Journal of Oral Rehabilitation

Journal of Oral Rehabilitation 2012

Bio-psycho-social assessment of occlusal dysaesthesia

patients
Y. TSUKIYAMA, A. YAMADA, R. KUWATSURU & K. KOYANO Section of Implant and
Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Higashi-ku, Fukuoka, Japan

SUMMARY Dentists occasionally experience occlusal OD patients and controls (mixed-model ANOVA,
dysaesthesia (OD) patients, who complain of bite P = 1Æ000). Regarding psychological tests, there were
discomfort without evident occlusal abnormalities. no significant differences between OD patients and
It is suggested that this condition is related to controls in the total scores for either GHQ60
somatosensory abnormalities of the trigeminal (P = 0Æ143) or POMS brief-form (P = 0Æ319) (Wilco-
system and ⁄ or psychological problems such as xon’s test). However, OD patients showed significant
somatoform disorders. The aim of this study was differences from controls in several subscales, that
to investigate the characteristics of OD with a is, ‘somatic symptoms’ (P = 0Æ039) and ‘severe
bio-psycho-social approach. Twelve OD patients depression’ (P = 0Æ039) for GHQ60 and ‘depression-
(10 women, two men; mean age 54Æ7 years) and dejection’ (P = 0Æ014) and ‘vigor’ (P = 0Æ008) for POMS
twelve healthy volunteers (10 women, two men; brief-form (Wilcoxon’s test). These results suggest
mean age 54Æ8 years) were selected. They were there is no difference in interdental thickness dis-
assessed using (i) interdental thickness discrimina- crimination ability between OD patients and normal
tion ability test using 2-, 5- and 10-mm-thick stan- controls, but OD patients tend to score higher on
dard blocks and 12 test blocks that were thinner or psychosomatic distress.
thicker than the corresponding standard block and KEYWORDS: occlusal dysaesthesia, interdental thickness
(ii) psychological tests: General Health Questionnaire discrimination, psychological evaluation, psychoso-
(GHQ60) and Profile of Mood States (POMS) brief- matic evaluation, occlusion, sensory mechanism
form. There was no significant difference in the
interdental thickness discrimination ability between Accepted for publication 15 April 2012

On the contrary, Baba et al. (3) conducted tactile

Introduction
sensation test at maxillary and mandibular central
Many dentists have experienced occasional patients with incisors using aluminium foils and thickness discrimi-
persistent complaints of bite discomfort in spite of the nation test using blocks and found no significant
absence of evident occlusal abnormalities, even though differences between OD patients and healthy controls.
there are no exact reports on the prevalence of this As the idea that OD patients have decreased or
condition to date. This troublesome condition is called increased proprioceptive sensitivity is not well
‘occlusal dysaesthesia (OD)’ (1), and the possible causes supported scientifically and is still controversial,
are considered to be abnormalities of sensory mecha- psychological factors have been frequently proposed
nisms and psychiatric or psychosomatic problems. as the aetiology of OD. It was reported that many
Jacobs et al. (2) reported that OD patients showed patients with occlusion-related complaints had comor-
significantly lower threshold levels for light touch bid mental disorders such as major depressive disorder
sensation in the alveolar mucosa than normal controls. and somatoform disorder (4–6).

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2 Y . T S U K I Y A M A et al.

