Cognitive behavioral therapy for psychosomatic problems in dental settings

Reappraising the psychosomatic approach in the study of "chronic orofacial pain": looking for the essential nature of these intractable conditions

As burning mouth syndrome (BMS) and atypical odontalgia (AO) continue to remain complex in terms of pathophysiology and lack explicit treatment protocol, clinicians are left searching for appropriate solutions. Oversimplification solves nothing about what bothers us in clinical situations with BMS or AO. It is important to treat a complicated phenomenon as complex. We should keep careful observations and fact-finding based on a pragmatic approach toward drug selection and prescription with regular follow-up. We also need to assess the long-term prognosis of treatment with a meticulous selection of sample size and characteristics. Further investigation of BMS and AO from a psychosomatic perspective has the potential to provide new insight into the interface between brain function and "chronic orofacial pain."

THE 3P MODEL AND ORAL HEALTH IMPACT: DEMONSTRATING THE IMPORTANCE OF BEHAVIORAL AND SOCIAL SCIENCES IN THE FUTURE OF EVIDENCE-BASED DENTISTRY

Oral health impact or oral health related quality of life is an increasingly important and well-known metric in dental care and research. There have been recent calls for greater integration of the behavioral and social sciences into oral health research and practice, including the need for frameworks and theories to guide this work. One such framework for understanding the role of predisposing, precipitating, and perpetuating biopsychosocial mechanisms in health and disease is the "3P" model. Here, the 3P model is described and applied to case examples to help understand the development and maintenance of oral health impact. Additionally, this paper outlines how this conceptualization using the 3P model and oral health impact makes way for greater integration of behavioral interventions to prevent, mitigate, or treat the negative impact that oral, craniofacial, or dental disease may have on individuals. Doing this allows for a broadening of what evidence-based dentistry means for the future and provides a roadmap going forward.

Should Preoperative Information Before Impacted Third Molar Extraction Be Visual, Verbal, or Both?

PURPOSE

Offering preoperative information is one option to help patients cope with the anxiety associated with oral and maxillofacial surgical procedures. Although this information is commonly delivered verbally, written information, audio recordings, and videos are also recommended. This study aimed to evaluate the effects of different preoperative information techniques on patients' anxiety levels before and after third molar tooth extraction.

MATERIALS AND METHODS

A single-blind randomized controlled clinical trial with parallel groups was performed. 92 patients who fulfilled the inclusion criteria were randomly assigned to one of four groups. Group 1 was provided information via a silent video with subtitles. Group 2 was informed via a video with background audio. Group 3 was provided a written information brochure. Group 4, designated as the control group, was informed verbally. The Spielberger state anxiety inventory (STAI-S), dental fear scale (DFS), modified dental anxiety scale (MDAS), and visual analog scale (VAS) were used pre- and postoperatively to evaluate the dental anxiety of patients. The primary predictor variable was the preoperative information method. The primary outcome variables were the scores of STAI-S, DFS, MDAS, and VAS. Gender was also set as a covariate variable. Data analysis was performed with the IBM SPSS Statistics 25.0 software program. Unless otherwise stated, P < .05 was considered statistically significant.

RESULTS

A total of 86 patients scheduled for impacted third molar extractions under local anesthesia were included in the study. There was no statistically significant difference among the groups in the mean age (P = .275) or distribution of gender (P = .070). Compared to preoperative values, the postoperative scores of MDAS and VAS were decreased significantly in group 1 (P = .002, P = .003, respectively) and group 3 (P = .007; P = .009, respectively). No statistically significant differences were found between the preoperative and postoperative scores of STAI-S, DFS, MDAS, and VAS in group 2 (P = .300, P = .028, P = .063, P = .038, respectively) and group 4 (P = .127, P = .587, P = .072, P = .016, respectively).

CONCLUSIONS

The findings indicate that visual or written material, without audio or oral delivery, substantially reduced the anxiety associated with oral and maxillofacial surgery. Therefore, clinicians should preferentially provide information via written methods to control patients' anxiety before impacted third molar surgery.

Comparison of the effect of acceptance and commitment therapy and cognitive behavioral therapy on pain tolerance and intensity perception in patients with dental anxiety: A randomized trial

Background

Dental anxiety has negative effects on dentists' pain management. Patients have different levels of pain tolerance. Therefore, providing psychological interventions can reduce treatment avoidance and promote oral health. This study compared the effect of acceptance and commitment therapy (ACT) and cognitive behavioral therapy (CBT) on pain coping strategies and pain perception intensity in patients with dental anxiety.

