The painful mind

The management of temporomandibular disorders (TMDs) has been a topic of much controversy, debate and diverse opinions for almost a century. The controversies relate not only to their diagnosis but also to their etiology and appropriate treatment [1]. More recently, sleep disordered breathing (SDB) has become another topic which has developed its own set of controversies, leading the dental, medical and allied health professions to have differing opinions about many aspects of these conditions [2,3].

There is little disagreement in accepting that sleep and pain have a bidirectional relationship. Much of the contention, however, relates to the assumptions made that the previous anecdotal and unsubstantiated beliefs regarding the etiology of TMDs are now also the same for SDB, and therefore much of the management of SDB is the same as it has been for TMDs.

These unsubstantiated etiologic claims range from the presence of dental and skeletal malocclusions, centric relation discrepancies, lack of canine protected occlusion, bruxism, retrusive maxillae and mandibles, narrow maxillae, mouth breathing, and aberrant lip, tongue and craniocervical postures, just to name a few [1–3]. As a result, many clinicians believe that in order to address one’s TMD and/or SDB, one has to primarily direct treatment towards eliminating one or more of these culprits.

The evidence-based literature, including placebo studies as early as the 1970s [4–7] and more recently the large-scale clinical studies called the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) trials [8–11], have gradually shifted our focus from the crude dental and mechanistic model of TMD care to a biopsychosocial model of care. The presence of a complex mind-body interrelationship was appreciated when placebo TMD treatments such as sham medications, non-occluding oral appliances and mock equilibrations yielded favourable biological and behavioural responses. Eventually, the majority of the profession progressed towards more conservative and reversible treatments for managing TMD patients. Further, as a result of Henry Beecher’s early observations about pain modulation [12], to Melzack and Wall’s gate control of theory of pain [13], to the concept of a pain neuromatrix [14,15] and the effectiveness of placebos, the medical and dental profession finally began to accept that the central modulation or top-down pathways of pain control are a highly effective intrinsic mechanism for managing one’s pain experience.

We know so much more today about how pain is processed and then perceived. We also better understand the chronification of pain and central sensitization, the influence of co-morbidities on TMD conditions, and the vulnerability of certain individuals to developing a TMD problem. Whether in an acute or chronic pain model, one’s pain experience or perception of pain is greatly influenced by cognitive and emotional factors [1].

While this editorial is not about TMDs per se, it is really about the lack of emphasis and/or involvement by many clinicians in dealing with the cognitive and affective aspects of their patients’ pain experience. If our thoughts affect our feelings (and in time our actions), then over a period of time we develop belief systems that ultimately influence our mindset and how we cope on a day-to-day basis. Cognitive distortions including catastrophising, aberrant interpretation or meaning of one’s situation, along with negative emotions such as anger, anxiety, fear and sadness play such a significant role in influencing how one perceives and manages their pain [16–23].

While many clinicians, whether in the form of screening questionnaires and/or chairside discussion, may consider their patients’ psychological health, how many of us actually spend the time with our patients trying to help them overcome their psychological barriers or help them better cope cognitively and emotionally beyond the usual minimum? It appears that we will continue to still argue about the nonevidence-based claims for diagnosing and addressing TMD for years to come, but perhaps, we could spend more time on the established evidence-based role of psychological factors in the initiation, exacerbation and the perpetuation of our patients’ pain experience and factor this into our daily clinical practice.

We are not all professional psychologists or psychiatrists, and referring our patients to better manage their psychological well-being is important, but this is also not often done. Imagine, however, what a significant improvement we could achieve on our treatment outcomes, beyond putting a splint in or prescribing a pill, if we helped our patients better modulate their pain experience from the “top-down” both cognitively and emotionally. Better still, if we identify and educate our patients about these underlying influencing factors and teach them skills with cognitive behavioural therapy (CBT) as well as reframing, mindfulness and relaxation, and awareness of potentially negative behaviors, we not only better position them to manage their pain experience but we also may empower them to be in a more favourable position to better cope with future painful or traumatic situations [24–29].

As this journal moves into the new chapter of evidence-based dentistry and medicine, this is an opportune time for us embrace evidence-based psychological methods and supplement our normal treatments to significantly improve our outcomes and empower our patients to better combat their pain in the future. We can all do better in helping our patients heal their painful mind.