Gene A Z&S&, 3X%, WS,a and les~l Andreasenb University of Iowa, College of Dentistry, Iowa City, Iowa male patieute with signs BEsymptoms of temporotwed wish those of B (rotltrol group havhg no &!IIS ers. &ores on the Crown Crisp Experimental Index or symp$omS and hysteria. (J resee in the profiles of somatization PROSTHET DENT lB~l;B%zSlO-2.)
T he
etiology of temporomandibular disorders appears to be multifactorial, with conflicting reports regarding the role of psychologic factors. Moulton1,2 attempted to characterize patients with temporomandibular joint (TMJ) pain, and through psychiatric interviews and the psychoanalytic approach she identified four types of interactions between the emotional and physical processes.3 A number of other studies have used a variety of evaluation devices including psychologic inventories in an attempt to characterize the TMD patient.4-10 The Crown Crisp Experimental Index (CCEI), formerly known as the Middesex Hospital Questionnaire, was developed by Crown and Crisp in 1966.11It is a 4%item selfadministeredquestionnaire.l’ This index is used to classify the subject in six different psychologic profiles: (1) free floating anxiety (FFA); (2) phobic anxiety (PHO); (3) obsessive-compulsive (OBS); (4) somatization (SOM); (5) depressive (DEP); and (6) hysteria (HYS). The CCEI has (TMD)
aProfessor, Department of Family Dentistry. bDenta1 student. 10/1/33698
been extensively validated as a cross-cultural screening tool for identification of patients with aberrant psychologic profiles.12-l6
METHODS
The CCEI was administered to all female patients over 18 years of age on their initial visit to the TMJ clinic at University Hospital and Clinic, Iowa City, Iowa. Due to the sexual explicitness of certain items in the questionnaire, females under the age of 18 were not included in the study. No specific oral instructions were given with respect to completion of the questionnaire. The subjects were given the questionnaire and were told to read the instructions and fill in their answers. The questionnaire was entitled “A Self Rating to Identify Areas of Stress,” followed by the statement, “the following questions are concerned with the way you feel or act. Please check the answer that best applies to you. Don’t spend a lot of time on any one question.” During the initial clinical examination, the following signs were noted, tenderness of muscles of mastication on palpation, tenderness of TMJ on lateral palpation, audible sounds in the TMJ on opening and closing, less than 25 m m between incisal surfaces of maxillary and mandibular teeth
Table I. Comparison of profile scores between TMD subjects and non-TMD FFA No.
M
SD
98
5.69
3.34
M
SD
3.22
2.66
subjects OBS
PHO T Cp)
AND MATERIALS
T (P)
M
SD
5.32
3.15
SOM T (P)
M
SD
5.17
3.37
T @)
v/ID Patients
1.12 (0.2673)
-0.62 (0.5578)
0.97 (0.3358)
4.84 (0.0001)
I ‘ontrol
!normal i
98
5.14
3.18
5.14
3.18
4.89
2.82
3.26
2.09
>11,Means; SD, standard deviation; T, Student’s t value; p, probability > t; FFA, Free floating anxiety; PHO, phobic anxiety; OBS, obsessive-compulsize;SOM, somatization; DEP. depressive; HYS, hysteria; TMD, temporomandibular disorders. Total Score-TMD patients 26.63; Control 24.67. The results of the paired Student’s t teat show that T M D patients score higher in the Somatization profile and lower in the Hysteria profile (t = 4.84, p < 0.0001 and t = 2.79, p < 0.0064, respectively) than do non-TMD subjects.
