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Oral Medicine The SCOPE ot orai medicine practice ard practitioner compelerles is evoiuticiiarv ir nature. Tiiis section of Quintessencs internationai \i committed to presenting evidenced-based clinical practice guidelines m Clinical Practice Guidelines coilaboration with orai and nonoral iieaitin care providers.

Post-traumatic disorder: Considerations for Edward F, Wright, DDS, MSVRussel L, Thompson, PhD^/Eleonore D, Paunovich, DDS,

A dentai patient with post-traumatic stress disorder (PTSDj may present with greater dental and behav- iorai chaiienges than most dental patients. The background review of PTSD's initiating tactors, diagnostic criteria, and medicai management shouid heip practitioners better understand and manage these ctiai- ienges. Many ot the challenges the ciinician may encounter and managing recommendations are de- scribed, A case report ot a PTSD patient complaining of constant bilateral tooth pain ot the maxiiiary and mandibuiar bicuspids and moiars is presented. Recommended techniques for identifying the tooth pain source and contributing factors are provided. The primary contributing tactcr tor the patient's tooth pain was determined tc be his severe tooth cienching activity, A maxiliary acrylic appiiance provided some pain reduction and a subsequent mandibular soft occlusal appliance worn opposing the maxillary appiiance provided additional relief. (Ouintessence Int2004,35:206-210)

Key words: bruxism, ccciusal appliance, periodontal ligament inflammation, post-traumatic stress disorder, , temporcmandibular disorder,

eople diagnosed with post-traumatic stress disorder Epidemiologie studies estimate 50% to 60% of the P(PTSD) experience pervasive and often disabling United States (US) population has experienced a sig- symptoms that interfere with social, occupational, and nificant traumatic event,''^^-'^ Most estimates suggest other important areas of functioning. Much of the early 10% to 300/D of those who survive a traumatic experi- research on PTSD involved male tnilitary veterans, es- ence report sufficiently severe symptoms to receive a pecially veterans of Vietnam,'•' However, subsequent diagnosis of PTSD,''2.«B research has described similar symptoms and levels of frequency in men, women, and children following Diagnosis rape," assault,^'^ natural disasters,' motor vehicle acci- dents,^-' and other life-threatening situations.'"''^ The primary diagnostic criteria for PTSD involves a past event in which an individual experienced or witnessed one or more situations in which a death or serious in- jury was threatened. Following the event, three addi- 'Assistant Professor, Department of Restoiative Dentistry, South Texas tional categories of symptoms are required to obtain a Veterans Health Care System, San Antonio, Texas, PTSD diagnosis: re-experiencing the event, avoiding re- ^Research Psychologist, GRECC, South Taxas Veterans iHeaith Care minders of the event, and increased arousal,'^ System, San Antonio, Texas. Re-experiencing can be in the form of recurrent sDireotoi, Clinical Orai Health Programs for Geriatrics and Extended Care, Soulti Texas Veterans i-iealth Care System, San Antonio, Texas, memories of images, thoughts or perceptions, , Reprint requests: Dr Edward R Wright, Department of Restorative rehvtng the event (flashbacks), or intense psychologic Dentistry, Mail Code 7390, 7703 Fioyd Curl Drive, San Antonio, TX or physiologtc distress with reminders. At least three 78229-3900. E-mail, [email protected] examples of avoidance are required to obtain the

