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Treating bruxism with the habit-reversal technique
TREATING
BRUXISM WITH THE HABIT-REVERSAL TECHNIQUE*
MICHAELS. ROSENBAUM1t and TE~D~RO AYLLON’ ‘University OFSouth Alabama Medical Center, Dept. of Paediatrics, 2451 Fillingim St, Mobile. Alabama 36617, U.S.A. and ‘Georgia State University, University Plaza, Atlanta, Georgia 30303, U.S.A. (Receioed
24 June
1980)
Snmmary-The habit-reversal technique developed by Azrin and Nunn (1973, 1977) was used in treating four clients with bruxism. Following a single treatment session, marked reductions in the frequencies of this behavior were obtained in each case. Subsequently, relaxation and stress management techniques were conducted with two of these clients who had facial pain. These procedures were associated with decreased pain ratings and medications for one client and a further decrease in bruxism and cessation of pain for the second. These results remained consistent over 6- and ltmonth follow-ups. Each of the components of habit-reversal appeared to be related to its effectiveness, and methods for performing component analyses of this technique are described.
Bruxism is a common and severe dental problem consisting of “a non-functional gnashing and grinding of the teeth” (Glaros and Rao, 1977, p. 767), which also may include clenching or clicking of the teeth (Olkinuora, 1969; Shepherd and Price, 1971). The estimated incidence of this behavior in the general population ranges from 5-20% (Glaros and Rao, 1977), whereas among dental patients the incidence is about 20% (Meklas, 1971). The most common symptomatic effects associated with this problem behavior have included: (a) abnormal wear to the teeth; (b) damage to the structures surrounding the teeth (e.g. recession of the gums); (c) hypertrophy of the masticatory muscles; and (d) facial pain (e.g. Glaros and Rao, 1977; Graf, 1969; Melamed and Mealiea, 1978; Olkinuora, 1969; Scharer, 1974; Shepherd and Price, 1971). Several causes have been proposed for the development and maintenance of bruxism, including occlusal abnormalities (Scharer, 1974), psychological factors (i.e. stress and subsequent nervous tension from environmental sources) (Glaros and Rao, 1977; Graf, 1969; Mikami, 1977; Olkinuora, 1969) and neurophysiological factors (e.g. nutritional deficiencies, mental retardation, cerebral injuries) (Brown, 1970; Lehvila, 1974). The psychoanalytic viewpoint has attributed bruxism to the expression of repressed oral agression indicative of underlying emotional conflicts, and depression and anxiety also have been mentioned (Mikami, 1977). In their review of the bruxism literature, however, Glaros and Rao (1977) emphasized that several studies have failed to find correlations between these factors and bruxism. Several treatments for bruxism have been suggested: (a) To eliminate mechanical causes for bruxism and/or to prevent further damage to the teeth and supportive tissue occlusal adjustment (Graf, 1969; Scharer, 1974) or acrylic occlusal appliances (e.g. bite plates, night guards) (Mikami, 1977; Thorp, 1975) have been described. The effectiveness of these procedures, however, has not been demonstrated in any controlled fashion (Glaros and Rae, 1977). Furthermore, the use of these procedures is suspect, since clients treated with them have continued to persist in the bruxism habit (Ayer and Gale, 1969; Glaros and Rao, 1977). (b) One study has included supplementing the diet with magnesium during periods of growth or extreme stress (Lehvila, 1974). (c) Drug therapy with tranquilizers and muscle relaxants has been advocated (Mikami, 1977; Scharer, 1974). (d) Psychotherapy aimed at resolving the conflicts associated with the hypothetical underlying emotional tension has been used (Mikami, 1977; Olkinuora, 1969). Either * This research was Part of the first author’s doctoral dissertation under the chairmanship of the second author. t To whom all reprint requests should be sent. 87
in partial fulfillment of the Ph.D. degree
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MICHAELS. ROSENBAUM and TEOCGROAYLLON
these psychotherapeutic approaches have been unsuccessful (Ayer and Levin, 1975) or no data on their efficacy have been presented (Glaros and Rao. 1977). (e) Some authors have used autosuggestion to increase the client’s awareness of the bruxism habit and its consequences (Graf, 1969; Olkinuora, 1969). Ayer and Gale (1969) regarded bruxism as a tic-like habit, which. through stimulus generalization, is performed in the presence of a variety of tension-producing stimuli. Consistent with this conceptualization several behavioral techniques have been used to treat bruxism, including massed practice (Ayer and Gale. 1969; Ayer and Levin, 1973, 1975; Heller and Forgione, 1975), presentation of an aversive stimulus contingent on grinding (Heller and Strang, 1973), relaxation and hypnosis (Goldberg, 1973). biofeedback (Kardachi and Clarke, 1977; Solberg and Rugh, 1972). and a combination of relaxation, biofeedback, assertiveness training, and systematic desensitization (Rappaport ef al., 1977). Unfortunately, each of these studies was limited by the fact that either only one client was included, data were not reported, or follow-ups were not conducted. One behavior therapeutic procedure that has been found to be most effective in eliminating nervous habits and tics is habit-reversal, a technique developed by Azrin and Nunn (1973). This technique consists of procedures designed to: (a) increase the client’s awareness of the occurrence of the habit movement; (b) interrupt the chain of behaviors terminating in the habit movement as early as possible in the chain: (c) teach the client a competing response opposite to the habit movement but involving the same muscle groups as in that movement; and (d) eliminate social reinforcement from the habit or shift it to being contingent on appropriate behavior. While the application of habitreversal to teeth grinding has been described (Azrin and Nunn, 1977). it has not been validated experimentally. The present study attempted to extend the generality of habit-reversal to the problem of bruxism.
