4.4 Facing It: Mindfulness for Chronic Orofacial Pain

By Saige Fong, MS; Molly Becker, MS; and Jonathan Greenberg, PhD (USA)

The concept of mindfulness originates from early Eastern traditions and Buddhist philosophy. In its contemporary Westernized form, mindfulness is most commonly defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally.” It is often described as having two main components: (1) regulating attention to whatever is happening in the present (e.g., whatever thoughts, feelings, and bodily sensations one is currently experiencing), coupled with (2) an intention of being open to and accepting of whatever arises. Thus, a person may be said to be mindful if they are attentive and aware of their current experience and try to be nonjudgmental and accepting toward it (e.g., noticing any resistance to one’s experience and simply allowing it to be as it is). Mindfulness may be portrayed as a trait, a theoretical construct, and a psychological process, although it is most often described in the context of a meditative practice.

In the late 20th century, Jon Kabat-Zinn pioneered the incorporation of mindfulness practices into Western medicine through a secular intervention aimed at managing chronic pain and health-related stress (mindfulness-based stress reduction, MBSR). Since then, there has been an exponential growth in therapeutic interventions involving mindfulness. In the 1990s, Segal and colleagues combined mindfulness practice with traditional Cognitive Behavioral Therapy (CBT) in a treatment program intended to prevent depression relapse (mindfulness-based cognitive therapy, MBCT). Other interventions such as acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT) include mindfulness as a component in the treatment of various mental and physical health conditions. The utilization of mindfulness practices is continuously expanding in the treatment of a wide array of populations, as well as in nonclinical settings such as schools and businesses.

Mindfulness for Chronic Orofacial Pain. Pain is inherently unpleasant and aversive. It is natural for us to try to resist pain and have negative behavioral, cognitive, and emotional reactions to it. Although these reactions can help us avoid or minimize harm in acute pain (e.g., feeling startled and quickly moving our hand if we accidentally touch a hot stove), they are far less helpful in chronic pain, including chronic orofacial pain, when pain most often no longer signals that harm is currently being done to our body. Mindfulness encourages individuals to adopt a curious and nonjudgmental approach to the presence of pain and discomfort, which may decrease our behavioral, cognitive, and emotional reactions to it. A growing body of research suggests that mindfulness-based interventions constitute safe and effective approaches to chronic pain management. Reviews and meta-analyses of mindfulness-based interventions for chronic pain report that mindfulness decreases pain intensity, depression, and pain bothersomeness; improves quality of life; and reduces the interference of pain in activities of daily living.

Although research on mindfulness specifically for orofacial pain remains sparse, emerging evidence suggests that it is a promising means to aid individuals with chronic orofacial pain. A recent study suggested that specific facets of mindfulness, particularly adopting a nonjudgmental attitude, were associated with favorable pain and mental health outcomes such as decreased pain-related disability, depression, and anxiety among members of the FPA.

How May Mindfulness Help Individuals with Chronic Orofacial Pain? There are several ways in which mindfulness may potentially aid chronic orofacial pain. Some of these are as follows:

Reducing Anxiety and Depression. Living with chronic orofacial pain is stressful and may take a significant emotional toll. A recent survey of more than 300 members of the FPA living with chronic orofacial pain indicated that almost 75% of participants experienced clinically significant symptoms of depression or anxiety, and more than one-third reported taking antidepressants. Mindfulness-based interventions have been demonstrated to alleviate symptoms of anxiety and improve quality of life. Research further demonstrated that mindfulness-based interventions can reduce the length of major depressive episodes, heighten positive affect, and buffer against depressive relapse. These benefits have been partially attributed to increased awareness of calm, experience, and acceptance of their symptoms. Mindfulness can also help reduce suicidal ideation and behavior, which are relatively prevalent among individuals with chronic orofacial pain.

