biopsychosocial aspects of orofacial pain · symptom reporting, catastrophizing, and fear...

Biopsychosocial Aspectsof Orofacial Pain

Richard Ohrbach and Justin Durham

AbstractThis chapter introduces the reader to the impor-tant concept of the biopsychosocial model ofillness and its role in healthcare. The chapterexplains the theoretical basis of thebiopsychosocial model and its relevance to anintegrated understanding of pain. Practicalapplication in assessing patients for psychoso-cial comorbidity and providing appropriateinterventions through the use of psychosocialinterventions including basic clinical practicesinformed by cognitive behavioral therapies aredescribed.

KeywordsOrofacial pain • Temporomandibular disor-ders • Biopsychosocial model • Diagnosis •Treatment

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Biopsychosocial Model . . . . . . . . . . . . . . . . . . . . . . . . . 3

Rationale for Applying the Biopsychosocialto OFP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Assessing the Psychosocial . . . . . . . . . . . . . . . . . . . . . . . . . . 5DC/TMD Psychosocial Axis (Axis II)

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Psychosocial Constructs Relevantto Persistent OFP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Somatoform Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Catastrophizing and Self-Efficacy . . . . . . . . . . . . . . . . . . . . 11Fear Avoidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Cognitive Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Behavioral Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Conclusions and Future Directions . . . . . . . . . . . . . . . . . 18

Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Introduction

The biopsychosocial model integrates psycholog-ical and social factors with traditional medicalfactors in order to better understand, and ulti-mately manage, the process of disease and illnessacross time and circumstance. Psychological fac-tors include, for example, anxiety, depression,

R. Ohrbach (*)Department of Oral Diagnostic Sciences, University atBuffalo, Buffalo, NY, USAe-mail: [email protected]

J. DurhamSchool of Dental Sciences, Newcastle University,Newcastle-Upon-Tyne, UKe-mail: [email protected]

# Crown Copyright 2017C.S. Farah et al. (eds.), Contemporary Oral Medicine,DOI 10.1007/978-3-319-28100-1_37-1

1

symptom reporting, catastrophizing, and fearavoidance, while social factors include, for exam-ple, support from family and friends, stigma, andaccess to medical care. Each of the listed exam-ples has extensive empirical support for their asso-ciation with pain disorders. Consequently, thismodel is currently the dominant paradigm withinpain medicine broadly, as evidenced by the scopeand values of the international congresses hosted,for example, by the International Association forthe Study of Pain, yet its incorporation withinspecific clinical or research settings remainshighly variable. Similarly, its recognition andincorporation into temporomandibular disorder(TMD) and orofacial pain (OFP) clinical orresearch settings remains variable. A brief histor-ical overview may help put this imperfectly real-ized but scientifically sound paradigm intocontext.

In many cultures, including ancient Greek cul-ture within the Western world, integrated views ofhealth have dominated. However, with the adventof anatomical and physiological investigationsinto the body, a biomedical view of healthcareprevailed in the Western world over the past sev-eral centuries: healthcare professions were fixatedon attending to the biological or the physicalmanifestations of diseases or disorders. Overtime with advances in biological, psychological,and sociological sciences, it has become more andmore apparent that the three disciplines are inex-tricably intertwined and any one of these caninfluence any of the other two. This is also trueof dysfunction or disorder in any of these threedomains affecting the other two domains, andhence the biopsychosocial model of healthcareand illness (described in the next section) becameestablished (Engel 1977). Although there was alarge push initially by medicine to explicitlyincorporate the biopsychosocial model, progresswas very slow. Over the past 40 years, however,with considerable research across multiple diseasedomains, there is now much greater understand-ing of the “bigger bang” you can get for yourtherapeutic “buck” if the clinician does not justtreat the biological in isolation to the psychoso-cial. In recent years an array of therapies has

emerged fulfilling the biopsychosocial model’sperspective on treatment (Astin et al. 2003). Yet,when the short-term costs associated withhealthcare economics are considered, medicinecontinues to struggle with the importance of fullimplementation of the model at the most basiclevel, that of evaluation and patient documenta-tion (Zulman et al. 2016).

The orofacial pain field, including TMD, hasdeveloped in a manner similar to the larger med-ical field with respect to the biopsychosocialmodel of healthcare and illness. For the particularcase of the development of the biopsychosocialmodel in TMD, further details are available(Ohrbach and Dworkin 2016). In brief, the earliestpublications of TMD (Annandale 1887; Costen1934) focused on structural perspectives, and thesubsequent dominant view in the field was tofocus on the correction of structure in order toaddress all types of patient complaints affectingthe masticatory system and associated sensorymechanisms. The publication of an integratedassessment and classification system, theResearch Diagnostic Criteria for TMD (RDC/TMD) (Dworkin and LeResche 1992) based onthe recently published biopsychosocial model,was followed initially by widespread skepticismif not rejection by the dental field that psychoso-cial factors had any relevance at all to the concernsof dentistry, including pain disorders. Over time,however, evidence using the RDC/TMD protocolconsistently demonstrated its relevance (Dworkin2010; Kotiranta et al. 2015), and today the major-ity of those researching and managing orofacialpain and TMD understand that comprehensiveand appropriate assessment and managementrequires consideration of the biopsychosocialmodel (Durham and Ohrbach 2010; Greene2010; Schiffman et al. 2014). The evidence fromthe larger field of generic pain research also sup-ports the significance of the biopsychosocialmodel as critical for understanding the complexityof pain processing (Campbell and Edwards 2009).Indeed, the orofacial pain and TMD field is repletewith healthy, critical discussion, reviews, and con-ference proceedings building on the core tenets ofthe biopsychosocial model (Ceusters et al. 2015;

2 R. Ohrbach and J. Durham

Greene et al. 1998; Greene and Obrez 2015;Michelotti et al. 2016; Ohrbach and Greene2013). Nevertheless, the biopsychosocial modelstill awaits full incorporation into the field of oralmedicine. In this chapter, we expand the consid-eration of the biopsychosocial model beyondTMD to include all of orofacial pain. This chapterwill guide the reader through the following: thetheoretical underpinning of the biopsychosocialmodel, psychosocial assessment of patients, andpsychosocial interventions.

The Biopsychosocial Model

Whenever someone suffers from a disease or dis-order, their psychological state will interact withtheir symptoms. Eventually the individual willdecide to seek help and present signs and symp-toms to a healthcare professional. The health pro-fessional will then pursue a cognitive process ofdeduction, induction, and pattern recognition inorder to attempt to match those signs and symp-toms to a known disease or disorder and, in addi-tion, may potentially institute furtherinvestigations in order to help identify the under-lying disease or disorder by its pathophysiology.

