Efficacy of Group Cognitive Behavior Therapy for the Treatment of
Masticatory Myofascial Pain
Guarantor:Col William J. Dunn, DC USAF
Contributors:Maj Robert K. Bogart, DC USAF*; Lt Col Randall J. McDaniel, DC USAF†;
Col William J. Dunn, DC USAF‡; Capt Christine Hunter, BSC USAF§; Lt Col Alan L. Peterson, BSC USAF§; Edward F. Wright, DDS MS¶
The purpose of this investigation was to evaluate the reduction in perceived pain in patients with myofascial pain (MFP) using a group cognitive behavior therapy (CBT) course. Twenty-six participants diagnosed as having MFP were enrolled. Each CBT session had a small-group format, where participants received instruction in habit reversal, stress management, and progres-sive relaxation. Participants served as their own control sub-jects and were surveyed for pain intensity, duration, and fre-quency at study enrollment, before attending the CBT course, and 2 to 3 weeks after course completion. Wilcoxon signed-rank tests revealed that changes in intensity, frequency, and duration were significant (p⬍0.001 top⬍0.045). Thirty-three percent of the participants showed improvement with home care instructions before CBT course start, whereas 65% of the participants showed improvement after the CBT course. Par-ticipants attending CBT group training exhibited significant improvements in MFP intensity, frequency, and duration, com-pared with levels reported at the initial evaluation.
Introduction
M
yofascial pain (MFP) disorder is regional muscle pain re-ferred from or emanating around active myofascial trigger points.1It is the most common condition presenting to orofacialpain centers.2,3 Masticatory MFP has been described as a
chronic condition with a cyclical nature.4However, studies have
demonstrated that MFP symptoms are often persistent over time without treatment.5,6It has been recommended that the initial
standard of care for the masticatory MFP patient include con-servative treatment to facilitate musculoskeletal healing and symptom improvement. Common therapies of this nature in-clude but are not limited to self-care modalities, cognitive be-havioral modification, physical medicine therapies, medica-tions, and oral appliances.1Therapy varies with the provider’s
training, expertise, and clinical experience.
Dentists commonly treat MFP patients with appliance ther-apy, often in combination with physical therapy and analgesics. This approach is effective for a limited number of MFP patients,
but a sizable percentage (23%) may not respond to this type of therapy.7One study demonstrated that 75% of 448 pain
pa-tients who were given patient education information, heat, massage, non-narcotic analgesics, and appliance therapy re-ceived satisfactory symptom relief, whereas the remaining 25% did not.8
Clinicians and researchers recognize the derived benefits of incorporating cognitive awareness and habit reversal instruc-tion into MFP treatment protocols. Directing awareness to the consequences of parafunctional activities proves clinically use-ful in reducing negative behaviors and alleviating MFP symp-toms.9Current literature supports the interrelationship between
chronic pain and behavioral, psychological, and psychosocial fac-tors.10 In addition, the contributions of cognitive behavioral
practices are well accepted among practitioners managing MFP with the interdisciplinary team concept.11,12
Clinical health psychologists, with their understanding of hu-man behavior, are valuable in assisting dental practitioners in treating MFP patients. In particular, the management of mal-adaptive habits and behaviors, such as bruxism and clenching, is widely accepted as a standard therapy in reducing contribut-ing factors in patients with orofacial pain.13Clenching is defined
as prolonged tooth contact, whereas bruxism implies grinding of the teeth.13Other oral habits, such as jaw bracing, lip biting,
gum chewing, and nail biting, may also contribute to MFP. Early thinking embraced malocclusion as a major or sole etiological factor for bruxing and clenching, on the premise of it causing unstable occlusal relationships. The theory proposed that an individual bruxed and/or clenched because he or she could not occlude the teeth to form a stable relationship because of interferences.14Subsequent studies found that occlusal
con-tributions to MFP symptoms were minimal and, when present, typically represented more-advanced occlusal instabilities.15,16
Symptoms of temporomandibular disorders (TMD) occur in healthy individuals and appear to increase in frequency and severity particularly during adolescence.15
Psychophysiological causes are the basis for another theory, in which increased stress and anxiety lead to increases in phys-iological reactivity and adverse oral behaviors such as clench-ing. It is hypothesized that bruxers experience greater daily physiological reactivity to stress than do nonbruxers. The theory does not explain the cause of bruxing; rather, it suggests that increased stress increases bruxing. Although many studies show a correlational relationship between stress and bruxism, they suggest nothing about the cause of bruxing or clenching.13
Although emotional difficulties exist for many TMD sufferers and addressing emotional disturbances may be critical for treat-ment success for some individuals, there is no clear evidence
*Hospital Dentistry Department, Wright-Patterson Air Force Base, OH 45433-5529.
