Cognitive Behavioral Therapy and Biofeedback Helps in Jaw Disorders

DALLAS, Feb. 5 -- For the acute phase of temporomandibular disorder (TMD), cognitive behavioral training and biofeedback reduces overall and jaw-related care costs, researchers found.

So reported Anna Stowell, Ph.D., of the McDermott Center for Pain Management of the University of Texas Southwestern Medical Center here, and colleagues, in a study published online today in the Journal of the American Dental Association.

An intervention group had significantly lower jaw-related costs during a year of follow-up than a nonintervention group (.67 versus .75, P=0.029) despite greater associated costs from pain onset to baseline (.27 versus .35).

The cost-effectiveness analysis did not include the cost of treatment, which Dr. Stowell estimated to be about total for a similar six-visit treatment course if performed outside the study.

However, Dr. Stowell said she expects that the intervention is cost effective even factoring in the cost of the visits because the treatment can prevent progression to chronic pain, according to an earlier analysis of the study.

"This is new 'uncharted' territory of dental care where the cost parameters have never been clearly delineated, and have always been uncertain for patients undergoing treatment for diagnoses such as TMD," Dr. Stowell said.

"Because of the multifactorial nature of these disorders, medical and dental insurance carriers typically pass the liability of TMD off to each other," she and colleagues added, which "leaves the TMD patient fully responsible for what is often very costly treatment."

TMD has been estimated as second only to chronic low back pain as the most common musculoskeletal condition resulting in pain and disability. It affects an estimated 10% to 15% of the U.S. population, with an annual cost said to be in the neighborhood of billion.

In a previous analysis of the study, the researchers reported that their combination of cognitive behavioral training and biofeedback--which they called early biopsychosocial intervention--was effective in reducing pain and decreasing progression to chronic TMD.

To see whether the reduction in pain would result in cost savings, the investigators looked at 96 patients with financial data available among the original 113 randomized to biopsychosocial intervention or nonintervention.

At baseline, patients were in the acute phase of TMD, less than six months since onset, and were classified as high risk for progression to chronic TMD using a predictive algorithm. Most were women (76 versus 20 men) with an average age of 37.54 (range 18 to 60.88), but there were no significant differences between groups at baseline in characteristics including duration of jaw pain as well as employment and health insurance status.

The biopsychcosocial treatment included six weekly sessions teaching patients about the body's reaction to stress and relaxation training as well as how to control muscle tension, respiration and body temperature during stress. Both groups were followed for a year and could continue to seek other medical, dental or complimentary care.

The researchers collected receipts or explanations of benefits of all expenditures for jaw treatment from symptom onset to baseline and then for the one year of follow-up. For those unable to provide data, a medical release was used to gather this information from treating health professionals.

The findings for healthcare utilization related to jaw pain were:

• Higher utilization from pain onset to baseline for the intervention group compared with the control group (,792 versus ,382), but
• Lower utilization during the year of follow-up for the intervention group compared with the control group (,505 versus ,916).

The intervention group also had fewer total visits to healthcare providers during the year of follow-up (14 versus 18) despite more visits from pain onset to baseline (60 versus 35).

However, this difference was not the result of fewer non-jaw related healthcare visits because there was no significant difference in the proportion of visits that were not TMD related (P=0.36).

Nor did the differences appear to be due to psychosocial health. Scores on the Beck Depression Inventory-2 and Characteristic Pain Inventory were not a significant predictor of results when controlling for group (P=0.54 and P=0.87, respectively).

The treatment efficacy findings among the study groups were similar to the larger, overall study with significant differences between the intervention and nonintervention groups for self-reported pain (22.96 versus 34.36, P<0.01), depression (5.33 versus 8.72, P<0.05), and problem-focused coping (24.98 versus 23/37, P=0.01).

The researchers concluded that cognitive-behavioral interventions are efficacious and cost effective efficacious treatment for TMD, "particularly when utilized in the acute stage of the dysfunction."

The findings reinforce that physicians should make appropriate referrals for TMD patients who are depressed or under substantial stress rather than sending them right to surgery, Dr. Stowell said.

She said her research group was unable to elicit exact costs of the intervention but is now evaluating this in a multi-year follow up that they expect to show accrual of cost savings over time.

"From our personal viewpoint, we expect that the non-intervention group costs will increase over the years as opposed to the costs of the group who received the intervention," Dr. Stowell said.

They noted that an important limitation of the study was the method used to collect cost data in that it relied on patients' memory and record keeping and healthcare provider data was not available for all patients.

While the study included only patients at high risk of chronic TMD, Dr. Stowell and colleagues said they expected low risk patients would benefit as well. Also, the study excluded those with fibromyalgia, which the researchers said "may have further produced an overly conservative estimate of treatment benefit/cost."