Materials and Methods

This clinical trial with a pretest-posttest control group design and a 3-month follow-up period was performed on 45 patients with dental anxiety. They were randomly selected by convenience sampling method and assigned to two experimental groups and one control group. The first experimental group underwent 10 sessions of ACT, the second experimental group underwent 10 sessions of CBT, and the control group underwent oral care training. Data were collected by the Rosenstiel and Keefe's Coping Strategies Questionnaire and McGill Pain Questionnaire and analyzed by SPSS (version 24) software. The considered significance level is 0.05.

Results

The results showed no significant difference between ACT and CBT in pain coping strategies and pain perception intensity (P < 0.05) but indicated a significant difference between the treatment groups and the control group. Moreover, the results showed a significant difference between posttest and follow-up and pretest in pain coping strategies and pain perception intensity (P < 0.01) but indicated no significant difference between posttest and follow-up (P < 0.05).

Conclusion

ACT and CBT can play an important role in the sustainable improvement of pain coping strategies and pain perception intensity in patients with dental anxiety.

Diagnosis and Treatment of Myogenous Temporomandibular Disorders: A Clinical Update

Myogenous temporomandibular disorders (M-TMDs) are the most common chronic orofacial pain, affecting the masticatory muscles and, thus, jaw movement. While a concise diagnosis is crucial to formulate a rational treatment plan, the similarities in clinical presentations that M-TMDs share with other neuromuscular disorders affecting the temporomandibular joint (TMJ) could easily confuse physicians. In addition to the basics, such as thorough history taking and meticulous clinical examinations, different imaging techniques are useful adjuncts to facilitate the diagnostic process. This review presents an overview of the current understanding on a variety of diagnostic and treatment modalities for M-TMD patients. It is essential to highlight that there is not a single treatment for all, and the benefits of multidisciplinary strategies have been noted for the effective management of myogenous TMD pain. Treatment modalities ranging from conservative to minimally invasive options are discussed in this review.

Temporomandibular Myofascial Pain Syndrome-Aetiology and Biopsychosocial Modulation. A Narrative Review

This review elaborates on the aetiology, diagnosis, and treatment of temporomandibular (TMD) myofascial pain syndrome (MPS) regulated by psychosocial factors. MPS impairs functioning in society due to the accompanying pain. Directed and self-directed biopsychosocial profile modulation may be beneficial in the treatment of MPS. Moreover, nutrition is also a considerable part of musculoskeletal system health. A fruit and vegetable diet contributes to a reduction in chronic pain intensity because of its anti-inflammatory influence. Cannabidiol (CBD) oils may also be used in the treatment as they reduce stress and anxiety. A promising alternative treatment may be craniosacral therapy which uses gentle fascia palpation techniques to decrease sympathetic arousal by regulating body rhythms and release fascial restrictions between the cranium and sacrum. MPS is affected by the combined action of the limbic, autonomic, endocrine, somatic, nociceptive, and immune systems. Therefore, the treatment of MPS should be deliberated holistically as it is a complex disorder.

Enhancing smart healthcare in dentistry: an approach to managing patients' stress

This paper presents a model of a smart healthcare service for stress management in dental patients during the interventions. The main goal is to provide dental clinics with a model that enables introducing a stress management service into everyday practice and provides patients with a better experience in a typically stressful situation. The approach is based on employing wearable sensors for monitoring physiological parameters, and a mobile application for progressive muscle relaxation therapy. Dental patients were divided into experimental and control groups. Participants from the experimental group were treated with progressive muscle relaxation through mobile health application with audio content, and patients from the control group were not exposed to any relaxation method. Heart rate was measured in both groups through three test phases: pre-intervention, intervention, and post-intervention. Evaluation of the anxiety level was performed using the STAI test. Results show that the measured heart rate in the post-intervention phase is lower than in the intervention phase in both testing groups, as well as in the pre-intervention phase. STAI scores were significantly higher in the control group through all test phases. The research found that the proposed system applied to dentist patients may relieve their anxiety symptoms and decrease stress level, which improves the patients' experience and leads to higher patients' satisfaction.

Catastrophising, pain self-efficacy and acceptance in patients with Burning Mouth Syndrome

BACKGROUND

Little is known about pain catastrophising, pain self-efficacy and chronic pain acceptance in burning mouth syndrome (BMS) and their effect on health-related quality of life (HRQoL) and symptoms of anxiety and depressive disorders.

OBJECTIVES

To describe pain catastrophising, pain self-efficacy and pain acceptance in BMS patients and explore associations with affective function and HRQoL.

