Signsandsymptoms Aetiology Introduction Abstract Temporomandibulardisorders(TMD):anoverview

Download (0)

Full text



Temporomandibular disorders (TMD): an overview

J. Durham

School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, UK


This article discusses the aetiology, signs and symptoms, diagnosis, psycho- logical factors and management of temporomandibular disorders (TMD).

It highlights the difficulty of evidence-based practice with respect to TMD.

Key words:

review, temporomandibular disorders, temporomandibular joint

Correspondence to:

Dr J Durham

School of Dental Sciences Newcastle University Framlington Place NE2 4BW UK

Tel.:+44 191 222 6000 Fax:+44 191 222 8191 email: Accepted: 28 April 2008



Signs and symptoms of temporomandibular disorders (TMD) were first recognised by Costen in 19341and since then a plethora of terms have been used, some- what interchangeably, to describe TMD. These include Costen’s syndrome, temporomandibular joint dys- function syndrome2, pain dysfunction syndrome3and facial arthromyalgia4. TMD5, defined by the American Association of Orofacial Pain (AAOP) as:

A collective term embracing a number of clinical problems that involve the masticatory

musculature, the Temporomandibular joint and associated structures, or both6.

The incorrect use of TMD as a catch-all term has recently been highlighted7. Laskin suggests that researchers have tended to use it as a singular noun and by doing so have made their findings difficult to inter- pret in relation to the differing origins of the complaint.

His editorial suggests that TMD should be removed from the diagnostic vocabulary and instead individual terms should be used that describe the origin of the complaint. This very recent suggestion has yet to be

debated within the literature and therefore this article will continue to use the term, as defined by the AAOP, for the interim.

This article will discuss the aetiology, signs and symptoms, diagnosis, psychological factors and man- agement of TMD. The article will highlight areas where there is a need for more research and illustrate why evidence-based management of TMD is difficult.


The aetiology of TMD is poorly understood and can easily be misrepresented. There are initiating factors, predisposing factors and perpetuating factors and consequently no single ‘cause’8. Okeson9identifies five factors associated with TMD: occlusal factors, trauma, emotional stress, deep pain input and parafunctional activities, but these have been the subject of much debate and enthusiastic treatment10–21.

Signs and symptoms

Signs and symptoms of TMD have a higher incidence in the general population (20–75%) than the proportion


of the population who present for treatment (2–4%).

The age range of presentation varies from the second to the fourth decade3. Gender differences in symptoms are not observed (1:1) but the ratio presenting for treat- ment is substantially different, with females outnum- bering males, 7:13,22–25. Suggestions that this is due to differences in gender behaviour are not scientifically supported23.

There is a great deal of inter-individual variability in the signs and symptoms of TMD but they can be divided into six broad groups3,8,26,27:

Joint noises – clicking, creptius (grinding);

Locking – open (inability to close fully) closed (inability to open fully);

Pain – in head, neck and shoulders;

Muscular tenderness – in face, neck and shoulders;

Ear complaints – otalgia, tinnitus;

Psychosocial effects.

The variability in the signs and symptoms of TMD can make diagnosis, and therefore, the standardisation of inclusion criteria for trials difficult unless specific criteria are followed.


Diagnosis of TMD has been attempted via epidemio- logical indices, radiography, electronic tests and clinical diagnostic indices.

Epidemiological indices have been created to screen populations for global signs and symptoms of TMD28–34. These indices are applicable for large population surveys but perhaps less applicable to individual clini- cal situations as they do not subclassify the patient in any way or discriminate between the differing origins of the complaint.

Simple plain radiography, despite much debate, has not been found to be particularly useful in the diagnosis or monitoring of TMD as defined by the Research Diagnostic Criteria (RDC)35–37. It is, however, useful for demonstrating, or excluding, other pathology of the temporomandibular joint, e.g. rheumatoid arthritis.

Computed tomography tends to be limited to the same use. Magnetic resonance imaging has been accepted as the current gold standard for imaging of the joint and its associated structures when the history and clinical exam indicate38 although it is not without problems such as false positives9,39and misinterpretation40. Other newer imaging techniques, such as ultrasound41, have yet to undergo thorough evaluation.

