Health is a team sport
Mary Downie presents the second article in her two-part series on how psychological practice and knowledge impacts on the dental team
This article seeks to look at chronic oral facial pain and the stress experienced by the dental team. This work will present evidence that in many cases both of these states are manifestations of the dis-ease in a divided mind. In chronic oral facial pain, we will examine the conditions of TMD, burning mouth and atypical facial pain from the mind body perspective. The work of John Sarno will be explored as he seeks to offer an explanation of how the brain diverts unconscious rage into physical symptoms without consulting the conscious rational mind.
The research by Goldthorpe et al (2016) offers an interesting complex intervention model based on CBT (cognitive behavioural therapy) which embodies many of the ideas proposed by Sarno. Linking the dis-ease of chronic oral facial pain and the pervading stress in our profession will be the Adverse Childhood Experiences (ACE) studies. Dr Robert Block, the former president of the American Academy of Pediatrics, purports that the results and implications of the ACE study, are the single greatest unaddressed public health threat facing America today. What is true in America is also true in the UK, as the ACE studies in Wales and England have demonstrated. The studies, which look at how adverse childhood experiences impact on all aspects of adult health, both physical and mental, is backed up by robust scientific evidence.
In light of this evidence, Gabor Mate’s (2003) seven A’s of healing hold great relevance for ‘health as a team sport’ approach. The pains, ills and addictions of our modern society are a sign of the great disconnects that both health providers and patients are experiencing in their lives. When a boy child with Attention Deficit Hyperactivity Disorder would be president of a major world power it is time to sit up and pay attention.
The cost of chronic pain
Let me begin with the potential cost to both the patient and the health service of ignored somatised pain. Late one Friday night, at an early stage in my career I was asked to attend an accident and emergency department at half past midnight. I had been awakened from my slumber by a young casualty officer who requested that I remove an anterior four-unit bridge from a very distressed lady. On entering the department, I was confronted by a 62-year-old anguished lady who had attempted suicide. Her mutterings were partly comprehensible and I learned that she’d had intractable pain in her anterior front teeth since the four-unit bridge had been fitted two years previously.
In a faltering voice influenced by her torment she revealed that no one would believe her when she had explained the intensity of the pain and how it was impacting on all areas of her life. In the last few months she had become fixated on her bridge and believed that if this was removed then the pain would disappear. She kept uttering “no one would believe me, no one would believe me”. I gently said that I believed her and if it was her wish I would remove her bridge.
On clinical examination, it was an aesthetically and technically good anterior fixed appliance and my heart sank at the prospect of removing it. With her written consent, the bridge was finally set free from her oral cavity and she was released from the dental chair into the waiting care of the psychiatry department.
That whole episode has remained with me over the years and has informed my disposition to patients who present with pain but with no obvious organic cause. It can be difficult to resist intervening when a patient presents with intractable symptoms but in the absence of pathology, resistance is the better part of valour. In dental practice it is not uncommon to encounter patients who have chronic oral-facial pain of a non-odontogenic origin. This pain may take the form of tempero-mandibular dysfunction, burning mouth syndrome (oral dysathesia) or atypical facial pain.
After a careful and thorough history into the nature and distribution of the pain the patient is often referred to an oral surgery or oral medicine department. Within these departments, after thorough investigation which may include expensive tests, the patient is often given treatment in line with the biomedical model. For many patients with chronic pain, research now shows psychological factors play a role in the development, exacerbation and maintenance of their symptoms. Even though this is recognised by many clinicians, there are few psychosocial models in place to offer long-term resolution for this cohort of patients.
The pain is real
Dr John Sarno, an American physician, wrote a best-selling book on healing back pain, where he describes tension myositis syndrome (TMS). He proposes that the pain from this syndrome is caused by unconscious repressed rage and the diversion of this rage into somatic symptoms. The pain, he states with great emphasis, is real, as demonstrated by eliciting tenderness on palpating the affected muscle groups. He goes onto describe how the pain experienced by the patient is mediated by the autonomic-peptide system often by way of a decrease in oxygen to the affected muscle group.
