Short- and long-term efficacy of brief cognitive-behavioral therapy
for patients with chronic temporomandibular disorder pain:
A randomized, controlled trial
Judith A. Turnera,b,*, Lloyd Manclc, Leslie A. Aarond
aDepartment of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
bDepartment of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
cDepartment of Dental Public Health Sciences, University of Washington School of Dentistry, Seattle, WA, USA
dDepartment of Oral Medicine, University of Washington School of Dentistry, Seattle, WA, USA
Received 26 August 2005; received in revised form 9 November 2005; accepted 21 November 2005
We evaluated the short- and long-term efficacy of a brief cognitive-behavioral therapy (CBT) for chronic temporomandibular
disorder (TMD) pain in a randomized controlled trial. TMD clinic patients were assigned randomly to four sessions of either
CBT (n = 79) or an education/attention control condition (n = 79). Participants completed outcome (pain, activity interference,
jaw function, and depression) and process (pain beliefs, catastrophizing, and coping) measures before randomization, and 3
(post-treatment), 6, and 12 months later. As compared with the control group, the CBT group showed significantly greater improve-
ment across the follow-ups on each outcome, belief, and catastrophizing measure (intent-to-treat analyses). The CBT group also
showed a greater increase in use of relaxation techniques to cope with pain, but not in use of other coping strategies assessed.
On the primary outcome measure, activity interference, the proportion of patients who reported no interference at 12 months
was nearly three times higher in the CBT group (35%) than in the control group (13%) (P = 0.004). In addition, more CBT than
control group patients had clinically meaningful improvement in pain intensity (50% versus 29% showed P50% decrease,
P = 0.01), masticatory jaw function (P < 0.001), and depression (P = 0.016) at 12 months (intent-to-treat analyses). The two groups
improved equivalently on a measure of TMD knowledge. A brief CBT intervention improves one-year clinical outcomes of TMD
clinic patients and these effects appear to result from specific ingredients of the CBT.
? 2005 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keywords: Cognitive-behavioral therapy; Temporomandibular disorders; Chronic pain; Brief psychotherapy; Randomized controlled trial
decrease maladaptive, and to increase adaptive, patient
cognitions and behaviors. These treatments are effective
for a variety of chronic pain problems (Keefe and Cald-
well, 1997; Morley et al., 1999; Astin et al., 2002; Eccle-
ston et al., 2002; Weydert et al., 2003; Chen et al., 2004).
CB therapies are time-limited; the median number of
treatment hours was 16 in the randomized controlled tri-
als (RCTs) of CBT for chronic pain included in a com-
prehensive review (Morley et al., 1999). However,
limitations in insurance coverage for psychological ther-
apies and the fact that most psychotherapy clients
attend fewer than six sessions (Shapiro et al., 2003) cre-
ate the need for effective very brief (six or fewer sessions)
CBTs for chronic pain problems.
We previously reported changes on electronic daily
diary measures of outcome and therapy process vari-
ables over the course of treatment in an RCT of a very
0304-3959/$32.00 ? 2005 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
*Corresponding author. Tel.: +1 206 543 3997; fax: +1 206 685
E-mail address: email@example.com (J.A. Turner).
Pain 121 (2006) 181–194
brief CBT for patients with chronic temporomandibular
disorder (TMD) pain (Turner et al., 2005). TMDs are a
group of conditions that involve the temporomandibu-
lar joints (TMJ), masticatory muscles, and associated
structures, and share the common symptoms of pain,
restricted jaw function, and TMJ noises (Dimitroulis,
1998). The etiology of the most common types of
TMD is largely unknown (Dimitroulis, 1998). TMDs
are the most frequent facial pain problems (Dworkin,
1995b), with an estimated prevalence of 10–12% (Von
Korff et al., 1988; Dworkin et al., 1990a; LeResche,
1997). Patients with TMD pain are similar to patients
with other chronic pain conditions (e.g., headache and
back pain) in terms of pain intensity and associated
behavioral and psychological dysfunction (Dworkin,
1995a), pain persistence and recurrence (Dworkin
et al., 1989), and refractoriness of pain to treatment
(Rudy and Turk, 1995). Suggesting the importance of
psychosocial factors in TMD problems, individuals with
TMD vary widely in levels of disability (e.g., pain inter-
ference with customary activities; difficulty with masti-
catory and non-masticatory jaw activities such as
opening jaws to bite food, chewing, and kissing) and
psychosocial dysfunction (Butterworth and Deardorff,
1987; Rudy et al., 1989; Suvinen et al., 1997) but objec-
tive findings do not appear to underlie these differences
(Rudy et al., 1989; Dworkin, 1995a), and changes over
time in jaw function measures are not clearly related
to course of pain (Ohrbach and Dworkin, 1998).