METHODS

A cross-sectional study of 36 BMS patients (31 female) referred to an Orofacial Pain Clinic completed the Pain Catastrophizing Scale, the Pain Self-Efficacy Questionnaire and the Chronic Pain Acceptance Questionnaire-8 in addition to standardised self-reported questionnaires measuring mood and oral and generic HRQoL.

RESULTS

Pain catastrophising levels were markedly higher than (non-clinical) population norms, with 32.0% of patients reporting clinically relevant levels. Pain self-efficacy and chronic pain acceptance varied widely; 24.0% evidenced low confidence to cope with pain, and 53.8% reported low activity engagement and/or low pain willingness. Catastrophising showed moderate-to-strong associations with measures of anxiety (r = 0.63), depression (r = 0.80), and oral (r = 0.61) and generic HRQoL (rho=-0.84). Self-efficacy and acceptance were also closely related to levels of depression (r/rho=-0.83 to -0.73) and generic HRQoL (r/rho = 0.74 to 0.75). These associations were stronger than those between pain severity and affective function/HRQoL and persisted after controlling for pain severity.

CONCLUSIONS

A substantial proportion of BMS patients evidence maladaptive beliefs about personal effectiveness in managing pain, which is closely related to affective disorders and impaired HRQoL. As such, treatment approaches targeting catastrophising, pain self-efficacy and acceptance may prove beneficial in improving mood and quality of life in BMS patients.

Effects of cognitive behavioral therapy on orofacial pain conditions

Numerous studies have confirmed the effectiveness of cognitive behavioral therapy (CBT) for chronic pain, and it is generally regarded as an appropriate intervention. However, it may not be effective for some pain sites, and the duration of the effect may be limited. In addition, some studies of CBT lacked a comparison group. This review summarizes evidence for the effectiveness of CBT for orofacial pain and assists in the development of guidelines for orofacial pain management. A literature search in PubMed was performed for studies published from April 1990 through March 2020. The search keywords were "burning mouth syndrome," "temporomandibular disorders," "myofascial pain syndrome,""chronic orofacial pain conditions," "cognitive behavioral therapy," and "non-pharmacological therapy." The results indicate that CBT alone or in combination with other treatments, such as intraoral appliance, stress management, or biofeedback, is effective for the vast majority of orofacial pain cases. Therefore, dentists should consider using CBT to manage orofacial pain in their patients.

Behavioral Sciences in the Promotion of Oral Health

The importance and value of behavioral sciences in dentistry have long been recognized, and their contribution to dental education, research, clinical practice, and oral health policy has been significant over the past half century. Over time behavioral sciences have expanded our understanding of oral health beyond "disease" to a broader biopsychosocial concept of oral health. This in turn has led dentistry away from a focus of "treatment" to oral health "care," notably in the new millennium. Key oral health behaviors have been identified for more than half a century: the importance of diet, oral hygiene, dental services, and other factors. Various behavioral models and theories have been proposed, particularly since the 1970s, providing useful frameworks with sound psychological basis to help understand the paths of oral health behaviors. These models draw on theories of self-efficacy, motivation, counseling, and "behavior change." Since the 1980s, there has been a greater understanding that these behaviors often share a common pathway with the etiology of other diseases (common risk factors). Furthermore, the relationship between individual factors and the broader environmental factors has been increasingly emphasized since the 1990s, leading to a united call for action in addressing oral health inequalities. Within the past decade, there are useful examples of models, frameworks, and techniques of behavior change with respect to oral health, involving planning, prompting, encouraging, goal setting, and/or motivating. In particular, there is a growing interest and use of motivational interviewing. Likewise, behavioral therapies, such as cognitive behavioral therapy, are increasingly being employed in dental practice in the management of dental anxiety, pain, and psychosomatic dental and oral problems, with promising results. Recommendations are outlined for future directions for behavioral sciences in the promotion of oral health.

Current management strategies for the pain of elderly patients with burning mouth syndrome: a critical review

Burning Mouth Syndrome (BMS), a chronic intraoral burning sensation or dysesthesia without clinically evident causes, is one of the most common medically unexplained oral symptoms/syndromes. Even though the clinical features of BMS have been astonishingly common and consistent throughout the world for hundreds of years, BMS remains an enigma and has evolved to more intractable condition. In fact, there is a large and growing number of elderly BMS patients for whom the disease is accompanied by systemic diseases, in addition to aging physical change, which makes the diagnosis and treatment of BMS more difficult. Because the biggest barrier preventing us from finding the core pathophysiology and best therapy for BMS seems to be its heterogeneity, this syndrome remains challenging for clinicians. In this review, we discuss currently hopeful management strategies, including central neuromodulators (Tricyclic Antidepressants - TCAs, Serotonin, and Norepinephrine Reuptake Inhibitors - SNRIs, Selective Serotonin Reuptake Inhibitors - SSRIs, Clonazepam) and solutions for applying non-pharmacology approaches. Moreover, we also emphasize the important role of patient education and anxiety management to improve the patients’ quality of life. A combination of optimized medication with a short-term supportive psychotherapeutic approach might be a useful solution.

