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F�� �������� ��������: Kafas P, Dalabiras S, Hamdoon Z. Chronic
temporomandibular joint dysfunction: an area of debate. Hard
Tissue. 2012 Nov 10 1(1):3.
Chronic temporomandibular joint dysfunction: an area of debate P
Kafas1*, S Dalabiras2, Z Hamdoon3
AbstractIntroductionTemporomandibular joint dysfunctio-ns
present with a variety of symptoms that comprise pain in the joint
and its surroundings, jaw clicking, limited jaw opening or locking
and head-aches. The management of chr-onic temporomandibular joint
dysfu-nction may be defined as simple or complex. The preference of
the treat-ment, based on the aetiology, may be characterized as
psychosomatic or operational. Conservative treatment is helpful in
most cases. This up-to-date review focuses on the pathog-enesis and
management of this multi-factorial clinical entity.
ConclusionChronic TMD is a complex clinical condition of yet
unknown pathogen- esis. Further research is required to investigate
the aetiological patterns.
On examination, the most com-mon features are tenderness
upon
palpation of the joint or muscles of mastication, diminished
mouth open-ing, side-to-side movement and click-ing or grating
sounds in the joint upon movements of the mandible4,5. Lack of
tenderness in the external auditory canal could be an additional
diagnos-tic feature of the pain syndrome4.
An acute episode of pain generally has a sudden onset due to
local tissue inflammation and it usually resolves within 4–12
weeks6. The conversion from acute to chronic pain may result from
the body’s inability to restore normal physiological
function7,8.
Historically, there have been several TMD classifications
emphasizing either mechanical or psychological concepts.
Classifying TMD has been a difficult task and several suggestions
exist in the literature.
One of the oldest classification sys-tems distinguishes two
categories of TMJ pain: (a) masticatory pain (muscle-related) and
(b) TMJ arthralgia (joint-related). The former is subdivided into
splinting, spastic and inflammatory pain while the latter into
discal, retrodiscal, capsular and arthropathic pain9,10. Later, TMJ
non-arthritic arthral-gia was re-classified as a deep somatic pain
of disc attachment11.
Currently, the Research Diagnostic Criteria (RDC)/TMD is the
most ac-cepted classification; it was reported by Dworkin and
LeResche12 and it dif-ferentiates the TMD entities along two axes.
The first axis (axis I) refers to the clinical evaluation of TMD
con-ditions. It is divided into three main groups: (a) muscular
involvement, (b) disc displacement and (c) arthritic origin of the
condition. The second axis (axis II) considers pain-related
disability and psychological status in association with TMD12. Good
to ex-cellent reliability results were found using these criteria
in an adolescent
study for each category of RDC/TMD13. RDC/TMD and, more
specifi-cally, the jaw disability checklist, eval-uates the jaw
function and determines in depth the extent of interference caused
by TMD12. Eating, yawning and chewing were found to be the most
common jaw functions that interfered with TMJ using
RDC/TMD14,15.
Another classification, reported by Goldstein16, separates the
condition into general groups of: (a) rheumatoid changes with
synovitis, (b) arthralgia, (c) condylar degeneration, (d) open bite
deformity, (e) chronic pain with link to behaviour, (f) myofascial
pain and dysfunction and (g) internal derangement with displacement
and reduction. A more recent classifica-tion system, reported by
Ogle and Hertz17 and which relates TMD to masticatory myofascial
pain in asso-ciation to TMJ pain with or without joint sounds,
suggests that myofascial pain dysfunction, masticatory myal-gia,
masticatory myositis, tendonitis and whiplash TMJ are all
variations of the myofascial pain syndromes. This review discusses
the impact of different factors on chronic TMJ dysfunction.
PathogenesisThere is a lack of scientific evidence regarding the
pathological origin of chronic TMJ dysfunction, and aetiology is
unknown in up to 95% cases16. Cur-rently, there are observation
studies indicating a multi-part aetiology of the disease.