METHOD Clients
There were four clients, one female and three males, who either responded to an advertisement in a school newspaper soliciting research volunteers or were referred by their dentists. These clients ranged in age from 23-42 and were screened. interviewed, and subsequently treated by the same researcher. Donald. Donald was a 23-year-old male college student who reported a two year history of jaw popping, which consisted of moving his jaw to the extent that the jaw bone popped in-and-out of the temporomandibular joint. Muscle spasms in the masseter muscle on the left side of his face produced severe pain every two or three days. A dental examination, including X-rays of the jaw and temporomandibular joint, revealed no organic causes for the pain. The dentist suggested that the pain was being produced by the excessive jaw movement, recommended that Donald stop this movement, and to alleviate the pain prescribed a muscle relaxing medication (Equagesic) which Donald was taking every two to three days for the pain. Diane. Diane was a 40-year-old housewife who reported having pain in the masseter muscle on the right side of her face for 10 years, in addition to an extensive history of teeth clenching. Visits to a dentist, oral surgeon, and ENT specialist had not revealed any organic causes for the pain and had resulted in several therapeutic suggestions, such as taking tranquilizers, chewing equally on both sides of her mouth, avoiding opening her mouth wide, and avoiding excessive anxiety-producing situations. None of these suggestions had resulted in relief from the pain. Rick. Rick was a 42-year-old male who was employed by the police department and worked in the section responsible for answering emergency phone calls. He reported a 20-year history of grinding his teeth, the occurrence of which was quite high at work. where he felt under a great amount of stress. According to the referring dentist, Rick’s
Habit-reversal and bruxism
89
teeth surfaces were worn down and failure to stop excessive teeth grinding could result in serious tooth, bone and tissue damage. Chuck. Chuck was a 28-year-old male who reported a three year history of clenching his teeth, with accompanying tightness in his jaw and neck for about one year. Chuck described his employment as a production manager as being quite stressful, due to the fact he neither liked the company nor the supervisors for whom he worked. He considered that his teeth clenching was a response to the stress at work. Setting and recording
During an initial interview with the client, the researcher explained the purpose of the research, asked the client to describe the problem behavior and instructed the client to self-record the frequency of this behavior. Self-recording consisted of dividing a 3” x 5” index card into seven columns, each representing one day of the week, and recording a slash mark each time a target response occurred. Clients were instructed to carry the card and record each instance of a target response throughout the entire day. In addition to this recording procedure, Diane was instructed to rate her facial pain every 2 hr on a scale of O-5 (0 = no pain, 5 = intense pain which makes it difficult to do any jobs and may require resting in bed) and record any medication taken for the pain. The recording procedures described above were conducted on a daily basis during baseline and throughout the first month following treatment. Baseline data were returned to the researcher at the treatment session. Each client was asked to report data via phone two weeks following the treatment session. Data for the next two weeks were brought to the one month follow-up session. Thereafter, Donald recorded the frequency of jaw popping one day per week for the next eight weeks, followed by one day per month for nine months, Following the daily recording period, Diane, Rick and Chuck recorded their frequencies of target responses one week per month for five months. These data were reported via phone on a monthly basis. Response definitions Jaw popping. This consisted of Donald moving his jaw slowly to the right and bringing it sharply to the left, thereby popping the jaw bone out of the left temporomandibular joint temporarily. This produced a slight clicking sound discernible only to Donald. Teeth grinding. This consisted of Rick closing his mouth, biting his teeth together and moving his jaw back-and-forth, thereby grinding the teeth surfaces against each other. This produced a noise audible to persons within 6 ft of him. Teeth clenching. For Diane and Chuck this consisted of biting the teeth together for at least 5 set, thereby producing muscular tension primarily in the masseter muscles. Biting the teeth together during meals or for purposes of eating at other times was not included in the response definition. Facial pain. For Diane this was rated according to the procedure described above. Research design
Separate comparison designs (AB) representing a group of direct replications used to assess the effectiveness of the treatment procedure.
were
Procedure Baseline. The period of time between the initial interview with the client and the initial
treatment
session constituted
the baseline.
Treatment I (habit-reoersal). This technique was similar to that described by Azrin
and
Nunn (1973, 1977). To increase the client’s awareness of his/her target response, several procedures were used. The client was asked to describe verbally and demonstrate physically the target response in the response description procedure. The researcher then taught the client to detect the earliest sign of the target response (earl) warning procedure). Donald was taught to detect a slight sensation in the left masseter muscle, which preceded jaw Popping about 50% of the time. Additionally, he was taught to detect 8.1T19I--G
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MICHAEL S. ROSENEAUMandT~ooo~o AYLLON
moving his jaw slightly to the right, which always preceded jaw popping. Diane and Chuck were taught to detect any urges to clench their teeth and the frrst instance of their teeth coming into contact accompanied by a slight increase in muscular tension. Rick was taught to detect the first instance of his teeth coming into contact accompanied by a slight jaw movement either to the right or left. The situation awareness truin~~g procedure consisted of the client listing and describing in detai1 those situations in which the target response usually occurred or increased in frequency (e.g. for Rick teeth grinding increased markedly while he was at work). Negative aspects associated with the target response were described by the client to increase his/her motivation to be rid of the problem behavior (habit ~~c~n~~~~e~cereview) (e.g. for Chuck teeth clenching was producing muscular tightness in his neck and jaw, which was associated with much discomfort). In the competing response practice procedure, the researcher taught the client an isometric exercise which was incompatible with the target response and had the following characteristics: (a) It was opposite to the target response; (b) It could be maintained for at least 1 min; (c) It involved isometric tensing of muscles used in the target response movement; (d) It was as socially inconspicuous as possible; (e) It could be practiced easily with normal activities; and (f) It prevented the target response from remaining a routine part of the client’s normal activities. The client was instructed to perform the competing response foflowing the urge to perform the target response, any antecedent to the target response, or any occurrence of the target response. For Donald and Rick the competing response consisted of closing the mouth and biting the teeth together until a comfortable amount of tension in the jaw was produced. This exercise was to be performed for 3 min for Donald and 2 min for Rick. For Diane and Chuck, the competing response consisted of opening the mouth until a comfortable amount of tension was felt in the masseter muscles. This exercise was to be performed for 2 min. To increase the probability of generalization of the competing response outside the treatment session, a symbolic rehearsal procedure was conducted. The client was asked to choose one situation from the list of those in which the target response increased in frequency. The client was then asked to recall an actual instance of the target response in that situation and perform the competing response as the target response was detected. This procedure was repeated several times. Finally, a conversation period was conducted, during which the researcher engaged the client in a discussion of topics of interest. During this period, conducted to allow further practice of the competing response, the client was instructed to perform the competing response whenever an urge to perform the target response, antecedent to the target response, or occurrence of the target response was present. When possible the researcher pointed out any occurrences of the target response that the client failed to detect and instructed the client to perform the competing exercise. The entire treatment session lasted approximately 60 min. Treatment II (re~uxarion pius stress ~~agement~. Two weeks following Habib-reversal treatment, Diane received an additional treatment session aimed at alleviating the pain in her right masseter muscle. She was given a rationale for deep muscle relaxation and a cassette tape on which the researcher had recorded a 30 min relaxation training procedure taken from Goldfried and Davison (1976). Diane was instructed to listen to the tape and practice the relaxation exercises twice daily (once in the morning and once in the evening). The researcher then engaged Diane in a conversation aimed at defining stress and pin~inting sources of stress in her life (e.g. thoughts, beliefs, major life changes, environmental pressures). Following this conversation, the researcher and Diane designed several alternative methods for managing these sources of stress (e.g. not scheduling several activities on a particular day so she would not feel rushed and pressured). Finally, in a cognitive restructuring framework (Goldfried and Davison, 1976) the researcher and Diane discussed self-defeating aspects of her belief system (e.g. to be worthwhile, one must be competent in all respects) and possible rational alternatives that she could incorporate (e.g. to be worthwhile, one does not have to be perfect in all respects). This session lasted about 75 min. A similar procedure was conducted with
Habit-reversal
91
and bruxism
Chuck one week following habit-reversal treatment to alleviate the muscular tightness in his jaw and neck. Treatment II! (Relaxation !I). One week following the relaxation plus stress management session, Diane was instructed to practice a 10 min relaxation procedure which the researcher had recorded on a cassette tape (Goldfried and Davison, 1976). Additionally, she was instructed to use the exercises in any situation associated with excessive levels of stress or tension. Follow-up. Follow-up sessions were scheduled one month and six months following treatment for all clients except Donald, for whom follow-up data were obtained via phone since he had moved out of town. Additionally, on each occasion that data were reported via phone, the researcher praised the client for improvement (i.e. a decrease in the frequency of the target response or maintenance of this response at a low level) and reminded him/her to continue following the treatment procedures.