PSYCHOLOGICAL
PROFILE
OF TMD PATIENTS
on maximal opening, and left or right deviation of mandible on opening estimated to be greater than 5 mm. Subjects with one or more of the above signs were placed in the base pool for this study. A total of 440 female subjects was thus identified. A control group of 98 female subjects were selected from patients and personnel from the College of Dentistry, University of Iowa, Iowa City, Iowa. The selection was based on the absence of any of the above signs, absence of history of treatment for TMD syndrome, no history of noise in the TMJ, or no tenderness in the area of the TMJ during mastication. The control group was administered the CCEI using the same instructions for subjects in the base pool. A test group of 98 subjects was randomly selected.from the base pool and was matched by age to the control group. Mean scores and standard deviation were calculated for each of the six profiles for each the control and test subjects. The paired Student t test was used to determine significant differences of profile scores between the two groups. RESULTS Roth groups had an age range of 18 to 65 years of age, with a median of 24.8 years, a mean of 30.4 years, and standard deviation of 11.3 years. The scores of the TMD subjects were significantly different from the scores of subjects in the control group in the profiles of SOM (t = 4.84,~ = 0.001) and HYS (t = 2.79, p = 0.0064) (Table I). DISCUSSION The difference in scores on the SOM profile indicates the TMD patient in this study is more anxious about bodily concerns than the non TMD subject. The question arises whether or not this anxiety existed prior to the onset of symptoms or was a result of the symptoms associated with TMD. The interpretation of the lower scores by the TMD patients in the profile of HYS is open to debate. Mavis-
DEP M
SD
3.60
2.52
HYS
T @)
M
SD
3.62
2.83
1.22 (0.2253) 3.19
2.25
T (P)
-2.79 (0.0064) 4.74
3.17
sakalian and Michelson” suggested that it may indicate a tendency of the TMD patient to develop stronger interpersonal relationships with other people. This could be a reflection of the TMD patients’ perception of their “locus of control.” The external-internal loci of control concept was developed by Rotterl* in 1966. The concept suggests that individuals perceive the forces that govern their lives as being either internal or external. A person with an internal locus of control feels responsible for what happens to him or her, while a person with an external locus of control feels that life situations are beyond his or her control and in most instances are a result of luck. This suggeststhat a person with an external locus of control is more dependent on other people, thus having a tendency to develop stronger interpersonal relationships with other individuals. This dependency, concurrent with strong interpersonal relationships, may affect the outcome of various treatment modalities for mental or physical diseases.Further study is needed to evaluate the TMD patients’ perception of their locus of control and the effect it has on treatment outcomes. It is possible the perception of the locus of control could be an identification factor of TMD patients and/or could delineate the interaction of patient characteristics with therapy processes and outcomes. CONCLUSION Further investigation using the CCEI is needed to determine if there are significant differences of profile scores between the sexes or subgroups of TMD patients-i.e., those with interarticular symptoms versus those with extraarticular symptoms. In addition, further inquiry into the evaluation of treatment outcomes using different treatment modalities is needed. These include: (1) conventional treatment only, (2) conventional treatment plus psychologic counseling, and (3) psychologic counseling only. REFERENCES 1. Moulton RE. Oral and dental manifestation of a anxiety. Psychiatry 1955;18:261-73. 2. Moulton RE. Psychiatric considerations in maxillofacial pain. J Am Dent Assoc 1955;51:406-14. 3. Moulton RE. Emotional factors in nonorganic temporomandibular joint pain. Dent Clin North Am 1966;10:609-19. 4. Kydd WL. Psychosomatic aspects of temporomandibular joint dysfunction. J Am Dent Assoc 19535931-44. 5. Granger ER. Occlusion in temporomandibular joint pain. J Am Dent Assoc 1958;56:659-64. 6. Lupton DE. A preliminary investigation of the personality of female temporomandibular joint dysfunction patients. Psychother Psychosom 1966;14:199-215. 7. Solherg WK, Flint RT, Branter JP. Temporomandibular joint pain and dysfunction: a clinical study of emotional and occlusal components. J PROSTHET DENT 1972;4:412-22.