The preceding paragraph oversimplifies thedescription of the presenting features of a diseaseor disorder by assuming that only biological pro-cesses can influence signs and symptoms andassumes a “biological truism.” Assessment ofonly the disease-relevant signs and symptomsand identifying the potential underlying biologi-cal pathophysiology complete the conventionalbiomedical assessment of the patient. That anydisease or disorder can exert other psychosocialeffects on the individual is ignored and that anyother psychosocial comorbidity can influence thepresenting signs and symptoms and the way theindividual reacts to them is also ignored. Anotherway of stating the same thing is that all individualspresenting to healthcare professionals for helpwith a disease or a disorder are necessarilyexperiencing “illness” which is a broader conceptthan just the clinical signs and symptoms of thedisease or disorder. As Eisenberg defines it, illness

is the “discontinuity of states of being and per-ceived role performances” (Eisenberg 1977), andthis is important to consider as this chapterexplores the biopsychosocial aspects and modelof care in persistent orofacial pain.

The biopsychosocial model of care was firstintroduced to the medical literature in the late1970s (Engel 1977, 1980, 1985) in order toacknowledge that there is more to a disease or adisorder than just its biomedical aspects. Thebiopsychosocial model acknowledges that anydisease or disorder is a biopsychosocial entity;that is, it has biological effects or consequences,psychological effects or consequences, and socio-logical effects or consequences, and these threeparts of the model are not mutually exclusive butrather can be reciprocal in their relationships.

To give a worked example from the field ofinterest, a person may have a disk displacementwith reduction affecting their temporomandibularjoint (TMJ) which (1) exerts a biological effect ofoccasional nociception and a loud clicking noiseand (2) may cause the person to worry that there issomething seriously “wrong” with their TMJ; thelatter is amplified if commented on by other socialcontacts and in particular can make the individualmore self-conscious about eating in publicbecause of the noise. Worry, in turn, is oftencomprised of catastrophizing and anxiety; bothare discussed later in this chapter. In this mannerthe biological affects the psychological and thesociological parts of the model, and there is alsosome reciprocation from the two latter parts of themodel as they both have the potential to feed intocentral mechanisms of pain. Hence, the pain maybe less than, proportional to, or greater than, thecorresponding nociception from the TMJ.

From the somewhat simple worked exampleabove, it is hopefully apparent how inextricablylinked the parts of the biopsychosocial model areand how one part can influence another part to agreater, or lesser, extent dependent on the diseaseor illness in question as well as on the circum-stances or environment surrounding the individ-ual. In persistent (chronic) pain, the reciprocallinks between the parts of the biopsychosocialmodel are of great therapeutic importance and

Biopsychosocial Aspects of Orofacial Pain 3

help both predict prognosis and determine thebiopsychosocial therapeutic approaches neces-sary (Apkarian et al. 2005; Campbell andEdwards 2009; Epker et al. 1999; Ohrbach andDworkin 1998; Turner et al. 2007). If therapy isnot initiated to address all three aspects of thebiopsychosocial triumvirate, then treatment willbe less effective (Gatchel and Okifuji 2006).

The majority of the body of research into thebiopsychosocial aspects of persistent OFP hasoccurred in TMD. The advancement of knowl-edge in TMD is largely due to the recognition ofits biopsychosocial nature through the seminalwork in the 1950s by Schwartz (Schwartz 1955),in subsequent years by Bell, Laskin, and Greene(Bell 1979; Greene and Laskin 1974; Laskin1979), and culminating in the 1992 by Dworkinand LeResche who created the first,operationalized, dual axis biopsychosocial diag-nostic criteria (Research Diagnostic Criteria forTMD; RDC/TMD) (Dworkin and LeResche1992).

The construction and publication of theRDC/TMD in 1992 and its successor the Diag-nostic Criteria for TMD (DC/TMD) (Schiffmanet al. 2014) in 2014 allowed the selection, for thefirst time, of truly homogenous samples to beexamined in research related to TMD and, anexploration, and consequently an understanding,of the influence of the biopsychosocial model onoutcome of interventions for TMD. The two axesof both instruments help biologically define thecondition of interest (Axis I, physical axis) andpsychosocially assess the individual (Axis II, psy-chosocial axis). The remainder of this chapterwill, therefore, use the knowledge on thebiopsychosocial model’s influence on outcomesin TMD gained from the application of the (R)DC/TMD in TMD and the principles of the (R)DC/TMD to exemplify the role of biopsychosocialfactors in persistent OFP. TMD can be used asthe model by which to explain the influence andmanagement of biopsychosocial factors as it islikely that most constructs relevant in TMD alsoexert influence in the biopsychosocial assessmentand treatment of patients with persistent OFP

(Durham et al. 2015). Currently, the other persis-tent OFP conditions, other than TMD, such aspersistent dentoalveolar pain disorder (PDAP)(Nixdorf et al. 2012), burning mouth syndrome(BMS), and trigeminal neuralgia (TN), have ascarcity of data on the implications of thebiopsychosocial model in their assessment andmanagement, but given the data that are available(Durham et al. 2015), it is reasonable to assumethat there will be sufficient similarities with TMD.

Rationale for Applyingthe Biopsychosocial to OFP

At a most basic level, it is known that anychronic illness exerts psychological effects, andcomorbid mental health problems are common-place affecting up to a third of those with long-term physical health problems (Cimpean andDrake 2011). Depression and anxiety are partic-ularly prevalent in those with any chronic phys-ical health problem, and persistent OFP is noexception to this. There is an argument overwhich came first, a mental health problem or(persistent) pain, but the argument is somewhatmoot as without managing the impacts of thepain and also the mental health problem neitheris likely to significantly improve on its own or ifmanaged in isolation. When one considers thesignificant biopsychosocial impacts of persistentOFP conditions, which are well described bothin quality-of-life and qualitative research, it ishardly a leap of faith to accept that if one hasunremitting pain radiating around one’s face,which clinicians fail to adequately explain ormanage, then one’s mood and mental healthmay begin to suffer. Indeed, qualitative researchsuggests that the disruption in day-to-day living,“biographical disruption” in sociological terms(Bury 1982), caused by TMD, can be of such amagnitude that individuals begin to lose theirsense of self, which compounds the impactsalready being experienced (Durham et al. 2010,2011). Further to this, if healthcare professionalsdo not adequately acknowledge the complaint as


a real phenomenon and give it “medical” legiti-macy, or implicitly suggest some type of psy-chosomatic process, then the data suggest thatindividuals begin to exist in a liminal state nei-ther truly “ill” in the eyes of society nor truly“healthy.” This can then detract from the socialsupport that they need in order to function intheir day-to-day lives (Durham et al. 2010).