RESULTS Donald
The mean frequency of Donald’s jaw popping was 169.8/day during baseline (Fig. 1). Following treatment with habit-reversal, this behavior decreased markedly to a mean of l/day (99”/, reduction from baseline) during the daily recording period, a level which was maintained throughout the weekly recording period (M = lA/day, 99% reduction from baseline). Jaw popping was eliminated completely during the monthly recording period (100% reduction from baseline). Additionally, Donald did not take any medications for jaw pain following treatment, as the pain did not recur. Diane
Diane’s mean frequency of teeth clenching was 13/day during baseline (Fig. 2). Following habit-reversal treatment, clenching decreased to a mean of Z.l/day (84% reduction from baseline). Relaxation plus stress management to alleviate facial pain was associated with a slight decrease in clenching (M = 1.5/day, 88% reduction from baseline) to a level that was maintained throughout the relaxation II phase (M = 1.6/day, 880/, reduction from baseline). The frequency of teeth clenching increased during the follow-up period (M = 2.5/day, 81% decrease from baseline). Diane’s mean daily pain estimates are also shown in Fig. 2. Her mean daily pain level was 2.5 during baseline, which did not change appreciably as a function of habit-reversal 200-
, I
DAYS Fig. 1. The frequency
of Donald’s
WEEKS
jaw popping
MONTHS
on a daily basis, one day per week, and one day
per month.
MICHAEL S. ROSENBAUM and TEOWRO AKLLON
92 25
BASELINE
1 t
5 -
HABIT-REVERSAL
RELAXATION
I I
RELAXATIONIII~
5
I ST&.5 ’ tblANAGMENli
.I0
1%
2b
28
CLENCHING PAIN
ti
i5
4.0
45
50..
DAYS
2
s
s
MONTHS
Fig. 2. The frequency of Diane’s teeth clenching (0) and her mean pain estimate (0) on a daily basis and averaged over one week per month.
for teeth clenching (M = 2.6, 4% increase from baseline). Relaxation plus stress management was associated with a slight decrease in the daily pain level (M = 2.2, 12% decrease from baseline), which decreased even further following relaxation II (M = 1.9, 24% decrease from baseline). During the follow-up period, Diane’s daily pain level increased (M = 2.1, 16% decrease from baseline). Additionally, Diane stopped taking Tranxene during baseline, restricting her medications for facial pain to Bufferin, Tylenol and Darvocet tablets. The number of tablets she consumed per day decreased from a mean of four to two following the relaxation plus stress management procedure and remained at that level throughout the relaxation II phase. During the follow-up period, Diane averaged three tablets per day for facial pain. Rick The mean frequency of Rick’s teeth grinding was 75/day during baseline (Fig. 3). Following treatment with habit-reversal, this behavior decreased markedly to a mean of
0-I
i I
5
I
,
f0
*5
DAYS
I
1
I
20
25
3o
I,<,
35
I
2 4
I
6
MONTHS
Fig. 3. The frequency of Rick’s teeth grinding on a daily basis and averaged over one week per
month.
93
Habit-reversal and bruxism 25
BASELINE
RELA%ATION + STRESS MANAGEMENT
HABIT-REVERSAL I :
i
: f :
20
x Y
15
I.
I
OJ I
5
i I
I
I
I
IO
15
20
25
DAYS
D-f
30%
MONTHS
Fig. 4. The frequency of Chuck’s teeth clenching on a daily basis and averaged over one week per month.
8S/day (89% decrease from baseline). The results at the six month follow-up showed a further decrease in teeth grinding (M = S/day, 93% decrease from baseline). Additionally, Rick reported that several of his co-workers commented on the reduction in teeth grinding noise he made. Chuck
Chuck’s mean frequency of teeth clenching was 17.ljday during baseline (Fig. 4). Habit-reversal treatment was associated with a decrease in teeth clenching (M = 8.l/day, 53% decrease from baseline). During the relaxation plus stress management phase to reduce the tightness in Chuck’s jaw and neck, clenching decreased even further (M = 3.8/day, 78% decrease from baseline). The results at the six month follow-up showed that this behavior remained at the previous low level (M = 4/day, 77”/, decrease from baseline). Additionally, at both the one and six month follow-ups, Chuck reported a marked reduction in the tightness in his neck and jaw relative to before treatment with relaxation plus stress management. DISCUSSION
The results of this study indicate that the habit-reversal technique (Azrin and Nunn, 1973, 1977) can be effective in decreasing and/or eliminating bruxism. The decreases obtained for the four clients were immediate and were maintained over long periods of time (i.e. six and 12 month follow-ups). Habit-reversal proved effective regardless of whether the pretreatment frequency of the problem behavior was high (e.g. M= 169.8/day for Donald’s jaw popping) or low (e.g. M = 13/day for Diane’s teeth clenching). Several aspects of the habit-reversal technique appeared to be associated with its effectiveness. Each client was instructed to self-record the frequency of the problem behavior daily during baseline and continuing on a daily basis throughout the first month following treatment By focusing on the target response, the client could become more aware of its occurrence and receive immediate feedback concerning its frequency. As a function of this feedback mechanism, the client could alter the frequency of occurrence of the target response. Several authors have documented and discussed this reactive effect associated with self-recording (e.g. Jeffrey, 1974; Kanfer, 1970, 1975; Kazdin, 1974a,b; McFall, 1977; Nelson, 1977). In the initial interview with the client in the present research, the researcher clearly indicated that the treatment technique was
94
MICHAELS. ROSENBALJM and TEOD~ROAYLLON
designed to decrease the frequency of the problem behavior. Therefore, self-recording may have been associated with lower frequencies of the problem behavior during baseline relative to what these frequencies may have been prior to self-recording. Additionally, baseline data for Donald, Diane, and Chuck showed a decreasing trend during the initial baseline sessions, thereby providing support for the reactive effects associated with self-recording. It is important to note, however, that even during baseline. target responses were occurring frequently enough to continue to represent problems for the clients. In addition to self-recording, the response description, early warning, situation awareness training, and habit inconvenience review procedures contributed to increasing the client’s awareness of the occurrence of the target response, including its antecedents and consequences. For example, Donald was unaware that the irritating sensation in his left masseter muscle and moving his jaw slightly to the right were associated with jaw popping. The addition of this type of information (i.e. a functional analysis) made it easier for each client to use the competing response practice procedure successfully. Yet. this information may have also contributed to an alteration in the self-recording process. Since these procedures increased the client’s awareness of the antecedents related to the target response, it is possible that certain responses not included as target responses during baseline were recorded as such following the treatment session. An equally plausible alternative is that certain responses recorded as target responses during baseline were not recorded as such following the treatment session. Unfortunately, data documenting the effect of increasing a client’s awareness of antecedents associated with a target response on subsequent self-recorded data have yet to be reported (Nelson, personal communication, 1979). The competing response practice procedure served two main functions: (a) It interrupted the usual chain of events terminating