†Orofacial Pain Department, Wilford Hall Medical Center, Lackland Air Force Base, TX 78236-5551.
‡Department of Dental Research, Keesler Medical Center, MS 39534.
§Department of Psychology, Wilford Hall Medical Center, Lackland Air Force Base, TX 78236-5000.
¶Department of General Dentistry, University of Texas Health Sciences Center, San Antonio, TX 78229-3900.
The opinions expressed in this article are those of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force or the Department of Defense.
This manuscript was received for review in May 2005 and was accepted for publi-cation in March 2006.
that emotional difficulties are causally related to the develop-ment of TMD.17,18There appears to be no greater incidence of
anxiety, depression, or major mental illness among initial TMD patients than among general medical patients.12
The learning theorists propose that TMD is the result of learned maladaptive oral habits. For example, a behavior may begin as relatively innocuous (e.g., lip licking or biting because of chapped lips). The behavior then becomes a learned habit that is no longer in response to the original stimulus. According to learning theories, bruxing is not necessarily related to greater stress or psychological disturbance.13It is likely that TMD is a
result of the relationship between patients’ stress, habits, and physical vulnerability.
Proposed treatment strategies exist for the various bruxism theories. Dentists who support the malocclusion theory treat the disorder by correcting occlusal disharmony via splints, oc-clusal adjustments, and restorative therapies. Ayer and Levin18
reported that these approaches have not eliminated detrimental grinding habits.
Azrin and Nunn19presented the behavioral learning theory as
an approach to treatment of maladaptive habit disorders and developed treatment regimens based on the philosophy of re-learning and habit breaking. A preliminary investigation evalu-ating habit reversal therapy produced significant masticatory muscle pain improvement.20,21Three adult patients with TMD
symptom duration of 8 months to 8 years were provided with six weekly sessions of habit reversal instruction, consisting of awareness education and substituting a nondetrimental activity for the parafunction. Participants were taught to separate their teeth slightly, to relax their jaws, and to breathe rhythmically. Results showed decreases in self-reported pain, pain upon pal-pation, and increased maximal interocclusal opening. Another approach is massed negative practice therapy, in which the patient practices bruxing and clenching habits until muscles are painful and fatigued, so that the patient becomes acutely aware of the habit and its consequences. Ayer and Levin18
re-ported 75% success with massed negative practice therapy at 1-year follow-up assessments. Aversion conditioning proce-dures and biofeedback have also been used.22Wohnilower and
Gross23suggested that a full understanding of bruxism may not
be necessary to change an individual’s bruxing behavior, be-cause any number of the previously proposed theories, as well as theories not yet articulated, may be contributing to the indi-vidual’s disorder.
For now, treatment must proceed without a clear understand-ing of the cause, and therapy should be easy for the patient to understand and to perform. Bruxism and clenching can be treated as habits, using several behavioral approaches such as self-monitoring and habit reversal.19,20 Although behavioral
strategies are frequently administered in a one-on-one setting, there are protocols for performing behavioral modalities in a group setting; few clinical trials have evaluated the effectiveness of behavior modification techniques in a group setting.11,12
One such project used a randomized clinical trial format to evaluate the effectiveness of group education and counseling for the management of facial pain and TMD and reported the re-sults from a seven-session group habit reversal program, but the results were difficult to interpret because of poor atten-dance.20Another study divided 139 patients into two groups.11
Group 1 received standard conservative TMD treatment consist-ing of flat-plane occlusal splints, nonsteroidal antiinflammatory medications, passive and active range-of-motion jaw exercises, modification of parafunctional and/or dietary habits, and reg-ular use of cold and heat packs. Group 2 received a cognitive behavioral intervention with a small-group format for two to five TMD patients. A psychologist led the sessions, instructing pa-tients through progressive relaxation methods and simple phys-iotherapy exercises for jaw muscles. Patients who received the cognitive behavioral intervention followed by standard conser-vative treatment showed greater long-term improvement in re-ported pain levels and less interference in daily activities than did patients who received standard conservative treatment alone.11
Adherence to treatment, habit reversal, and self-management are the cornerstones of successful behavior-modification treat-ment techniques, whether taught with one-on-one instruction or in a group setting. Patients are taught therapies and educated in self-responsibility, which is significant in the overall treat-ment strategy. Research suggests that adherence during the first month of treatment is the most powerful predictor of long-term adherence; the patient-provider relationship, communica-tion skills, patient educacommunica-tion, and social support networks are also key factors in patient compliance.24
In the present study, a cognitive behavior therapy (CBT) course was designed to benefit patients with diurnal pain (symptoms during the day) or symptoms resulting from diurnal and nocturnal (occurring during sleep) behaviors, because the course addressed diurnal activities that may be altered via con-scious efforts. The purpose of this preliminary project was to determine the relationship between the CBT course and pain intensity, frequency, and duration measured before and after CBT instruction. This study was conducted with the approval of the medical center’s institutional review board.
