Bio-Psychosocial Perspective

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Clayton Chan Patient Ed3

Bio-Psychosocial Perspective

The National Institute of Dental and Craniofacial Research (NIDCR) ignores that TMD may have not only a muscular component to this disease/dysfunction, but that it also may have an occlusal component as well is an over-site which only exemplifies its intent to ignore the bio-physiologic factors of the stomatognathic system and posture of the upper quarter of the bodies systems.

  1. It suggests that medicine is the solution to TMD problems.
  2. It suggests that TMD often resolves itself and is self-healing.
  3. It emphasizes that TMD is a self-limiting disease and occlusal (bite) changes are to be avoided.
  4. It does not acknowledge that TMD is a major component in the scope of dental practice nor does it recognize that the dentist has a major role in dealing with muscles, joints and teeth as it pertains to temporomandibular joint disorder and all the associated signs and symptoms that relate to the trigeminal system.

Taking a “wait and see” approach to disease based on unfounded, conflicting opinions that TMD is both innocuous and unaffected by preventative therapy lacks responsibility to the public. A support for pain medications that can lead to dependency and drug abuse in dealing with chronic pain rather than a philosophy of support toward prevention is irresponsible.

To improperly suggest that occlusion is not even remotely related to TMD when it has been well demonstrated that loss of posterior occlusal support and parafunction have a role, even if an indirect one, is fatuous.  If the latter is an unfair criticism, why then would one support the use of flat splints presumably to avoid parafunction?

To convey that jaw joint X-rays (transcranial/tomographic radiographs) are not generally useful in diagnosing TMJ disorders is unconscionable and confused as to the understanding and appreciation of the TM joint. Not having an ability to distinguish normal from abnormal, pathologic from physiologic affords the doctor no possible way to diagnose nor render appropriate therapy.  It is not customarily used as a first radiographic procedure, but rather for conditions of long-standing pain and limitation of jaw movement that have not been responsive to conservative treatment. MRI may be indicated in cases of direct trauma to the joints as an early diagnostic modality.

No mention of the American Dental Association’s granted Seal of Acceptance to three computerized measurement devices that aid in the management of TMD are mentioned in this philosophy.

BACKGROUND: Psychosocial factors have a role in the onset of chronic orofacial pain. However, current management involves invasive therapies like occlusal adjustments and splints which lack an evidence base.

OBJECTIVES: To determine the efficacy of non-pharmacologic psychosocial interventions for chronic orofacial pain.

SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 25 October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE via OVID (1950 to 25 October 2010), EMBASE via OVID (1980 to 25 October 2010) and PsycINFO via OVID (1950 to 25 October 2010). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA: Randomised controlled trials which included non-pharmacological psychosocial interventions for adults with chronic orofacial pain compared with any other form of treatment (e.g. usual care like intraoral splints, pharmacological treatment and/or physiotherapy).

DATA COLLECTION AND ANALYSIS: Data were independently extracted in duplicate. Trial authors were contacted for details of randomisation and loss to follow-up, and also to provide means and standard deviations for outcome measures where these were not available. Risk of bias was assessed and disagreements between review authors were discussed and another review author involved where necessary.

MAIN RESULTS: Seventeen trials were eligible for inclusion into the review. Psychosocial interventions improved long-term pain intensity (standardised mean difference (SMD) -0.34, 95% confidence interval (CI) -0.50 to -0.18) and depression (SMD -0.35, 95% CI -0.54 to -0.16). However, the risk of bias was high for almost all studies. A subgroup analysis revealed that cognitive behavioural therapy (CBT) either alone or in combination with biofeedback improved long-term pain intensity, activity interference and depression. However the studies pooled had high risk of bias and were few in number. The pooled trials were all related to temporomandibular disorder (TMD).

AUTHORS’ CONCLUSIONS: There is weak evidence to support the use of psychosocial interventions for chronic orofacial pain. Although significant effects were observed for outcome measures where pooling was possible, the studies were few in number and had high risk of bias. However, given the non-invasive nature of such interventions they should be used in preference to other invasive and irreversible treatments which also have limited or no efficacy. Further high quality trials are needed to explore the effects of psychosocial interventions on chronic orofacial pain.

DATA SOURCES: Cochrane Oral Health Group’s Trials Register, Central, Medline, Embase, PsycINFO.

STUDY SELECTION: Randomised controlled trials of psychosocial interventions for chronic orofacial pain were included. Psychosocial interventions targeted towards changing thoughts, behaviours and/or feelings that may exacerbate pain symptoms through a vicious cycle were eligible. Primary outcomes were pain intensity/severity, satisfaction with pain relief and quality of life.

DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened studies, extracted data and assessed risk of bias. Dichotomous outcomes, were expressed as risk ratios with 95% confidence intervals, continuous outcomes as mean differences with 95% confidence intervals. Heterogeneity was assessed using the Cochrane test for heterogeneity and the I2 test. Meta-analyses were conducted using the random-effect or the fixed-effect models.

RESULTS: Fifteen of the 17 eligible studies were on temporomandibular disorders (TMDs), two on burning mouth syndrome. Psychosocial interventions improved long-term pain intensity (standardised mean difference (SMD) -0.34, 95% confidence interval (CI) -0.50 to -0.18) and depression (SMD -0.35, 95% CI -0.54 to -0.16). However, the risk of bias in these studies was high.

CONCLUSIONS: There is weak evidence to support the use of psychosocial interventions for chronic orofacial pain.