Over the years, electronic tests such as jaw tracking, vibratography, sonography, electromyography and thermography have all been suggested as diagnostic

aids. Only thermography has yet to be fully investi- gated; the others have been rejected as unreliable in all potential functions as diagnostic aids42–46.

The final option available for diagnosing TMD is the clinical diagnostic index. There have been a number of attempts over the years to construct a definitive index5,6,47–51 and the National Institute of Dental Research in the U.S.A. supported research into producing clinically applicable research criteria for TMD. The result of this sponsorship was the RDC51, a dual-axis approach to the diagnosis of TMD.

Axis 1 of the RDC concentrates on the clinical examination and Axis 2 focuses on the psychosocial effects of the condition. Axis 1 has a standardised pro- tocol for the clinical examination, has well defined inclusion and exclusion criteria, and permits multiple diagnoses. Axis 1 is, however, extremely long which may make it inapplicable to routine clinical use in all but its simplest classification. Its three groups of TMD are: Group I – myofascial pain disorder; and Group II – disc displacement disorder; Group III – degenerative disease disorder.

Axis 2 of the RDC consists of a self-administered questionnaire that the patient completes. The clinician can use this questionnaire, with the scoring system provided, to assess the level of the patient’s: chronic jaw pain; disability caused by their jaw complaint;

depression and non-specific symptoms. The question- naire can also be used as a basis for discussion when eliciting the patient’s complaint.

The RDC has shown fair to good reliability in diag- nosing into its three distinct Axis 1 subgroups52,53and is reliable enough to be the only descriptive diagnostic system in wide spread use for TMD research. Further details and videos of how to complete both axes are available on the RDC web site (http://www.

Psychological and psychosocial factors in TMD

TMD is now recognised as a group of biopsychosocial illnesses; a trio of physical, psychological and psycho- social factors27. The physical, psychological and psy- chosocial factors of TMD have measurable impacts on oral health related quality of life54but the relationship between these impacts and the effects on the patient is best described as indirect and complex55. There is still no real evidence to equate any aspect of psychology as an aetiological factor, or as a consequence of TMD.

Irrespective of this, the influence of psychological factors on TMD is of therapeutic importance27.


It is known that psychological disorders are prevalent in patients suffering from TMD56,57, that they increase the risk of progressing to long-term TMD, which is dif- ficult to manage58, and that their role varies depending on gender59. Specifically, the presence of psychological disorders is more frequent in females, in the form of depression59.

Psychological disorders are present both in acute and in chronic TMD patients but more so in the latter. It is thought that they may have an influence on the pro- gression towards chronic TMD56. It is known that the myofascial subgroup of TMD (Group I in RDC Axis I) have a predisposition to experiencing more psycho- logical distress than the other subgroups60.

Two of the more common psychological disorders in chronic TMD are somatisation (55% of patients)56,61,62 and depression (39% of patients)62,63; this is in keeping with chronic pain generally64. Both somatisation and depression are felt to affect treatment adversely, with patients being less able to cope and placing greater demands on health care62,65,66,58. It is reasonable, however, to question whether this is a ‘chicken and egg’ situation and therefore TMD sufferers should not be stigmatised.

Management of TMD

The literature surrounding the management of TMD is vast, often confusing, idiosyncratic, and can be scien- tifically unsubstantiated. This is in the main due to:

methodological flaws, the multitude of outcome mea- sures employed9, the lack of a reliable standardised outcome measure so that meta-analysis of randomised controlled trials can occur67,68and until recently (1992), the lack of a clear diagnostic classification of TMD for research purposes.

There is now a consensus that reversible conser- vative therapy, because of its efficacy in relieving symptoms, should be the first-line management for TMD8,69–71. It should be instituted once organic pathol- ogy such as systemic disease, hereditary conditions, or neoplasia is excluded as a possible diagnosis. Such organic pathology is rare, recent figures for incidentally found tumours of the temporomandibular joint show their incidence to be less than 1% of cases72, but cases of fibrosarcoma, nasopharyngeal carcinoma and lateral pharyngeal space infections have been reported in the literature as mimicking the signs and symptoms of TMD73–75. Practitioners should therefore ensure they have undertaken a thorough examination of the patient and should investigate patients appropriately.