Emotion Regulation. Emotion regulation refers to one’s capacity to effectively manage and respond to an emotional experience. By observing emotions from a “detached” perspective (e.g., noticing phenomena arising and passing rather than identifying with them), individuals can avoid becoming overwhelmed by negative emotions surrounding their pain. Mindfulness practice also has the potential to open new avenues of thinking, including about pain, that can improve emotion regulation. Having an intense emotional reaction in response to pain, feeling victimized by the pain, and feeling overly critical of oneself or others are emotion-laden responses to pain that can become habitual and automatic. Research suggests that mindfulness may help change habitual patterns and increase the degree to which individuals can identify and implement novel, more helpful ways of responding than those they are used to. As mindfulness is characterized by curiously paying attention to things “as they are” (as opposed to our preconceptualized notions about them), it may increase one’s capacity to respond in nonhabitual manners. Rather than ruminating on pain-related fears and engaging in harmful behaviors, new ways of responding to pain may become more accessible, thus improving emotion regulatory skills. This conclusion is in line with evidence suggesting that mindfulness can increase one’s distress tolerance and capacity to be present with discomfort, further supporting one’s capacity to effectively regulate their emotions.

Reducing Social Isolation. Chronic orofacial pain may have significant social implications, leading to social isolation and impaired quality of life. Many individuals with chronic orofacial pain face unique challenges with talking, eating, and making facial expressions, which are important for communicating effectively and creating social bonds. These challenges are particularly prominent for individuals with orofacial pain conditions such as type 1 trigeminal neuralgia (TN), who experience severe, spontaneous, and shock-like episodes of facial pain that last for varying intervals. The added uncertainty of spontaneous pain episodes causes many of these individuals to avoid social activities altogether, thus exacerbating their sense of isolation. Mindfulness has been shown to decrease feelings of isolation and bolster perceived connectedness with others. Mindfulness-Based Stress Reduction (MBSR) has been identified as an effective tool for managing loneliness, and participation in group-based mindfulness practices may also facilitate feelings of social connectedness. The impact of mindfulness on social isolation, particularly in the contexts of chronic orofacial pain and TN, warrants additional research.

Adaptive Coping. The “nonjudgmental” stance in response to pain promoted by mindfulness and its associated reduced reactivity can aid individuals in coping more adaptively with orofacial pain. A common nonadaptive response to pain, including orofacial pain, is pain catastrophizing—constantly thinking about how bad the pain is and its potential negative effects. Individuals with orofacial pain who tend to catastrophize their pain are more likely to experience higher rates of pain intensity and pain-related disability. Several studies have indicated that mindfulness is associated with decreased pain catastrophizing. By observing and accepting such catastrophizing thoughts as passing events, one may stop “feeding the flame” of these thoughts and thereby reduce negative reactivity.

Mindfulness has further been shown to promote the use of other adaptive strategies of coping with pain and adversity.

Many individuals with chronic orofacial pain tend to be harsh or critical toward themselves. Mindfulness has been shown to increase self-compassion, stave off self-blame, and foster treating oneself with kindness. Mindfulness has also been shown to increase qualities associated with adaptive coping such as expressing gratitude, exhibiting pain acceptance, displaying increased self-efficacy in managing pain, and leading a healthier and more active lifestyle.

Pain Awareness. Practicing mindfulness may benefit pain tolerance and awareness. Given that mindfulness commonly involves paying attention to one’s body, individuals may begin to identify triggers for and patterns in their pain. Many people with chronic orofacial pain find that they tend to subconsciously clench their jaw or grind their teeth, particularly in stressful contexts. Increased attention toward these triggers can guide individuals to reduce unhelpful behaviors and thus reduce pain. Pain awareness also allows for curious, nonjudgmental observation of pain without resistance, including awareness of how pain naturally waxes and wanes over time, leading to a more accurate perception of pain (e.g., perceiving it as changing and dynamic rather than constantly severe). Some individuals with orofacial pain may experience pain hypervigilance, or overfixation on their current or next painful experience, as a result of constantly living on the precipice of another painful episode. Living in a state of constant worry may also prime them to magnify their pain experience, identifying unassociated bodily sensations as signs of an impending “attack.” Indeed, a recent qualitative analysis of the experience of people with chronic orofacial pain found that the unpredictability/uncertainty of pain was a major stressor. Mindfulness may ease this negative cognitive tendency and improve attention regulation, a mechanism that is vital for people with chronic orofacial pain given that pain and anxiety may distract from present experiences. Individuals may gently redirect their attention to neutral stimuli such as the sensations of their breath or sounds in their environment, and thus reduce hypervigilance toward uncomfortable sensations.