Methods Participants
Twenty-six participants with MFP participated in the CBT course. Twenty-three participants (88.5%) were female and three (11.5%) were male. Eleven participants (42.3%) self-iden-tified as Caucasian, two (7.7%) as African American, and 13 (50%) as Hispanic. The participants’ ages ranged from 20 to 42 years, with a mean age of 29.2 years. Educational levels varied from high school diploma to master’s degrees. Participants had been experi-encing MFP symptoms for a mean of 80.9 months. Orofacial pain providers initially examined all participants, with the diagnoses being made according to subjective evaluation of symptoms and intraoral and extraoral physical examination results.
The comprehensive examination included a detailed medical history and subjective pain history. The frequency, duration, intensity, and character of pain were also documented. Intraoral and extraoral masticatory and cervical muscle palpation, bilat-eral temporomandibular joint palpation, and auscultation ac-cording to research diagnostic criteria were performed. The in-traoral examination attempted to identify signs of cheek biting, lip biting, and parafunction such as tooth wear.
A primary diagnosis of MFP was made for 46.2% of subjects, whereas the remaining 54% received diagnoses of MFP and
temporomandibular joint arthralgia. Participant inclusion crite-ria consisted of a diagnosis of MFP, having diurnal (daytime) pain for at least 6 months, consenting to a comprehensive oro-facial examination, and attending the CBT course. MFP patients with only morning symptoms that were suspected to be a result of nocturnal activities were not enrolled in this study, and MFP participants who were scheduled but failed to attend at least one of the CBT sessions were excluded. Participants who attended at least one class were included in the study, and a correlation between course attendance and improvement was evaluated. Individuals experiencing pain for less than 6 months, those diagnosed as having primarily a joint disorder, and those taking medication were also excluded. All participants received verbal and written home care instructions that encouraged partici-pants to eat a soft diet, to avoid chewing gum, to eliminate caffeine, to avoid a stomach sleeping position, to avoid oral parafunction, to maintain a relaxed jaw posture, and to perform jaw-stretching exercises. The participants served as their own controls, by allowing a period of 3 to 7 weeks to elapse between receiving the home care instructions and attending the CBT course. Each group session consisted of two to five participants. The CBT course focused on habit reversal, relaxation training, and changing alarming cognition, strategies that have been shown to benefit patients with symptoms resulting from diurnal habits. The analysis was accomplished by using the Friedman rank test for repeated measures for one sample, with posthoc testing using the Wilcoxon signed-rank test at␣⫽0.05.