Lacking sufficient reports about this disorder, the University Hospital. Twenty-five patients who com-
information on characteristics of OD is not enough to plained of bite discomfort without evident occlusal
date. Hence, there are no established diagnostic tools abnormalities were screened clinically according to the
that can differentiate OD from other common dental inclusion and exclusion criteria. Inclusion criteria of OD
problems. As Marbach (7) described, the best approach patients were that (i) subjects have been suffered by
to the diagnosis of and treatment for these patients lies bite discomfort for more than 6 months without
in the dentist’s familiarity with the signs and symptoms observable bite discrepancies; (ii) subjects have maxil-
of these syndromes. lary and mandibular central incisors; (iii) subjects are
Interdental thickness discrimination ability is one of over 20 years old. Exclusion criteria were that (i) the
the physical aspects that might be affected in OD complaints are associated with removable prostheses;
patients. Although any prevalent instrument or method (ii) the complaints are associated with periodontal
has not been produced to evaluate the sensory dis- disease, dental caries, trauma or other dental diseases;
crimination thresholds of the teeth and the kinesthetic (iii) subjects have temporomandibular disorders based
performance of the mandible to date, interdental on the research diagnostic criteria for temporomandib-
thickness discrimination ability test using various test ular disorders (RDC ⁄ TMD) (14); (iv) subjects exhibit
blocks (8–12) is one of the methods evaluating somato- unstable intercuspal position; (v) subjects are suffered
sensory function and mandibular kinesthesia. Those from severe mental disorders like schizophrenia.
applied for healthy subjects have been reported and the Among these 25 candidates, 13 were excluded: three
mechanism of discriminating thickness is suggested, but patients reported a complaint associated with remov-
reports about this method applied for OD patients are able prostheses, two reported a complaint associated
not sufficient and inconsistent findings make it difficult with periodontal disease, four had TMD, three exhib-
to understand the physical characteristics of OD (1, 3, ited unstable intercuspal position and one had been
13) as described above. Hence, the interdental thickness diagnosed as having schizophrenia by a psychiatrist.
discrimination ability test using blocks was employed Finally, 12 OD patients (10 women and two men;
for assessing the physical characteristics of OD in the average age 54Æ7 years) and sex- and age-matched
present study. controls, 12 healthy dentate volunteers (10 women and
The purpose of this study was to assess the charac- two men; average age 54Æ8 years), participated in this
teristics of OD by bio-psycho-social (biological and study.
psycho-social) approach. In this study, the interdental Subjects were informed of the experimental proce-
thickness discrimination test and two psychological dure and were free to withdraw from the study
tests were conducted. The NULL hypotheses tested in whenever they wanted. The study was approved by
the present study were (i) there was no difference in the Ethics Committee at Kyushu University.
interdental thickness discrimination ability between OD
patients and normal controls and (ii) there was no
Interdental thickness discrimination test
difference in the psychological status evaluated with
psychological tests between OD patients and normal As a biological approach, interdental thickness discrim-
controls. ination test was carried out for an assessment of sensory
perception. In this test, standard blocks made of
stainless steel with the thickness of 2, 5 and 10 mm
Materials and methods
and 12 kinds of test blocks that have thicknesses
different from the corresponding standard block by
Subjects
0Æ25, 0Æ50, 0Æ75, 1Æ00, 1Æ25 and 1Æ50 mm were used
In this study, OD was defined as ‘a persistent uncom- (Fig. 1). The reproducibility of the following technique
fortable sense of maximum intercuspation after all using these tools had been already reported (12). The
pulpal, periodontal, muscle and temporomandibular standard block was first placed between the subject’s
joint (TMJ) pathologies have been ruled out and a maxillary and mandibular central incisors by the
physically obvious bite discrepancy cannot be observed’ investigator. Then, the subject was instructed to bite
(1). The study was conducted from February 2006 to the block gently with the minimal bite force for 2 s.
April 2007 in the prosthodontic clinic of Kyushu Two seconds after the removal of standard block, one of

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 BIO-PSYCHO-SOCIAL ASPECTS OF OCCLUSAL DYSAESTHESIA 3

(one-way repeated-measures ANOVA, followed by

Scheffe’s multiple comparisons). The number of wrong
answers was also compared between OD patients and
controls for the test blocks thicker than the correspond-
ing standard block and for those thinner than the
standard block in each thickness (unpaired t-test).
Finally, data were compared within OD patients and
controls (paired t-test). As for psychological tests, total
scores and scores for each subscale were compared
between OD patients and controls (Wilcoxon’s test). All
statistical analyses were conducted by SPSS 17.0 for
Fig. 1. Interdental thickness discrimination ability test. The block Windows*. For all tests, significance was set at 5%
made of stainless steel is placed between the subject’s maxillary
(P < 0Æ05).
and mandibular central incisors. The subject was instructed to bite
the block gently with the minimal bite force for 2 s.
Results
the test blocks was placed in the same position as the Regarding the primary endpoint on interdental thick-
standard block. The subject was then asked to indicate ness discrimination ability test, there was no significant
whether the test block felt ‘thicker’ or ‘thinner’ than group difference in the number of wrong answers
the standard block, that is, forced-choice paradigm. between OD group and control group (P = 1Æ000)
When the subject indicated ‘thicker’ for a test block that without significant interaction (P = 0Æ096), although
was actually thinner than the standard block or vice significant within-subject difference was observed
versa, the response was recorded as a wrong answer. among 2-, 5- and 10-mm standard blocks (P < 0Æ001)
The order of the standard block and the test block was (Fig. 2). In addition, one-way repeated-measures ANOVA
randomly assigned to eliminate the systematic error. revealed that there was a significant main effect in
These procedures were performed twice for all test control group (P = 0Æ002), and the multiple comparison
blocks. The number of wrong answers was submitted to showed significant differences between 2- and 5-mm
the data analysis. (P = 0Æ038) and between 2- and 10-mm standard blocks
(P = 0Æ003). However, no significant main effect was
observed in OD group (P = 0Æ354) (Fig. 2). There were
Psychological tests
no significant differences in the number of wrong
As a psycho-social approach, two types of psychological
tests, General Health Questionnaire (GHQ60) and
10
Profile of Mood States (POMS) brief-form, were carried
Number of wrong answers