How Does One Practice Mindfulness? Listed here are several exercises that can be implemented anywhere. Note that, during each of these exercises, you will likely find that your attention wanders quickly to other topics and thoughts. This is natural, expected, and not a sign that you are doing anything wrong. Each time you notice that your mind has wandered, gently bring it back to the exercise. With each return of your attention, you are training your mind to be more present.

• Mindful breathing is an exercise that encourages curiosity about breath as it is without trying to change it. First, get into a comfortable position for your practice, and then either close your eyes or lower your gaze, depending on your comfort levels. Begin to notice where you can feel your breath in your body, maybe in your chest, belly, or nostrils. Notice the sensation of your breaths in and your breaths out. Take a deep breath and exhale, placing your hand on your belly to feel the changes through expansion and deflation. Feel the warmth of an exhale and the cool air of an inhale in your nose. If your focus begins to drift, gently return to the sensation of your breath. Observe the quality of your breath with curiosity—whether it is jagged or smooth, rushed or slow, shallow or deep. Whatever you experience may simply exist without your trying to change it. Allow yourself to experience the sensations of breathing right here and right now.
• Mindful body scans allow for an increased, curious awareness toward bodily sensations that may have been previously avoided or feared, such as pain. Start by finding a comfortable position and then closing your eyes or lowering your gaze. Begin to direct your attention to your breath. What sensations do you notice? Perhaps the rise and fall of your chest or the coolness of your breath coming out of your nostrils. After several moments of attending to the sensations of breathing, focus on the soles of your feet. Notice any temperature, pressure, tingling, or lack of sensation here. Raise your attention up to your legs and any sensations that may live there. Should your mind naturally begin to wander, notice this without judgment and gently bring your attention back to the task at hand. Continue to allow your awareness to drift upward on your body, landing on your back. Maybe you can feel the sensation of your shirt against your skin or your back against a chair. What does it feel like? Guide your attention to your abdomen. Observe any tension you may hold there and release it with an exhale. Move up to your chest and feel the way it rises and falls with each breath. Bring your attention to your hands—you may experience buzzing or tingling here—and then to your arms and shoulders. Notice if you are holding any tension or stiffness there. Focus on any sensations present on your face and head. Once you have made it to the top of your head, see if you can experience your body as a whole. No need to change anything, but simply observe your body with curiosity and without judgment.
• Informal mindfulness practice. Although formal mindfulness practices are beneficial, people may find that they lack the ability to carve out time in their day for a recording or meditation. A key element of mindfulness is its properties as a tool that can be applied during any moment of the day: mindfulness in everyday life. There are numerous activities that one engages in over the course of a day that are often executed on “autopilot.” You are encouraged to attend to sensory experiences that accompany such activities throughout the day with a mindful attitude. For example, when you brush your teeth, notice the sensory experience of the bristles against your teeth and the sound that it makes, perhaps the taste of mint. When you are outside, pay attention to the warmth of the sun on your face and the touch of a breeze. By applying a present and nonjudgmental awareness to basic daily tasks, individuals can become more grounded and appreciative of the small sensations, sights, and sounds that comprise the previously unnoticed moments of life. This allows individuals to manage their pain throughout the day. The benefits of mindfulness thus are available without the resources it may take to practice more formally.

Conclusion. Although research on the use of mindfulness for chronic orofacial pain remains limited to date, there is broad evidence indicating that mindfulness practice may help manage chronic pain and aid with specific challenges faced by individuals with chronic orofacial pain. The incorporation of mindfulness into the treatment of chronic orofacial pain can expand a growing movement toward viewing chronic orofacial pain through a biopsychosocial lens, accounting for the biological, psychological, and social factors affecting individuals with chronic orofacial pain, as well as the interactions among them. Given that mindfulness exercises are free and accessible, mindfulness may pose a safe, easy, affordable, and accessible means to help individuals cope with chronic orofacial pain.