The somatisation of psychological distress has been described since the time of Charcot, Breur and Freud and was written extensively about in Studies on Hysteria. They describe the split between the conscious rational mind and the more childish primitive unconscious mind. The unconscious mind is often described in terms of the shadow and holds all the emotions that we fear to look at consciously. Take the parapraxis, also known as the Freudian slip, where the unconscious repressed wishes reveal themselves to the light of day. They can often be funny anecdotes but they do reveal part of what is repressed. For example, the slip of tongue that states “A Sale of Two Titties” instead of “A Tale of Two Cities” (see Fig 1).
The masseter muscle is the strongest muscle in the body, helping to exert upwards of 200 pounds of force when the molar teeth are clenched. It is also the holder of a great deal of tension with the unconscious nocturnal grinding of teeth and the diurnal clenching of teeth. The question is, what is the purpose of this grinding and clenching which can lead to micro fractures of the teeth and hypertrophy of the masseter muscles? The pain from this muscle tension can cause great distress to patients impacting on all areas of their life.
Patients often report that when their life is more stressful this pain increases in intensity. The Dr Sarno methodology counsels patients that this pain is real and, indeed it is, but the source of the pain is psychological as opposed to physical. If a patient can accept this fact and acknowledge that it is due to repressed emotions, then the conditions for the reduction in pain and even cure are set in place. Secondly, and just as importantly, it is essential that the patient familiarises themselves with the sources of their repressed emotions. Sources can include childhood events, high expectations of themselves, perfectionism, inner criticism, sensitivities, people pleasing, worrying, the need to be good, responsibilities – the list is endless.
The patient can be given instructions on jaw massage and exercises to ease the muscle tension but the definitive treatment is recognising the emotions that the patient is afraid to bring into the light of day. Techniques such as mindfulness are good to identify emotions but it is important that the patient becomes aware of the real source of these emotions. This would not only help to ease their TMD but their greater awareness could offer the opportunity to a far richer life.
The research by Goldthorpe et al (2016) offers an interesting complex intervention model based on CBT which may prove to be of great value to TMD and patients with chronic oral facial pain.
There are to date no clinical guidelines to offer definitive care pathways to patients suffering from chronic oral facial pain. This is perhaps because the true extent of the mind-body connection is not fully acknowledged. Future research in this domain is necessary in order to relieve the distress of this increasing number of patients.
The complex intervention model need not be complex at all, as the primary purpose of it is to gently educate the patient as to a plausible explanation for their symptoms. This education is based primarily on believing fully the extent of the symptoms and the impact they are having on the life of the individual. From this starting point of unconditional acceptance, the long-term management of the condition can be forged in a collaborative environment. There is much research work to be done in the mind body spirit connection in order to reach health and balance for this group of patients.
Epidemiological research connecting early childhood experience to the later development of physical and psychological diseases may offer answers to chronic oral facial pain, and the stress many of the dental team will experience in their lives. The ACE study was carried out in 1995 and 1997 in California by Kaiser Permanente, a private health company, and the Centers for Disease Control and Prevention. The 17,337 participants have been followed up regularly ever since and monitored for their experience of health and well being. The average age of participants was 57, with 74.8 per cent being caucasians and
75.2 per cent had a college education. All had jobs and good health care, demographics which would closely parallel the dental team in this country. The study asked 10 questions enquiring whether a person had experience of any of the following conditions during childhood:
- physical abuse
- sexual abuse
- emotional abuse
- physical neglect
- emotional neglect
- mother treated violently
- household substance abuse
- household mental illness
- parental separation or divorce
- incarcerated household member.