The message for clinicians is that persistentOFP is often not a simple and unidimensionalproblem. All three aspects of the biopsychosocialmodel need to be assessed and acknowledged aspertinent to the persistent OFP complaint withoutplacing a prejudicial emphasis (or de-emphasis)on any psychosocial comorbidity. The interplaybetween the biological and psychosocial domainsneeds to be assessed and acknowledged with thepatient early in the process so that the patientunderstands the need to address all three elementswithin any treatment plan. If broaching the psy-chosocial aspects of the persistent OFP with thepresenting patient is delayed until late in the ther-apeutic plan and biological managements areexhausted prior to engaging with psychosocialinterventions, then the conversation about thepsychosocial aspects of the persistent OFP runsthe risk of becoming, from the patient’s perspec-tive, “Well everything else has failed and now youare saying this is all in my head or I’m imaginingit.” If this becomes the status quo through latediscussion of the biopsychosocial model with thepatient, then it is likely that interventions of thebiopsychosocial type that could have been effec-tive had they been implemented in a manner con-sistent with the biopsychosocial model will be lesseffective when presented in the context of treat-ment failures or, worse, the patient feeling blamedfor not responding to the earlier treatments. Con-sistent data from varying types of persistent painconditions show that when biopsychosocial man-agement of persistent pain is begun early, out-comes are dramatically improved (Gatchel andOkifuji 2006), but this is not to say that everypatient with persistent OFP needs psychosocialintervention. All patients do, however, need psy-chosocial assessment of some form or another,and it is imperative that at least a basic screeningassessment of any psychosocial comorbidity is

conducted at first presentation. This psychosocialassessment is not, so the oral medicine specialistcan play the role of psychologist but rather so anyinterplay between the aspects of thebiopsychosocial model is identified and discussedwith the patient early, and a multidimensionaltreatment plan formulated in consultation withthe patient so they understand the aims of itsvarious dimensions and why these dimensionsare being tackled simultaneously.

Assessing the Psychosocial

Assessing the psychosocial status of patients canfeel like unfamiliar and difficult territory for someoral medicine specialists. However, in dentistry,we have spent innumerous years as a professionassessing the level of (dental) anxiety of our pre-senting patients for dental procedures and dealingwith this anxiety through a variety of behavioraland pharmacological techniques. The assessmentof wider psychosocial factors or comorbidities canbe thought of as simply an extension of thisapproach. Psychosocial assessment should notbe fraught with trepidation for the clinician as itcan be used to tactfully broach and demonstrate topatients that there are also other influencing fac-tors to the complaint. When discussing the resultsof the psychosocial assessment, it is important tobe very careful to choose words sensitively andcarefully to ensure that the patient does not inter-pret what is stated by the clinician as assertingcausation.

Given the time pressures inherent in most clin-ical practices, the recent proliferation of basic,short to ultra-brief, screening instruments for psy-chosocial comorbidity over the last 10–20 yearshas been very helpful. This profligacy of reliable,valid, and sufficiently short screening instrumentshas been used to help dramatically refine, andmake much more clinically applicable, thebiopsychosocial axis (Axis II) of the redevelopedRDC/TMD, the DC/TMD. The remainder of thissection will focus on explaining the utility of theDC/TMD’s Axis II and demonstrating its clinicalapplicability.


DC/TMD Psychosocial Axis (Axis II)Assessment

There are two versions of the DC/TMD Axis II: ascreening and a comprehensive version (seeTable 1). The screening version is intended forclinical settings where the clinician can performa biopsychosocial assessment using the fewestnumber of questions and any positive responseswill result in referral for more detailed evaluation;this type of usage is the main focus of the furtherdiscussion of Axis II in this chapter. The compre-hensive version is intended for settings where theclinician will actively integrate the information; itis of course also intended for clinical researchersso that they can more reliably measure the con-structs of interest – for example, to select, orstratify, their samples related to their (bio)psycho-social profile. The instruments in both versions aredesigned to be completed by the patient prior tothe consultation and aim at identifying the mostcommon psychosocial comorbidities associatedwith TMD. Both versions of the Axis II are freelyavailable with interpretation guides for the scoringat the following website: www.rdc-tmdinternational.org.

As demonstrated in Table 1, there are threecommon elements to both versions of Axis II:pain drawing, Graded Chronic Pain Scale, andOral Behaviors Checklist. This is because oftheir prognostic and therapeutic importance.

The pain drawing (also known in the widerliterature as a “body manikin” Fig. 1) is an expe-dient and time-efficient method for identificationof the patient’s pain location(s) and referral orradiation patterns. Because multiple pain loca-tions are more common than not in individualswith TMD pain, the body manikin is a very help-ful method to identify widespread pain; this helpsidentify one major risk determinant for pain chro-nicity (Ohrbach et al. 2011), with an odds ratio ofbetween 3 and 5 for chronicity of TMD whenwidespread pain is reported on the body manikin.This thereby helps delineate more complex casesfrom simpler ones by visual inspection of thecompleted pain diagram. In addition, patientstend to like to be able to precisely describe(through graphical means) their pains.

The Graded Chronic Pain Scale (GCPS, v 2.0)is a widely used and validated instrument exam-ining pain persistence, pain intensity, and pain-related disability. It has four outputs, two of whichare most commonly used: characteristic painintensity, a composite 0–10 numerical ratingscale of average, worst and current pain intensitywhich can be used for initial assessment (e.g., howdoes the reported pain intensity compare to otherparts of the pain history), as well as a primarymeasure of outcome relevant to most individual’sreasons for seeking care. The second commonlyused output is overall graded chronic pain status,which is a five-point, potentially expandable tosix-point, ordinal scale ranging from 0 (no pain or

Table 1 Screening and comprehensive assessment versions of DC/TMDAxis II. Instrument names and number of itemsare listed. Three instruments are common to both assessment versions

Screening Assessment Comprehensive AssessmentInstrument # items

Pain drawing 1 Graded Chronic Pain Scale v2.0 8 Oral Behaviors Checklist 21

Instrument # items Instrument # items

PHQ-4 (distress) 4 PHQ-9 (depression) 9 GAD-7 (anxiety) 7 [no corresponding instrument] PHQ-15 (physical symptoms) 15 Jaw Functional Limitation Scale (short form)

8 Jaw Functional Limitation Scale (long form)

20

TOTAL 42 TOTAL 81


related disability) to IV (high level of pain-relateddisability). Graded chronic pain status (0, I, II, III,IV; grade II can be usefully subdivided into IIaand IIb) has been shown to usefully predicthealthcare utilization, thereby helping provide amechanism to stratify patients for levels of care(Durham et al. 2016) through the level of carerequired. Graded chronic pain status is also anindicator of prognosis in that higher gradedchronic pain status predicts greater chance ofchronicity of pain (Dworkin et al. 2002; Epkeret al. 1999; Kotiranta et al. 2015; Manfrediniet al. 2013; Von Korff and Dunn 2008). For exam-ple, a graded chronic pain state of III or IV wassignificantly more likely to result in a chronicTMD (Garofalo et al. 1998). The importance ofhigher graded chronic pain status was mirrored inthe observation that grades IIb, III, and IV

exhibited ten times greater odds of being associ-ated with chronic TMD (Ohrbach et al. 2011). Theremaining two outputs reflect pain persistence (thenumber of days of pain in the prior 6 months) anda direct measure of interference in daily activities(range, 0–100) caused by pain. The latter measureis a core component of the graded chronic pain.