Procedure
Patients who demonstrate MFP symptoms related to diurnal or both diurnal and nocturnal behaviors are thought to benefit from a structured program such as the CBT course. The key components of the CBT course were (1) educating patients about TMD, MFP, and research related to effective treatments, (2) increasing awareness of clenching and parafunctional habits, (3) decreasing these behaviors through habit reversal tech-niques, (4) reducing sympathetic nervous system arousal via regulated and/or diaphragmatic breathing and progressive muscle relaxation techniques, and (5) increasing control over stressful events through an understanding of the impact of thoughts and beliefs on emotional and physical functioning. Patients were taught specific skills during the group sessions and were provided with recommendations to practice these skills daily. Manuals and audiotapes were provided to the par-ticipants as guides. Clinical health psychologists experienced in the management of MFP patients led the CBT program sessions. Session 1 included education about the biopsychosocial na-ture of orofacial pain, as well as expectations of management options. The impact of muscle hyperarousal and oral parafunc-tional habits on pain, diaphragmatic breathing, and cue-con-trolled relaxation were reviewed and taught. Additionally, habit reversal was taught, to increase awareness of maladaptive oral behaviors (e.g., clenching) and to teach a competing response that was antithetical to and incompatible with the oral behav-iors. The habit reversal technique involved identifying both in-ternal (physiological, behavioral, cognitive, or emotional) and external (environmental) cues for implementation of the com-peting response. Internal cues included behaviors such as tight-ening the jaw muscles or clenching the teeth and the onset of tension headaches. External cues were regularly occurring
ex-ternal events, such as the telephone ringing, used as a signal for consistent use of the competing response. Participants were taught to identify cues that were salient and frequent enough to make a difference, and it was emphasized that, as they engaged in the competing response, they were building the more-adap-tive behavior into habit. Participants were taught the acronym “DTMD” as the competing response that is incompatible with clenching and other parafunctional habits; “D” was to drop the jaw slightly (6 –10 mm), “T” was to separate the teeth about the width of a pencil (lips opened or closed), “M” was to relax the muscles of the jaw and face, and “D” was to initiate deep or diaphragmatic breathing.
Session 2 began by reviewing habit reversal and relaxation progress, with retraining as needed. This session, in general, focused on helping participants understand the stress re-sponse, identifying how the autonomic stress response mani-fests negatively in their lives and body, and training them in progressive muscle relaxation. Participants were instructed to consistently practice habit reversal throughout the day and to practice diaphragmatic breathing and progressive muscle relax-ation one or two times per day.
Session 3 included a presentation from a dentist on self-management strategies for MFP, including changes in eating, sleeping, and postural habits and the use of heat or ice on the painful areas. The dentist reinforced the therapeutic benefits presented by the psychologist. The psychologist then reviewed material taught in sessions 1 and 2 and led a discussion of the role of cognition in either triggering or effectively managing the stress response. Participants were taught a model for identifying and modifying unrealistic or alarming beliefs that may exacer-bate the stress response and were provided instruction for re-placing these thoughts with more-helpful cognitions.
The MFP participants were surveyed to measure pain before, during, and after treatment.25 The surveys of pain intensity,
frequency, and duration were completed at three distinct times, (1) during the initial evaluation appointment, (2) at the first session of the CBT course, and (3) 1 to 2 weeks after completion of the CBT course. The average time between patient evaluation and the first CBT course session was 2 weeks. The CBT course consisted of three sessions, 2 hours each, held on three consec-utive Wednesdays. The participants served as their own con-trols. The period between the initial evaluation appointment and the start of the CBT course allowed evaluation of the response to self-management strategies, compared with the treatment from the CBT course.
Responses to questions were measured on a Likert scale for pain intensity (range of 0–10, with 0 representing no pain and 10 representing the worst pain imaginable), pain frequency (0–7 days/week), and pain duration (length of each pain episode). Pain measurement via patient self-report is a well-established standard in the MFP literature.18
Statistical Analyses
The Friedman two-way analysis of variance by ranks test was used to determine statistical significance, and the Wilcoxon signed-rank test was used to make pairwise comparisons. For all tests, the significance level was established asp⬍0.05. The data were measured in intervals of time, i.e., initial examination to the beginning of the CBT course (interval 1), beginning of the CBT course to the end of the course (interval 2), and initial
examination to the end of the CBT course (interval 3). Each interval was further subdivided into participant reports of symp-toms upon waking (morning) and sympsymp-toms in the evening.
Results
The overall primary data analysis indicated that self-reported changes in pain intensity, frequency, and duration between each of the three intervals were all statistically significant (p⬍
0.05, Tables I–III). Pain intensity decreased, on average, 73.1% from the initial examination to the end of the CBT course (interval 3). During interval 1, 30.8% of participants (8 of 26 participants) reported a decrease in pain intensity during the morning period and 54% (14 of 26 participants) reported decreased pain during the evening period. Review of interval 2 data indicated that 57.5% of participants (15 of 26 participants) reported decreased pain intensity in the morning and 80.8% (21 participants) had decreased pain intensity dur-ing the evendur-ing period. Similarly, durdur-ing the interval 3 period, 61.6% of participants (16 of 26 participants) experienced de-creased pain intensity in the morning and 85.0% (22 of 26 participants) noted a decrease in pain intensity in the evening. Only a small percentage of participants (morning, 11.5%; evening, 7.7%) reported an increase in pain during the interval
3 time period. Across all three intervals, the reported reductions in pain intensity were greater in the evening measures, com-pared with the morning measures. Additionally, the magnitude of the reported decreases in pain intensity was greater across each time interval. Overall, the values found to be statistically significant for intensity were interval 1 evening and intervals 2 and 3 both morning and evening (Table I).