Oral burning: local and systemic connection for a patient-centric approach

Burning symptoms in the oral cavity are caused by a range of systemic and local factors, in addition to the neuropathic pain disorder burning mouth syndrome (BMS). Patients may state oral burning as a standalone symptom or may report as a secondary symptom in association with other factors, most commonly with oral dryness, oral mucosal lesions, or certain systemic conditions. There is a level of uncertainty in the presentation of this condition which creates a diagnostic challenge from both the patient's perspective and the practitioner evaluating these individuals. The diagnoses are complicated due to the lack of a clear definition of BMS and clinical guidelines to distinguish BMS from other conditions that are responsible for oral burning symptoms. A clinician should be able to differentiate oral burning from burning mouth syndrome. This integrative review discusses on local and systemic etiologies of oral burning based on current evidence that needs to be excluded for a diagnosis of BMS. It also provides an algorithm for diagnostic workup and therapeutic management to medical providers for patients experiencing oral burning symptoms. This comprehensive system provides a systematic stepwise workup in diagnosing and managing patients presenting with a complaint of oral burning that optimally meets a predictive, preventive, and personalized medicine (PPPM) approach.

Effect of acceptance and commitment therapy on body image flexibility and body awareness in patients with psychosomatic disorders: a randomized clinical trial

OBJECTIVE

The aim of this research was to examine the effectiveness of the acceptance and commitment therapy (ACT) for body image flexibility and body awareness in these patients.

METHODS

A randomized clinical trial was conducted at Kashan University of Medical Sciences clinics in Kashan, Iran, from December 1, 2017 to March 30, 2018. A sample of 75 patients with psychosomatic disorders was selected by convenience sampling. The selected patients were randomly divided into three 25-member groups. The experimental group received medicinal treatment combined with the (ACT). The active control group received the usual treatment plus psycho education in general psychology, and the treatment group solely received the medicinal treatment usually used in the treatment centers. The results were obtained using the following scales in the pretest and posttest phases and the two-month follow-up: the demographic questionnaire; Shields' body awareness questionnaire; and Sandoz's body image flexibility questionnaire. The data were analyzed using the descriptive statistics tests (mean and standard deviation) and the repeated measures analysis of variance and chi-square tests in IBM-SPSS version 21.

RESULTS

There was no significant difference among the three groups in terms of body image flexibility, body awareness, somatic symptoms, and demographic variables. The results of the posttest and follow-up examinations suggested that the ACT group more effectively and significantly improved body image flexibility and body awareness as compared to both of the control groups (p=0.02).

CONCLUSIONS

The ACT successfully improves body image flexibility and body awareness in patients with psychosomatic disorders.

CLINICAL TRIAL REGISTRATION

This research was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT2017092532057N2.

FUNDING

Research and Technology Department of Kashan University of Medical Sciences funded the study (Ref: 96053).

Recent Advances in the Etiology and Treatment of Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a debilitating condition that has a striking female predilection. Although the oral mucosa is normal in appearance, patients with BMS experience oral burning that most commonly localizes to the lips and tongue. BMS is a diagnosis of exclusion, and all underlying pathoses associated with allodynia must be ruled out prior to rendering the diagnosis. The etiopathogenesis of BMS remains poorly understood, and thus patient management is challenging. Data indicate that oral and systemic factors both contribute to the development and persistence of the condition. Of particular interest, emerging work identifies structural and functional deficits within the nervous system that may lead to a more mechanistic understanding of BMS pathology. In addition, several novel findings suggest that circadian rhythm dysfunction may be a previously unappreciated yet clinically significant driver of disease. Circadian rhythm controls pain perception, mood, and sleep and plays a key role in the regulation of the hypothalamic-pituitary-adrenal axis. Since these are altered in patients with BMS, this may be reflective of underlying circadian dysfunction. While evidence-based treatment strategies for BMS are lacking, current treatment approaches consist of local and systemic medications, such as clonazepam, alpha lipoic acid, capsaicin, low-level laser therapy, gabapentin, and amitriptylin. In addition, the use of cognitive behavioral therapy is reported. This review provides an overview of the recent literature related to the etiology and treatment of BMS and identifies current challenges facing researchers and clinicians alike.