The National Institute of Health in the U.S.A. suggests reversible conservative therapy as the primary treat-

ment modality for TMD once organic pathology is excluded76. They define conservative therapy as including: supportive patient education, physical therapy (physiotherapy), pharmacological pain control, intraoral appliances and simple occlusal therapy.

The other, irreversible, therapies purported for TMD are complex occlusal interventions (such as full rehabilitation) and surgical approaches76. There are, of course, other ‘medical’ therapies available for TMD including transcutaneous electrical nerve stimulation, soft laser, radiofrequency surgical cauterisation and chiropractic care. None of these, according to Greene, has any scientific foundation to be recommended as a treatment modality in TMD77.

Before considering the literature behind the man- agement of TMD in detail it is important to bear in mind Greene and Laskin’s statement, ‘with TMD patients it is often not what is done for them, but how it is done, that is important.’ This statement is based on their research which that elicited a 35–60% placebo response rate70,78–82with TMD patients.

Conservative therapy

A number of approaches have been used within conservative therapy: cognitive behavioural therapy, physical therapy, pharmacological therapy and intra- oral appliances. Although cognitive behavioural therapy has been used with varying success in TMD patients83, it is suggested that all patients might experi- ence some benefit from it84. It aims to increase patients’

knowledge about factors that influence TMD symp- toms; increase functional and physical activities; and train individuals to use relaxation, hypnosis and other techniques to modify the perception of pain and related sensations85. At the most basic level some of this can be provided by simple reassurance from the clinician that TMD usually follows benign self-limiting course when managed conservatively86–88and is a chronic illness89.

Physical therapy (physiotherapy) seems an intuitive choice for an individual who may have pain in their musculature. Its aim is to restore normal joint function, decrease loading and pain and facilitate rehabilitation to normal everyday activities90. Although physical therapy produces short-term relief of signs and symp- toms, there is little evidence suggesting that it produces a long-term reduction in signs and symptoms of TMD91–95. It will, however, perform a useful role in helping the sufferer re-establish a degree of control in an acute phase of TMD.

Pharmacological therapy for TMD has included such classes of drugs as non-steroidal anti-inflammatories, opiates, antidepressants, anxiolytics and cortico-


steroids. As Dionne96points out, in his review of phar- macological interventions for TMD, most of those pharmacological agents used to manage TMD have not completed any standardised assessment of efficacy. They therefore, as with most TMD treatment, require careful evaluation through appropriately constructed ran- domised controlled trials to demonstrate their efficacy.

The final approach to conservative management is the use of intra-oral appliances. Many designs of intra- oral appliances have been purported as efficacious in the management of TMD; this review will discuss the two most common splints, the soft splint and the sta- bilisation splint97,98. The soft splint is usually a flexible polyvinyl, 2 mm thick, full coverage ‘mouth guard’

type lower jaw appliance99. It is not adjusted to the occlusion but it will provide approximate bilateral occlusal contact.

The mechanism of action of splints is poorly under- stood and disputed, with physiological and behavioural mechanisms the main theories mooted13. Splints’

effectiveness is also a matter for debate because of:

variation in outcome measures, variability in follow-up and explanation of treatment outcomes100.

Soft splints have little evidence to support their effi- cacy. In myogenous TMD they appear to significantly improve symptoms in comparison to no intervention101 and perform as well as stabilisation appliances102. As with stabilisation splints there are, however, counter claims that they are ineffective103,104and some say that they can cause increases in symptomatology in a small number of sufferers99. These claims and counter-claims are all somewhat flawed because of the methods used in the studies investigating. In light of the poor evi- dence base for most TMD treatment and as soft splints are reversible, inexpensive, easy to construct, well tol- erated by most patients and possibly efficacious, they seem a reasonable choice for the initial management of TMD sufferers.

The stabilisation splint can be provided in either jaw but often is provided in the upper jaw (maxillary). It is usually constructed from hard acrylic or from softer polyvinyl, or a combination, although these are less common approaches105,106. It is accurately adjusted to the patient’s occlusion and provides an optimal occlu- sion for the individual which places their condyles in their most ‘musculoskeletally stable position’9.

Stabilisation splints have their proponents107–109and opponents110,111. Their efficacy, as with so many TMD treatments, may also be questionable as there is some evidence to show the placebo effect is similar to their own112. A systematic review of stabilisation splints usage67recently concluded that there was insufficient evidence to argue for or against their widespread usage

and therefore they continue to be used, most com- monly for myogenous and arthogenous TMD112.