Nowadays, the involvement of psychological factors in the
aetiology of many TMJ disorders is well estab-lished; these
implicate emotion, behaviour and personality disorders as major
contributors to the pain dysfunction syndrome18. Furthermore,
* Corresponding authorEmail: [email protected] Department of
Oral Surgery and Radiology,
School of Dentistry, Aristotle University of Thessaloniki,
Thessaloniki, Greece
2 Department of Oral and Maxillofacial Surgery, School of
Dentistry, Aristotle University of Thessaloniki, Thessaloniki,
Greece
3 UCLH Head and Neck Unit, University College London Hospitals,
London, UK
Oral
& C
rani
o-M
axill
ofac
ial
Surg
ery
IntroductionTemporomandibular joint dysfuncti-on (TMD) is a
common condition aff-ecting up to 33% of population1. It is
characterized as a unilateral or bilat-eral pain in the
temporomandibular joint (TMJ) and its associated craniof-acial
musculature2; in addition, there could be joint clicking, limited
mouth open-ing or locking, headaches, tinnitus, ear fullness and
popping3.
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temporomandibular joint dysfunction: an area of debate. Hard
Tissue. 2012 Nov 10 1(1):3.
trauma, parafunctional habits, multi-ple dental extractions,
somatization and female gender were identified as risk factors in
patients with myofas-cial pain as well as in subjects with
concurrent myofascial pain and arthralgia19,20.
TraumaTMJ injuries can be direct or indirect and micro- or
macro-traumatic. The reaction of the mandible to whiplash injury
may induce tearing in TMJ ligaments, which tends to affect mainly
the temporalis and masseter by the sudden protrusion and
retro-positioning of the mandible in re-sponse to the rapid
deceleration of the motor vehicle17. Other traumas of TMJ could be
related to scuba diving, childbirth, endotracheal intubation,
violin playing, direct blow and ‘banana peel’ slip21,22. The
parafunctional hab-its such as chewing gums, biting nails and
pencils and grinding teeth may cause microtrauma, which in chronic
existence of the stimulus, may induce pain and various sounds of
TMJ (i.e. clicking, crepitation). Because sounds of the joint are
not always pathognomonic, the necessity of assessing the condition
carefully is essential. In general, past trauma of the head and
neck region may be a contributing factor of the joint
disa-bility23,24. Trauma patients may show higher psychological
disability than non-trauma patients25, thereby em-phasizing the
psychological role in this disorder.
Psychological factorsIt is well known that pain disorders may be
directly or indirectly associ-ated with the psychological status of
an individual. However, the question whether chronic pain is caused
by an existing psychological condition or vice versa cannot be
easily answered. Presence of widespread pain (neck-ache, backache,
irritable bowel syn-drome or other non-head and neck chronic
myalgia disorders), or pain outside the masticatory system are
a
risk factor for chronic TMD pain among women26. This means that
pain in multiple body sites was sig-nificantly more common in TMD
group compared with control group27. This association possibly
indicates a role of psychological factors in TMJ disorders in
addition to the well-understood somatic causes of the related
condi-tions, including hormonal effects. The occurrence of TMD
symptoms was also found to be related to work and social
factors28.
Psychological factors play a more prominent role when the pain
is of muscular origin14,15,29 and are consid-ered to be a major
issues in the onset, exacerbation or perpetuation of the pain30.
This theory is partly supported by scientific evidence, concluding
that the perpetuation of chronic pain is influenced by psychosocial
implica-tions31. In a study group, the muscular tenderness of the
masticatory system was found to be correlated with facial pain32.
It is also identified that these patients are more distressed by
cephalalgias14,15. The cause of muscu-lar involvement seems to be
related to fatigue from chronic parafunctional habits secondary to
psychological stress conditions4. Patients who develop chronic TMD
appear to have more psychosocial distress before diagnosis of
chronicity than those individuals who have acute symp-toms that
subside33. The demograph-ics, emotion, behaviour and cognition, as
general factors from the psycho-logical point of view, may predict
the treatment outcome31. Women who developed chronic TMD were
signifi-cantly more likely to be diagnosed as having a muscle
disorder than those who did not develop chronic TMD33. Furthermore,
it is important to note that about 50% of low-mood (depressed)
individuals have pain as a current complain at examination34.
Depression and catastrophizing contribute to the progression of TMJ
pain; therefore, they should be considered as important factors35.
The need for psychological assessment
should be emphasized for the pa-tients’ benefit.
In a study with a control group, a history of physical or sexual
abuse was reported in 44.8% of diseased (TMD) group; a percentage
that is slightly greater than the control group36. Physical abuse
in females seems to be worse than sexual abuse, as supported by the
enhanced pres-ence of symptoms such as pain, anxi-ety and
depression37. Patients with a history of both physical and sexual
abuse in childhood suffered from more depression38. Taken together,
the above observations indicate a possible synergistic effect
between these two entities.