in the performance of the problem behavior; and (b) It provided an interval of time (2 or 3 min) during which the client could remain aware that either an urge to perform a target response, an antecedent to that response, or the response itself had occurred. By requiring a minimal amount of effort on behalf of the client, the competing response practice procedure was minimally aversive and could be incorporated easily into the client’s daily routine. The symbolic rehearsal procedure provided the client with an opportunity to apply the competing response practice procedure, thereby potentially contributing to the generalization across settings of treatment effects associated with habit-reversal. In the case of facial pain, it appears that whereas habit-reversal can be effective in markedly reducing and/or eliminating bruxism associated with the pain, this may not be sufficient to alter the degree of pain experienced by the client. The relationship between a reduction in bruxism and a reduction in pain may be related to the type of problem behavior (e.g. jaw popping, teeth grinding, or teeth clenching) and/or the duration of the pain. Perhaps eliminating or markedly reducing bruxism can be effective in reducing or eliminating pain of short duration (e.g. Donald’s pain had been present for less than two years) but not of long duration (e.g. Diane’s pain had been present for at least 10 years). Alternatively, the pain may be maintained by certain environmental contingencies and may function as a behavior separate from bruxism (Sanders, personal communication, 1979). The addition of a relaxation plus stress management procedure appeared to be effective in reducing Diane’s pain to a level below that achieved with a muscle relaxing medication. This procedure can also help to alleviate muscular tightness in clients who have not developed pain symptoms (e.g. Chuck). Although conclusive statements would be premature at this time, the results of the present research demonstrate the applicability of habit-reversal in treating the cause of the facial pain (i.e. bruxism). The clinical usefulness of habit-reversal can be determined only through judging its effectiveness relative to other forms of treatment for bruxism. The most commonly used and successful treatment has been massed practice (Ayer and Gale, 1969; Ayer and Levin, 1973, 1975). However, there appear to be several limitations to using this procedure. First, massed practice could result in the development of sustained muscular tightness
Habit-reversal
and bruxism
95
and pain if it were used over an extended period of time, because of the requirement that the client bite the teeth together. Second, since it results in muscular fatigue, massed practice represents an aversive procedure with which many clients may not comply in the absence of supervision by a therapist. Third, massed practice would not be indicated for clients with facial pain, since biting the teeth together would result in increased muscular tension and an aggravation of the pain. In the present research, habit-reversal did include a competing response of biting the teeth together for some clients (i.e. Donald and Rick). Yet, since the problem behavior decreased so rapidly, it was not necessary for the client to use this competing response frequently. This, in turn, reduced the possibility that muscular tightness or facial pain would develop. The other competing response for bruxism, opening the mouth wide, was used with one client with pain (i.e. Diane) and another with muscular tightness (i.e. Chuck). Since this competing response enabled the masseter muscle to remain relaxed, it did not exacerbate these conditions any further. One limitation to using self-recording with teeth clenching is that many individuals remain unaware of several occurrences of this behavior even following a response description type of procedure (Sanders, 1979). Through the use of electromyographic recording procedures, Sanders (1979) has noted that electrical activity indicative of clenching was not always accompanied by the client’s self-report of cl~ching. Findings such as these indicate the applicability of a portable biofeedback apparatus to signal the client that clenching has just commenced (Solberg and Rugh, 1972), followed by the use of a competing response to interrupt the behavioral chain. This represents one direction for future research in the area of bruxism and facial pain. In terms of future research, component analyses of the habit-reversal technique to identify the relative contribution of each component procedure seems warranted. This research could be conducted in the following single-subject design: (a) During baseline the client would be instructed to self-record the frequency of the problem behavior; (b) During the Treatment I phase, the client would engage in the response description, early warning, situation awareness training, and habit inconvenience review procedures; (c) The competing response practice procedure would be taught in the Treatment II phase; and (d) The symbolic rehearsal procedure would constitute the Treatment III phase. Preferably this design would be included in a multiple-baseline-across-subjects design, although a series of comparison designs (ABCD) might be sufficient. Alternatively, this research could be conducted in the following between subjects design: (a} Group I would be instructed to self-record the frequency of the problem behavior; (b) Group 2 would perform self-recording in addition to participating in the response description, early warning, situation awareness training, and habit inconvenience review procedures; (c) Group 3 would receive the same training as the previous group, with the addition of the competing response practice procedure; (d) Group 4 would receive training in the entire habit-reversal technique; and (e) Group 5 would serve as a no-treatment control group. In either of these two research designs the relative contributions of selfrecording, response awareness training, competing response practice, and symbolic rehearsal could be assessed separately. Acknowledgements-The authors wish to express their sincere appreciation to the other committee members, Michael A. Milan and Robert C. Brown. Part of this research was presented in a paper entitled, The Behavioral Treatment of Myofascial Pain Dysfunction, at the meeting of the Southeastern Psychological Association, New Orleans. March 1979.
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KAZDIN A. E. (1974b) Self-monitoring and behavior change. In Self-Conrrol: Power to rhe Person (Edited by MAHONEYM. J. and THORESENC. E.). Brooks/Cole. Monteray, CA. LEHVILAP. (1974) Bruxism and magnesium: literature review and case reports. Proc. Finn. dent. SOC. 70, 217-224.
MCFALL R. M. (1977) Parameters of self-monitoring. In Behavioral Self-Management (Edited by STUARTR. B.). Bruner/Mazel, New York. MEKLASJ. F. (1971) Bruxism: diagnosis and treatment. J. Acad. gen. Dent. 19. 31-36. MELAMEDB. G. and MEALIEAW. L. (1978) Behavioral interventions in pain related problems in dentistry. In Advances in Behaoioral Medicine (Edited by TAYLORC. B. and FERGUWN1.). Plenum, New York. MIKAMID. B. (1977) A review of psychogenic aspects and treatment of bruxism. J. prosth. Dent. 37, 41 l-419. NELS~INR. 0. (1977) Methodological issues in assessment via self-monitoring. In Behavioral Assessment--Neb Directions in Clinical Psychology (Edited by CONEJ. D. and HAWKINSR. P.). Brunner/Mazel. New York. OLKINUORAM. (1969) Bruxism: a review of the literature on. and a discussion of studies of bruxism and its psychogenesis and some new psychological hypotheses. &omen Hammaslaakariseuran Toimituksia 65, 312-324.
