Behavioral Treatment of Sleep Problems for Orofacial Pain Patients

by Joshua R. Oltmanns and Charles R. Carlson

Orofacial pain often co-occurs with problems falling asleep, maintaining sleep, and waking too early that cause impairment in daytime functioning (Carlson et al., 1998; Porto et al., 2011). These problems are captured with the definition of insomnia (American Psychiatric Association, 2013; Edinger et al., 2004) and are also associated with disruptions in mood, health, social and occupational functioning (Ohayon, 2002). It appears that the relationship between pain and insomnia is bi-directional, that is, that insomnia exacerbates pain, and pain exacerbates insomnia symptoms (Smith & Haythornthwaite, 2004). Thus, insomnia is a central problem in the experience of orofacial pain, and the treatment of insomnia is an important target for orofacial pain patients.

Pain patients are often provided pharmacological treatment for sleep difficulties. Behavioral treatment of insomnia, however, is at least equally as effective (Morin et al., 2006; Murtagh & Greenwood, 1995; Smith et al., 2002). Cognitive-Behavioral Therapy for Insomnia (CBTI) is a fusion of empirically-supported behavioral techniques for reducing insomnia symptoms. It is a straightforward intervention that can be effectively provided by non-sleep specialists such as dentists, nurses, social workers, or other health professionals (Bothelius, Kyhle, Espie, & Broman, 2013; Espie et al., 2007; Manber et al., 2012). CBTI can be introduced in one-on-one or group settings, either in person or online (Matthews, Arnedt, McCarthy, Cuddihy, & Aloia, 2013). Manuals are available that include education about the treatment, as well as complete session-by-session guides along with examples of provider-patient dialogues (Morin & Espie, 2003; Perlis, Jungquist, Smith, & Posner, 2005). CBTI offers an opportunity for any professional healthcare provider to reduce insomnia effectively in patients.

Two simple “first-line interventions” (Per lis et al., 2005) of CBTI are stimulus control therapy (SCT; Bootzin, 1972) and sleep restriction therapy (SRT; Spielman, Saskin, & Thorpy, 1987). The bedroom can become associated, or conditioned, with non-sleep related thoughts and activities. Thus, SCT involves re-associating the bedroom only with sleep and relaxation, and developing a consistent sleep/wake schedule. SRT restricts time in bed, which increases the homeostatic drive for sleep the following night. As sleep efficiency (i.e., the proportion of the time spent in bed awake versus time spent asleep) increases, time in bed is gradually expanded, until the patient is sleeping a healthy number of hours efficiently. CBTI includes several other components that can be used to improve sleep quality: relaxation therapy (i.e., diaphragmatic breathing and other techniques that increase relaxation and decrease physiological arousal), sleep hygiene education (i.e., education about adaptive and maladaptive sleep-related behaviors), paradoxical intention (i.e., attempting to stay awake as long as possible, thereby eliminating anxiety about falling asleep rapidly), and cognitive therapy (i.e., restructuring maladaptive beliefs about sleep) (Harvey & Asarnow, 2014). When applied separately, SCT and SRT are each useful for reducing insomnia symptoms (Morin et al., 2006). When used together with the other components of CBTI, patients experience even greater improvements in sleep (Morin et al., 2006).


CBTI offers an opportunity for any professional healthcare provider to reduce insomnia effectively in patients.

Cognitive Behavioral Therapy for Insomnia is the most empirically supported and efficacious behavioral treatment for insomnia (Harvey & Asarnow, 2014). A review of 37 treatment outcome studies conducted between 1998 and 2004 found that individuals with insomnia who completed CBTI experienced improvements in the time it took to fall asleep, the time spent awake after falling asleep, total sleep time, and sleep efficiency (Morin et al., 2006). Further, studies showed that these improvements were maintained over follow-up periods ranging from several months to years.

Sleep quality improvements from CBTI predict long-term reduction in pain and fatigue in chronic pain patients.

There have also been studies of CBTI administered specifically to pain patients. These studies have indicated that insomnia in pain patients s very similar to insomnia experienced by primary insomnia patients (Tang, Goodchild, Hester, & Salkovskis, 2012), and CBTI significantly reduces insomnia symptoms in a variety of pain patient populations (Currie et al., 2002; Jungquist et al., 2010; Pigeon et al., 2012; Quartana, Wickwire, Klick, Grace, & Smith, 2010; Vitiello et al., 2014; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009). Further, CBTI may have beneficial, indirect effects on pain. For example, sleep quality improvements from CBTI have also been shown to predict long-term reduction in pain and fatigue in chronic pain patients (Currie et al., 2002; Vitiello et al., 2014). While more studies are needed, these findings provide evidence of CBTI’s effectiveness for reducing insomnia symptoms, and also its potential for reducing pain and pain-related distress (Finan et al., 2014).

Pharmacological treatment is the most common sleep treatment provided to orofacial pain patients. However, behavioral treatments that are practical and effective have been shown to be at least equally effective for reducing insomnia (Morin et al., 2006). CBTI can be provided by dentists, nurses, social workers and other health professionals. CBTI is useful because it teaches behavioral skills that improve sleep quality, while at the same time removes the possibility of side effects or dependency that may result from pharmacological treatment. Implementation of this treatment in orofacial pain clinics provides patients with safer and longer-lasting behavioral skills to reduce their insomnia.

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