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M.
Charlotte Wharton, Ph.D., Milwaukee, Wis., and Port Charlotte, Fla.
Pioneers
in dental treatment of Tempormandibular Joint Disorder stated that
the disorder results from a complex of factors including heredity,
function and stress. (Gelb 1977; Laskin 1969; Scott 1981). It is
only now that this assessment is becoming accepted. According to
a recent article by Samuel F. Dworkin (1996), no generally accepted
etiology for TMD has been developed, but the evidence for the role
of stress, as expressed in tooth clenching, is clearly part of the
picture.
Over the years, efforts have been made to separate true TMJ derangement
patients from those whose problems are primarily behavioral (Butterworth
& Deardorff, 1987). This distinction has proven to be spurious,
as our findings discussed below will show, and it seems evident
today that such an artificial dichotomy is counter productive.
Psychologists have attempted to understand the relationship between
stress and bruxism, or tooth clenching or grinding. (Rugh &
Harlon, 1988) Night time clenching has been related to preceding
daytime stressful events, for example. Chronic bruxism has been
shown to lead to TMD internal derangement. In other words, chronic
clenching damages the joint. TMD patients have been characterized
as anxious and neurotic by various researchers. Dworkin (1996) states
that there is no clearly defined TMD patient psychological profile
but that "virtually every scientific investigation finds significant
amounts of psychological and behavioral distress and dysfunction
in TMD sufferers."
The American Dental Association has recommended palliative and reversible
therapy due to a lack of knowledge of the natural history of the
disorder and the incidence of spontaneous remission and placebo
effects. Our work with TMD patients indicates that many of these
spontaneous remissions may be due to behavioral changes in the patient's
life that reduce stress and bruxism.
TMD,
A CHRONIC PAIN DISORDER
Temporomandibular
Joint Dysfunction or TMD is a chronic pain condition estimated to
effect 80 million Americans (Jaw Joints & Allied Musculoskeletal
Disorders Foundation, Inc., 1996). Demographic studies suggest men
and women are affected equally but clinical data shows three women
seek treatment for every man who does. The reason for this discrepancy
is not clear. The writer has speculated that it is partly due to
the increased stress in women's lives as they react to changes in
society's expectations. Many must be mother, wife and successful
worker in a competitive environment and find a way to balance these
social roles. Also, resentment may develop as society's mores no
longer sanction male dominance over women.
Common symptoms of temporomandibular disorder or TMD include pain
in and around the masticatory muscles and the tempormandibular joint,
limited mouth opening, the presence of "popping" or "crunching"
sounds emanating from the joint as the mouth opens, headache, earaches,
dizziness and ringing in the ears. In our sample of 179 female patients,
83% complained of frequent headaches: 61% complained of severe joint
pain; 61% complained of joint noises; 58% said they had trouble
chewing; and 46% had limited jaw opening. Among 31 men studied,
headaches were also the number one symptom, but joint noise and
chewing difficulties were ranked slightly higher than jaw pain.
Dworkin (1996) estimates that pain is the presenting complaint in
approximately 85% of the cases seen. In our research, described
below, we used pain at the beginning of treatment and at the end
of treatment to evaluate the success of our treatment.
THE
PORT CHARLOTTE, FLORIDA TMD TEAM
Dental
Journal has been developed to inform interested professionals
and patients of our team approach to TMD as well as other innovative
dental procedures. A recent unpublished psychology doctoral dissertation
(Legler, 1999) showed that dental professionals are reluctant to
refer their TMD patients to a clinical psychologist although they
were more comfortable doing so after meeting one in person. However,
the Legler study indicated that the dentists who were contacted
felt uncomfortable referring patients to a psychologist. This electronic
journal will, hopefully, help to overcome this reluctance.
Approximately twelve years ago, a team to treat TMD patients was
assembled by orthodontist Michael C. Alpern, DDS, MS. in Port Charlotte,
Florida. To date, we have examined and treated more than 1200 patients.
Each patient is initially examined and diagnosed by the orthodontist
and then referred to the clinical psychologist team member for an
evaluation, to be described below. After the evaluation, the patient
is assigned a rating on the 5-point Wharton Scale with 1 meaning
no stress component to their TMD, and 5 meaning stress from severe
mental illness. Our initial report, (Alpern, Nuelle and Wharton,
1998), describes the development of this 5-point Wharton Scale.