RAPPA~~RTA. F.. CAMMERL., CANNISTRACI A. J., GELB H. and STRONGD. (1977) EMG feedback for the treatment of bruxism. In Diseases of the Temporomandibular Apparatus: A Multi-Disciplinary Approach (Edited by MORGAND. H., HALL W. P. and VAMVASS. J.). Mosby. St Louis. MO. SCHARERP. (1974) Bruxism. Front. oral Physiol. 1, 293-322. SHEPHERDR. W. and PRICEA. S. (1971) Bruxism: the changing situation. Amt. dent. J. 16, 243-248. SOLBERGW. K. and RUGHJ. D. (1972) The use of biofeedback devices in the treatment of bruxism. J.‘sth. Calij: St. dent. Ass. 40, 852-853.
THORP P. D. E. (1975) An appliance to be worn at night for the heavy tooth grinder.
Dent.
Tech. 28.
144-145.
BRUXISM WITH THE HABIT-REVERSAL TECHNIQUE*
MICHAELS. ROSENBAUM1t and TE~D~RO AYLLON’ ‘University OFSouth Alabama Medical Center, Dept. of Paediatrics, 2451 Fillingim St, Mobile. Alabama 36617, U.S.A. and ‘Georgia State University, University Plaza, Atlanta, Georgia 30303, U.S.A. (Receioed
24 June
1980)
Snmmary-The habit-reversal technique developed by Azrin and Nunn (1973, 1977) was used in treating four clients with bruxism. Following a single treatment session, marked reductions in the frequencies of this behavior were obtained in each case. Subsequently, relaxation and stress management techniques were conducted with two of these clients who had facial pain. These procedures were associated with decreased pain ratings and medications for one client and a further decrease in bruxism and cessation of pain for the second. These results remained consistent over 6- and ltmonth follow-ups. Each of the components of habit-reversal appeared to be related to its effectiveness, and methods for performing component analyses of this technique are described.
Bruxism is a common and severe dental problem consisting of “a non-functional gnashing and grinding of the teeth” (Glaros and Rao, 1977, p. 767), which also may include clenching or clicking of the teeth (Olkinuora, 1969; Shepherd and Price, 1971). The estimated incidence of this behavior in the general population ranges from 5-20% (Glaros and Rao, 1977), whereas among dental patients the incidence is about 20% (Meklas, 1971). The most common symptomatic effects associated with this problem behavior have included: (a) abnormal wear to the teeth; (b) damage to the structures surrounding the teeth (e.g. recession of the gums); (c) hypertrophy of the masticatory muscles; and (d) facial pain (e.g. Glaros and Rao, 1977; Graf, 1969; Melamed and Mealiea, 1978; Olkinuora, 1969; Scharer, 1974; Shepherd and Price, 1971). Several causes have been proposed for the development and maintenance of bruxism, including occlusal abnormalities (Scharer, 1974), psychological factors (i.e. stress and subsequent nervous tension from environmental sources) (Glaros and Rao, 1977; Graf, 1969; Mikami, 1977; Olkinuora, 1969) and neurophysiological factors (e.g. nutritional deficiencies, mental retardation, cerebral injuries) (Brown, 1970; Lehvila, 1974). The psychoanalytic viewpoint has attributed bruxism to the expression of repressed oral agression indicative of underlying emotional conflicts, and depression and anxiety also have been mentioned (Mikami, 1977). In their review of the bruxism literature, however, Glaros and Rao (1977) emphasized that several studies have failed to find correlations between these factors and bruxism. Several treatments for bruxism have been suggested: (a) To eliminate mechanical causes for bruxism and/or to prevent further damage to the teeth and supportive tissue occlusal adjustment (Graf, 1969; Scharer, 1974) or acrylic occlusal appliances (e.g. bite plates, night guards) (Mikami, 1977; Thorp, 1975) have been described. The effectiveness of these procedures, however, has not been demonstrated in any controlled fashion (Glaros and Rae, 1977). Furthermore, the use of these procedures is suspect, since clients treated with them have continued to persist in the bruxism habit (Ayer and Gale, 1969; Glaros and Rao, 1977). (b) One study has included supplementing the diet with magnesium during periods of growth or extreme stress (Lehvila, 1974). (c) Drug therapy with tranquilizers and muscle relaxants has been advocated (Mikami, 1977; Scharer, 1974). (d) Psychotherapy aimed at resolving the conflicts associated with the hypothetical underlying emotional tension has been used (Mikami, 1977; Olkinuora, 1969). Either * This research was Part of the first author’s doctoral dissertation under the chairmanship of the second author. t To whom all reprint requests should be sent. 87
in partial fulfillment of the Ph.D. degree
88
MICHAELS. ROSENBAUM and TEOCGROAYLLON
these psychotherapeutic approaches have been unsuccessful (Ayer and Levin, 1975) or no data on their efficacy have been presented (Glaros and Rao. 1977). (e) Some authors have used autosuggestion to increase the client’s awareness of the bruxism habit and its consequences (Graf, 1969; Olkinuora, 1969). Ayer and Gale (1969) regarded bruxism as a tic-like habit, which. through stimulus generalization, is performed in the presence of a variety of tension-producing stimuli. Consistent with this conceptualization several behavioral techniques have been used to treat bruxism, including massed practice (Ayer and Gale. 1969; Ayer and Levin, 1973, 1975; Heller and Forgione, 1975), presentation of an aversive stimulus contingent on grinding (Heller and Strang, 1973), relaxation and hypnosis (Goldberg, 1973). biofeedback (Kardachi and Clarke, 1977; Solberg and Rugh, 1972). and a combination of relaxation, biofeedback, assertiveness training, and systematic desensitization (Rappaport ef al., 1977). Unfortunately, each of these studies was limited by the fact that either only one client was included, data were not reported, or follow-ups were not conducted. One behavior therapeutic procedure that has been found to be most effective in eliminating nervous habits and tics is habit-reversal, a technique developed by Azrin and Nunn (1973). This technique consists of procedures designed to: (a) increase the client’s awareness of the occurrence of the habit movement; (b) interrupt the chain of behaviors terminating in the habit movement as early as possible in the chain: (c) teach the client a competing response opposite to the habit movement but involving the same muscle groups as in that movement; and (d) eliminate social reinforcement from the habit or shift it to being contingent on appropriate behavior. While the application of habitreversal to teeth grinding has been described (Azrin and Nunn, 1977). it has not been validated experimentally. The present study attempted to extend the generality of habit-reversal to the problem of bruxism.