out for an assessment of mental condition (4). GHQ60 **

8
consists of the following four subscales: (i) somatic
*
symptoms, (ii) anxiety ⁄ insomnia, (iii) social dysfunc- 6
tion and (iv) severe depression, and POMS brief-form
4
consists of the following six: (i) tension-anxiety, (ii)
depression-dejection, (iii) anger-hostility, (iv) vigor, (v) 2
fatigue and (vi) confusion.
0
2 mm 5 mm 10 mm
Statistical analyses
Fig. 2. Results of the number of wrong answers in control and
Regarding the interdental thickness discrimination test, occlusal dysaesthesia groups for 2-, 5- and 10-mm-thick blocks.
, control group (n = 12), , occlusal dysaesthesia group
the number of wrong answers was compared between
(n = 12). *P < 0Æ05, **P < 0Æ01, ANOVA, Scheffe’s test. Error bar:
OD patients and controls and between 2-, 5- and standard deviation.
10-mm-thick blocks (mixed-model ANOVA). The data
were then compared within OD patients and controls *SPSS, Tokyo, Japan.

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4 Y . T S U K I Y A M A et al.

10 median values, ranges and P-values for total score and

9 : Control group (n = 12) each subscale are shown in Table 1.
Number of wrong answers

8 : OD group (n = 12)
7 **
6 *** ** Discussion
5 **
*** This study showed no difference in the interdental
4 *** thickness discrimination ability between the OD
3 patients and normal controls, but the difference in the
2 psychological status was observed between the two
1
groups. This would be the first scientific report in which
0
Thin Thick Thin Thick Thin Thick OD patients and sex- and age-matched controls were
2 mm 5 mm 10 mm compared using both physical and psychological eval-
uations.
Fig. 3. Results of the number of wrong answers in control and
In the present study, we focused on interdental
occlusal dysaesthesia groups for thinner and thicker test blocks.
thickness discrimination ability to assess the physical
OD, occlusal dysaesthesia, Thin, test blocks thinner than the
corresponding standard block, Thick, test blocks thicker than the profiles of OD because it could be associated with
corresponding standard block. **P < 0Æ01, ***P < 0Æ001, unpaired sensation of occlusion and is thought to be a possible
t-test. Error bar: standard deviation. method evaluating the status of sensory components
that regulate mandibular position and occlusion (10,
12). As a result of interdental thickness discrimination
answers between OD and control groups for the test ability test, the control group showed similar tenden-
blocks thicker than the corresponding standard block cies as reported in previous studies (15–17): namely,
and for those thinner than the standard block in each the thickness discrimination ability decreases in accor-
thickness (unpaired t-test) (Fig. 3). Significant differ- dance with the mouth-opening increases (Fig. 2 and
ences were observed between thinner and thicker test 3). The OD group showed slightly weak different
blocks for both OD and control groups (P < 0Æ05, paired tendencies as compared to control group, but no
t-test) (Fig. 3). statistically significant differences were observed
Regarding psychological tests, there were no signif- between these two groups (Fig. 2). This result was
icant differences between OD and control groups in the also in agreement with the previous study in which
total score for either GHQ60 (P = 0Æ143) or POMS brief- the similar method was utilised for OD patients and
form (P = 0Æ319) (Fig. 4). As for subscales in each test, normal controls (3).
OD patients showed significantly higher scores in Possible causes of the absence of differences in inter-
‘somatic symptoms’ (P = 0Æ039) and ‘severe depression’ dental thickness discrimination ability are that the
(P = 0Æ039) for GHQ60 and ‘depression-dejection’ sensory test used in the present study is not sensitive
(P = 0Æ014) for POMS brief-form and lower scores in enough to detect the difference between OD and control
‘vigor’ for POMS brief-form (P = 0Æ008) (Fig. 5). The groups and that OD symptoms occur not from abnor-

60 70

60 Fig. 4. Comparison of total scores for

50
50 each psychological test between con-
40 trol (n = 12) and occlusal dysaesthe-
40
sia (n = 12) groups. OD, occlusal
Score
Score

30 30 dysaesthesia. Wilcoxon’s test. In box

20 plots, upper and lower brackets rep-
20
resent 90% and 10% of the values,
10
respectively; upper and lower hori-
10
0 zontal lines of the box represent the
0 –10 third and first quartiles of the values,
Control group OD group Control group OD group respectively; and the horizontal line
GHQ60 POMS brief-form in the box represents the median.