The Oral Behaviors Checklist contains a list of21 oral region activities individuals may engagein, such as clenching the teeth, bracing the man-dible, or talking (see Fig. 2). The intent is toidentify high levels of masticatory system para-functional behaviors. The original RDC/TMDasked only two questions about these behaviors,ignoring a large range of possible other behaviorsthat people can engage in. The frequency of eachbehavior is rated on a five-point ordinal scale. Forassessing behaviors that are largely unconscious,

Right face

Left face

L R LR

Mouth and teeth

Fig. 1 Body manikin (alsocalled pain drawing) forbody as well as the head,face, and oral cavity(Copyright InternationalRDC/TMD ConsortiumNetwork. Available athttp://www.rdc-tmdinternational.org.Version 12 May 2013. Nopermission required toreproduce, translate,display, or distribute)


a limitation of both interview and thetwo-question approach within the RDC/TMD isthat self-knowledge of such behaviors oftenremains unconscious. In contrast, a 21-iteminstrument that lists each type of behavior sepa-rately and inquires into how often the behavioroccurs leads to the respondent more carefullyconsidering each behavior; respondents willoften report that in completing this survey ofpossible behaviors, each individual behavior was“tested” in order to determine if it was familiar,thereby bringing the awareness to the consciousstate. Test-retest reliability of this instrument inassessing largely unconscious behaviors is sur-prisingly good, and its semantic validity as wellas correspondence with behaviors reported in real-time in the field is also good (Kaplan and Ohrbach2016; Markiewicz et al. 2006; Ohrbach et al.2008c). Scoring is, at present, based on a simplesum of the endorsed frequencies of each item.Current evidence indicates that a sufficient num-ber and frequency of these behaviors lead to TMD(Ohrbach et al. 2013) and that even higher levelsare associated with chronic TMD (Ohrbach et al.2011). Other experimental and observationalstudies lead to the same conclusions (Carlssonet al. 2003; Glaros et al. 2016; Glaros and Burton2004; Glaros and Williams 2012). In contrast,very little is known about whether these behaviors

have any role in the OFP conditions, and thereforeif clinicians use the instrument in other OFP con-ditions, they should bear this in mind and only useit to explore the possible issues with the patient, totest out a hypothesis.

Those instruments specific to the screeningversion of DC/TMD’s Axis II are the PatientHealth Questionnaire-4 (PHQ-4) and the JawFunctional Limitation Scale – short form (JFLS-SF). The PHQ-4 is a product of the PRIMary careEvaluation of Mental Disorders (PRIME-MD)project (Spitzer et al. 1999) which occurred duringthe 1990s in the USA. The PRIME-MD projectwas based on the DSM-IV and aimed to producediagnostic instruments for five of the most com-mon mental health problems presenting to pri-mary care: anxiety, depression, somatoform,alcohol, and eating disorders (Kroenke et al.2010). The results from PRIME-MD were thenrefined further to produce shorter and quickerinstruments such as Patient HealthQuestionnaire-9 (PHQ-9) for depression, Gener-alized Anxiety Disorder-7 (GAD-7) for anxiety,and Patient Health Questionnaire-15 (PHQ-15)for somatic symptom severity. The PHQ-9 andGAD-7 were then examined in order to identifyquestions from both that could be made into acomposite anxiety and depression screeninginstrument. Two questions from each instrument

Fig. 2 Basic item content of the Oral Behaviors Checklistis shown, illustrating this method of assessing para-functional or overuse behaviors of the facial and

masticatory region; actual item content is typically morecomprehensive. Response options displayed are theextreme anchors of the five-point ordinal response scales


were used to create the ultra-brief PHQ-4 anxietyand depression screening instrument which is nowwidely in use across North America and Europe.PHQ-4 consists of four questions each using afour-point ordinal response scale of frequency(0, not at all; 3, nearly every day) with theresponse codes summed to give a summaryscore. A summary score of !6 is a yellow flagand !9 is a red flag and both demand furtherinvestigation; subscale scores within the instru-ment are also possible (Kroenke et al. 2007;Löwe et al. 2005; Löwe et al. 2010) albeit withreduced reliability compared to the full score. Inaddition, anxiety and depression collectively rep-resent “distress,” a construct that patients are gen-erally very comfortable with, further supportingthe use of the full instrument in order to simplifyinterpretation for the patient.

The RDC/TMD included a checklist (yes, no)of jaw functions that can be limited, for instance,by pain, and it was intended as a placeholder for abetter instrument in recognition of the criticalimportance of not only assessing jaw functionthrough clinical measures but also through theperson’s experience, known as functional limita-tion (Ohrbach 2010). The Jaw Functional Limita-tion Scale (JFLS) directly emerged from theRDC/TMD limitation checklist and uses gradedresponses, which have superior psychometricproperties to the binary response and whichpatients prefer, and the 20-item version measuresthree domains: limitation in chewing, jaw open-ing, and verbal and emotional expression(Ohrbach et al. 2008a, b). The first two arestrongly validated subscales with initial cross-cultural validity, while the third subscale shouldbe used in an exploratory manner in the clinic andin research. The short form consists of eight itemsrepresentative of the three subscales and measuresa global level of functional limitation that corre-lates almost perfectly with the global scale of thefull instrument. The short form is equally reliable,valid, and sensitive to change, and unless theclinician wishes to know about mobility and mas-tication separately, the short form is likely to besufficient. All three subscales are elevated in indi-viduals with TMD as well as other conditions,such as burning mouth syndrome and Sjogren’s

syndrome (Ohrbach et al. 2008b) which suggeststhat the functional limitation construct is probablyrelevant to all OFP conditions.

The DC/TMD Axis II in either its screening orits comprehensive version is not a replacement forthe involvement of a clinical psychologist to thor-oughly assess the patient if required as both ver-sions simply examine for the more commonpsychosocial comorbidities and thereby helpidentify the need for further involvement of spe-cialized teams. This is particularly true, as psy-chosocial interventions for complex cases oftenneed to be individualized, tailor-made, interven-tions for the presenting patient rather than a “onesize fits all” approach. Further constructs otherthan disability, anxiety, depression, andsomatoform disorders likely need to be examinedby clinical psychologists, and the next sectionoutlines both the role of the more common psy-chosocial constructs plus emerging other con-structs of importance in persistent OFP such ascatastrophization, self-efficacy, and fearavoidance.

Psychosocial Constructs Relevantto Persistent OFP

Depression

Depression is a mood state characterized primar-ily by low mood and loss of interest in usualactivities and, when more severe, accompaniedby vegetative symptoms such as decreased con-centration, appetite changes, and feelings ofworthlessness. When referring to the mood state,“depressive symptoms” is the better term, and thisis what the self-report instruments such as thePHQ-4 and PHQ-9 assess. When vegetativesymptoms become dominant, a diagnosable dis-order may be present, referred to as “majordepression disorder,” for example, and this disor-der includes significant morbidity in terms offunction and disability. Depression, as a disorder,is determined on the basis of careful interviewaccording to established criteria, and such clinicalassessment would logically follow a referral based


on a patient reporting high levels of depressivesymptoms (PHQ-9) or distress (PHQ-4). In addi-tion to referral for formal evaluation of a debili-tating disorder, screening for depressivesymptoms is standard in any pain treatment set-ting due to the comorbidity of depressive stateswith pain disorders. Depressive states impact onpain in a variety of ways: decreased pain modula-tion, decreased self-efficacy, inactivity, symptomamplification, and sometimes doctor shopping tofind an answer for why one feels so bad. Abundantdata indicate the high rate and extent of depressionin those with TMD (Gatchel et al. 2006; Suvinenet al. 2005), and its relevance to OFP appears to besimilar (Durham et al. 2015).