It comes from a distillation of knowledge gained about the psychodynamics
and life style of TMD patients studied, a total of 200 patients.
If the orthodontist discovers possible neurological, e.g. cervical,
damage or the patient reports severe and frequent headaches, the
neurologist team member examines the patient and prescribes any
needed medication and treatment. This also prevents misdiagnosis
of potentially serious disorders such as temporal arteritis, a blood
vessel disease which can lead to sudden and permanent blindness.
The final team member, the orthopedic surgeon, performs arthroscopic
surgery together with the orthodontist if it is indicated. During
our first few years of working together, approximately 12 percent
of our patients received such surgery. In recent years, this figure
has been reduced to less than 1 per cent per year due to obtaining
successful results without surgery. The reader may be familiar with
the pioneer work in the use of arthroscopic surgery techniques on
the temporomandibular joint (Nuelle & Alpern, 1986).
TMD
RESEARCH BY THE PORT CHARLOTTE TEAM
During
her work with TMD patients, the clinical psychologist gathered data
from patients and from the surgeon's operative records to perform
three research projects. The first project showed psychological
characteristics of TMD patients and suggested ways to help them.
The second and third studies evaluated our teamwork and showed our
success in terms of pain reduction after treatment. The psychologist
also developed a highly successful short term treatment program
which is described in detail in Wharton,(1992).
FIRST
RESEARCH PROJECT
The
first project was based on an examination of interview and psychological
test data of 104 female patients and 24 male patients. This study
generated answers to the following questions: What attitude and
emotional patterns do these individuals have in common? What experiences
in childhood and in present life characterize these patients? Do
these patients clench or grind their teeth? Are there test patterns
on the Minnesota Multiphasic Personality Inventory (MMPI) which
characterize them and can serve as a template against which to compare
MMPI profiles of future TMD patients? Findings of this first study
suggested that the typical TMD patient is "a woman in her mid-thirties
who was raised by a demanding and critical parent, and who responded
to this by becoming overly conscientious and passive in trying to
meet that parent's expectations. In order to do this, she had to
learn to push her feeling of resentment out of consciousness. This
persistent pattern of behavior has become maladaptive, so that she
remains out of touch with some of her feelings, tense and rigid
in her approach to tasks, unable to express anger appropriately,
and unable to relax her body and especially her jaw" (Alpern,
Nuelle & Wharton, 1988).
From the 1988 study, two tools were generated which have been used
since then. These are the Wharton Scale which rates patient stress
from 1 (low) to 5 (high). The second is a list of subjects to be
covered in a psychological interview called the TMJ Interview Points.
The Wharton Scale rating summarizes results from the interview and
from psychological tests (Minnesota Multiphasic Personality Inventory
and State-Trait Anger Expression Inventory) to give a single score
which can be used by other team members. Approximately 51% of our
patients are rated 3, 28.5% are rated 1 or 2 and 20.5% are rated
4 or 5 on the Wharton Scale. This suggests that about 72% of our
patients needed psychological help to overcome bruxism.
These findings also led to a short term psychological treatment
program for patients rated 3 or higher on the Wharton Scale. This
program is described in detail in Wharton (1992). Cooperation and
communication among the team members became essential and some patients
were asked to return for "booster" sessions with the psychologist
as dental treatment proceeded.
THE
SECOND RESEARCH PROJECT
This
study was designed to explore findings from the first one, namely,
that chronic resentment, usually against family members, characterized
TMD patients. A second psychological test, the State-Trait Anger
Expression Inventory or STAXI, was studied and its value as a template
for future use was determined. In other words, future patients could
be evaluated in their experiences with anger using the STAXI test
and compared to study subjects. TMD patients were shown to be persons
who were chronically angry but who kept the feelings in rather than
finding a healthy way to express them.
The second study also took advantage of surgical records on patients
who had received arthroscopic surgery. It was hypothesized that
if some patients have true internal derangement while others have
stress, surgical findings on patients rated 1 or 2 on the Wharton
Scale (low stress) should be more serious than surgical findings
on patients rated 3 or 4 on the Wharton Scale (high stress). However,
when analyzed, we found no statistical difference between high stress
and low stress patients. We did find, however, that higher Wharton
Scale ratings increase the likelihood that a patient will find herself
in surgery. Wharton Scale 1's and 2's were under represented while
3's were over represented in the surgical group. (Wharton Scale
4's were also under represented but this was because the surgeon
early on avoided surgery on these patients because stress was felt
to be their main problem and surgery was not the best medical treatment
for them.) In general our findings suggest that surgery was done
because of persistent stress and pain rather than because of discoverable
abnormalities in the joint.
