Dentistry and Health Psychology

For more than a quarter-century, health psychology approaches to dentistry and oral health have been active and productive areas of research. Among the topics that researchers have investigated are bruxism (night-time clenching or grinding of the teeth) and other oral habits (e.g., thumb sucking), taste disorders, the impact of craniofacial anomalies, oral health needs of special populations (e.g., the medically compromised and the seriously mentally ill), and a esthetics (orthodontic treatment and tooth whitening). This entry focuses on temporomandibular disorders, dental fears, and adherence to oral health care regimens. These topics address themes important to health psychology, including the impact of chronic conditions on behavior and emotional functioning, the role of behavior in the etiology of disease, and strategies for attaining and maintaining optimal health.

Temporomandibular Disorders

Temporomandibular disorders (TMD) form a heterogeneous collection characterized by or facial pain and/or masticatory dysfunction. They are frequently organized into three broad diagnostic classes involving masticatory disorders (“chewing”) and disorders involving the hard and soft tissues of the temporomandibular joint (TMJ). These diagnostic classes are not mutually exclusive, and patients may be diagnosed with several disorders simultaneously.

Unlike many chronic pain conditions, which are increasingly frequent with age, TMD is more prevalent in those under age 45 years. In population studies, approximately twice as many women are diagnosed with TMD than men, and in clinical samples, women can outnumber men by a ratio of 8:1. Approximately 4.5 percent of the adult population reports pain and dysfunction sufficiently severe to prompt help seeking.

The pain reported by TMD patients is typically located in the muscles of mastication, in the area just in front of the ears, or in the TMJ. TMD patients may also report headache, other facial pains, earache, dizziness, ringing in the ears, and neck/shoulder/upper and lower back pain. TMD patients may report a variety of TMJ problems other than pain, including locking in the open or closed position and clicking, popping, and grating sounds. Patients may report difficulty opening their jaws wide as well as a sense that their occlusion (“bite”) feels “off.” The spectrum of symptoms leads patients to seek care from dentists, physicians, and other health professionals. Para-functional tooth contact may be an important mechanism by which individuals develop the muscle pain of TMD. Like other joints, the TMJ is subject to degenerative changes typical of arthritis.

The best-validated measure for assessing TMD, the Research Diagnostic Criteria (RDC) (Dworkin & LeResche, 1992), is unique among chronic pain (and many medical) conditions in requiring comprehensive assessment of both physical and psychological status. This two-axis system codes physical findings under Axis I of the RDC and psychological findings under Axis II.

Like many chronic pain conditions, patients with chronic TMD may experience depression. TMD patients who report chronic muscle pain are more likely to experience psychological distress than those who only report simple clicking or popping noises. Many activities of daily living (e.g., eating, talking, social and recreational activities) are affected by TMD pain.

When rendered by a dentist, treatment of TMD often involves the fabrication of an interocclusal appliance (“splint”) that covers the upper or lower teeth and recommendations for use of a nonsteroidal anti-inflammatory drug. Psychological treatments, including biofeedback, relaxation training, habit reversal training, and cognitive-behavioral management of pain, have all been used successfully to treat TMD (e.g., Crider & Glaros, 1999). Evidence shows that psychological treatments are a competitive alternative to dental approaches and may produce better long-term outcomes.

Dental Fears

Approximately 20-30 percent of the adult population has significant fear of dentists and dental procedures. In 5-10 percent of the population, the fear is sufficiently strong to cause avoidance of routine dental care. Dental fears tend to increase during childhood and adolescence, reaching a peak in late adolescence and early adulthood and diminishing thereafter. Only a small proportion of children with dental fears continue to report fear later in life. Women report more dental fear than men. Observation of patient behavior and careful, sympathetic questioning will often identify many individuals with high levels of dental fears. Well-validated self-report questionnaires can also be used to screen individuals for dental fears.

People with dental fears are often concerned with pain, anesthetic injections, sounds, and other sensations that accompany dental assessment and treatment. In others, dental visits can induce claustrophobia, panic, or severe gagging. Patients may distrust dental personnel and the treatment plan for their care. Still others experience a perceived lack of control over the course of a visit.