METHOD Clients
There were four clients, one female and three males, who either responded to an advertisement in a school newspaper soliciting research volunteers or were referred by their dentists. These clients ranged in age from 23-42 and were screened. interviewed, and subsequently treated by the same researcher. Donald. Donald was a 23-year-old male college student who reported a two year history of jaw popping, which consisted of moving his jaw to the extent that the jaw bone popped in-and-out of the temporomandibular joint. Muscle spasms in the masseter muscle on the left side of his face produced severe pain every two or three days. A dental examination, including X-rays of the jaw and temporomandibular joint, revealed no organic causes for the pain. The dentist suggested that the pain was being produced by the excessive jaw movement, recommended that Donald stop this movement, and to alleviate the pain prescribed a muscle relaxing medication (Equagesic) which Donald was taking every two to three days for the pain. Diane. Diane was a 40-year-old housewife who reported having pain in the masseter muscle on the right side of her face for 10 years, in addition to an extensive history of teeth clenching. Visits to a dentist, oral surgeon, and ENT specialist had not revealed any organic causes for the pain and had resulted in several therapeutic suggestions, such as taking tranquilizers, chewing equally on both sides of her mouth, avoiding opening her mouth wide, and avoiding excessive anxiety-producing situations. None of these suggestions had resulted in relief from the pain. Rick. Rick was a 42-year-old male who was employed by the police department and worked in the section responsible for answering emergency phone calls. He reported a 20-year history of grinding his teeth, the occurrence of which was quite high at work. where he felt under a great amount of stress. According to the referring dentist, Rick’s
Habit-reversal and bruxism
89
teeth surfaces were worn down and failure to stop excessive teeth grinding could result in serious tooth, bone and tissue damage. Chuck. Chuck was a 28-year-old male who reported a three year history of clenching his teeth, with accompanying tightness in his jaw and neck for about one year. Chuck described his employment as a production manager as being quite stressful, due to the fact he neither liked the company nor the supervisors for whom he worked. He considered that his teeth clenching was a response to the stress at work. Setting and recording
During an initial interview with the client, the researcher explained the purpose of the research, asked the client to describe the problem behavior and instructed the client to self-record the frequency of this behavior. Self-recording consisted of dividing a 3” x 5” index card into seven columns, each representing one day of the week, and recording a slash mark each time a target response occurred. Clients were instructed to carry the card and record each instance of a target response throughout the entire day. In addition to this recording procedure, Diane was instructed to rate her facial pain every 2 hr on a scale of O-5 (0 = no pain, 5 = intense pain which makes it difficult to do any jobs and may require resting in bed) and record any medication taken for the pain. The recording procedures described above were conducted on a daily basis during baseline and throughout the first month following treatment. Baseline data were returned to the researcher at the treatment session. Each client was asked to report data via phone two weeks following the treatment session. Data for the next two weeks were brought to the one month follow-up session. Thereafter, Donald recorded the frequency of jaw popping one day per week for the next eight weeks, followed by one day per month for nine months, Following the daily recording period, Diane, Rick and Chuck recorded their frequencies of target responses one week per month for five months. These data were reported via phone on a monthly basis. Response definitions Jaw popping. This consisted of Donald moving his jaw slowly to the right and bringing it sharply to the left, thereby popping the jaw bone out of the left temporomandibular joint temporarily. This produced a slight clicking sound discernible only to Donald. Teeth grinding. This consisted of Rick closing his mouth, biting his teeth together and moving his jaw back-and-forth, thereby grinding the teeth surfaces against each other. This produced a noise audible to persons within 6 ft of him. Teeth clenching. For Diane and Chuck this consisted of biting the teeth together for at least 5 set, thereby producing muscular tension primarily in the masseter muscles. Biting the teeth together during meals or for purposes of eating at other times was not included in the response definition. Facial pain. For Diane this was rated according to the procedure described above. Research design
Separate comparison designs (AB) representing a group of direct replications used to assess the effectiveness of the treatment procedure.
were
Procedure Baseline. The period of time between the initial interview with the client and the initial
treatment
session constituted
the baseline.
Treatment I (habit-reoersal). This technique was similar to that described by Azrin
and
Nunn (1973, 1977). To increase the client’s awareness of his/her target response, several procedures were used. The client was asked to describe verbally and demonstrate physically the target response in the response description procedure. The researcher then taught the client to detect the earliest sign of the target response (earl) warning procedure). Donald was taught to detect a slight sensation in the left masseter muscle, which preceded jaw Popping about 50% of the time. Additionally, he was taught to detect 8.1T19I--G
90
MICHAEL S. ROSENEAUMandT~ooo~o AYLLON
moving his jaw slightly to the right, which always preceded jaw popping. Diane and Chuck were taught to detect any urges to clench their teeth and the frrst instance of their teeth coming into contact accompanied by a slight increase in muscular tension. Rick was taught to detect the first instance of his teeth coming into contact accompanied by a slight jaw movement either to the right or left. The situation awareness truin~~g procedure consisted of the client listing and describing in detai1 those situations in which the target response usually occurred or increased in frequency (e.g. for Rick teeth grinding increased markedly while he was at work). Negative aspects associated with the target response were described by the client to increase his/her motivation to be rid of the problem behavior (habit ~~c~n~~~~e~cereview) (e.g. for Chuck teeth clenching was producing muscular tightness in his neck and jaw, which was associated with much discomfort). In the competing response practice procedure, the researcher taught the client an isometric exercise which was incompatible with the target response and had the following characteristics: (a) It was opposite to the target response; (b) It could be maintained for at least 1 min; (c) It involved isometric tensing of muscles used in the target response movement; (d) It was as socially inconspicuous as possible; (e) It could be practiced easily with normal activities; and (f) It prevented the target response from remaining a routine part of the client’s normal activities. The client was instructed to perform the competing response foflowing the urge to perform the target response, any antecedent to the target response, or any occurrence of the target response. For Donald and Rick the competing response consisted of closing the mouth and biting the teeth together until a comfortable amount of tension in the jaw was produced. This exercise was to be performed for 3 min for Donald and 2 min for Rick. For Diane and Chuck, the competing response consisted of opening the mouth until a comfortable amount of tension was felt in the masseter muscles. This exercise was to be performed for 2 min. To increase the probability of generalization of the competing response outside the treatment session, a symbolic rehearsal procedure was conducted. The client was asked to choose one situation from the list of those in which the target response increased in frequency. The client was then asked to recall an actual instance of the target response in that situation and perform the competing response as the target response was detected. This procedure was repeated several times. Finally, a conversation period was conducted, during which the researcher engaged the client in a discussion of topics of interest. During this period, conducted to allow further practice of the competing response, the client was instructed to perform the competing response whenever an urge to perform the target response, antecedent to the target response, or occurrence of the target response was present. When possible the researcher pointed out any occurrences of the target response that the client failed to detect and instructed the client to perform the competing exercise. The entire treatment session lasted approximately 60 min. Treatment II (re~uxarion pius stress ~~agement~. Two weeks following Habib-reversal treatment, Diane received an additional treatment session aimed at alleviating the pain in her right masseter muscle. She was given a rationale for deep muscle relaxation and a cassette tape on which the researcher had recorded a 30 min relaxation training procedure taken from Goldfried and Davison (1976). Diane was instructed to listen to the tape and practice the relaxation exercises twice daily (once in the morning and once in the evening). The researcher then engaged Diane in a conversation aimed at defining stress and pin~inting sources of stress in her life (e.g. thoughts, beliefs, major life changes, environmental pressures). Following this conversation, the researcher and Diane designed several alternative methods for managing these sources of stress (e.g. not scheduling several activities on a particular day so she would not feel rushed and pressured). Finally, in a cognitive restructuring framework (Goldfried and Davison, 1976) the researcher and Diane discussed self-defeating aspects of her belief system (e.g. to be worthwhile, one must be competent in all respects) and possible rational alternatives that she could incorporate (e.g. to be worthwhile, one does not have to be perfect in all respects). This session lasted about 75 min. A similar procedure was conducted with
Habit-reversal
91
and bruxism
Chuck one week following habit-reversal treatment to alleviate the muscular tightness in his jaw and neck. Treatment II! (Relaxation !I). One week following the relaxation plus stress management session, Diane was instructed to practice a 10 min relaxation procedure which the researcher had recorded on a cassette tape (Goldfried and Davison, 1976). Additionally, she was instructed to use the exercises in any situation associated with excessive levels of stress or tension. Follow-up. Follow-up sessions were scheduled one month and six months following treatment for all clients except Donald, for whom follow-up data were obtained via phone since he had moved out of town. Additionally, on each occasion that data were reported via phone, the researcher praised the client for improvement (i.e. a decrease in the frequency of the target response or maintenance of this response at a low level) and reminded him/her to continue following the treatment procedures.