The second study also analyzed reports of pain from 28 consecutively
treated female patients. Each person rated right and left joint
pain on a 5 point scale ranging from no pain, to slight pain, to
some pain, to moderate pain to severe or unbearable pain. Before
team treatment, the average or mean rating was 2.6 (between slight
and some pain). After team treatment the mean rating was 0.5 (no
pain). Joint noise was reduced from 2.9 to 0.9 on a 5 point noise
scale and chewing difficulty from 3.93 on a 5-point scale to 1.0.
All differences were statistically significant at the .0001 level.
THE
THIRD RESEARCH PROJECT
Our
third research project was basically a repeat of the second project
described above. This time however, 27 consecutive TMD patients
rated their joint pain, joint noise and headache frequency before
treatment began and when it was finished. In the earlier study,
patients remembered their pre-treatment pain after treatment was
finished and rated it on a 5-point scale retroactively. This was
then compared to pain after treatment was completed. The results
of this second outcome study were virtually identical to those in
the first study of pain before and after team treatment. Pain started
at a 2.9 rating and ended at a 0.6 level. The following table, taken
from Alpern and Wharton, 1997, shows these results.
PRETREATMENT POSTTREATMENT
Joint Noise (0-4) 2.2 +/- 1.6 S.D. 0.7 +/-1.1 S.D*
Facial Pain (0-5) 2.9 +/- 1.4 S.D. 0.6 +/- 1.0S.D*
Headaches (0-4) 2.3 +/- 1.5 S.D. 0.7 +/- 1.2S.D*
*p
<0.00001, paired the test compared with pretreatment score.
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PRETREATMENT
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POSTTREATMENT
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Joint
Noise (0-4)
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2.2
+/- 1.6 S.D.
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0.7
+/-1.1 S.D*
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Facial
Pain (0-5)
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2.9
+/- 1.4 S.D.
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0.6
+/- 1.0S.D*
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Headaches
(0-4)
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2.3
+/- 1.5 S.D.
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0.7
+/- 1.2S.D*
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In
summary, we have evaluated and treated approximately 1,200 patients.
Three research projects have established the following facts: Approximately
72% of the TMD patients had stress significant enough to require
psychological help. This treatment was usually short term and involved
altering tooth clenching habits, day and night, overcoming habitual
feelings of resentment, and altering habit patterns of over conscientiousness
and perfectionism. Two studies showed that pain was virtually eliminated
by our team treatment approach. Eighty-nine percent of our patients
in the second follow up study ended treatment with no pain. We contrasted
this to a long term study published in 1987 in which 24 percent
of finished patients had no pain after approximately three years
of orthodontic treatment only. (Williamson & Sheffield, 1987).
Arthroscopic surgery incidence was drastically reduced by the growing
success of our non-surgical treatment methods. These included occlusal
splint therapy, dietary changes, changes in sleep posture, learning
to never touch or lean on one's face and to refrain from chewing
on objects or chewing gum, and psychological stress reduction treatment.
A second outcome from our work involved methods of communicating
among team members using the Wharton Scale. We also developed a
short term psychological treatment protocol which was research based
and very effective.
We are confident that future workers will combine dental, medical
and psychological evaluation and treatment as they treat TMD patients.
These cross discipline treatment plans have become common in other
chronic pain disorders such as back pain, and headache. Psychological
factors are becoming more and more widely recognized in total treatment
of health problems. For example, chronic hostility presents a serious
threat to cardiac health, as serious as well known risk factors
of smoking, obesity and a high-fat diet (Hafen, 1999). Habits such
as smoking cigarettes are widely understood to be related to health.
Dentists have recognized the importance of habits in dental health
for years as they encourage flossing and brushing. This work on
bruxism and TMD falls in this tradition of behavioral and lifestyle
factors considered along with biological factors in studying disease
and disorder.
The public is generally more accepting of such collaborative treatment
than are some dental professionals. Perhaps better preparation for
this kind of practice in dental education would prepare dentists
to work in teams with other professionals.
TMJ
INTERVIEW POINT
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