Dental fears may develop in children or adolescents as a result of a perceived bad experience (e.g., poorly controlled pain) in a dental office, but a more likely source is modeling of dental fears by parents. Patients who develop dental fears in adulthood may have a higher likelihood of being diagnosed with other anxiety disorders. Patients with fears of injections or of health professionals may generalize those fears to a dental environment.

A variety of techniques have been developed to help fearful patients cope successfully with a dental visit. For example, the use of a stop signal will help many patients recover a sense of control over a visit. Use of breathing exercises, relaxation, and imagery can improve a patient’s ability to cope with the sensations created by treatment or prophylaxis. The distraction provided by portable tape and CD players can help mask noises. Systematic desensitization and graduated exposure can help patients overcome fears of injections or a tendency to gag. Dentists themselves can manage fearful patients by providing up-to-date information regarding dental care.

The use of antianxiety agents for managing dental fear is common among many dentists. These agents may include nitrous oxide gas, tranquilizers (e.g., Valium), and intravenous sedation. Unfortunately, long-term follow-up studies show that patients who receive medication alone for managing fears do not experience reduction in fear and often fail to receive routine care. In contrast, behavioral interventions appear to produce good long-term results, as measured by the ability to receive continued, routine care by the patient (Milgrom et al., Getz, 1995).

Adherence

Failure to remove plaque, a sticky biofilm containing bacteria, from the teeth causes gingivitis, an inflammation of the gums. Left untreated, gingivitis can progress to periodontitis (a more serious infection), loss of supportive bone, and eventually tooth loss. Thorough, effective brushing accompanied by flossing can disrupt and remove plaque, resulting in healthier gingiva and reduced numbers of carious lesions (“cavities”).

The connection between oral care habits and oral health is more obvious and visible to patients than the connection between other disease and health care regimens (e.g., consumption of dietary fats and cardiovascular disease). Failure to brush teeth can result in gingivitis within 2-3 weeks. Treatment of gingivitis and periodontal disease patients can result in markedly reduced signs of infection (e.g., bleeding or pain with brushing and flossing, puffiness in the gums) within 2 weeks. Advertising by manufacturers of oral health care products such as mouthrinses and toothbrushes has increased public awareness of good oral health. The time needed to carry out oral health care is small. Thus, patient adherence to an oral health regimen should be greater than to programs in which the time and effort required from patients is greater and in which the connection between the regimen and an outcome is less obvious.

However, the first-ever Surgeon General’s report on oral health (Public Health Service, 2000) identified a “silent epidemic” of dental and oral diseases that are disproportionately represented among members of racial and ethnic groups and among the poor and elderly. The report called the mouth a “mirror for general health and well-being” and noted how oral heath problems were frequently associated with other health problems, including cardiovascular diseases, premature/low term birth weight, and diabetes.

According to the Surgeon General’s report, a major barrier to seeking and obtaining professional help is a general lack of public understanding and awareness of the importance of oral health. In some individuals, maintenance of oral health is not a high priority. This may be due to the patient’s low value for oral health, dental fears, or concerns about the financial cost of dental care. In some cases, a dentist’s autocratic communication style does not encourage the shared responsibility that can increase patient compliance with oral care regimens.

A variety of approaches have been developed to encourage individuals to engage in oral health promotion behaviors. One set of strategies focuses primarily on parents. In this approach, parents are encouraged to introduce oral care activities at a very early age and to be good models for oral care. In addition, parents are encouraged to limit intake of sugary foods. For children with good motor control and for adolescents and adults, careful instruction in the techniques of brushing and flossing may improve these behaviors sufficiently so that the risk for gingivitis and carious lesions is reduced. The use of disclosing solutions or tablets that stain plaque can help patients identify areas on the teeth that need more careful brushing.

An ideal oral care regimen may require tooth and tongue brushing, flossing, and the use of a mouth rinse, but not all patients are willing to perform all these tasks. In this situation, techniques that reduce the risk for plaque build-up are preferable to a complicated oral care regimen that the patient does not follow. For example, it may be beneficial to recommend the use of an electric toothbrush alone when a patient is unwilling to brush and floss or when a patient’s skill at either technique is marginal.

For those patients who need a more structured approach, adherence regimens based on operant models of behavior are used. These regimens emphasize successive approximation to the goal, careful monitoring by the patient (or other responsible party) of oral care behaviors, positive reinforcement for attainment of intermittent goals, and high levels of praise by dental personnel for success in maintaining good oral health.

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