Dr Robert London

Stress-Related Temporomandibular Dysfunction

Clinical Psychiatry News - Volume 34, Issue 10, Page 60 (October 2006)

Since ancient times, the connection between psychological and physical states has been known to medicine.

Thus, it should not be surprising that the psychiatrist's understanding of mental illness and stress can be brought to bear to help patients with a variety of physical maladies, including temporomandibular joint disorder (TMJ).

Of course, traditionally, these conditions have been under the purview of either dentists or physicians specializing in pain medicine. For dentists and pain specialists, solving TMJ problems has been challenging and frustrating. TMJ, known today as temporomandibular dysfunction (TMD), has been responsible for severe facial pain and discomfort for centuries.

According to Donald Marks, D.D.S., who has many years of experience with the New York University College of Dentistry and the Manhattan Veterans Affairs Medical Center, TMD has three basic causes: malocclusions or improper wisdom tooth alignment; anatomical problems may exist and the joint itself could be misaligned; or stress may lead to muscle spasm and grinding, causing the internal and external pterygoid and masseter muscles to go into spasm-causing pain.

The first two causes, when diagnosed and treated properly, can solve the dysfunction and should be the main approach. It is also possible that stress-related problems may coexist with the physiological or anatomical problems, said Dr. Marks.

When stress and anxiety issues are present, an examination of vocational, familial, and social stressors is important. These forces may be playing on the patient's psyche, leading to jaw muscle spasms—not unlike other stress-related life situations that affect different organ systems.

Over the years, when patients were referred to me for assistance in relieving some of the pain of TMD, they already had seen a dentist and non-stress-related causes were either treated concurrently or ruled out. The first thing I would do is to talk with them to identify stressors that might have been missed in the psychological dental evaluation.

At times, I simply identified a set of stressors and described how they could be translated to a specific system in the body and lead to nighttime teeth grinding and muscle spasms during sleep. I also used the Franz Alexander or Helen Flanders Dunbar models to help the patient's understanding. Some patients who gained insight into a particular situation and a different perspective on the stress and pain pattern were able to find relief through these insights.

The effectiveness of these approaches is not only supported by my own experiences but with data. In one study, researchers at Virginia Commonwealth University showed that “promising behavioral interventions are available for TMD patients in whom psychological factors appear to be playing a significant role” (J. Oral Maxillofac. Surg. 2001;59:628–33).

But if behavioral interventions do not work, I use my modification of the Jacobson relaxation techniques developed in the 1920s. This technique, as developed by Dr. Edmund Jacobson, was lengthy and cumbersome. He proposed contracting specific muscle groups, creating a tension in them, and then relaxing them to first identify these groups and then gain a measure of control over these muscles. This is a sort of physiological version of paradoxical intention, as I see it.

In the Jacobson technique, 50 sessions can be used in an effort to reach the successful outcome of muscle tension and relaxation of specific muscle groups. Wow!

By using rapid relaxation induction techniques, I am able to teach muscle tension/relaxation in one or two visits and offer the patient a rapid goal-oriented method to gain symptom control. Through a series of mouth and jaw movements in which the patient clinches and relaxes, she becomes aware of the muscle groups. As this awareness grows, the patient has the chance to gain control over muscle groups and can begin to exert her own influence on the TMD.

For example, I tell the patient to bite down and clinch her teeth and then try to grimace. This will generate muscle tension. As she relaxes those muscles, the patient not only gains an awareness of the muscle groups but a sense of relief and a measure of control over the muscles in spasm.

A series of repetitions is necessary to fine-tune this process so that the patient gains the mastery effect of the technique. Once again, practicing after the office visits end is important in gaining long-lasting success in these procedures.

Another strategy for stress-related TMD is what Dr. Marks calls “midline exercises.” After I learned what he does, I took the liberty of renaming them “midline behavior modification exercises.” He said it was okay for me to rename them, and in turn, I offered him a more in-depth psychological evaluation technique.

Now, my modified version is an eight-point patient-oriented program aimed at reestablishing normal jaw opening and closing in an improved manner. Often in TMD, the jaw will deviate when opened. A set of muscles goes into spasm and there is a subsequent deviation to one side or the other. As a means to help correct this, the following midline exercises are introduced. The eight-point behavior modification approach is aimed at altering the physical problem by correcting the jaw deviation, reducing spasm and pain.

The steps are as follows:
1.Look into the mirror.

2.Stare at yourself.

3.Open your jaw, and note the deviation.

4.Observe the deviation.

5.Close your jaw.

6.Reopen your jaw and focus on keeping it straight as you control the muscles.

7.Do this for 5 minutes in the morning and 5 minutes in the evening.

8.You will retrain your muscles—avoid deviation and reduce spasm and pain.

As you will note, the practice effect is crucially important in these relearning approaches.

Although psychiatrists clearly are not the primary clinicians in treating TMD, our willingness to lend our expertise to a dental problem that may be related to emotions or at times solely an expression of some inner tension, anxiety, or stress will allow us to make a significant contribution in overcoming this dysfunction.

Let me know your treatment experiences with TMD, and I'll try to pass them along to my readers.

PII: S0270-6644(06)71843-4


© 2006 Elsevier Inc. All rights reserved.