One adverse childhood experience was reported by about two-thirds of the participants. The number of ACEs was highly correlated with adulthood behaviours such as smoking, alcohol, drug-taking, obesity, promiscuity and ill health including depression, heart disease, cancer and chronic lung disease. The more ACEs the more likely a shortened life span in adulthood (Fig 2). The neurobiology of stress in childhood offers an explanation of how these negative consequences may occur. Under stressful conditions, neural networks are altered along with the biochemistry of the neuroendocrine system.
The scientific evidence to support how early deprivation alters neuro pathways is now firmly established and unless these deficiencies are addressed the damage acts like chaos theory later on in life.
Forging a new path
The good news for our patients and for our own personal wellbeing is neuroplasticity. The ability of the brain to form new neuro pathways can now be demonstrated by neuroimaging. The work of Lindon (2006) has shown how psychotherapy can alter brain pathways in conditions such as depression and post traumatic stress disorder. I am not advocating mass uptake of psychotherapy, but I am suggesting that the more conscious we become and the more aware of our lives we become then the richer our experience of life will be.
Socrates stated that the unexamined life was not worth living and, in fact, he was willing to die for that. But what is meant by that in our personal lives and indeed our professional lives? The GDC in its Standards for the Dental Team and their document Developing the Dental Team both mention reflective practice. Yet, do we know the physiological, cognitive and psychosocial skills necessary to truly reflect?
We live in very fast and furious times, connected day and night to cyberspace and external stimulation. Is it any wonder that many of us feel disconnected from what really matters in life? The good life or happy life has been the focus of philosophy and psychology from the beginning of time. Much wisdom has come to us from these sources but we have to slow down to listen to the wisdom of our own hearts. There is much to be said for finding a quiet time in our busy schedules to develop the art of mindfulness. Mindfulness has been born again from its ancient origins in the East. It can be thought of as a simple form of meditation which if practiced regularly has been shown to decrease stress and lessen the symptoms of depression.
At it simplest form, the practitioners of this art seat themselves in a comfortable chair with plenty of support for the back. If doing this in a busy day, it can be good to set the alarm on your mobile phone so that your are not distracted worrying about time. It is good to close your eyes and listen to the sound of your breathing and become aware of any sensations in your body. While doing this, you will notice that thoughts may arise; notice them with compassion, but do not become attached to them, as thoughts are passing. If you are tempted to dwell on the thoughts, return to your breathing, noticing your inhalations and expirations.
In a busy surgery the practice of mindfulness together on a daily basis can enable each team member to see the world with a greater clarity. Do not worry about becoming some Zen-like monk, the practice of mindfulness enables you to cultivate a deep compassionate awareness which allows you to assess your values and goals. There are many courses available to help you with mindfulness, I believe NES even facilitates one.
Jon Kabat Zinn, emeritus professor of medicine and creator of the Stress Reduction Clinic and the Center for Mindfulness in Medicine has been credited with bringing this ancient art into modern medicine. He is quoted as saying that “You can’t stop the waves but you can learn to surf”. YouTube has many helpful videos to get you started on this life changing path.
Face your reality
In the quest to reduce stress it is good to remember the famous maxim: “If you always do what you’ve always done you’ll always get what you’ve always got.” There is great wisdom in this quote. If we are not prepared to look at ourselves, then things will continue as they are. It is not life that makes us stressed, it is the way that we respond to life. How we respond to life is chiefly influenced (as borne out in the ACE studies) by our early childhood conditioning.
Gabor Mate who wrote the book When the Body says NO, exploring the stress-disease connection, advocates what he terms the seven As of healing. These are: Acceptance, Awareness, Anger, Autonomy, Attachment, Assertion, and Affirmation. True reflection requires that we are able to accept ourselves as we truly are, not as we would like to be but as we are in this moment in time. Change is only possible after acceptance and acceptance is only possible if we are able to have compassionate curiosity about ourselves and other.
When I talk about acceptance I do not mean passive acquiescence but the ability to look at myself and my situation as it truly is. Facing and acknowledging our reality brings much greater awareness and means we can be fully present and responsible. We accept responsibility for ourselves and the experience we are having at this time whether it is a good or a bad experience.