Anxiety

Anxiety, the vague sense that something terri-ble will happen manifests as worry and per-vades medical settings. Anxiety may besituation specific (prior to an injection), or itmay be generalized (occurring in relation toevery event in one’s life). Anxiety amplifiespain perception (Robinson et al. 2004) andleads to hypervigilance: heightened attentionto the experience of the body and subsequentamplification of those signals (Cioffi et al.2016). In turn, pain will lead to heightenedanxiety due to worry about the pain episodeand worry about the sufficiency of a treatment.Anxiety has physiological correlates, such asincreased heart rate or muscle tone or sweatingfrom the apocrine glands, as well as behavioralcorrelates, such as twitching behavior or rapidspeech. Anxiety is a distinct construct fromdepression, yet both symptom states frequentlyco-occur, which is why the PHQ-4 is an excel-lent screening instrument for “distress” thataccompanies anxiety and depressive states.Abundant evidence indicates the relevance ofanxiety to pain disorders including TMD(Fillingim et al. 2011), and its relevance toOFP appears to be similar (Aggarwal et al.2006).

Somatoform Disorders

The understanding of the somatoform disordershas changed with each edition of the Diagnosticand Statistical Manual of Mental Disorders(DSM), reflecting the difficulty in understandingthe core structure of the disorders containedwithin this group which all involve the reportingof physical symptoms not accompanied by appro-priate signs supportive of a disease diagnosis.“Somatization” is a well-known label for thesetypes of disorders, with somatization referring tohigh symptom reporting without a disease diag-nosis and accompanied by use of the symptoms toavoid social or day-to-day responsibility (enteringthe Parsonian Sick Role) (Parsons 1975). Somati-zation became perhaps well known due to its useas the label for a physical symptom scale in theSCL-90 (and later SCL-90R), as used in theRDC/TMD, but “somatization” was not assessedby that scale; only frequency of physical symptomreporting was assessed. Consequently, the term“somatization” should not be used unless anappropriate psychiatric interview is employed.Physical symptom reporting without acorresponding disease may be, among currentlydefined psychiatric disorders (American Psychiat-ric Association 2013), somatic symptom disorder,illness anxiety disorder, conversion disorder (andqualified according to involved system), psycho-logical factors affecting other medical conditions,or factitious disorder. Due to the reasonably lowprevalence of the somatoform disorders (Escobaret al. 1998), versus the reasonably high prevalenceof physical symptom reporting alone (Lorduyet al. 2013), attention has shifted to a moredescriptive approach, variously termed as func-tional disorders, medically unexplained symp-toms, and symptoms without medical utility(Kirmayer and Robbins 1991; Rief and Broadbent2007). For pain disorders, this shift is useful, but itmust be noted that it does not provide an expla-nation to the patient that allows them to movefrom a liminal state of neither being healthy norvalidly “ill” into a legitimate state of illness. Thiscomes with advantages and disadvantages for thepatient.


Physical symptom reporting may reflect sev-eral different mechanisms. A commonlysuspected mechanism is increased tendency toreport about the body; in other words, the individ-ual focuses on the body as something to talk aboutand to worry about (which, if extreme, is referredto as hypochondriasis). Another suspected mech-anism is hypervigilance to possible problems inthe body, and hence one’s sensory perception isheightened resulting in the report of experiences(e.g., ache) that everyone may have but does notreport because it does not exceed the perceptionthreshold (Rief and Broadbent 2007). An exten-sion of this mechanism underlies occlusaldysesthesia (Melis and Zawawi 2015) and maybe reflected in various symptoms that accompanythe persistent OFPs (Aggarwal et al. 2008; Peterset al. 2015). A third mechanism refers to changesin the body that are accurately detected and per-ceived, thereby not being overreporting and notbeing hypervigilance and amplification; symp-toms reported here reflect interoception, the expe-rience of our bodily states outside the specialsenses (Craig 2002). Craig has proposed animportant model regarding pain processingwhich directly incorporates interoception as acore part of what emerges as pain experience,particularly when pain becomes chronic (Craig2003).

At present, the full understanding of physicalsymptom reporting remains unknown. A largenumber of symptoms in the body or in the oralregion strongly predict new onset of TMD(Ohrbach et al. 2013; Sanders et al. 2013), and avery large number are commonly reported withina matrix of multiple comorbid disorders (Aaronet al. 2000; Kanaan et al. 2007; Ohrbach et al.2011). Until a better understanding emergesregarding mechanism, interpretation, and treat-ment of multiple physical symptom reporting,our recommendation is for the clinician to usethe body manikin as a direct measure within thesuggested short screening instrument set of mul-tiple pain disorders and to follow up via interviewfor pain locations marked on the body. A medicalhistory checklist can be used as an alternative,albeit less efficient, version of the PHQ-15 andwhen a pattern of responses indicative of

functional disorders is present, to follow up viainterview with a clinical psychologist. The avail-able evidence underlying the OFPs suggests thatthey are no different from TMD and other com-mon pain disorders with regard to the probableimportance of physical symptom reporting. Whilewe do not at this time know what high levels ofphysical symptom reporting means, it seemshighly plausible that clinical hypothesis genera-tion and evaluation will be productive.

Catastrophizing and Self-Efficacy

Catastrophizing and self-efficacy are consideredtogether as recent evidence from studies in TMDsuggests that, together, they are among the fewreproducible psychosocial therapeutic targets inall TMD patients (Litt and Porto 2010) and mayhelp predict treatment response (Litt and Porto2013).

Catastrophization about pain is “characterizedby the tendency to magnify the threat value ofpain stimulus and to feel helpless in the contextof pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or fol-lowing a painful encounter” (Quartana et al.2009). Perhaps unsurprisingly, therefore, higherlevels of catastrophization are linked to increasedhealthcare utilization, expression of pain, andpoorer outcomes of treatment. Thus, catastro-phization is important to identify and manage inthe biopsychosocial management ofpersistent OFP.

As a construct self-efficacy may be linked tocatastrophization as self-efficacy refers to thelevel of belief an individual has in their ownability to plan and bring about a course of actionsfor their own benefit (Bandura 1977). High self-efficacy emerges when individuals can be confi-dent in their ability to self-manage their symptoms(which the dental clinician plays a critical role infostering), and catastrophizing will lose its rele-vance. Alternatively, the clinician can fosterlearned helplessness by not helping the patient tobe independent in their self-management, andcatastrophizing will continue unabated. In thisrespect, therefore, self-efficacy may be affected


by catastrophization, and in studies examiningboth constructs in TMD patients, both have beenfound to mediate outcome of therapy (Brister et al.2006; Litt and Porto 2013; Turner et al. 2005,2006).

Fear Avoidance

The fear-avoidance model emerged from behav-ioral observations of people reporting pain thatwas not congruent with behavior or physical find-ings. The fear-avoidance model begins with anevent (e.g., injury) that can either proceed towardnormal tissue healing and resolution of the pain ortoward persistent pain (Vlaeyen and Linton2000). The model explicitly identifies the directexperience of pain and its interpretation as theinitial step, from which no fear of the pain leadsto engaging in the appropriate behaviors that willresult in recovery from the injury. In contrast, fearof the pain leads to pain catastrophizing, pain-related fear, avoidance, disuse and depression,and disability, feeding forward to further painexperience and the absence of recovery. In gen-eral, pain-related catastrophizing and fear of painfocus on the pain as a signal that something in thebody is broken, and therefore any activity thatleads to pain should be avoided in the belief that“healing” will be facilitated. Unfortunately, how-ever, the opposite is true and disuse breeds disre-pair and further dysfunction.

