It may seem like an unlikely scenario:
You're suffering from temporomandibular joint dysfunction (TMJ), the painful jaw disorder, and while you're stretched out in the dental chair your dentist starts asking if you've had any changes in appetite or energy level. Have you been feeling tense and irritable? Do you feel a sense of hopelessness? You answer in the affirmative and your dentist, recognizing signs of depression, refers you to a psychologist.
While the psychological probing may seem unusual, a San Francisco psychologist who specializes in behavioral medicine and stress and pain management maintains that it is not only an appropriate but necessary line of questioning for dentists treating patients with chronic pain.
"The point I'm going to make is that you can't treat a jaw alone, that you have to treat the whole patient," Ross Goldstein said Sunday at the outset of his discussion of the "Psychological and Social Aspects of TMJ Dysfunction and Pain" at the annual Spring Scientific Session of the California Dental Assn. in Anaheim.
'The Whole Patient'
"It's important to treat the whole patient," Goldstein said, "because the whole person is experiencing the symptoms, not just the jaw, and the elements of what the whole person is about affect the symptoms themselves. To deal with just the jaw is like dealing with the tip of the iceberg."
TMJ dysfunction is a malfunctioning of the hinge mechanism of the upper and lower jaw that can trigger muscle spasm and pain in anatomical areas far removed from the actual joint. Clicking or grinding noises on opening or closing of the jaw and pain on opening of the jaw or chewing are common symptoms. In stressing the importance of dealing with personality in dentistry, Goldstein, who serves as a consultant for the department of postgraduate dentistry at UC San Francisco, said that Type A individuals are more likely to suffer from TMJ, which includes symptoms such as headache, dizziness and tightness in the back of the neck and face.
Describing Type A individuals as hard-driving, competitive, hostile and time urgent, Goldstein said they are prone to higher stress levels and body tension. And when symptoms of TMJ emerge, radical personality changes often are noticed because stress often leads to depression and increased anxiety.
"You can't deal with this phenomenon without asking, 'Why is this person sitting in my chair?' " he told the dentists.
"I encourage you to ask because the data shows that 80% of the population at large will experience some TMJ at some point in their lives."
Goldstein describes pain as being both a psychological and a physiological experience and that in treating patients with chronic pain, dentists must pay attention to both variables. As scientists and practitioners, he said, dentists tend to think of pain as "the cry of the wounded nerve." But that's not true, Goldstein said. He asks dentists to think about the pain they've experienced when, for example, things are going great as well as pain they've experienced "when everything's in the pits."
"You experience more pain when you're anxious, tense, depressed--when there are situational factors working against you," he said.
Pain, Life Crises Link
Goldstein observed that people always have more pain and more disease around times of life crises or major changes. Cultural factors also play a role in pain, he noted. "What's the patient's family background? What have they learned about pain from watching their parents? Certain cultures encourage a lot of acting out around pain and others very actively discourage it."
In assessing patients who are in chronic pain, Goldstein advises dentists to sit down and talk with them. Ask them about personality factors. How do they deal with pain? How is it affecting them? What's going on in their lives? Have there been any changes? Any losses?
"The more psychologically involved patients show multiple symptoms," he noted. "In the course of telling you about their jaw, they'll mention to you, 'My neck also hurts, and my stomach . . . .' They'll give you a whole variety of symptoms."
But why should a dentist assess all these variables? Is it, Goldstein asks rhetorically, appropriate for a dentist to ask questions about these things?
"I say absolutely," he said. "I think, in fact, you're doing the patient a service. Do you have a right to do it? I think you have the right insomuch as what you're really there for is to give the patient the best care possible. I don't think you can give them the best care possible if you have a very depressed patient and you're just ignoring the depression because you feel you don't have the right to talk about it."
Goldstein encourages dentists to develop a "treatment team": to have professionals in their community to whom they can refer patients such as psychologists, physical therapists and biofeedback therapists.
Goldstein acknowledged that some patients may regard the probing of their personality and making referrals as an intrusion. But, he said, "the patients for whom it's most appropriate, I have found, regard it as a healthy and a helpful gesture.
"The patients who are really depressed, who are really anxious, are relieved to find that someone finally noticed they are depressed or anxious. Most of them know already that these factors have a role in their disease and they're usually relieved to know someone else is noticing it and that there are treatment techniques that can help them."
Goldstein recommends such techniques as biofeedback, cognitive restructuring (changing one's thinking about pain), stress management, relaxation techniques, exercise and even family therapy which, he said, "is particularly important if the person's pain has disrupted his family life."
In terms of treating patients with TMJ, Goldstein said, psychological factors are especially important because they affect whether the patient cooperates with treatment.
"Most people come in expecting a traditional medical model: that there's a disease, it will be diagnosed, treated and it will go away."
But, he said, "when they come up against something like TMJ, it's a whole new ballgame." The diagnosis, he said, is not that simple, the treatment is ongoing, the pain fluctuates and the prognosis is ambiguous--"That in itself causes stress and you really have to educate your patients about dealing with management as opposed to cure."
Out of Passivity
The patient, he said, must become an active member of the treatment team. "Get them out of the passivity of showing up and you doing it for them."
Goldstein observed that one of the "overwhelming effects of chronic pain is that people's worlds begin to shrink. They get into pain and they give up their work, they give up their sex lives, their recreational life, their hobbies, intellectual interests and their social lives.
"Pretty soon they find themselves with what? Their pain. They've painted themselves into a corner. If you can begin to turn that around what will happen is the pain begins to slip into the background. The single most important variable in treating chronic-pain patients is getting them back to work or some productive function."
The end result of treating a patient in chronic pain as a person rather than just a jaw or a tooth, Goldstein said after his talk, "is better patient care and more rapid resolution of their pain complaint as well as any other problems." It creates, he added, "a system that is more sensitive to their needs, and the dental office becomes a more humane place to be."