Chapter 27

RESTORATIVE PROBLEMS OF PSYCHOGENIC ORIGIN

Symptoms and signs of psychogenic origin of relevance to the restorative dentist are:

• Facial Arthromyalgia
• Atypical Facial Pain
• Atypical Odontalgia
• Tension Headache
• Phantom Bite
• Dysmorphophobia
• Anorexia Nervosa and Bulimia
• Factitious Lesions
• Oral Dysaesthesia
• Conversion Disorders

The clinical features are described in Chapters 1, 3 and 4 (Pages 20–23; 40; 92).

The Restorative Patient with Pain or Discomfort of Psychogenic Origin

Diagnosis

Diagnosis is made primarily from patient history (Chapters 1, 3), but signs in, for example, atypical odontalgia such as multiple root fillings, apicectomies and missing teeth help confirm the diagnosis (Chapter 4). In the presence of a positive history, manipulative dental investigation such as the removal of restorations to observe the underlying tooth, should be kept to a minimum, but where there is doubt, additional diagnostic assistance must obviously be obtained. The differential diagnosis must always be considered (Chapters 1, 3, 4). It is advisable to reconsider the diagnosis whilst keeping the patient under review in case evidence of pathological change appears.

Most patients with orofacial pain or discomfort of psychogenic origin do not have a psychiatric disorder and do not require referral to a psychiatrist (see Referral, page 402).¹ These patients are emotionally vulnerable and, as a response to emotional disturbances, develop end organ changes which result in pain and dysfunction in the TMJ, muscles or teeth.

Management

Counselling

A key feature of symptoms, not explained by organic disease, is the patient’s belief that the symptoms are due to physical illness. This is termed attribution. Clinicians hope that investigations will reassure the patient, yet patients perceive such intervention as confirmation of their fears of illness.² An aim of counselling is to change the patient’s beliefs about the origin and nature of the symptoms. This is termed reattribution.

Goldberg (1992)³ has described three stages in the clinical encounter:

• Feeling understood
• Changing the agenda
• Making the link

Goldberg (1992)³ considers these stages further as follows:

Feeling Understood

The process of reattribution is more likely to succeed if the patient feels that his/her problems have been understood. The clinician should:

(i)  Take a full history of the pain and elicit other associated symptoms.

(ii)  Respond to mood ‘cues’: clarify the complaint, make empathetic comments.

(iii) Explore family and social factors.

(iv) Explore the patient’s health beliefs.

(v)  Carry out necessary physical examination and only carry out investigations if indicated.

Changing the Agenda

The physical findings should be summarized and the reality of the pain acknowledged in a sympathetic manner, for example:

‘The muscles in your face are rather tender, but apart from that I haven’t found anything abnormal in your teeth or bite, but you have been getting a lot or discomfort, haven’t you?’

The clinician then proceeds to re-frame the complaints by summarizing other symptoms and mentioning life events, for example:

‘People can get pain like this when they are stressed and it’s interesting that since you were made redundant and moved house, you have had pain in your face, your stomach and your back.’

Goldberg stresses that there are three steps, none of which can be omitted:³

(i)   Feedback results from the physical examination.

(ii)  Acknowledge the reality of the pain.

(iii) Re-frame the patient’s complaint, mentioning other symptoms and any life events.

Making the Link

The aim is to provide the patient with an explanation of how stress or disorder may be producing the symptoms, for example:

‘Some people develop diarrhoea before an examination or interview. This is a response to the stress. In your case, stress results in the formation of certain chemicals in your body, which affect blood vessels, giving rise to discomfort in your muscles and mouth. It’s a bit like migraine in your face or teeth.’

The patient should understand the need to control this discomfort before making restorations, and that restorations are not being provided to treat the pain. A handout is helpful, see below. The dental hygienist, if adequately trained, can provide counselling during the hygiene appointments. This also enables the dentist to be present only for short periods during each appointment and this is a very cost effective way of administering such care. In many cases further therapy is not required.

Medical Therapy

The efficacy of tricyclic antidepressant therapy in the management of facial arthromyalgia, atypical facial pain, atypical odontalgia and tension headaches is now proven,⁴ although simple analgesics may be used in acute episodes of the latter. As sedation is not required in most cases, medication with low sedative and low anticholinergic side effects, such as nortriptyline, is recommended. This is started at a level of 10 mg at night for 10 days, increasing as necessary, every 10 days, by 10 mg increments – up to 40 mg. In hospital practice this may be increased to 100 mg. For patients with insomnia, 25 mg to 50 mg of a sedative drug, such as dothiepin, may be given at night instead of nortriptyline (25 mg increasing by 25 mg every 10 days, to a maximum of 100 mg in hospital practice). Contra-indications to tricyclic antidepressants are recent myocardial infarction since they can cause tachycardia, pregnancy, lactation and monoamine oxidase inhibitor medication. Patients with cardiovascular disease and those with hyperthyroidism or on thyroid medication should be closely supervised by a physician because of the tendency to produce cardiac arrhythmias and to prolong conduction time. The action of some antihypertensives may be blocked. In elderly patients with constipation and glaucoma and in patients with a history of urinary retention, for example, males with prostatic hypertrophy, nortriptyline, which has a low anticholinergic effect, should be chosen, but close supervision is required. Constipation can be managed with lactulose, 10 ml administered at night. Patients with a history of seizure should be closely monitored as the convulsive threshold may be lowered. Patients should be warned of the possibility of impairment in performing tasks such as driving and using hazardous machinery. Impairment may be exaggerated by alcohol. Dentists must check prescribing rights in the country in which they practice and are recommended to consult their pharmacopoeia for further details of precautions and adverse reactions. Medication must not be prescribed without supportive counselling. Despite the foregoing, side effects are rare and, if present, usually resolve rapidly. Clinicians should not be reluctant to prescribe appropriate medication.