Fear of pain is measured via several instru-ments, of which the Tampa Scale forKinesiophobia (TSK) (Kori et al. 1990) is thebest known and perhaps most used. Using theTSK, for example, as a measure of the core con-struct, this model has very strong utility for backpain (Boersma and Linton 2006). The TSK itemcontent is largely focused on body activities, andconsequently it is not so suitable for the mastica-tory system. Consequently, an adaptation of theTSK was developed for the masticatory system,the TSK-TMD (Visscher et al. 2010), but verylittle has been published to date in the originalDutch or English versions or the few languageadaptations made so far.

The applicability of the fear-avoidance modelto both back pain and TMD pain appears torevolve, at a mechanistic level, around motor sys-tem responses as part of the avoidance behavioralpattern. This perspective would suggest that fearavoidance is not applicable to most other OFPs.However, the model itself is a more person-levelmodel with regard to how behavior and beliefsaffect the central processing of pain (and therebyinfluencing next central nervous system opera-tions), and in this perspective, the model wouldlikely be applicable to the OFP conditions. Con-sequently, the clearly plausible hypotheses relat-ing fear of movement to recovery among thosewith injury to the masticatory system and theprobable emergence of chronic pain amongsome of those individuals warrant investigation(Wall 1979), and present data suggest that thisperspective is applicable to OFP as well.

Psychosocial Interventions

“Psychosocial intervention” is a broad term thathas been used to group a wide variety of tech-niques under one heading in a recent systematicreview for the Cochrane Oral Health group(Aggarwal et al. 2011). This systematic reviewexplains that psychosocial interventions arethought to work in persistent OFP through focus-ing on either inactivity or overactivity, in relation-ship to persistent OFP. So, for example, inactivitymay be due to fear of moving the jaw because ofthe pain from myalgia; the inactivity further leadsto physical disuse, disrepair, and dysfunction, anda vicious cycle emerges. This sequence of eventswas described previously under the fear-avoidance model. An example of overactivitymay be due to anxiety because of uncertaintyregarding what the myalgia represents in termsof underlying pathology or possible long-termdamage or disability to the face or jaw; the anxietywill feed into central and peripheral processesrelated to pain, thereby amplifying pain percep-tion, as well as into generally heightened motortone, both of which perpetuate, if not worsen,the pain.


Both inactivity and overactivity require directtreatment, and either is targeted by using a varietyof techniques generally classified under psycho-social interventions that largely fall into twogroups: cognitive techniques and behavioral tech-niques. More commonly, however, both cognitiveand behavioral techniques are combined as cog-nitive behavioral therapy (CBT). Typically, psy-chosocial interventions will be individualized forthe presenting patient, with tailoring based on aresultant profile from the Axis II instrumentscores, e.g., a high GCPS grade will point topain-relevant functional factors, while a lowGCPS will point to non-pain-relevant factors aspotentially more important, and specific detailsthat emerge from a careful behavioral analysis ofwhich behavior, at which time, under which cir-cumstances are adopted or should be adopted.Such psychosocial interventions will includeboth cognitive and behavioral techniques.

Socratic questioning, perhaps the oldest formof cognitive therapy, is an essential componentthat supplements the psychometric data from thepatient in order to fully understand the patient andthe underlying constructs related to their com-plaint. The understanding of the involved

constructs built up by the questioning will thenbe fed back, through a process known as guideddiscovery, to the patient in order to explain howthe various biopsychosocial factors interrelate inorder to help prolong, potentiate, or precipitatetheir complaint. This feedback can be accom-plished using any one of a variety of methods,but one of the easiest to use and exemplify in thetext of this chapter to nonclinical psychologists iswhat is colloquially known as the “hot cross bun”method (Fig. 1) but also known as the five-part orgeneric model of CBT (Padesky and Mooney1990; Sage et al. 2013).

The hot cross bun method (see Fig. 3) uses theinterrelationship of our environment, thoughts,physical sensations, emotions (feelings), andbehaviors to explain how any one of these fivecomponents can influence another. This is com-pleted as an iterative and interactive process withthe psychologist and the patient contributing tocompleting the model. So to continue our workedexample from the very first section of this chapter,a person with a disk displacement with reductionwhich is painful: they experience loud clickingwhen eating, and this can occasionally be painful(physical sensation); the clicking and pain cause

Physical sensations

Client/Psychologistwrites details

Emotions/feelings/mood


Behaviour


Thoughts


Environment

Fig. 3 Hot cross bun method (Padesky and Mooney 1990)


them anxiety (emotions/feelings) as they believethere may be ongoing damage in their jaw(thoughts), the click occurs during a meal withfriends, and one of the friends remarks on it in aconcerned manner (environment) which rein-forces the anxiety over ongoing damage. All ofthese processes converge and amplify the painexperience. In this way the biopsychosocialaspects of the persistent OFP complaint are crys-tallized for the patient; one role of the psycholo-gist is to explain that while the anxiety is normal,there is little evidence to suggest there is ongoingdamage to their jaw joint and a very low chance ofthe present disk disorder progressing to a diskdisplacement without reduction with limitedopening; moreover, it would be emphasized thatif this were to occur, it can be simply managedwithout the need for surgery. This explanation initself starts to form part of a cognitive technique ofeducation via enhanced medical literacy as well asaddressing reality via reappraising thoughts; thiscould be supplemented by a behavioral techniquefor the patient to use if they feel themselves get-ting anxious about their jaw. The remainder of thissection will give a brief summary of some of themore common cognitive and behavioral tech-niques employed in CBT.

Cognitive Interventions

Distraction. Turning one’s attention to other mat-ters, particularly ones that are pleasant or mean-ingful, is a well-known active coping method thatmany people use intuitively for reducing worryand pain, for example. Active imagery is one wayto intentionally implement this method – forexample, imagining a particular problem visuallyinside a bubble and letting it float away into thedistance. High-functioning individuals often usethis method extensively, which can be quite effec-tive over the long term, in reducing pain intensity;however, a long-term cost is that one is also dis-tracted from the circumstances tied to one’s painor stress, and thereby initiating situations can con-tinue unchanged.

Reappraising Thoughts. Modifying thoughtsto change the present reality of one’s mind is anancient method, one central to many religioustraditions as well as cognitive behavioral therapytraditions. The general sequence is to identify athought as underlying one’s current distress, chal-lenge the thought for its reality base, provide acorrective thought in its place, engage in anybehavior implied by the corrective thought, andobserve the outcome in order to obtain additionalevidence for the next time the troublesomethought occurs. For example, a thought associatedwith the distress of a bad pain flare-up might be,“This pain will never go away,” and this is knownas pain cognition. Challenging this thoughtquickly leads to the memory that all other similarpain flare-ups did in fact resolve back to one’susual level of pain and that a flare-up is not thesame experience as the usual ongoing pain; thecorrective thought might be to remind oneself,“Taking time to stop pushing myself has alwaysworked in the past” and to then do exactly whatthe corrective thought indicates; and observingthe outcome could lead to a thought such as,“When I stop pushing myself and stop punishingmyself, my pain is not nearly as bad as it seems inthe middle of the flareup when I feel helpless.”