GenderCompared with males, chronic TMJ dysfunction is more
prevalent in females of reproductive age, with the prevalence being
up to 80%39. Chronic facial pain is also more common in women,
accounting for 75% cases11. The high prevalence of TMD in women is
supported by several studies19,28,40–44. Interestingly, subjective
symptoms such as pain are more frequently reported by females,
while objective disabilities such as diminished jaw opening and
masticatory disability more commonly affect males45. The uneven
valence of TMJ disease between the two genders is not currently
understood. Three main theories have been suggested implicating the
hormonal factor, pain signal process and need for seeking medical
care45–47.
The involvement of sex hormones in the pathology of TMJ pain
derives mainly from observations correlating the intake of
post-menopausal hor-mones with an increased risk for TMD
development40. Furthermore, women who report orofacial pain are
more likely to report symptoms associated with menstruation41.
Though the precise pathogenesis of the disease is unknown, the
activation of cytokine production via oestrogen receptors in TMJs
of females has been suggested to explain the hormonal
involvement33,46.
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temporomandibular joint dysfunction: an area of debate. Hard
Tissue. 2012 Nov 10 1(1):3.
Another possible explanation is based on the general suggestion
that men and women may not process pain sig-nals in the same
manner, developing a different perception and reaction to pain
between the two sexes48.
Finally, the fact that women seek healthcare for pain more often
than men also contributes to the existing high prevalence of TMD in
women47. Although TMD is more prevalent in women, men appear to
have greater prevalence of objective difficulties such as jaw
opening and masticatory disability than women45,49.
MalocclusionThe role of occlusion in the pathogen-esis of TMD is
still controversial. Some authors support the theory that the
functional patterns of malocclu-sion correlate to TMD. The findings
from the studies in favour of this the-ory include the following:
(a) relation of mandibular prognathism to TMJ symptoms50 and (b)
reduction of symptoms in Angle class II retrocclu-sion
post-operatively50,51; however, in none of the studies, the results
were statistically significant. Furthermore, it was shown that
orthodontic treat-ment leading to extensive changes in the
occlusion was not associated with the development of TMD16,20.
Stronger evidence comes from studies supporting that occlusion
is not considered to be a significant fac-tor for the pathogenesis
of TMD52–54. The negative correlation of occlusion with TMD
symptoms was established in an observational study with two groups
of individuals, one with nor-mal occlusion and the other with
mal-occlusion with no statistical difference between the two
cohorts55.
Occlusal malfunction such as brux-ism has not been found to
induce TMD56,57. Moreover, bruxismic activity was not correlated
with myalgias57. The predictors of the two compo-nents of bruxism,
clenching during daytime and nocturnal grinding, were not the same
indicating that these two entities may be different58. The
explanation here is that more than 60% of bruxismic individuals
pre-sented with TMD59. Overall, there is unsufficient evidence to
implicate occlusion patterns in the pathogene-sis of TMD16.
DiscussionThe authors have referenced some of their own studies
in this review. These referenced studies have been conducted in
accordance with the Declaration of Helsinki (1964) and the
protocols of these studies have been approved by the relevant
ethics committees related to the institution in which they were
performed. All human subjects, in these referenced studies, gave
informed consent to participate in these studies.
Psychosomatic approaches Informed reassuranceInformed
reassurance, as a psycho-logical technique, is an explanation of
the disease status either in verbal or written form. This should be
done in ‘layman’ terms to facilitate under-standing by the patient.
The technique of reassurance has been found to be very useful in
around 80% cases when used in conjunction with simple analgesics,
physiotherapy and occlusal splints60. Informed reassurance and
placebo were found to be equally ef-fective in relieving symptoms
in 45% cases61. Early discussion and inter-vention may prevent the
development of chronicity43,62. It is important to mention that
only 2% to 5% of all patients treated for TMJ disorders undergo
surgery, thereby emphasiz-ing that majority of patients receive
conservative management63 with 70% reporting good outcome64. Most
of these patients suffered from stress and pain other than TMD and
were found to be sensitive to reassurance65.
Mind–body therapyStress was found to be an important factor in
the genesis of musculoskeletal
disorders with techniques such as yoga to relieve individual
stress and leading to a state of relaxation66. Eval-uation of this
technique was difficult due to transpersonal and philosophi-cal
dimensions66. Yoga, hypnosis, relaxation, meditation, imagery and
biofeedback are considered as mind–body therapies67,68,69.
