Stress, Bruxism, and TMJ Pain and Dental Prosthesis Tolerance
13th September, 2010
The quickening pace of life in the modern world has many consequences. One of these consequences is stress. It is estimated that up to 15 million people in the UK have some form of stress related condition. This often takes the form of night grinding, jaw clicking or mastication pain. Stress is also an obstacle to effective dental treatment. Your patient may feel little or no anxiety towards an appointment, but what about the patient’s external relationships at home and work? What about your own stresses that you bring into the surgery?
We’ve all been there, a sense of tightening in our bodies, a lack of focus, shallow breathing, reactive and sometimes irrational behaviour. The natural ‘flight or fight’ response is corrupted. Instead of an acute reaction to the threat of the Sabre Toothed Tiger, the anticipation of what might happen keeps you in the ‘Get set’ position before the sprint. But the sprint doesn’t happen, how long can your body stay healthy in this position? Welcome to the biggest threat to your health apart from perhaps an ill advised audition on ‘The X Factor’. The link between the emotional and physical body is never more evident in stress. We are evolved beings, we experience consciousness through the development of the prefrontal cortex in our brains, we can consciously analyse ourselves and our behaviour. This is all wonderful but your subconscious mind is 1 million times more powerful than your conscious mind and this part of the mind is very much in the ‘now’. Your subconscious mind does not recognise time, everything, all your experiences your subconscious mind perceives are irrelevant to the time they happened. Through regression it is possible to return to a ‘trigger’ point in your memory but to the subconscious the experience or memory is stored not in chronological order but filed A-Z and presents itself very much in the present. What does this mean when you try and change a behaviour pattern such as getting stressed out? All the positive thinking in the world means very little on a conscious level if your subconscious mind has not changed its ‘wiring’. The ‘wiring’ is the network of neural pathways in your brain and throughout your body. Simply put, you behave in a certain manner enough times you are conditioned in this behaviour and the neural pathways become thicker and ‘stuck’ in this pattern.
If someone is stressed over a period of time, the symptoms can filter through their subconscious mind during sleep and the pressure of their teeth constantly in contact creates tension in the temporomandibular joint which involves all the nerves of each side of the face and head. The resulting symptoms can be headaches and joint pain which can be so great that it can lead to a loss of function. Pain can be increased through the narrowing of the blood vessels and teeth may also prematurely wear, the facets created can alter the occlusion and give an appearance of premature ageing.
Where hypnosis can be of benefit is in increasing the patients awareness of comfort associated with the appropriate amount of freeway space between their teeth through the use of direct suggestion. Unlike the induction (initial relaxation) technique with phobic and panic attack patients which puts attention on focussing outside the body with non dental stress related techniques it is more important to use focus on the internal sensations. Suggestion of muscle relaxation around the eyes and later with specific attention on the localised areas of tension is appropriate. Milton Erickson (1901-1980) developed techniques that used ‘reverse suggestion’. In essence reverse suggestion is where the patient is encouraged to try as hard as they can to continue the symptom when asleep but as they try they become more and more relaxed. This can be extremely effective if bruxism is a presented as one of the stress related symptoms;
For example a typical script might include;
‘As you try harder and harder to keep your teeth in contact…. You will find that the muscles of your jaw, neck and head will become more and more relaxed... .’
Relaxation and direct suggestion during a hypnosis session can be carried forward to the time that the symptom manifests itself, i.e. during sleep. Language is the tool of the hypnotherapist and suggestion of when the patient is asleep that their muscles will relax is carried with the patient in their subconscious mind associating sleep with the release of rather than increase of tension. The technique would incorporate using the time the patients head touches the bed as a starting point for delightful relaxation. Some form of pain management can be included to assist in the changing of any proprioception responses. Proprioception is the sensing of the position of neighbouring parts of the body, in this case occlusal surface against occlusal surface and the amount of force with which the patient closes and the perceived pain they may feel.
The combination of bruxing and TMJ appliances with hypnosis can increase the success of relieving these symptoms. A suppressing appliance is of no use for eliminating stress as its name indicates. However, if the patient is made aware of the benefits of the stability created within their mouth, jaws and head of the appliance provided, the hypnotic script can include this and thus facilitate a change of habit.
Hypnosis with children requires different techniques according to their age. In my first article I wrote of the differences in the alpha and beta brainwaves according to the level of relaxation of the individual. As daydreaming is a form of trance and a favourite child’s pastime, focus based techniques are unlikely to be effective with a child as they will probably be resistant or get bored quickly. The use of imagination such as cartoon characters to build a story that involves suggestion helps create a daydream trance in which the therapist can communicate with the child’s subconscious. The presence of a parent or guardian is mandatory and eye closure is not necessary to be effective. Once the child is relaxed, suggestion of awareness to the sensations in the mouth and how it works utilising the child’s story can be used. In the case of a child presenting bruxism, the additional awareness of ‘hearing’ the teeth rubbing together is of use. It is suggested to the child that when they are asleep hearing the bruxism will immediately awaken them and they will be able to comfort themselves that they have a good pattern for going back to sleep whenever they awaken. The suggestion asks the question ‘How many times does a person want to awaken in the middle of the night to prove that they can hear their bruxism?’.
Whatever functional and aesthetic benefits can be derived from an implant retained bridge or full dentures, to a patient who has had little or nothing in its place for a long period of time it is still foreign body. The beautiful smile is welcome but suddenly this small space that is their mouth is ‘filled’. An advantage of temporary restorations is that it allows the patient to get used to a new design but, there is the possibility of triggering the patients gag reflex after tooth extraction. This is most likely to occur in cases of immediate dentures or immediate loading implant restorations. With the denture in situ trance is induced and deepened with suggestion of the discomfort disappearing and that, providing your lab has done it job well, the bulky feeling of the new denture will also become tolerable. It is important to state that the goal is tolerance and not the disappearance of awareness to the denture being in place. The patient will still be able to feel if an area is being damaged by poor fit or if healing is being prevented by contamination. In extreme cases the use of a ‘Glove anaesthesia’ technique can reduce pain by ‘freezing’ the painful area.
Stress is easily manifested in the TMJ and mouth. By linking relaxation with localised attention on the surrounding muscle groups relief can be achieved and symptoms decrease. A continuing programme of self hypnosis, life style change and continuing awareness to when the patient gets stressed will further decrease the symptoms. In my next article I shall discuss the use of hypnosis in surgery for the control of blood and saliva flow, increasing healing rates and pain management.
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