also recommended that the primary responsibility for managing the majority of TMD patients rests with the general dentist. Indeed, it is apparent from available studies that many of the so-called conservative therapies currently advocated as highly desirable in TMD management are in fact biobehavioral treatment methods that seek to change diet, exercise and general health behaviors-and dentists are delivering these treatments, albeit not in a systematic fashion. These behaviors include sleep and behavioral pathogens that have been directly implicated in the maintenance of TMD-related pain and mandibular dysfunction, such as bruxism and other destructive oral habits. SUIMMARY AND EPILOGUE
Obviously, much more research is needed before a reliable and valid assessment of these biobehavioral therapies can be accomplished-but the same caveat applies to all modalities for treating TMD. We have very few data based on randomized clinical trials that evaluate the long-term safety and effectiveness of such diverse treatments as occlusal splints or occlusal adjustments, physical therapy, arthroscopy and joint surgery. When seen in this context, it is encouraging that the available evidence, although not abundant, does support the effectiveness of beJADA, Vol. 127, November 1996 1609
COMMENTARY havioral and educational modalities. t seems important to note that in the past, psychologi-
cally based therapies for the medically ill have been met with resistance among some patients and some health care providers. The resistance to incorporating biobehavioral treatments seems to have been largely resolved by the medical profession, as evidenced by the large number of psychologists and behavioral medicine specialists employed in scientific research and rehabilitation of patients with stroke, cardiac conditions, cancer and other chronic diseases-including, as already noted, chronic pain patients treated in major multidisciplinary pain centers. No review of the efficacy of and potential role for biobehavioral
1610 JADA, Vol. 127, November 1996
interventions incorporated into the management of TMD would be complete withDr. Dworkin is a proout at least ac- fessor, Departments knowledging, of Oral Medicine Psychiatry and frankly, that re- and Behavioral sistance to such Sciences, University approaches re- of Washington, School of Dentistry, mains. Seattle, Wash. Clinicians 98198. Address reprint requests to may need to Dr. Dworkin. offer support and encouragement to patients when recommending treatments centered around behavioral change. Patient resistance still too often greets a recommendation of using a psychologically based treatment for TMD. Such recommendations seem to carry, for some patients, the negative and clearly undesirable implication that TMD
problems must be all in the head or somehow psychological, hence not "real." No such destructive implication is ever intended when behavioral medicine specialists advocate a biobehavioral treatment. It is destructive to dentist-patient relationships if the patient perceives the dentist to hold such a view. TMD-related pain and distress is as real as the distress associated with any other chronic condition, and people vary in their capacity to endure, let alone thrive, under such difficult physical conditions. It is unfortunate if unhealthy and unwarranted negative misapprehensions prevent any patient with TMD from being helped through the use of readily available, scientifically sound and safe methods that integrate biomedical and biobehavioral treatments. m