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.

Joshua R. Oltmanns, MS, is a third-year graduate student in clinical psychology at the University of Kentucky. He completed a clinical placement at the University of Kentucky Medical Center’s Orofacial Pain Center under the supervision of Dr. Charles Carlson from 2015-2016. His research and clinical interests include the assessment and structure of normal and abnormal personality traits, insomnia, and the treatment of insomnia. His current clinical placement is at the Harris Psychological Services Center at the University of Kentucky.

Dr. Charles R. Carlson, Ph.D., ABPP, obtained his Ph.D. in clinical psychology from Vanderbilt University and completed a clinical residency at the University of Mississippi Medical Center. Since 1988, he has been a member of the Department of Psychology at the University of Kentucky where he is the Robert H. and Anna B. Culton Professor of Psychology; he also holds joint appointments as a professor in the Colleges of Dentistry and Medicine and is currently the Director of Behavioral Medicine and Research at the Orofacial Pain Center in the University’s College of Dentistry. Dr. Carlson has been awarded the diplomate in clinical health psychology from the American Board of Professional Psychology and received the U.S. Navy’s Civism Award for service to the Naval Postgraduate Dental School in Bethesda, MD. His research and clinical interests focus on self-regulation skills training for the management of pain in areas mediated by the trigeminal nerve.

  1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. Bothelius, K., Kyhle, K., Espie, C. A., & Broman, J. (2013). Manual-guided cognitive-behavioural therapy for insomnia delibered by ordinary primary care personnel in general medical practice: A randomized controlled effectiveness trial. Journal of Sleep Research, 22, 688-696.
  3. Carlson, C. R., Reid, K. I., Curran, S. L., Studts, J., Okeson, J. P., Falace, D., … & Bertrand, P. M. (1998). Psychological and physiological parameters of masticatory muscle pain. Pain, 76, 297-307.
  4. Currie, S. R., Wilson, K. G., & Curran, D. (2002). Clinical significance and predictors of treatment response to cognitive-behavior therapy for insomnia secondary to chronic pain. Journal of Behavioral Medicine, 25, 135-153.
  5. Finan, P. H., Buenaver, L. F., Runko, V. T., & Smith, M. T. (2014). Cognitive-behavioral therapy for comorbid insomnia and chronic pain. Sleep Medicine Clinics, 9, 261-274.
  6. Harvey, A. G., & Asarnow, L. D. (2014). Insomnia. In S. G. Hofmann, Dozois, D. J. A., W. Rief, and J. A. J. Smits (Eds.), The Wiley handbook of cognitive behavioral therapy (Vols. 1-3) (pp. 541-565) Wiley-Blackwell.
  7. Jungquist, C. R., O’Brien, C., Matteson-Rusby, S., Smith, M. T., Pigeon, W. R., Xia, Y., … & Perlis, M. L. (2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep Medicine, 11, 302-309.
  8. Manber, R., Carney, C., Edinger, J., Epstein, D., Friedman, L., Haynes, P. L., … & Trockel, M. (2012). Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. Journal of Clinical Sleep Medicine, 8, 209-18.
  9. Matthews, E. E., Arnedt, J. T., McCarthy, M. S., Cuddihy, L. J., & Aloia, M. S. (2013). Adherence to cognitive behavioral therapy for insomnia: a systematic review. Sleep Medicine Reviews, 17, 453-464.
  10. Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). SLEEP, 29, 1398-1414.
  11. Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. New York, NY: Kluwer Academic/Plenum.
  12. Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for insomnia: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79-89.
  13. Ohayon, M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97-111.
  14. Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. A. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York, NY: Springer.
  15. Pigeon, W. R., Moynihan, J., Matteson-Rusby, S., Jungquist, C. R., Xia, Y., Tu, X., & Perlis, M. L. (2012). Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: a pilot study. Behaviour Research and Therapy, 50, 685-689.
  16. Porto, F., de Leeuw, R., Evans, D. R., Carlson, C. R., Yepes, J. F., Branscum, A., & Okeson, J. P. (2011). Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients. Journal of Orofacial Pain, 25, 117-124.
  17. Quartana, P. J., Wickwire, E. M., Klick, B., Grace, E., & Smith, M. T. (2010). Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: a crosslagged panel analysis. PAIN, 149, 325-331.
  18. Smith, M. T., & Haythornthwaite, J. A. (2004). How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Medicine Reviews, 8, 119-132.
  19. Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buysse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11.
  20. Tang, N. K., Goodchild, C. E., Hester, J., & Salkovskis, P. M. (2012). Pain-related insomnia versus primary insomnia: a comparison study of sleep pattern, psychological characteristics, and cognitive-behavioral processes. The Clinical Journal of Pain, 28, 428-436.
  21. Vitiello, M. V., McCurry, S. M., Shortreed, S. M., Baker, L. D., Rybarczyk, B. D., Keefe, F. J., & Von Korff, M. (2014). Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia. PAIN, 155, 1547-1554.
  22. Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine, 5, 355-362.

Stay Relevant with Dental Sleep Practice

Join our email list for CE courses and webinars, articles and more..

Read our following terms and conditions before subscribing.

Terms and Conditions checkbox is required.
Something went wrong. Please check your entries and try again.

Subscribe Today

Dental Sleep Practice is a leading dental journal and publication for obstructive sleep apnea case studies, dental continuing education, and more. Subscribe to Dental Sleep Practice today!

Online Dental CE

Medmark Media Dental Marketing Logo
AGD PACE MedMark White

Copyright © 2021 Dental Sleep Practice - Dental Journal and Online Dental CE | MedMark LLC
15720 North Greenway Hayden Loop, Suite #9 Scottsdale, AZ 85260 | All rights Reserved | Privacy Policy | Terms & Conditions

Scroll to Top