If weight gain becomes a problem when using nortriptyline or dothiepin, these can be replaced by 20 mg of fluoxetine hydrochloride ([Prozac], a 5 hydroxytriptymine reuptake inhibitor) administered daily, but not in the presence of renal impairment, lactation, epilepsy, liver failure, cardiac disease, diabetes or pregnancy. This drug is relatively new and response to it must be carefully monitored, preferably by a physician.

If doses higher than those described are required, these are best prescribed by a medical practitioner. Many dental practitioners may also prefer a medical practitioner to prescribe and monitor low doses. It is frequently necessary to continue medication for three to six months, and then slowly reduce it in the reverse order to that in which it was increased. The time taken to reach a therapeutic plasma level is variable and, therefore, instant results should not be expected. Three to six weeks of treatment is required before suppression of symptoms can be expected. Treatment must not be withdrawn prematurely, or symptoms are likely to recur. Lack of response at nine weeks indicates an insufficient dose, the need for different medication (see below), or the need for further investigation. The relief of symptoms provides the dentist with the opportunity to perform the necessary restorative treatment, working to the principles outlined in Chapter 26. Therapeutic levels of the drug should be maintained for six to eight weeks after completion. Frequent checks, especially in the early weeks of treatment, should be made for any side effects such as drowsiness, dry mouth and constipation. The patient should be encouraged to persist with treatment, notwithstanding a side effect as, except for rarely occurring cardiac arrhythmias, a tolerance appears to develop. Palpitations, either from anxiety states or from the antidepressant drug therapy, can be controlled with a beta blocker such as propranalol 20–40 mg taken two or three times daily, prescribed and monitored by a physician. In the study of Feinmann and Harris (1984),⁴ patients on the placebo tablets developed more side effects than those on the tricyclic medication. The best prognosis is for those patients who obtain pain relief within nine weeks of therapy and who present a history of a major life event within the six months preceeding the onset of symptoms.⁴

Little or no response after two months of treatment, or persistent pain associated with extreme anxiety or bizarre symptoms, indicates the need for referal and alternative medication. This may be a phenothiazine, for instance, trifluoperazine hydrochloride 2–4 mg in the morning, or flupenthixol 0.5–1.0 mg twice daily as a supplement to tricyclic medication. This medication may be particularly useful in the management of patients with phantom bite syndrome, although such patients will often not comply with either medication or advice to consult with a psychiatrist. Refractory patients require conversion to a monoamine oxidase inhibitor, such as phenelzine (Nardil); one tablet every four hours (at 8.00 a.m., 12.00 and 16.00 hours). Most patients do not require psychiatric support but, when necessary, particularly in the psychotic patient, that is, one who is out of touch with reality, this is best provided through a dental specialist in liason with a psychiatrist.

The purpose of the medication should be explained to the patient. It is helpful to explain that the antidepressant is non-additictive and is not being prescribed to treat depression, but to counter ‘the production of those agents that cause the pain’. It must be stressed that the tricyclic antidepressants have been shown to be highly effective, both for pain control and as muscle relaxants in non-depressed patients. It is useful to emphasize that many drugs act in several ways, the analogy of aspirin having dual but unrelated therapeutic values is helpful – both to treat pain and in post-coronary thrombosis patients to reduce the risk of clot formation.

Several difficulties may arise, firstly, patients who are naturally reluctant to take medication for what may appear to be a ‘dental problem’ and secondly, clinicians who are too timid to provide an adequate dose for an adequate period of time or who are content to regard the pain as being untreatable. Seventy five percent of patients referred for hospital management respond to medical treatment in up to 12 weeks.⁴ Where a limited opening of less than 30 mm persists, arthroscopy should be considered.⁵ Approximately 15% of patients require continuous review and medication to remain pain free, the remaining 10% appear to suffer varying degrees of intractable pain.^4–5 Despite this, such patients are grateful for the support provided by brief, but regular consultation and protection from unnecessary surgery. Ineffective medication should be withdrawn.