Mindfulness. In its simplest terms, mindfulnessconsists of moment-to-moment awareness of whatis present to one’s senses, and to simply acceptthat experience without judgment and withoutavoidance. In this sense, distraction is a tool oppo-site to the process one might attempt to cultivatevia mindfulness. The origins of mindfulness perse lie within Buddhist psychology, but the processis found in other traditions as well such as in hathayoga. Mindfulness can be implemented in ahighly structured manner via training as part ofstress reduction or as part of cognitive therapy fordepression (Kabat-Zinn et al. 1985; Teasdale et al.1995), or it can be implemented in a much lessstructured manner. The evidence for efficacyseems to be independent of structure of imple-mentation (Farb et al. 2015); the implication isthat intent may be more powerful than mode oftraining. Mindfulness is highly complementarywith most other behavioral and cognitivemethods; however, one caveat is that providers


should have extensive direct experience with themethod in order to understand the various diffi-culties and challenges that emerge when patientsattempt to learn the method. This caveat applies toall of these methods.

Pros and Cons. This exercise helps facilitatedecision-making (Sage et al. 2013). It involvesestablishing a list of all the potential choices forthis particular decision. Once the list isestablished, the patient then removes any thatwould not get chosen irrespective of their impor-tance rating, for instance, the choice might betotally unpalatable or impossible. The patientthen writes down the advantages and disadvan-tages for each option and ranks the importance ofeach as an advantage or disadvantage. Totalscores are then generated for each choice optionon the basis of their advantage and disadvantagescores, and the one that scores the best is usuallythe one to choose. There is also an opportunity toreflect, reconsider, and rescore, a process which,in itself, may tell the patient something abouttheir value set in relationship to this particulardecision.

Continua. Continua can be used with Socraticquestioning to examine where patients see them-selves on a continua. The exercise is begun byasking the patient to create a visual analogue scale(VAS) – that is, a straight line about 10 cm inlength – with two extreme anchors; for example,the patient might write “not at all anxious” on theleft side and “as anxious as I have ever been” onthe right side of the line. The context for theanxiety rating, in this example, might be about adisk displacement with reduction becoming a diskdisplacement without reduction with limitedopening. The patient is then asked, “Where areyou on that scale?” and, following their indicationwhere they currently are, the patient is asked,“Where would you like to be on the scale?” Theevidence for their being at the point they indicateon the scale is then explored in depth and so tooare facilitators and barriers to moving to the desir-able point on the continua (VAS scale) thenexplored systematically. A similar approach canbe used if it is a generic concept or quality one isexamining, for instance, success: the patient cangrade a person they perceive as successful first

and then grade themselves following this, and thesame exploration can then occur.

Positive Log. This is a very simplistic tech-nique to remind patients of the successes theyhave had in the time since the last visit. Thepatient is asked to keep a diary (log) of the suc-cesses they have had since their last visit, and thenthe provider can review it with patient and explorewith Socratic questioning.

Behavioral Techniques

Breathing Control. Control of the breath is one ofthe most easily approached methods for self-regulation. However, skill in breath controlrequires, for many individuals, extensive practice;for pain patients who, in general, more often do notutilize full abdominal breathing, acquiring suchskills can be even more difficult. The shift fromtightly controlled chest breathing to a more fluidand relaxed abdominal breathing induces paradox-ical anxiety in many individuals; this will be par-ticularly true if psychological trauma such as fromsexual abuse is part of the history. Thus, what canseem like a simple process of teaching a skill canrapidly become complex due to the various issuesthat permeate a developmental history.

Abdominal breathing control is associated withmeasurable changes in heart rate, slower respira-tion, and improved oxygenation. It is perhaps theself-regulatory method of first choice because itcan be implemented at any time, in any circum-stance; because of the immediate physiologicalchanges induced by such breathing control, itsuse as an immediate intervention tends to behighly rewarding to the individual. It is notewor-thy that breath control necessarily requires theinclusion of mindfulness if only for thosemoments of breath control, whether the individualis aware or not that that is being done. Jointimplementation of two techniques results in avery useful synergy.

Relaxation. Relaxation skills can be applied toa selected body part, perhaps as part of oral para-functional behavior control, or to the full body.When applied to a targeted body part, the effect isunderstood to necessarily focus on reductions in


motor cortex activation. When applied to the fullbody, the same reasoning is often used, yet theapplication of relaxation skills to the full body canbe taught in alternative ways, such that the focus ison creating ease in the mind, rather than restrictedto only the body as the focus. A large and longhistory of literature exists that describes thesevarious aspects of relaxation. Relaxation canalso be taught as a method for practicing mindful-ness, and it can be induced via self-hypnosis.Relaxation training necessarily requires settingpriorities, in terms of making time for practice,and dealing with frustration, as attaining skillswith relaxation are unlike most skills: one doesnot reach the goal by necessarily trying harder.Indeed, forced attempts to “relax” typically causethe opposite to occur. Finally, relaxation can beaugmented with a range of context-related tech-niques. For example, cognitive reappraisal andbeing nonjudgmental are central to maintainingthe focus during a relaxation process. Relaxationhas been regarded as the self-regulatory methodwith the strongest support for a medium effect sizein efficacy (NIH 1995), and to date, no chronicpain disorder has been identified that does notbenefit from the patient acquiring this skill.

Activity. Activity levels, as distinct from exer-cise, can range from inactivity to overactivity.Inactivity is more often found in individuals withback pain, whereas overactivity typically accom-panies headache and TMD pain. The implicationof inactivity for back pain is well understood,whereas the implications of overactivity in headpains are as yet not really understood, though thecyclic pattern between inactivity due to pain exac-erbations followed by overactivity when the exac-erbation resolves (and which leads to the nextexacerbation) is well understood. This pattern isreferred to as problems in pacing activities andwhile the conceptual basis leads to readily under-stood therapeutic intervention, i.e., leveling outactivity demands in order to have neither overac-tivity (and thereby no triggers for pain exacerba-tions) nor inactivity (and thereby avoid thefeelings of guilt that accompany decreased activitylevels). The role of this mode of therapeutic

intervention for TMD is unknown and, by exten-sion, for OFP as well.

The other aspect of activity pertains specifi-cally to physical exercise. Much data exist forwhy regular exercise is beneficial for overallhealth, and it has been speculated that regularexercise serves to regulate various aspects of thepain system, in particular the pain modulatorysystem. However, the data in general for paindisorders remains mixed. If nothing else, if regularexercise enhances mood, then it is worthwhile inthe individual with pain.