Irreversible therapy

The two main forms of irreversible therapy for TMD are occlusal therapy and surgery and over the years their popularity has waxed and waned.

The inception of occlusal therapy was probably with Costen’s original theory1 where he questioned the

‘bite’ of individuals presenting with signs and symp- toms of TMD and suggested that treatment ought to be directed towards correcting it. In particular, correcting overclosure because of loss of teeth or worn dentures.

Subsequently, the ideal occlusion of teeth became somewhat of a mantra and prophylactic measures to correct it became briefly acceptable113. The theory underlying the correction of occlusion was that it, to a large extent, controlled the forces applied to the TMJ and muscles of mastication and therefore if the occlu- sion was optimised there would be no TMD.

The process of equally distributing contacting forces across the teeth and ‘correcting’ the occlusion is known as equilibration and it is done through a complex process of a diagnostic stabilisation splint, sometimes mounted study model trials (a mock equilibration) and eventual grinding of the teeth in the mouth (the occlusal equilibration).

Occlusal therapy has been shown to be effective in some cases37,114–116 but evidence for its widespread use as prophylaxis or treatment has found to be lacking68,109,117 and this includes the replacement of posterior teeth21.

The best summation of the indications for occlusal therapy is by De Boever et al.20, ‘Occlusal therapy and occlusal adjustment as the only treatment modality is rarely defendable; however, in combination with other forms of therapy, occlusal adjustment can contribute to a positive treatment outcome in selected cases’.

Temporomandibular joint surgery has taken many forms over the years, ranging from open joint proce- dures to minimally invasive arthroscopy. Indications for surgery have been suggested to be either absolute or relative118,119. Absolute indications are associated with trauma, ankylosis, congenital anomalies or organic pathology that requires excision. Relative indications, it is suggested, are subjectively deter- mined by the surgeon and should not blindly include failure of conservative therapy as this may be based on inaccurate diagnosis and treatment. Psychological and cultural background should also play a large part in helping the surgeon determine whether or not surgery is an option. In the main the philosophy that


surgery ‘should avoid further harm to the joint’

should be adopted120 and there should be objective signs that it is indicated. Given the limitations of imaging techniques already mentioned, it is important to use these as supportive evidence rather than as an absolute indication for surgery119.

Arthroscopy and arthrocentesis have been reported as minimally invasive and efficacious in the manage- ment of a range of TMD including disc displacement, arthogenous TMD, and TMD that is refractory to con- servative treatment121–123. Unfortunately the numerous studies of arthroscopy and arthrocentesis suffer from the same flaws as other trials of TMD management. A recent meta-analysis of surgical treatments highlighted this, specifically mentioning the lack of randomised controlled trials124.

Reston and Turkelson in their meta-analysis124did, however, use a method to minimise the possibility of spontaneous improvement in a parallel control group.

Using this method they found that arthrocentesis and arthroscopy were effective for disc displacement without reduction. Interestingly, they also found no significant difference in outcome between arthroscopy and arthrocentesis. These results must, however, be interpreted with caution as Reston and Turkelson rec- ognise the ‘low quality’ TMD literature their review is based on and call for better designed trials of surgical therapy for TMD, as do other reviews of surgical therapy125,126. A recent randomised effectiveness study has demonstrated that, as a primary treatment modal- ity for closed lock, arthroscopy provides no significant benefit over medical management127. These discrepan- cies in the literature mean that definitive answers on the place of arthrocentesis and arthroscopy in the management of TMD are still lacking.


TMD are a group of complex biopsychosocial chronic illnesses, which may exhibit high placebo response rates to therapy. This along with the lack of a standar- dised reproducible patient-based outcome measure makes the evidence for TMD management difficult to interpret. Reversible therapies are currently considered to be the first-line management of TMD. There may be specific indications for when irreversible therapies might be efficacious in the management of TMD but these are yet to be substantiated by high-quality evi- dence. There is a need for an accepted standardised reproducible outcome measure for TMD so that large- scale meta-analyses of management modalities can be carried out. Only then will truly evidence-based man- agement of TMD be possible.