The data were also analyzed in terms of changes in the fre-quency of pain (Table II). A review of the pain frefre-quency mea-sures beginning with interval 1 indicated that 27% of partici-pants (7 of 26 participartici-pants) noted decreased pain frequency during the morning period, compared with 30.9% during the evening period. Interval 2 analysis revealed that one-half of the participants (13 of 26 participants) reported decreased pain frequency in the morning and 61.6% (16 of 26 participants) reported a decrease during the evening. During interval 3, 50% of participants (13 of 26 participants) reported a decrease in pain frequency in the morning measures and 57.7% (15 of 26 participants) reported a decrease in the evening recordings, which was statistically significant (p⬍0.05). Participants expe-rienced a statistically significant reduction of pain frequency during intervals 2 and 3 for morning and evening measures (Table II). Similar to the measures of pain intensity, the reported reductions in pain frequency were greater in the evening mea-sures, compared with the morning meamea-sures, across all three time
TABLE I
CHANGES IN PAIN INTENSITY (N⫽26)
Morning Evening Change from Baseline No. of Participants (%) Change from Baseline No. of Participants (%) Interval 1 ⫺3.0 1 (3.8) ⫺3.0 2 (7.7) ⫺2.0 1 (3.8) ⫺2.0 4 (15.4) ⫺1.0 4 (15.4) ⫺1.0 8 (30.8) ⫺.5 2 (7.7) Baseline 9 (34.6) Baseline 13 (50) ⫹.5 1 (3.8) ⫹1.0 5 (19.2) ⫹2.0 1 (3.8) ⫹3.0 1 (3.8) Interval 2 ⫺7.0 1 (3.8) ⫺7.0 1 (3.8) ⫺5.0 1 (3.8) ⫺6.0 3 (11.5) ⫺4.0 1 (3.8) ⫺5.0 1 (3.8) ⫺3.0 4 (15.4) ⫺4.0 3 (11.5) ⫺2.0 3 (11.5) ⫺3.5 1 (3.8) ⫺1.5 2 (7.7) ⫺3.0 3 (11.5) ⫺1.0 3 (11.5) ⫺2.0 2 (7.7) Baseline 9 (34.6) ⫺1.0 7 (26.9) ⫹1.0 2 (7.7) Baseline 4 (15.4) ⫹1.0 1 (3.8) Interval 3 ⫺8.0 1 (3.8) ⫺8.0 2 (7.7) ⫺6.0 1 (3.8) ⫺7.0 1 (3.8) ⫺5.0 2 (7.7) ⫺6.0 2 (7.7) ⫺3.0 3 (11.5) ⫺5.0 1 (3.8) ⫺2.0 4 (15.4) ⫺4.0 3 (11.5) ⫺1.5 1 (3.8) ⫺3.0 7 (26.9) ⫺1.0 3 (11.5) ⫺2.0 4 (15.4) ⫺.5 1 (3.8) ⫺1.0 2 (7.7) Baseline 7 (26.9) Baseline 2 (7.7) ⫹1.0 3 (11.5) ⫹1.0 2 (7.7) TABLE II
CHANGES IN PAIN FREQUENCY (N⫽26)
Morning Evening Change from Baseline No. of Participants (%) Change from Baseline No. of Participants (%) Interval 1 ⫺4.0 3 (11.5) ⫺4.0 2 (7.7) ⫺3.0 1 (3.8) ⫺3.5 1 (3.8) ⫺2.0 1 (3.8) ⫺3.0 2 (7.7) ⫺1.5 1 (3.8) ⫺2.0 1 (3.8) ⫺1.0 1 (3.8) ⫺1.0 2 (7.7) Baseline 18 (69.2) Baseline 16 (61.5) ⫹5.0 1 (3.8) ⫹1.5 1 (3.8) ⫹4.0 1 (3.8) Interval 2 ⫺7.0 3 (11.5) ⫺7.0 3 (11.5) ⫺4.0 3 (11.5) ⫺6.0 1 (3.8) ⫺3.0 5 (19.2) ⫺4.0 3 (11.5) ⫺1.5 1 (3.8) ⫺3.0 3 (11.5) ⫺1.0 1 (3.8) ⫺2.0 4 (15.4) Baseline 12 (46.2) ⫺1.5 1 (3.8) ⫹2.0 1 (3.8) ⫺1.0 1 (3.8) Baseline 9 (34.6) ⫹3.0 1 (3.8) Interval 3 ⫺7.0 7 (26.9) ⫺7.0 6 (23.1) ⫺4.0 2 (7.7) ⫺6.0 1 (3.8) ⫺3.0 3 (11.5) ⫺5.0 1 (3.8) ⫺1.0 1 (3.8) ⫺4.0 1 (83.8) Baseline 12 (46.2) ⫺3.0 4 (15.4) ⫹4.0 1 (3.8) ⫺2.0 2 (7.7) Baseline 10 (38.5) ⫹1.5 1 (3.8)
intervals. However, the magnitude of the reported decreases in pain frequency was greater between intervals 1 and 2, whereas values remained relatively stable between intervals 2 and 3.