Sometimes, when the dentist prescribes such medication without prior consultation with a general medical practitioner, it can lead to conflict. It is advisable to write to the medical practitioner to enlist his or her assistance, usually requesting them to provide the prescriptions and monitoring. Certainly, if other than tricyclic antidepressants are required, they should be prescribed by a medical practitioner. Usually, the medical practitioner is grateful for the diagnosis and more than willing to help. A letter along the following lines may be helpful:

Action of Tricyclic Antidepressants

These have been comprehensively reviewed by Kreisburg (1988).⁶ Evidence suggests that the brain and spinal cord cells which use serotonin as their neurotransmitter are intimately involved in normal pain responses, as well as in mediating at least some of the effects of analgesic drugs. Increases in serotoninergic neurotransmission are associated with decreased pain sensitivity, enhanced endorphin activity and increased analgesic drug potency. The tricyclic antidepressants are potent blockers of serotonin uptake, resulting in increased levels particularly in the midbrain, with the associated therapeutic effect. These drugs do not cause tolerance or addiction and relieve pain in the absence of depression, but are ineffective in the management of acute pain. In contrast, the benzodiazepines inhibit serotonin release and may, therefore, increase pain perception.

An hypothesis for the pain has been proposed by Harris et al. (1993)⁵ as follows: Emotional or physical stress in a biochemically vulnerable subject promotes the release of neuropeptides such as substance P and calcitonin gene related peptide (CGRP) in the joint capsule,^7–8 muscles or such sites as the periodontal membrane and dental pulp. These neuropeptides can induce vasodilation and an inflammatory response generating free radicals from leukocytes.⁹ Localized free radical damage of cell membranes can then produce eicosanoid algesic agents such as PGE₂ and 15 HPETE.¹⁰ Although the non-steroidal anti-inflammatory agents such as aspirin can block pain producing prostaglandins such as PGE₂, they do not affect the neuropeptides or the leukotrienes such as 15 HPETE. This may explain why simple analgesics offer little relief in these conditions. These biochemical changes may sensitize the peripheral tissues. Lowered midbrain serotonin levels reduce tolerance and the patient may, therefore, experience pain. The ‘facial pain patient’ can be identified by a reduced urinary excretion of conjugated tyramine sulphate, which is also found in patients with endogenous depression.¹¹ However, this tyramine trait marker occurs in facial pain patients without any evidence of depression and may explain why tricyclic antidepressants relieve pain in non-depressed patients.

Marbach (1986)¹² and Graff-Radford et al. (1992)¹³ consider that atypical odontalgia is due to deafferentation, resulting from trauma to a pulp. However, this would not explain the crossing of the midline by pain, nor its occurrence in healthy teeth, nor its consistent lack of removal by local anaesthesia, nor the positive response to tricyclic medication and counselling.

Tricyclic antidepressants also decrease the time spent in REM sleep (rapid eye movement) and increase the time in delta sleep. The latter is associated with a low steady metabolic state and with heart rate and blood pressure at their lowest daily level. Pharmacological depletion of brain serotonin has been associated with a decrease in non REM sleep, insomnia and even total consciousness. Nocturnal bruxists with severe symptoms of facial arthromyalgia have been shown to brux primarily during the REM stages of sleep.¹⁴ By increasing serotonin levels, the tricyclic antidepressants may increase the non REM delta sleep and, therefore, reduce bruxism. It is possible that a disorder in serotonin metabolism may be an aetiologic factor in nocturnal bruxism.

Do Not Let the Patient Manipulate Therapy

Patients with psychogenic disorders, particularly if exhibiting psychoses or neuroses, may try and manipulate therapy in terms of both the timing and the type of treatment. It is imperative that the practitioner maintains control and sets the aims, duration, timing and complexity of treatment. Once control is lost it may be impossible to provide the necessary restorations. Appointments must be kept punctually and the patient must not be allowed to introduce new problems as the appointment draws to a close. The latter is common with patients with pain of psychogenic origin and although it may appear to be uncaring to terminate the appointment, it is essential. If the dentist loses control and is manipulated, the patient will not be helped. Similarly, the patient must not be allowed to manipulate the receptionist. Although it may occasionally become necessary to change appointments to fit in with alterations of the patient’s plans, a very close watch must be kept and a firm approach adopted.

Records

For medico-legal reasons, accurate records are essential. If possible, they should be signed by the chairside assistant, particularly in patients with phantom bite.

Restorative Therapy

Only essential restorative care is provided. It is important to be aware that the patient with symptoms of psychogenic origin frequently has a disorder of perception. For example, an occlusion that would be perfectly acceptable to another patient, may be intolerable to the patient. It has been reported that patients with depressive illness and facial arthromyalgia respond well to tricyclic antidepressant therapy and even better to a combination of such therapy and occlusal stabilization appliance therapy.¹⁵ In a depressed patient with a real restorative need, particularly if a reorganised approach is required, appliance therapy may be helpful. In the absence of a real restorative need, there is a danger that those patients who do not respond to such therapy will be convinced that dental intervention will solve their problem, with all of the associated implications and hence a combination of drug and app/>

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