206 Volume 35, Number 3, 2004 • Wrigbl el ai diagnosis, including behaviors sucb as efforts to avoid points and tbe TMJs were not able to reproduce his thinking, feeling, talking, visiting anjthing associated pain complaint, suggesting tbe pain was not referred with the trauma, impaired memorj' regarding all or pain from tbe masticatory muscles or TM]s.'^ pan of the trauma, withdrawal from daily life, re- Tbe diagnosis for patient's pain complaint was de- stricted feelings, and a sense of ha\ing no future. At termined to be generalized periodontal ligament in- least two sxTnptoms of increased arousal are required flammation of tbe posterior teetb. Inquiring about pos- for diagnosis, inciuding disturbance, irritability' sible clencbing activities, tbe patient related be or increased anger, concentration problems, byper\ig- routinely woke up several times a nigbt witb night- ilance, and exaggerated startle response.'* mares in which he would find himself maximally clenching his teeth and believed his pain and night- Medical management mare severity' appear to be correlated. Tbe patient had recently been treated with relax- Psycho dynamic. beha\ioral. cognitive, and netirobio- ation and blofeedback therapy, was receiving psycho- It^c models have been used with some degree of suc- logic cotmseling. and his medical pro\ider felt he was cess to explain the origins and actions of the disorder, recei\ing maximal pharmaceutical intervention. In an but there is no clear consensus in the field favoring attempt to decrease the patient s pain, he was pro- one model over the otbers. One frequent e.xplanation vided a well-adjusted ma.xillar\' acrj'hc stabilization for the onset of PTSD has been the diathesis-stress appliance and the applicable portion of TMD self- model originally advanced in research'^ management instructions (soft diet, observe for and in which individual vulnérabilité' is considered in com- discontinue any daytime parafunctional babits. etc). bination with circumstances to explain the de\'elop- After several appliance adjustments, the patient re- ment of PTSD. Althougb indi\idual differences sucb lated his pain had decreased to a fi\'e out of a possible as coping stj'les.^ femaie gender." a personal or family ten. The patient related tbat be continued to awaken history of psychiatric disorder,'- and degree of social nightly «ith and fotmd he was maximally support-' explain to some degree the onset of PTSD clenching his appiiance. symptoms foüoning a traumatic event, the strongest It was speculated that a mandibtilar soft tbermoplas- predictors have been severity- of Stressors, •^'--•' and the tic appliance adjusted and worn against the maxillarj' experience of multiple Stressors.^ appliance migbt belp cusbion tbe impact the severe Group and individual psychotherapy using behav- nocturnal clenching was having on the periodontal lig- ioral, cognitive, and psychod™amic approaches have ament pain. been helpful to patients with PTSD.-"-^^ Drug tberapy A sheet of 0.15-inch (3.8 millimeter)-thick soft with selective serotonin reuptake inhibitors (SSRIs) thermoplastic material was utilized for the appliance, has been found to be superior to nontreatment control because it is the thickest material commercially av'ail- g'oup.^-^' while bave not been par- able and v^'ould provide the greatest amount of cusb- ticularly effective.^^^' Otber psychotherapy techniques, ion. The laboratory technician wanned tbe material such as hv'pnosis and eye movement desensitization, and by pressurized air. molded it over tbe patient's may be belpful, but are less supported by controlled cast WTien tbe patient returned to tbe clinic, it was clinical studies.^"^ seated on the patient's mandibular teetb and a minor internal adjustment was made viith an acrj'Hc bur. The appliance's occiusal surface was modified to CASE REPORT approximate the final occlusai surface.'^ This was ac- complished by placing the appliance on the cast, uti- A US veteran, who had fought in the Vietnam «'ar. lizing an torch to evenly warm the appliance's complained of constant bilateral maxillary and occiusal surface, and placing tbe warm appiiance over mandibular bicuspid and molar pain that he rated as the patient's mandibular teeth. With the patient wear- an 8 out of a possible 10 (pain scale where 0 is no ing the maxillary appliance, the patient's pain and 10 is the worst ima^nable pain). W'as manipulated to tbe position the appliance would Radiographie and oral examination revealed the be adjusted and the patient was asked to close onto patient had no caries, no deep restorations, and tbe softened tbermoplastic appliance and slide the healthy (no pocket depth greater tban mandible into the excursive positions. three millimeters). All of the posterior teeth were ten- The soft thermoplastic appliance was placed back der to mouth-mirror percussion and this intensified on the cast and any material that extruded beyond the his pain complaint The masticator^' muscles and tem- occiusal plane was removed witb an acryrlic bur. Tbe poromandibtüar joints (TMJs) were also tender to pal- appliance was reinserted with the patient continuing to pation. Ten-second loading of the myofascial trigger wear the maxillary appliance, marked with articulating

Ouintesseoce inlemational 207 • Wright et al

Fig 1 Mandibular soft thermoplastic appliance adjusted (o an Fig 2 Maxillary acrylic appliance worn opposing a mandibular opposing maNÜIary acrylic appliance and with even blue articulat- soft (Inermoplastic appliance. ing paper marks.