RESULTS Donald
The mean frequency of Donald’s jaw popping was 169.8/day during baseline (Fig. 1). Following treatment with habit-reversal, this behavior decreased markedly to a mean of l/day (99”/, reduction from baseline) during the daily recording period, a level which was maintained throughout the weekly recording period (M = lA/day, 99% reduction from baseline). Jaw popping was eliminated completely during the monthly recording period (100% reduction from baseline). Additionally, Donald did not take any medications for jaw pain following treatment, as the pain did not recur. Diane
Diane’s mean frequency of teeth clenching was 13/day during baseline (Fig. 2). Following habit-reversal treatment, clenching decreased to a mean of Z.l/day (84% reduction from baseline). Relaxation plus stress management to alleviate facial pain was associated with a slight decrease in clenching (M = 1.5/day, 88% reduction from baseline) to a level that was maintained throughout the relaxation II phase (M = 1.6/day, 880/, reduction from baseline). The frequency of teeth clenching increased during the follow-up period (M = 2.5/day, 81% decrease from baseline). Diane’s mean daily pain estimates are also shown in Fig. 2. Her mean daily pain level was 2.5 during baseline, which did not change appreciably as a function of habit-reversal 200-
, I
DAYS Fig. 1. The frequency
of Donald’s
WEEKS
jaw popping
MONTHS
on a daily basis, one day per week, and one day
per month.
MICHAEL S. ROSENBAUM and TEOWRO AKLLON
92 25
BASELINE
1 t
5 -
HABIT-REVERSAL
RELAXATION
I I
RELAXATIONIII~
5
I ST&.5 ’ tblANAGMENli
.I0
1%
2b
28
CLENCHING PAIN
ti
i5
4.0
45
50..
DAYS
2
s
s
MONTHS
Fig. 2. The frequency of Diane’s teeth clenching (0) and her mean pain estimate (0) on a daily basis and averaged over one week per month.
for teeth clenching (M = 2.6, 4% increase from baseline). Relaxation plus stress management was associated with a slight decrease in the daily pain level (M = 2.2, 12% decrease from baseline), which decreased even further following relaxation II (M = 1.9, 24% decrease from baseline). During the follow-up period, Diane’s daily pain level increased (M = 2.1, 16% decrease from baseline). Additionally, Diane stopped taking Tranxene during baseline, restricting her medications for facial pain to Bufferin, Tylenol and Darvocet tablets. The number of tablets she consumed per day decreased from a mean of four to two following the relaxation plus stress management procedure and remained at that level throughout the relaxation II phase. During the follow-up period, Diane averaged three tablets per day for facial pain. Rick The mean frequency of Rick’s teeth grinding was 75/day during baseline (Fig. 3). Following treatment with habit-reversal, this behavior decreased markedly to a mean of
0-I
i I
5
I
,
f0
*5
DAYS
I
1
I
20
25
3o
I,<,
35
I
2 4
I
6
MONTHS
Fig. 3. The frequency of Rick’s teeth grinding on a daily basis and averaged over one week per
month.
93
Habit-reversal and bruxism 25
BASELINE
RELA%ATION + STRESS MANAGEMENT
HABIT-REVERSAL I :
i
: f :
20
x Y
15
I.
I
OJ I
5
i I
I
I
I
IO
15
20
25
DAYS
D-f
30%
MONTHS
Fig. 4. The frequency of Chuck’s teeth clenching on a daily basis and averaged over one week per month.