The anxiety and pain complex may be the most common indication
for dental hypnosis70. Although hypnotic-induced reduction in
frequency, duration and intensity of TMD pain has been observed71,
there is no sig-nificant difference in analgesia with the addition
of suggestion under hypnosis72. Another suggestion that hypnosis
could be effective for the treatment of a wide range of acute and
recurring painful conditions should be considered73.
In general, relaxation and imagery techniques are not clearly
understood in the treatment of both acute and chronic pain
syndromes. Individuals with strong religious beliefs or other
objections should be excluded from these alternatives74. A possible
target of relaxation is to control the sympathetic nervous system
where decreasing function reduces metabolic activity 75.
Cognitive–behavioural therapy Any patient with long-term pain
may benefit from cognitive–behavioural therapy (CBT), which is
divided into cognitive restructuring and coping skills training76.
The inter-related components of the treatment are edu-cation, skill
acquisition, cognitive and behavioural rehearsal, homework,
generalization and maintenance77. A recent randomized clinical
trial concludes that after 6 sessions of CBT, patients with
enhanced psychological and social disability showed improve-ment in
pain variables78. Combination treatment of cognitive skills
training and biofeedback were more effective in comparison with the
use of these alternatives alone79. Individuals who suffered from
dysfunctional profiles or patterns of TMD, in other terms
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temporomandibular joint dysfunction: an area of debate. Hard
Tissue. 2012 Nov 10 1(1):3.
high distress and pain, were associated with both failure of
conservative and surgical treatment80. Additionally, patients with
dysfunctional pain did not benefit from brief CBT81. The need for
more research in this field has been emphasized82.
Combining biofeedback with intra-oral appliances was more
favourable in comparison with each treatment alone in reducing
pain, hence sup-porting the concept of combined management83. In a
study designed with a pre-test and post-test control groups, the
use of habit reversal treat-ment for TMD revealed that reduction in
pain was accompanied by a reduc-tion in oral habits with minimal
clini-cal contact84.
Operational approaches Occlusal therapiesOcclusal therapies can
be subdivided into occlusal adjustment and appli-ances. Occlusal
adjustment is an irre-versible alteration of occlusion and it has
been used for the treatment of TMD without a sound literature
supporting its efficacy85. The role of occlusal adjustment was
considered to be the decompression of the con-dyle in the
articulating fossa, but research showed that there is no increase
in joint space during clench-ing86. A study showed that occlusal
adjustment was not convincing for the alleviation of symptoms of
chronic TMD because of the non-powerful experimental evidence87.
Thus, occlusal adjustment cannot be recommended for the management
of TMD88–90.
Occlusal splints, as two major types of removable orthopaedic
appliances, can be distinguished into reposition-ing and
stabilization appliances; the former is used to decrease pain,
clicking and secondary muscular symptoms, while the latter is
mainly indicated for muscular relaxation and protection of teeth91.
Occlusal splints can be further classified as permissive and
non-permissive92. The efficacy of occlusal appliances is based on
the reduction of the electromyographic
activity and in modification of the parafunctional
behaviour93–95. A rand-omized controlled trial concluded that
stabilization appliances are more effective in the myalgia type of
the disorder, with regard to reduction in symptoms and signs96,
while the role of anterior repositioning splints is restricted
mainly in joints with arthralgia and painful click97.
In general, occlusal appliances are found to be significantly
effective in pain reduction than the combined treatment alternative
of informed reas-surance and relaxation98. Failure of occlusal
splint therapy to resolve symp-toms, particularly pain, may be
related to psychological implications59.
Prolonged splint wear may induce remodelling and even TMJ
injury, as in-dicated in a study involving miniature pigs99.
Therefore, splints can be con-structed as an initial form of
therapy60. These appliances are suggested to have equivalent effect
when compared with placebo94,95.
Although splint therapy and occlusal adjustment have been
extensively used, there is no evidence to suggest that they can be
curative. A number of evidence-based trials have concluded that
these appliances should not be suggested as part of routine
care.
Pharmacological modalitiesThe medications reported to be
effec-tive in the management of TMD are non-steroidal
anti-inflammatory drugs, corticosteroids, anti-depressants, mus-cle
relaxants, sedative hypnotics, botu-linum toxin and
capsaicin100–103. Opiates have been used for a long time for pain
control, especially in chronic condi-tions104. Intra-articular
morphine has been used in a randomized double blind study showing a
significant increase in pain threshold in the dis-eased joint105.