In terms of pain duration (Table III), only 15.2% of partici-pants noted decreased pain duration during the interval 1 morning period, whereas 34.6% reported decreases in the evening period. The majority of participants reported no changes in pain duration during interval 1 (morning, 69.2%; evening, 61.5%). In contrast, during interval 2, 92.3% of partic-ipants (24 of 26 particpartic-ipants) reported decreased duration of pain during the morning and 61.6% (16 of 26 participants) during the evening. Fifteen participants (57.7%) reported de-creased pain duration during the interval 3 morning period and 18 participants (69.2%) in the evening. Duration values with statistical significance were interval 1 evening and intervals 2 and 3 both morning and evening (Table III). Similar to the mea-sures of pain intensity and frequency, the magnitude of the decrease in pain duration was greater across all three time intervals. However, this pattern did not hold for the morning period, primarily because of the rather dramatic 92% decrease in the duration of pain during the interval 2 morning period.
Overall, 26 participants with MFP for at least 6 months and a pain intensity rating of at least 3 (on a Likert ordinal scale of
0–10) were enrolled in this study. The majority of the partici-pants (69.2%) attended all three sessions (19.2% attended two sessions and 11.5% attended one session). All 26 participant survey results were included in the study. The participants overwhelmingly reported that the CBT course was beneficial in reducing their MFP pain, and all except one participant favored the group session format over individual treatment. Almost one-half (46.2%) of the participants reported that they were able to identify previously unrecognized oral behaviors that possibly contributed to their symptoms.
Discussion
Few studies have evaluated the effectiveness of a brief CBT group treatment for a MFP population, although the long-term management benefits of CBT have been extolled in the pain literature. This preliminary project gave patients the opportu-nity to participate in a three-session CBT course. Twenty-six individuals elected to do so and were subsequently enrolled. The CBT course took a small number of participants (2–5 per ses-sion) through a total of 6 hours (2 hours per session, with three total sessions) of instruction. The small class size and number of classes were factors expected to improve adherence to suggested behavior modifications. However, a number of participants failed to attend all three sessions and/or their follow-up ap-pointments, despite enrollment as a test participant with mon-itored progress.
Studies have demonstrated that many MFP patients report symptom improvement through palliative treatments only, such as resting the masticatory system,14,25habit awareness
educa-tion, home physiotherapy to improve posture, reducing exces-sive caffeine consumption, and taking over-the-counter medica-tions when indicated.26The initial portion of the present study
evaluated the responses to palliative therapy only (interval 1), finding that 32% of the participants experienced improvement. The CBT course was designed to augment self-care modali-ties, to enhance awareness, and to eliminate diurnal oral para-function and muscle-tensing behaviors. Oral parapara-functional be-haviors are nonproductive movements of facial and oral tissues; they are not limited to clenching or bruxing but also include cheek biting, tongue thrusting, fingernail biting, unusual jaw posture habits (i.e., jaw thrusting), tooth tapping, and others.26
It was expected that patients with diurnal habits or a combina-tion of diurnal and nocturnal habits would benefit from the group-format therapy. Nocturnal parafunctional activities are commonly those of clenching or grinding. These cannot be con-trolled by the patient while asleep and are most likely a result of centrally induced muscle activity associated with sleep auto-nomic nervous system activation.12,27–29Patients who
demon-strated MFP symptoms related to diurnal activity, which some studies weakly related to stress or parafunctional behaviors, appeared to benefit from the current CBT course. Overall, 76.1% of our participants experienced decreased pain intensity, fre-quency, and duration over the period from the initial examina-tion to the end of the CBT course (Tables I to III, interval 3).