8S/day (89% decrease from baseline). The results at the six month follow-up showed a further decrease in teeth grinding (M = S/day, 93% decrease from baseline). Additionally, Rick reported that several of his co-workers commented on the reduction in teeth grinding noise he made. Chuck
Chuck’s mean frequency of teeth clenching was 17.ljday during baseline (Fig. 4). Habit-reversal treatment was associated with a decrease in teeth clenching (M = 8.l/day, 53% decrease from baseline). During the relaxation plus stress management phase to reduce the tightness in Chuck’s jaw and neck, clenching decreased even further (M = 3.8/day, 78% decrease from baseline). The results at the six month follow-up showed that this behavior remained at the previous low level (M = 4/day, 77”/, decrease from baseline). Additionally, at both the one and six month follow-ups, Chuck reported a marked reduction in the tightness in his neck and jaw relative to before treatment with relaxation plus stress management. DISCUSSION
The results of this study indicate that the habit-reversal technique (Azrin and Nunn, 1973, 1977) can be effective in decreasing and/or eliminating bruxism. The decreases obtained for the four clients were immediate and were maintained over long periods of time (i.e. six and 12 month follow-ups). Habit-reversal proved effective regardless of whether the pretreatment frequency of the problem behavior was high (e.g. M= 169.8/day for Donald’s jaw popping) or low (e.g. M = 13/day for Diane’s teeth clenching). Several aspects of the habit-reversal technique appeared to be associated with its effectiveness. Each client was instructed to self-record the frequency of the problem behavior daily during baseline and continuing on a daily basis throughout the first month following treatment By focusing on the target response, the client could become more aware of its occurrence and receive immediate feedback concerning its frequency. As a function of this feedback mechanism, the client could alter the frequency of occurrence of the target response. Several authors have documented and discussed this reactive effect associated with self-recording (e.g. Jeffrey, 1974; Kanfer, 1970, 1975; Kazdin, 1974a,b; McFall, 1977; Nelson, 1977). In the initial interview with the client in the present research, the researcher clearly indicated that the treatment technique was
94
MICHAELS. ROSENBALJM and TEOD~ROAYLLON
designed to decrease the frequency of the problem behavior. Therefore, self-recording may have been associated with lower frequencies of the problem behavior during baseline relative to what these frequencies may have been prior to self-recording. Additionally, baseline data for Donald, Diane, and Chuck showed a decreasing trend during the initial baseline sessions, thereby providing support for the reactive effects associated with self-recording. It is important to note, however, that even during baseline. target responses were occurring frequently enough to continue to represent problems for the clients. In addition to self-recording, the response description, early warning, situation awareness training, and habit inconvenience review procedures contributed to increasing the client’s awareness of the occurrence of the target response, including its antecedents and consequences. For example, Donald was unaware that the irritating sensation in his left masseter muscle and moving his jaw slightly to the right were associated with jaw popping. The addition of this type of information (i.e. a functional analysis) made it easier for each client to use the competing response practice procedure successfully. Yet. this information may have also contributed to an alteration in the self-recording process. Since these procedures increased the client’s awareness of the antecedents related to the target response, it is possible that certain responses not included as target responses during baseline were recorded as such following the treatment session. An equally plausible alternative is that certain responses recorded as target responses during baseline were not recorded as such following the treatment session. Unfortunately, data documenting the effect of increasing a client’s awareness of antecedents associated with a target response on subsequent self-recorded data have yet to be reported (Nelson, personal communication, 1979). The competing response practice procedure served two main functions: (a) It interrupted the usual chain of events terminating in the performance of the problem behavior; and (b) It provided an interval of time (2 or 3 min) during which the client could remain aware that either an urge to perform a target response, an antecedent to that response, or the response itself had occurred. By requiring a minimal amount of effort on behalf of the client, the competing response practice procedure was minimally aversive and could be incorporated easily into the client’s daily routine. The symbolic rehearsal procedure provided the client with an opportunity to apply the competing response practice procedure, thereby potentially contributing to the generalization across settings of treatment effects associated with habit-reversal. In the case of facial pain, it appears that whereas habit-reversal can be effective in markedly reducing and/or eliminating bruxism associated with the pain, this may not be sufficient to alter the degree of pain experienced by the client. The relationship between a reduction in bruxism and a reduction in pain may be related to the type of problem behavior (e.g. jaw popping, teeth grinding, or teeth clenching) and/or the duration of the pain. Perhaps eliminating or markedly reducing bruxism can be effective in reducing or eliminating pain of short duration (e.g. Donald’s pain had been present for less than two years) but not of long duration (e.g. Diane’s pain had been present for at least 10 years). Alternatively, the pain may be maintained by certain environmental contingencies and may function as a behavior separate from bruxism (Sanders, personal communication, 1979). The addition of a relaxation plus stress management procedure appeared to be effective in reducing Diane’s pain to a level below that achieved with a muscle relaxing medication. This procedure can also help to alleviate muscular tightness in clients who have not developed pain symptoms (e.g. Chuck). Although conclusive statements would be premature at this time, the results of the present research demonstrate the applicability of habit-reversal in treating the cause of the facial pain (i.e. bruxism). The clinical usefulness of habit-reversal can be determined only through judging its effectiveness relative to other forms of treatment for bruxism. The most commonly used and successful treatment has been massed practice (Ayer and Gale, 1969; Ayer and Levin, 1973, 1975). However, there appear to be several limitations to using this procedure. First, massed practice could result in the development of sustained muscular tightness
Habit-reversal
and bruxism
95
and pain if it were used over an extended period of time, because of the requirement that the client bite the teeth together. Second, since it results in muscular fatigue, massed practice represents an aversive procedure with which many clients may not comply in the absence of supervision by a therapist. Third, massed practice would not be indicated for clients with facial pain, since biting the teeth together would result in increased muscular tension and an aggravation of the pain. In the present research, habit-reversal did include a competing response of biting the teeth together for some clients (i.e. Donald and Rick). Yet, since the problem behavior decreased so rapidly, it was not necessary for the client to use this competing response frequently. This, in turn, reduced the possibility that muscular tightness or facial pain would develop. The other competing response for bruxism, opening the mouth wide, was used with one client with pain (i.e. Diane) and another with muscular tightness (i.e. Chuck). Since this competing response enabled the masseter muscle to remain relaxed, it did not exacerbate these conditions any further. One limitation to using self-recording with teeth clenching is that many individuals remain unaware of several occurrences of this behavior even following a response description type of procedure (Sanders, 1979). Through the use of electromyographic recording procedures, Sanders (1979) has noted that electrical activity indicative of clenching was not always accompanied by the client’s self-report of cl~ching. Findings such as these indicate the applicability of a portable biofeedback apparatus to signal the client that clenching has just commenced (Solberg and Rugh, 1972), followed by the use of a competing response to interrupt the behavioral chain. This represents one direction for future research in the area of bruxism and facial pain. In terms of future research, component analyses of the habit-reversal technique to identify the relative contribution of each component procedure seems warranted. This research could be conducted in the following single-subject design: (a) During baseline the client would be instructed to self-record the frequency of the problem behavior; (b) During the Treatment I phase, the client would engage in the response description, early warning, situation awareness training, and habit inconvenience review procedures; (c) The competing response practice procedure would be taught in the Treatment II phase; and (d) The symbolic rehearsal procedure would constitute the Treatment III phase. Preferably this design would be included in a multiple-baseline-across-subjects design, although a series of comparison designs (ABCD) might be sufficient. Alternatively, this research could be conducted in the following between subjects design: (a} Group I would be instructed to self-record the frequency of the problem behavior; (b) Group 2 would perform self-recording in addition to participating in the response description, early warning, situation awareness training, and habit inconvenience review procedures; (c) Group 3 would receive the same training as the previous group, with the addition of the competing response practice procedure; (d) Group 4 would receive training in the entire habit-reversal technique; and (e) Group 5 would serve as a no-treatment control group. In either of these two research designs the relative contributions of selfrecording, response awareness training, competing response practice, and symbolic rehearsal could be assessed separately. Acknowledgements-The authors wish to express their sincere appreciation to the other committee members, Michael A. Milan and Robert C. Brown. Part of this research was presented in a paper entitled, The Behavioral Treatment of Myofascial Pain Dysfunction, at the meeting of the Southeastern Psychological Association, New Orleans. March 1979.
REFERENCES AYERW. A. and GALE E. N. (1969) Extinction of bruxism by massed practice therapy. J. Can. dent. Ass. 35, 492494, AVER W. A. and LEVIN M. P. (1973) Elimination of tooth grinding habits by massed practice therapy. J. Periodont. 44, 569-571. AYER W. A. and LEVIN M. P. (1975) Theoretical basis and application of massed practice exercises for the elimination of tooth grinding habits. J. Periodonr. 46, 306-308. AZRIN N. H. and NUNN R. G. (1973) Habit-reversal: a method of eliminating nervous habits and tics. Behac. Res. Ther. 11, 619628.
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