Anti-depressants such as tricyclics have been shown to produce
effective pain relief at low dosage amongst chronic cases, a good
example being amitriptyline and nortriptyl-ine106,107. Tricyclic
anti-depressants are central analgesics acting by inhibition
of serotonin re-uptake, norepinephrine and α2-receptor
blockade108,109. Treat-ment with anti-depressants cannot be
expected to give immediate pain relief because of the delayed onset
of their ac-tion which usually takes 4–6 weeks110. Corticosteroids
can be injected or applied topically in cases of condylar erosion,
myalgia and trismus with rela-tively positive therapeutic
results99,111.
A randomized controlled trial did not support the use of
botulinum toxin A in patients with moderate to severe chronic
muscular type of pain, concluding that these patients had less wide
jaw opening compared with a placebo group112. A similar design
study showed that the topical appli-cation of capsaicin is
statistically insignificant when compared with the placebo
effect113.
PhysiotherapyA study of complementary and alter-native medicine
showed that massage is rated as the most frequent and amongst the
most effective treatment modalities114. This approach seems to be
more effective in sub-acute and chronic non-specific conditions115.
Others characterize massage as inef-fective for pain in general due
to lack of scientific evidence115.
Heat and cold techniques (lasers, diathermy, microwaves and ice
packs) and therapeutic ultrasound may be used to relieve
musculoskeletal pain. These methods have been found effective
through a ‘counter-irritant’ mechanism, by relaxing the muscle and
reducing the spindle response, respectively116.
Management with electrotherapy remains controversial due to the
lack of high evidence-based studies114. There is no substantial
improvement of TMD signs and symptoms when managed with
transelectrical nerve stimulation59. An electromyographic study
revealed that an imbalance of the masticatory muscles may lead to
clicking, locking, headaches, earaches and deviation of the
mandible. It was suggested that this finding could be
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temporomandibular joint dysfunction: an area of debate. Hard
Tissue. 2012 Nov 10 1(1):3.
beneficial for the management of masseteric involvement using
neuro-muscular electrostimulation of the weakened muscle117. The
use of micro-current stimulation and mid-laser were significantly
better than the placebo effect118. Silver spike point
electrotherapy combined with occlusal splint was found to be a
favourable treatment outcome inter-vention (good response in 90%
pa-tients)119. Alternatively, no statistically significant results
were identified in randomized controlled trials in pa-tients
receiving electrogalvanic stim-ulation120, low-level laser121,
pulsed radio-frequency and pulsed electro-magnetic
fields122,123.
AcupunctureThe use of acupuncture in TMJ pain management seems
to be positive, although the analgesic effect of this technique is
still under considera-tion124. It has been suggested that
acupuncture is comparable to con-servative treatment
alternatives125. The use of acupuncture in combina-tion with
occlusal splint and point injection was found to be useful for
managing TMD126. The level of analge-sia induced by this method may
be modified by stress and anxiety127. It is worth noting that
electrical stimula-tion of acupuncture needles in com-parison with
transcutaneous electrical nerve stimulation has not shown any
significant difference128. A recent meta-analysis has shown limited
evidence that acupuncture is effective for treat-ing
temporomandibular disorders129.
SurgeryLess than 8% of facial arthromyalgia cases require
surgery130. The surgical approach should be considered in pa-tients
diagnosed with advanced inter-nal derangement caused by ankylosis
or severe degenerative joint disease with no improvement after
conserva-tive methods63.
Surgical procedures such as arthos-copy, arthocentesis,
interpositional grafting, arthrotomy and arthroplasty
can be helpful in certain situations where adherence to
indications and limitations are observed63,131,132. TMJ arthroscopy
with added arthrocente-sis and morphine injection in the joint
compartment can be associated with symptom relief for up to 10
years. The most recently published National Institute for Health
and Clinical Excel-lence guidelines did not support total joint
replacement due to lack of good long-term outcome.
ConclusionChronic TMD is a complex clinical condition of yet
unknown pathogen-esis. Further research is required to investigate
the aetiological patterns of this disorder. Management of TMD
requires a multi-disciplinary approach. Working as a team of
dentists, maxil-lofacial surgeons, psychologists, psy-chiatrists
and physiotherapists, with interest in pain disorders, can lead to
the development of a successful ther-apeutic strategy for the
management of TMD patients.
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