Changing Behavior: Graded Practice. A com-mon cause of failure for any treatments thatrequire behavioral change is expecting too much,too quickly. Both clinician and patient are suscep-tible to this understandable hope for rapidimprovement. Real behavioral change occurs ata pace specific to the given individual, and whenthe changes made are rooted in correct under-standing by the patient, the changes tend to bemore stable. In contrast, rapid change, regardlessof motivation, can result in early burnout andabandonment of the change process.

Change made at a pace appropriate to the indi-vidual patient is generally associated with pro-gress that can be almost observed as steps; tothat end, graded practice with goals that aretitrated to increase as mastery develops in thedesired behavioral change is perceived as morerewarding to most individuals, and self-efficacyimproves correspondingly.

Behavioral Experiments. Patients will oftenchallenge tenets underlying a CBT model, andindeed the model intrinsically encourages suchchallenges. “Will relaxation really help my neu-ropathic pain?”might be appropriately asked by apatient with that type of diagnosis. A behavioralexperiment is typically the most effective way toanswer such a question: request the patient tocommit to the necessary period to sufficientlymaster the identified skill, relative to the natureof the challenge, and then develop a care plan thatmonitors the use of the skill along with situationsand symptom reporting. Intentional periods wherethe skill is not to be used can often help create thenecessary contrast, whereby the utility of the skill


in the service of best responding to the challengecan be evaluated. The goal, made explicit, to thepatient is to discover which treatments work bestfor this patient, under what circumstances.

Problem-Solving. Similar to behavioral exper-iments, acquisition of cognitive and behavioralskills needs to be accompanied by an understand-ing of what works, when, as well as acquiring anappropriate understanding of what is a reasonableexpectation. Trying to use a newly learned relax-ation skill during the middle of a migraine episodewill probably not result in clinical change;problem-solving would approach the delay in theuse of the skill as opposed to earlier in the episode,and problem-solving would focus even more oncircumstances surrounding the pain onset andchoices at that point in what, if anything, couldhave been done in the way of enhancing self-regulation. The goal is for patients to becomeindependent problem-solvers by better under-standing all aspects of behavioral approaches totreatment: circumstances related to triggering oraggravating factors for pain episodes; knowledgeof their unique symptom progression, what cop-ing skill works at which stage of a pain episode,understanding their mastery level of differentacquired skills, knowledge of what symptomscan or cannot change, and developing skill inhow to monitor the process.

Pharmacology. The indications and types ofmedications used to treat OFP are beyond thescope of this chapter and are covered elsewherein this text. However, one implication of thebiopsychosocial model is that pharmacologicalmanipulation of a bodily system should be con-sidered within the larger context in order to max-imize the potential of the medication to help theindividual. A simple example is to prescribe amedication with the assurance to the patient thatthe medication will likely not be at all effective;clearly, clinicians do not do that, but why not? Theintuitive understanding is that medicationresponse is not solely a province of the chemicalsmanipulated by the medication but rather the indi-vidual’s beliefs about the medication will helpshape the body’s response.

For some types of medications, such as anal-gesics, the research data are very clear that

placebo, or expectation, shapes medicationresponse and reported side effects; the same isequally true for medications used to treat psychi-atric conditions. What about medications thataffect systems more removed from the CNS, forexample, the inflammatory system and infections?Antibiotic response does not seem to be plaguedby placebo effects, yet the person response forhealing can very much be influenced in directionsopposed to the healing that a prescribed antibioticwould otherwise induce. An individual refusing torest, for example, as part of the healing response toantibiotic treatment for an overwhelming infec-tion would contribute to an ongoing infection,despite the dose of the antibiotic. Similarly, theprovision of all medications should be accompa-nied by considerations of what behavioralchanges are needed in order to maximize thevalue of the medication. This clear implicationof the role of biopsychosocial model in treatmentis, however, difficult to implement for severalreasons: significant practitioner time is requiredto assess the person in all indicated dimensions,the time required to interpret the results of thatassessment in relation to the physiological pro-cesses to be altered with the planned medication,and the time (and skill) required to address andsuccessfully implement a behavioral self-careplan alongside the planned medication. Surgeonsperhaps perform this process more instinctively,because they can readily observe the immediateand obvious consequences when normal tissuehealing following a surgical procedure is not pro-ceeding as expected, weigh this in the balance,and request behavioral changes from the patient;consequently, surgeons are more behaviorally ori-entated than they might describe themselves. Inpersistent OFP conditions, in contrast, the impor-tant parameters for inclusion into behavioral man-agement that would accompany medicationmanagement are not obvious, are not easy toaddress, and are not likely to be easy to measurein terms of process.

Another example may help. Consider the useof an analgesic that could be used for break-through pain as part of a biopsychosocial treat-ment approach that also includes, say, relaxation


skills as part of reducing anxiety that amplifies theperson’s pain in certain situations. If, in this exam-ple, the medication is not clearly prescribed asintended for rescue, when the pain is beyond thepatient’s self-management skill level, the patientmay rely solely on the medication, because it iscertainly easier than invoking a relaxationresponse, and thereby the patient begins to giveinsufficient (or no) attention to skill building inrelaxation. The patient may, however, report at afollow-up consultation that “The relaxation pro-cess does not help,” and the clinician may con-clude that more analgesic needs to be prescribed.Similarly, psychopathology will undermine anal-gesic response (Wasan et al. 2005), and if theclinician has not pursued the sufficient assessmentto understand this patient, the lack of expectedresponse to the medication may be interpreted asinsufficient dosing rather than other factors withinfrom the biopsychosocial model affecting analge-sic response or adherence to the managementplan.

Conclusions and Future Directions

As science moves forward and further explora-tions of the biopsychosocial nature of, and influ-ences on, orofacial pain conditions are conducted,it will be possible to produce much more tailoredand multimodal programs of care for individuals.These more tailored and multimodal approacheswill hopefully increase the therapeutic yield ofstandard biomedical therapies such as pharmaco-logical or surgical approaches. Adjunctive to this,we will be better able to assess thebiopsychosocial outcome of therapeutic interven-tions so that we understand what pieces of thetherapeutic jigsaw remain to be put into place forprograms of care to be more effective at a popu-lation and patient level. The key message readersof this chapter should take away is that thebiopsychosocial model of illness and healthcareis here to stay, and if it is ignored, then interven-tion outcomes may suffer, and relationships withpatients may become strained.

Cross-References

▶Arthritic Diseases Affecting the TMJ▶Burning Mouth Syndrome▶Classification of Orofacial Pain▶Clinical Evaluation of Orofacial Pain▶Headache▶ Internal Derangements of the Temporomandib-ular Joint

▶Masticatory Muscle Pain▶Neuropathic Orofacial Pain▶Neurophysiology of Orofacial Pain▶Neurosensory Disturbances Including Smelland Taste

▶Neurovascular Orofacial Pain▶Oral Appliance Therapy for Sleep DisorderedBreathing

▶Oral Manifestations of Systemic Diseases andtheir Treatments

▶Orofacial Pain Associated with Oral MucosalDisease and Cancer

▶Orofacial Pain in the Medically ComplexPatient

▶Orofacial Pain and Sleep▶ Sleep Bruxism▶ Sleep Medicine for Oral Medicine Specialists

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biopsychosocial aspects of orofacial pain · symptom reporting, catastrophizing, and fear...

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