8. Rugh JD, Solberg WK. Psychological implications in temporomandibular pain and dysfunction. Oral Sci Rev 1976;1:3-30. 9. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg Oral Med Oral Pathol 1985;60:269-74. 10. Goodman P, Greene CS, Laskin DM. Response of patients with myo-
THE JOURNAL
OF PROSTHETIC
DENTISTRY
811
ZACR
fascial pain dsefunction syndrome to mock equilibration. J A m Dent Aseoc J978;92:765-8. I 1. C&n s, Crisp A?. A short di+g.ric&ic self-rating scale for psychoneurotic pa$ienta, Br J Psychiatry i966;112:917-23. 12. Ryle A, Lun&d b&. The maaaurgment of relevant changesafter psychotherapy. Br J Psychiatry 1969;115:1297-304. 14. Gadd RA, Merskey H. Middtesex Hospital Questionnaire scoresin patiends with hystarical conversion symptoms. Br J Med Psycho1 1975;&:367-70.
14. Crisp AH, Jones MG, Slater P. The Middlasex Hospital Questionnaire: a validity&dy. Br J Psychiatry 1978;119:385-92. t5. Hurwitz TA, Nicbol H, Beiser M, Kozak J. Validation of the Middlesex Hospital Questionnaire as a self-rating screening instrument for clinical significant psychological distress. Psychiatr J Univ Ottawa 1987;4:239-41.
Bound volumes
AND
ANDRRASEN
16. Bagley C. The factorial reliability of the Middlesex Hospital Question-
naire in norm& subjects. Br J Med Psycho11980,53:53-8. 17. Mavissakalian M, Michelson L. The Middlesex Hospital Questionnaire: a validity study with American psychiatric patients. Br J Psychiatry 1981;139:336-40. 18. Rotter JB. Generalized expectanciesfor internal versus external control of reinforcement. Psycho1Monogr 1966;80:1-28.
Reprintrequeststo: DR. GENE A. ZACH COLLEGE OF DENTISTRY UNIVEFSJTY OF IOWA IOWA CITY, IA 52242
available
to subscribers
Bound volumes of THE JOURNAL OF PROSTHETIC DENTISTRY are available to subscribers (only) for the 1991 issues from the publisher at a cost of $50.00 ($63.00 international) for Vol. 65 (January-June) and Vol. 66 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 63 and 64 are also available. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800) 3254177, ext. 4351. Subscriptions must be in force to qualify. Bound volumes are not available in plaae of a reguiar JOURNAL subscription.
T he
etiology of temporomandibular disorders appears to be multifactorial, with conflicting reports regarding the role of psychologic factors. Moulton1,2 attempted to characterize patients with temporomandibular joint (TMJ) pain, and through psychiatric interviews and the psychoanalytic approach she identified four types of interactions between the emotional and physical processes.3 A number of other studies have used a variety of evaluation devices including psychologic inventories in an attempt to characterize the TMD patient.4-10 The Crown Crisp Experimental Index (CCEI), formerly known as the Middesex Hospital Questionnaire, was developed by Crown and Crisp in 1966.11It is a 4%item selfadministeredquestionnaire.l’ This index is used to classify the subject in six different psychologic profiles: (1) free floating anxiety (FFA); (2) phobic anxiety (PHO); (3) obsessive-compulsive (OBS); (4) somatization (SOM); (5) depressive (DEP); and (6) hysteria (HYS). The CCEI has (TMD)
aProfessor, Department of Family Dentistry. bDenta1 student. 10/1/33698
been extensively validated as a cross-cultural screening tool for identification of patients with aberrant psychologic profiles.12-l6
METHODS
The CCEI was administered to all female patients over 18 years of age on their initial visit to the TMJ clinic at University Hospital and Clinic, Iowa City, Iowa. Due to the sexual explicitness of certain items in the questionnaire, females under the age of 18 were not included in the study. No specific oral instructions were given with respect to completion of the questionnaire. The subjects were given the questionnaire and were told to read the instructions and fill in their answers. The questionnaire was entitled “A Self Rating to Identify Areas of Stress,” followed by the statement, “the following questions are concerned with the way you feel or act. Please check the answer that best applies to you. Don’t spend a lot of time on any one question.” During the initial clinical examination, the following signs were noted, tenderness of muscles of mastication on palpation, tenderness of TMJ on lateral palpation, audible sounds in the TMJ on opening and closing, less than 25 m m between incisal surfaces of maxillary and mandibular teeth
Table I. Comparison of profile scores between TMD subjects and non-TMD FFA No.