Integral to successful CBT is patient management, and this was emphasized as a key aspect of the course.21In medical care,
rates of noncompliance are reported to range from 15% to 93%.30,31 Factors known to significantly influence compliance
levels are patient knowledge and understanding, previous levels
TABLE III
CHANGES IN PAIN DURATION (N⫽26)
Morning Evening Change from Baseline No. of Participants (%) Change from Baseline No. of Participants (%) Interval 1 ⫺8.0 1 (3.8) ⫺8.0 1 (3.8) ⫺5.0 1 (3.8) ⫺4.0 2 (7.6) ⫺3.0 1 (3.8) ⫺2.0 3 (11.5) ⫺2.0 1 (3.8) ⫺1.0 3 (11.5) Baseline 18 (69.2) Baseline 16 (61.5) ⫹1.0 2 (7.7) ⫹4.0 1 (3.8) ⫹7.0 1 (3.8) ⫹10.0 1 (3.8) Interval 2 ⫺20.0 3 (11.5) ⫺10.0 3 (11.5) ⫺17.0 2 (7.7) ⫺9.0 2 (7.7) ⫺15.0 1 (3.8) ⫺8.0 1 (3.8) ⫺12.0 3 (11.5) ⫺6.0 2 (7.7) ⫺11.0 1 (3.8) ⫺5.0 1 (3.8) ⫺10.0 8 (30.8) ⫺4.0 3 (11.5) ⫺8.0 2 (7.7) ⫺2.0 2 (7.7) ⫺6.0 1 (3.8) ⫺1.0 2 (7.7) ⫺3.0 2 (7.7) Baseline 9 (34.6) ⫺2.0 1 (3.8) ⫹4.0 1 (3.8) Baseline 2 (7.7) Interval 3 ⫺10.0 7 (26.9) ⫺10.0 6 (23.1) ⫺8.0 1 (3.8) ⫺9.0 1 (3.8) ⫺5.0 2 (7.7) ⫺8.0 2 (7.7) ⫺4.0 1 (3.8) ⫺5.0 1 (3.8) ⫺3.0 3 (11.5) ⫺4.0 2 (7.7) ⫺1.0 1 (3.8) ⫺2.0 4 (15.4) Baseline 9 (34.6) ⫺1.0 2 (7.7) ⫹1.0 1 (3.8) Baseline 8 (30.8) ⫹2.0 1 (3.8)
of compliance, perceived benefits of therapy, and complexity of therapy. Assessment of compliance, measured as the number of sessions attended, revealed that three participants (11.5%) at-tended one session, five (19.2%) atat-tended two sessions, and 18 (69.2%) attended all three sessions. No attempts were made to identify the reasons for nonattendance in the group treatment sessions.
The group CBT course appears to provide awareness of and tools to address behaviors perpetuating MFP symptoms. Results from this study indicated that a majority of participants experi-enced improvement in the intensity, frequency, and duration of their MFP symptoms. Furthermore, it was demonstrated that the CBT was beneficial when conducted in a group treatment format. Ninety-six percent of the study participants reported preferring a group format that allowed sharing of successes and frustrations in the pain management process, although it must be noted that these participants had no experiences other than the group format and no statistical analysis of this information was conducted. Benefits of the group format included patient-doctor relationship building, patient awareness, and patient sharing. The group format also maximized the therapist’s time by allowing the management of a greater number of patients in less time. A weakness of the current preliminary study was that it did not include a no-treatment comparison group. Future studies should incorporate a randomized two-group design, with the control group receiving the home care instructions only, compared with the treatment group with home care in-structions in addition to the group CBT course. Additional re-search is needed to further evaluate the efficacy of brief inter-ventions performed in the dental clinic, as well as CBT approaches for the treatment of MFP.
Acknowledgments
We thank our epidemiologist, Dr. Anneke Bush, for her biostatistical support.
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