ª 2012 Blackwell Publishing Ltd

 BIO-PSYCHO-SOCIAL ASPECTS OF OCCLUSAL DYSAESTHESIA 5

* *
7 7

6 6

5 5

Score

Score
4 4

3 3

2 2

1 1

0 0
Control group OD group Control group OD group
somatic symptom (GHQ) depression-dejection (GHQ)
Fig. 5. Comparison of subscale scor-
es for GHQ60 and POMS brief-form
* **
20 20
between control (n = 12) and occlu-
18 18
sal dysaesthesia (n = 12) groups. OD, 16 16
occlusal dysaesthesia. *P < 0Æ05, 14 14
12 12
Score

Score
**P < 0Æ01, Wilcoxon’s test. In box
10 10
plots, upper and lower brackets rep-
8 8
resent 90% and 10% of the values, 6 6
respectively; upper and lower hori- 4 4
zontal lines of the box represent the 2 2
0 0
third and first quartiles of the values,
Control group OD group Control group OD group
respectively; and the horizontal line
in the box represents the median. severe depression (POMS) vigor (POMS)

malities of muscle spindles of jaw-closing muscles but ‘recognition of the mandibular position’, ‘thickness
from other mechanisms. The physiological mechanisms discriminating’ and ‘tactile sense of the teeth contact’.
of this disorder are thought to involve abnormalities of These conditions attribute to the dysfunction or hyper-
sensitisation of mechanoreceptors in periodontal liga-
Table 1. Results of psychological tests
ment, temporomandibular joints or muscle spindles of
jaw-closing muscles. To assess the relation of other
Control OD Patient
(n = 12) (n = 12)
receptor and OD symptoms, various types of sensory tests
are necessary in the future studies. Moreover, it is
Item Median Range Median Range P value considered that OD symptoms may occur from hyper-
GHQ60 sensitisation in the central nervous system related to
Total score 5 0–37 11 1–50 0Æ143 trigeminal regions. According to the neuromatrix theory
Somatic symptoms 0Æ5 0–5 3 0–7 0Æ039* of pain (18), for instance, the neuromatrix, which is
Anxiety ⁄ insomnia 1 0–7 1Æ5 0–7 0Æ478
genetically determined and modified by sensory experi-
Social dysfunction 0 0–3 0 0–6 0Æ590
Severe depression 0 0–0 0Æ5 0–6 0Æ039*
ence, is the primary mechanism that generated the
POMS brief-form neural pattern that produces pain. Its input pattern is
Total score 10Æ5 )6–34 15 0–60 0Æ319 determined by multiple influences – of which the
Tension-anxiety 3 1–15 6 1–16 0Æ178 somatic sensory is only a part – that converge on the
Depression-dejection 0 0–8 3 0–11 0Æ014* neuromatrix. Similar underling mechanisms might be
Anger-hostility 3Æ5 0–5 1Æ5 0–16 0Æ671
involved in the development of OD. Further examina-
Vigor 6Æ5 3–19 3Æ5 0–11 0Æ008*
Fatigue 4 0–13 6 0–19 0Æ410 tions with quantitative sensory tests should be con-
Confusion 5 3–10 5 3–10 0Æ977 ducted in terms of peripheral and central sensory
abnormalities in the trigeminal system (19–21).
Median values and range of scores for GHQ60 and POMS brief-
form in controls and occlusal dysaesthesia (OD) patients; Wilco-
In the present study, two self-rating psychological
xon’s test. questionnaires were incorporated. GHQ and POMS
*P < 0Æ05. have been used to screen the existence of mental

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6 Y . T S U K I Y A M A et al.

disorders and to evaluate the treatment outcome in Graduate School of Medical Sciences, Kyushu Univer-
studies of chronic pain (22–25). More importantly, a sity, for his advice on psychological tests. This study was
previous study revealed that these two psychological partly supported by the Grants-in-Aid for Scientific
questionnaires reported to be useful screening tools for Research from Japan Society for the Promotion of
detecting mental disorders in dental patients with Science (No. 17592028).
occlusion-related problems (4). This study showed that
OD patients exhibited the more psychological problems
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