M
SD
98
5.69
3.34
M
SD
3.22
2.66
subjects OBS
PHO T Cp)
AND MATERIALS
T (P)
M
SD
5.32
3.15
SOM T (P)
M
SD
5.17
3.37
T @)
v/ID Patients
1.12 (0.2673)
-0.62 (0.5578)
0.97 (0.3358)
4.84 (0.0001)
I ‘ontrol
!normal i
98
5.14
3.18
5.14
3.18
4.89
2.82
3.26
2.09
>11,Means; SD, standard deviation; T, Student’s t value; p, probability > t; FFA, Free floating anxiety; PHO, phobic anxiety; OBS, obsessive-compulsize;SOM, somatization; DEP. depressive; HYS, hysteria; TMD, temporomandibular disorders. Total Score-TMD patients 26.63; Control 24.67. The results of the paired Student’s t teat show that T M D patients score higher in the Somatization profile and lower in the Hysteria profile (t = 4.84, p < 0.0001 and t = 2.79, p < 0.0064, respectively) than do non-TMD subjects.
PSYCHOLOGICAL
PROFILE
OF TMD PATIENTS
on maximal opening, and left or right deviation of mandible on opening estimated to be greater than 5 mm. Subjects with one or more of the above signs were placed in the base pool for this study. A total of 440 female subjects was thus identified. A control group of 98 female subjects were selected from patients and personnel from the College of Dentistry, University of Iowa, Iowa City, Iowa. The selection was based on the absence of any of the above signs, absence of history of treatment for TMD syndrome, no history of noise in the TMJ, or no tenderness in the area of the TMJ during mastication. The control group was administered the CCEI using the same instructions for subjects in the base pool. A test group of 98 subjects was randomly selected.from the base pool and was matched by age to the control group. Mean scores and standard deviation were calculated for each of the six profiles for each the control and test subjects. The paired Student t test was used to determine significant differences of profile scores between the two groups. RESULTS Roth groups had an age range of 18 to 65 years of age, with a median of 24.8 years, a mean of 30.4 years, and standard deviation of 11.3 years. The scores of the TMD subjects were significantly different from the scores of subjects in the control group in the profiles of SOM (t = 4.84,~ = 0.001) and HYS (t = 2.79, p = 0.0064) (Table I). DISCUSSION The difference in scores on the SOM profile indicates the TMD patient in this study is more anxious about bodily concerns than the non TMD subject. The question arises whether or not this anxiety existed prior to the onset of symptoms or was a result of the symptoms associated with TMD. The interpretation of the lower scores by the TMD patients in the profile of HYS is open to debate. Mavis-
DEP M
SD
3.60
2.52
HYS
T @)
M
SD
3.62
2.83
1.22 (0.2253) 3.19
2.25
T (P)
-2.79 (0.0064) 4.74
3.17
sakalian and Michelson” suggested that it may indicate a tendency of the TMD patient to develop stronger interpersonal relationships with other people. This could be a reflection of the TMD patients’ perception of their “locus of control.” The external-internal loci of control concept was developed by Rotterl* in 1966. The concept suggests that individuals perceive the forces that govern their lives as being either internal or external. A person with an internal locus of control feels responsible for what happens to him or her, while a person with an external locus of control feels that life situations are beyond his or her control and in most instances are a result of luck. This suggeststhat a person with an external locus of control is more dependent on other people, thus having a tendency to develop stronger interpersonal relationships with other individuals. This dependency, concurrent with strong interpersonal relationships, may affect the outcome of various treatment modalities for mental or physical diseases.Further study is needed to evaluate the TMD patients’ perception