Accepting yourself in the present moment means you learn to let go of the thoughts that say “you are bad or good, hopeful or hopeless”. You just are. You show up as you are letting go of all the things you fear to lose.
The second wish to a stress-free life is to become more aware. Awareness is the ability to recognise the physiological signals within your own body and the ability to interpret the emotional truth in the other. How many times have you had a gut feeling that you should have done one thing and only realised the cost of not heeding that after the event.
There is not enough space to go into the other As but each of them if engaged with sincerely offers a way of gaining greater understanding of our inner world. Carl Jung, the great Swiss psychiatrist, is quoted as saying “Who looks outside, dreams; who looks inside, awakes”. It is only in the depths of our inner world that we will discover the wealth of our being. Mindfulness is a great starting point, but in order to undergo long-term change we must be prepared to explore the uncharted waters of our inner life.
Taking a more pragmatic stance, there are things we can do to reduce stress but they must be done on a consistent basis. It goes without saying a healthy diet, regular exercise, and sleep are essential to reduce stress. In fact one of the main signs of stress is that we give up doing the things that are good for us and the things that give us pleasure. In times when life is difficult it is often the wisdom of poets who help us to see new light.
I leave you with the words of Max Ehrmann and invite you to take a seat and slowly listen:
Desiderata: Words for Life
Go placidly amid the noise and haste,
and remember what peace there may be in silence.
As far as possible without surrender
be on good terms with all persons.
Speak your truth quietly and clearly;
and listen to others,
even the dull and the ignorant;
they too have their story.
Avoid loud and aggressive persons,
they are vexations to the spirit.
If you compare yourself with others,
you may become vain and bitter;
for always there will be greater and lesser persons than yourself.
Enjoy your achievements as well as your plans.
Keep interested in your own career, however humble;
it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs;
for the world is full of trickery.
But let this not blind you to what virtue there is;
many persons strive for high ideals;
and everywhere life is full of heroism.
Especially, do not feign affection.
Neither be cynical about love;
for in the face of all aridity and disenchantment
it is as perennial as the grass.
Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.
Beyond a wholesome discipline,
be gentle with yourself.
You are a child of the universe,
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.
Therefore be at peace with God,
whatever you conceive Him to be,
and whatever your labors and aspirations,
in the noisy confusion of life keep peace with your soul.
With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Strive to be happy.
ABOUT THE AUTHOR
Mary graduated from Glasgow University in dentistry in 1980 and from the Open University in psychology in 2001. She obtained a postgraduate diploma in counselling and psychotherapy from Stirling University in 2013 and a postgraduate diploma in clinical education in 2017. She has enjoyed a plethora of experiences in dentistry, both in the UK and abroad. Mary is now in full-time psychotherapy practice. If you would like to contact her with regard to anything in this article, please email email@example.com or call 07970 909 373.
- Adverse Childhood Experiences (ACE) Study (Web Archive)
- CDC – Ace study
- Block, R – Who needs to pay attention to the ACE study (Georgetownta.wordpress.com) – accessed on 23/05/2013
- Breuer J, Freud S. Studies on Hysteria, 1895.
- Goldthorpe. J, Peters. S, Lovell. K, McGowan. L, and Aggarwal. V. ‘I just wanted someone to tell me it wasn’t all in my mind and do something for me’: Qualitative exploration of acceptability of a CBT based intervention to manage chronic orofacial pain. British Dental Journal, Volume 220, No. 9 (May 13, 2016)
- Linden, D.J. 2006. How psychotherapy changes the brain – the contribution of functional neuroimaging. Molecular Psychiatry, 11, 528-538
- Mate, G.‘When the Body says NO, exploring the stress-disease connection’. Alfred A. Knopf Canada (2003)
- Sarno, J. The Divided Mind: The epidemic of mind body disorders. Duckworth Overlook, London (2008)
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