1. Costen JB. A syndrome of ear and sinus symptoms based on disturbed function of the tempromandibular joint. Ann Otol Rhinol Laryngol 1934;43:1–15.

2. Shore NA. Occlusal Equilibration and

Temporomandibular Joint Dysfunction. Philadelphia, PA: JB Lippincott, 1959.

3. Gray RJ, Davies SJ, Quayle AA. A clinical approach to temporomandibular disorders. 1. Classification and functional anatomy. Br Dent J 1994;176:429–35.

4. Madland G, Feinmann C, Newman S. Factors associated with anxiety and depression in facial arthromyalgia. Pain 2000;84:225–32.

5. Bell WE. Clinical Management of Temporomandibular Disorders. Chicago, IL: Year Book Medical Publishers, 1982.

6. McNeill C. Temporomandibular Disorders. Guidelines for Classification, Assessment and Management.

Chicago, IL: Quintessence, 1990.

7. Laskin DM. Temporomandibular disorders: a term past its time? J Am Dent Assoc 2008;139:124–8.

8. McNeill C. Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent 1997;77:510–22.

9. Okeson JP. Management of Temporomandibular Disorders and Occlusion. St. Louis, MO: Mosby, 2003.

10. Lobbezoo F, Lavigne GJ. Do bruxism and

temporomandibular disorders have a cause-and-effect relationship? J Orofac Pain 1997;11:15–23.

11. Ciancaglini R, Gherlone EF, Radaelli G. The relationship of bruxism with craniofacial pain and symptoms from the masticatory system in the adult population. J Oral Rehabil 2001;28:842–8.

12. Auerbach SM, Laskin DM, Frantsve LM, Orr T.

Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients. J Oral Maxillofac Surg 2001;59:628–33;

discussion 634.

13. Dao TT, Lavigne GJ. Oral splints: the crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med 1998;9:345–61.

14. Macfarlane TV, Gray RJM, Kincey J, Worthington HV.

Factors associated with the temporomandibular disorder, pain dysfunction syndrome (PDS):

Manchester case-control study. Oral Dis 2001;7:321–30.

15. Kirveskari P, Alanen P. Occlusal variables are only moderately useful in the diagnosis of

temporomandibular disorder. J Prosthet Dent 2000;84:114–5.

16. Mongini F, Ciccone G, Ibertis F, Negro C. Personality characteristics and accompanying symptoms in temporomandibular joint dysfunction, headache, and facial pain. J Orofac Pain 2000;14:52–8.


17. John MT, Hirsch C, Drangsholt MT, Mancl LA, Setz JM. Overbite and overjet are not related to self-report of temporomandibular disorder symptoms. J Dent Res 2002;81:164–9.

18. John MT, Miglioretti DL, LeResche L, Von Korff M, Critchlow CW. Widespread pain as a risk factor for dysfunctional temporomandibular disorder pain. Pain 2003;102:257–63.

19. Alanen P. Occlusion and temporomandibular disorders (TMD): still unsolved question? J Dent Res 2002;81:518–9.

20. De Boever JA, Carlsson GE, Klineberg IJ. Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part I:

occlusal interferences and occlusal adjustment. J Oral Rehabil 2000;27:367–79.

21. De Boever JA, Carlsson GE, Klineberg IJ. Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part II:

tooth loss and prosthodontic treatment. J Oral Rehabil 2000;27:647–59.

22. Von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988;32:173–83.

23. de Bont LG, Dijkgraaf LC, Stegenga B. Epidemiology and natural progression of articular

temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:72–6.

24. De Kanter RJ, Kayser AF, Battistuzzi PG, Truin GJ, Van ’t Hof MA. Demand and need for treatment of craniomandibular dysfunction in the Dutch adult population. J Dent Res 1992;71:1607–12.

25. De Kanter RJ, Truin GJ, Burgersdijk RC, Van’t Hof MA, Battistuzzi PE, Kalsbeek H et al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms of temporomandibular disorder. J Dent Res 1993;72:1509–18.

26. Turk DC. Psychosocial and behavioral assessment of patients with temporomandibular disorders:

diagnostic and treatment implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:65–71.

27. Suvinen TI, Reade PC, Kemppainen P, Kononen M, Dworkin SF. Review of aetiological concepts of temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Eur J Pain 2005;9:613–33.