of their locus of control and the effect it has on treatment outcomes. It is possible the perception of the locus of control could be an identification factor of TMD patients and/or could delineate the interaction of patient characteristics with therapy processes and outcomes. CONCLUSION Further investigation using the CCEI is needed to determine if there are significant differences of profile scores between the sexes or subgroups of TMD patients-i.e., those with interarticular symptoms versus those with extraarticular symptoms. In addition, further inquiry into the evaluation of treatment outcomes using different treatment modalities is needed. These include: (1) conventional treatment only, (2) conventional treatment plus psychologic counseling, and (3) psychologic counseling only. REFERENCES 1. Moulton RE. Oral and dental manifestation of a anxiety. Psychiatry 1955;18:261-73. 2. Moulton RE. Psychiatric considerations in maxillofacial pain. J Am Dent Assoc 1955;51:406-14. 3. Moulton RE. Emotional factors in nonorganic temporomandibular joint pain. Dent Clin North Am 1966;10:609-19. 4. Kydd WL. Psychosomatic aspects of temporomandibular joint dysfunction. J Am Dent Assoc 19535931-44. 5. Granger ER. Occlusion in temporomandibular joint pain. J Am Dent Assoc 1958;56:659-64. 6. Lupton DE. A preliminary investigation of the personality of female temporomandibular joint dysfunction patients. Psychother Psychosom 1966;14:199-215. 7. Solherg WK, Flint RT, Branter JP. Temporomandibular joint pain and dysfunction: a clinical study of emotional and occlusal components. J PROSTHET DENT 1972;4:412-22.
8. Rugh JD, Solberg WK. Psychological implications in temporomandibular pain and dysfunction. Oral Sci Rev 1976;1:3-30. 9. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg Oral Med Oral Pathol 1985;60:269-74. 10. Goodman P, Greene CS, Laskin DM. Response of patients with myo-
THE JOURNAL
OF PROSTHETIC
DENTISTRY
811
ZACR
fascial pain dsefunction syndrome to mock equilibration. J A m Dent Aseoc J978;92:765-8. I 1. C&n s, Crisp A?. A short di+g.ric&ic self-rating scale for psychoneurotic pa$ienta, Br J Psychiatry i966;112:917-23. 12. Ryle A, Lun&d b&. The maaaurgment of relevant changesafter psychotherapy. Br J Psychiatry 1969;115:1297-304. 14. Gadd RA, Merskey H. Middtesex Hospital Questionnaire scoresin patiends with hystarical conversion symptoms. Br J Med Psycho1 1975;&:367-70.
14. Crisp AH, Jones MG, Slater P. The Middlasex Hospital Questionnaire: a validity&dy. Br J Psychiatry 1978;119:385-92. t5. Hurwitz TA, Nicbol H, Beiser M, Kozak J. Validation of the Middlesex Hospital Questionnaire as a self-rating screening instrument for clinical significant psychological distress. Psychiatr J Univ Ottawa 1987;4:239-41.
Bound volumes
AND
ANDRRASEN
16. Bagley C. The factorial reliability of the Middlesex Hospital Question-
naire in norm& subjects. Br J Med Psycho11980,53:53-8. 17. Mavissakalian M, Michelson L. The Middlesex Hospital Questionnaire: a validity study with American psychiatric patients. Br J Psychiatry 1981;139:336-40. 18. Rotter JB. Generalized expectanciesfor internal versus external control of reinforcement. Psycho1Monogr 1966;80:1-28.
Reprintrequeststo: DR. GENE A. ZACH COLLEGE OF DENTISTRY UNIVEFSJTY OF IOWA IOWA CITY, IA 52242
available
to subscribers
Bound volumes of THE JOURNAL OF PROSTHETIC DENTISTRY are available to subscribers (only) for the 1991 issues from the publisher at a cost of $50.00 ($63.00 international) for Vol. 65 (January-June) and Vol. 66 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 63 and 64 are also available. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800) 3254177, ext. 4351. Subscriptions must be in force to qualify. Bound volumes are not available in plaae of a reguiar JOURNAL subscription.