We now report, following the Consolidated Standards
of Reporting Trials (CONSORT) guidelines (Moher
et al., 2001), the short- and long-term results of our
RCT of CBT versus an education/attention control con-
dition for chronic TMD pain as assessed by standard
questionnaire measures of outcome and therapy process
variables. We hypothesized that the CBT group would
show greater short- and long-term improvement on each
depression) and process (pain-related beliefs, catastro-
phizing, and coping) measure. We examined clinically
important as well as statistically significant change on
interference and the primary endpoint was one-year.
2.1. Setting and participants
The study was approved by the University of Washington
(UW) Institutional Review Board and all participants provid-
ed written informed consent. Study participants were recruited
by research staff from patients seeking care at the UW Orofa-
cial Pain Clinic between June 2001 and February 2004. Study
inclusion criteria were: (1) age 18 years or older; (2) a Research
Diagnostic Criteria/Temporomandibular Disorders (RDC/
TMD) Axis I TMD diagnosis (Dworkin and LeResche,
1992) made by an oral medicine specialist based on a
structured RDC/TMD clinical examination; (3) residence
within a 2-h drive of the TMD clinic; (4) facial pain for at least
three months; (5) facial pain-related disability, as defined by a
chronic pain grade (Von Korff et al., 1992) of II high, III, or IV
(see Section 2.3 for definitions); and (6) ability to communicate
in English. Study exclusion criteria (assessed by the patient’s
oral medicine specialist and the study coordinator) were need
for further diagnostic evaluation, pending litigation or disabil-
ity compensation for pain, current or previous CBT for pain,
and major medical or psychiatric conditions that would inter-
fere with ability to participate.
Among the 366 patients approached and found to be eligible
for the RCT, 158 (43%) enrolled (Fig. 1). The most commonly
cited reason for decision not to enroll was the time commitment
ic). Two participants were withdrawn from the study shortly
after randomization because severe psychiatric problems unde-
tected before enrollment (and that would have made them inel-
igible for the study had they been known) became evident. The
other 156 subjects randomized did not differ significantly from
patients who declined to participate in the study (n = 208) in
gender, race, education, chronic pain grade, characteristic pain
intensity, activity interference, or any RDC/TMD clinical diag-
nosis (see Measures for definitions). However, study partici-
pants were somewhat younger on average [mean (SD) = 37.0
(11.4) versus 39.6 (12.5) years; P = 0.04]. All participants who
completed at least one post-treatment or follow-up assessment
were included in analyses for this report. Those randomized
who did (n = 148, 95%) versus did not (n = 8, 5%) complete at
least one post-treatment or follow-up assessment did not differ
significantly at baseline on any sociodemographic variable
assessed, chronic pain grade, RDC/TMD diagnosis, pain dura-
tion, or any outcome or process measure, with one exception:
those who provided no follow-up data had higher baseline
ing self-statements) [mean (SD) = 3.7 (2.1) versus 2.5 (1.7),
P = 0.049].
Participants were asked to complete questionnaires at home
and return them in person or by mail prior to randomization
(baseline), and 3 (post-treatment), 6, and 12 months after ran-
domization. Participants were compensated for questionnaire
completion (post-treatment $25, 6-month $10, 12-month $50,
and an additional $15 if all questionnaires were completed
on schedule). Participants were also asked to complete elec-
tronic diaries three times daily for eight weeks while participat-
ing in their randomly assigned treatment.
All study participants received treatment as usual from
their dentist at the Orofacial Pain Clinic. These treatments
were conservative and typically included instruction in jaw
posture monitoring and correction (including instruction to
keep jaws relaxed and teeth apart, but no training in muscle
relaxation techniques), advice to apply heat and/or cold to
painful facial areas, and recommendations concerning diet
modifications. Medications (e.g., non-steroidal anti-inflamma-
tory drugs), jaw stretching exercises, and occlusal splints were
prescribed for some patients.
J.A. Turner et al. / Pain 121 (2006) 181–194
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