Chronic temporomandibular joint dysfunction: an area of debate...TMJ pain: (a) masticatory pain...

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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 pathogenesis. 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

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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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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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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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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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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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Chronic temporomandibular joint dysfunction: an area of debate...TMJ pain: (a) masticatory pain...

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