paper (Bausch Articulating Paper, Pulpdent), and ad- toms secondary to tooth clenching will have palpation justed with an acrylic bur (Fig 1). The appliance was tenderness of the masticatory muscles and/or TMJs, polished utilizing a gauze moistened with halothane {a while dental pain secondary to tooth clenching are general inhalation anesthetic often used as a substitute more complicated to identify. for chloroform'^}, which was firmly ruhbed over any rough area. Dental evaluation At night, the patient wore the mandihular soft ther- moplastic appliance against his maxillary acrylic appli- Patients with dental pain complaints should first be ance and reported his pain decreased to a three out of evaluated to determine whether the source is from a a possihle ten (Pig 2). dental pathology, such as caries, , or incomplete tooth fracture. If these pathologic con- ditions are ruled out as the source of the pain, the DISCUSSION practitioner should consider other causes for dental pain, such as periodontal ligament inflammation sec- Dental practice implications ondary to parafunctional activity,^'"*^ reversible pulpi- tis secondary to parafunctional activity/^-" or referred A history of traumatic experiences (ie, abuse, war pain,"-^' trauma) have been associated with problems of keep- Dental pain caused by chronic severe tooth clench- ing dental appointments, distress behavior while in the ing may be due to a combination of both referred pain dental chair, and stress-related dental problems (ie, from the masticatory muscles and TMfs, as well as temporomandibuiar disorder [TMD], , brux- local periodontal ligament inflammation or reversible ism, and tooth extraction complications),'' Regardless pulpitis secondary to parafunctional activity.^'''^'-'''' The of age and gender, PTSD patients may exhibit symp- source(s) can often be identified by aggravating the toms that complicate dental treatment (ie, reluctance suspected structure(s), thereby reproducing or intensi- to be close to others, exaggerated startle response, irri- fying the patient's pain complaint If necessary and if tability, or signs of re-experiencing a past traumatic event when exposed to a stressftil situation).'''^* the patient currently has the pain, local anesthetic to Recommended strategies clinicians can use for accom- the structure(s) can further help verify the source(s).''^ modating PTSD symptoms may include increasing the Maintaining heavy palpation pressure on the masti- patient's sense of control and empowerment, minimiz- catory muscles (especially the myofascia! trigger ing physical proximity, and providing reassurance. points) and TMJs can aggravate these structures to the degree that if they are causing or contributing to the Tooth clenching is a very common behavior utilized dental pain, this will cause the pain to be reproduced during a PTSD episode.^"* People with this disorder or intensified,'-t Periodontal ligament inflammation may go to their clinician with cither TMD symptoms can be aggravated by apically or laterally loading the and/or dental pain due to chronic severe tooth tooth, eg, percussing the tooth with the end of a clenching related to PTSD. Patients with TMD symp- mouth-mirror handle.^i If the clinician identifies the

208 Volume 35, Number 3, 2004 • Wright et ai

sotirce as the periodontal hgament and concludes the REFERENCES pritnar\' cause for the pain is the patient's chronic parafunctional activity, the clinician «iU need to iden- 1. Keane TM. Wolfe |. Taylor KL. Post-traumatic stress disor- tify' treatment options to mitigate these activities and der: E\idence for diagnostic validity and methods of psy- their effect chological assessment J Clin Psycho) 1987:43:32-43. 2. Keane TM. Cadde)l JM, Taylor KL. Mississippi scale for combat-related posttraumatic stress disorder: Three studies Treatment goais in reliability and validity. J Consult Clin Psycho) 1988:56: 85-90. One of the goals in TMD therapy is to decrease the 3. Keane TM. Zimering RT. Kaloupek DG. Posttraumatic parafunciional acti\it\' and its effects on the mastica- stress disorder. In: Hersen M. Bellack AS (eds). Psycho- tory system.-*" Therefore many of the therapies utilized pathologi' in Adukhood. Needham Heights, MA: AUyn & for TMD may also be beneficial for patients with den- Bacon. 2000:208-231. tal pain due to tooth clenching. 4. Calhoun KS. Resick PA. Post-traumatic stress disorder In: Barlow DH (ed). Clinical Handbook of Psychological For PTSD patients with periodontal ligament in- Disorders: A Step-by-Step Treatment Manual. New York: ñammation caused by excessive parafunctional activ- Guiiford, 1993:48-98. ity, the practitioner may conclude PTSD is a major 5. Kilpatrick DG. Best CL. Veronen LJ. .%nick AE. Villepon- contributor. This could present a treatment dilemma teaux LA. Ruff GA. Mental health correlates of criminal vic- for the clinician, becatise tbese patients may already be timization: A random community survev. J Consult Clin Psyehol 1985:53:866-873. receiving many of the therapies traditionally utilized to 6. Resnick HS, Kilpatrick DG. Dansky BS, Saunders BE, Best decrease parafunctional activitj' for TMD patients. CL. 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