28. Helkimo M. Studies on function and dysfunction of the masticatory system. 3. Analyses of anamnestic and clinical recordings of dysfunction with the aid of indices. Sven Tandlak Tidskr 1974;67:165–81.

29. Helkimo M. Studies on function and dysfunction of the masticatory system. I. An epidemiological investigation of symptoms of dysfunction in Lapps in

the north of Finland. Proc Finn Dent Soc 1974;70:37–49.

30. Helkimo M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Sven Tandlak Tidskr 1974;67:101–21.

31. Levitt SR, Lundeen TF. The TMJ scale: quantitative measurements of symptoms and treatment results.

TMJ Update 1987;5:77–80.

32. Levitt SR, McKinney MW, Lundeen TF. The TMJ scale:

cross-validation and reliability studies. Cranio 1988;6:17–25.

33. Fricton JR, Schiffman EL. The craniomandibular index: validity. J Prosthet Dent 1987;58:222–8.

34. Fricton JR, Schiffman EL. Reliability of a craniomandibular index. J Dent Res 1986;65:1359–64.

35. Crow HC, Parks E, Campbell JH, Stucki DS, Daggy J.

The utility of panoramic radiography in temporomandibular joint assessment.

Dentomaxillofac Radiol 2005;34:91–5.

36. Epstein JB, Caldwell J, Black G. The utility of

panoramic imaging of the temporomandibular joint in patients with temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod


37. Vallon D, Ekberg E, Nilner M, Kopp S. Occlusal adjustment in patients with craniomandibular disorders including headaches. A 3- and 6-month follow-up. Acta Odontol Scand 1995;53:55–9.

38. Laskin DM, Greene CS, Hylander WL

Temporomandibular Disorders: An Evidence-Based Approach to Diagnosis and Treatment. Chicago, IL:

Quintessence Pub., 2006:xii, 548.

39. Ohnuki T, Fukuda M, Nakata A, Nagai H, Takahashi T, Sasano T et al. Evaluation of the position, mobility, and morphology of the disc by MRI before and after four different treatments for temporomandibular joint disorders. Dentomaxillofac Radiol 2006;35:103–9.

40. Widmalm SE, Brooks SL, Sano T, Upton LG, McKay DC. Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders. Dentomaxillofac Radiol 2006;


41. Melis M, Secci S, Ceneviz C. Use of ultrasonography for the diagnosis of temporomandibular joint disorders: a review. Am J Dent 2007;20:73–8.

42. Lund JP, Widmer CG, Feine JS. Validity of diagnostic and monitoring tests used for temporomandibular disorders. J Dent Res 1995;74:1133–43.

43. Mohl ND, Lund JP, Widmer CG, McCall WD, Jr.

Devices for the diagnosis and treatment of temporomandibular disorders. Part II:

electromyography and sonography. J Prosthet Dent 1990;63:332–6.


44. Mohl ND, McCall WD Jr., Lund JP, Plesh O. Devices for the diagnosis and treatment of temporomandibular disorders. Part I: introduction, scientific evidence, and jaw tracking. J Prosthet Dent 1990;63:198–201.

45. Mohl ND, Ohrbach RK, Crow HC, Gross AJ. Devices for the diagnosis and treatment of temporomandibular disorders. Part III: thermography, ultrasound,

electrical stimulation, and electromyographic biofeedback. J Prosthet Dent 1990;63:472–7.

46. Lund JP, Lavigne G, Feine JS, Goulet JP, Chaytor DV, Sessle BJ et al. The use of electronic devices in the diagnosis and treatment of temporomandibular disorders. J Can Dent Assoc 1989;55:749–50.

47. Eversole LR, Machado L. Temporomandibular joint internal derangements and associated neuromuscular disorders. J Am Dent Assoc 1985;110:69–79.

48. Laskin DM, Block S. Diagnosis and treatment of myofacial pain-dysfunction (MPD) syndrome.

J Prosthet Dent 1986;56:75–84.

49. Truelove EL, Sommers EE, LeResche L, Dworkin SF, Von Korff M. Clinical diagnostic criteria for TMD. New classification permits multiple diagnoses. J Am Dent Assoc 1992;123:47–54.

50. Farrar WB. Differentiation of temporomandibular joint dysfunction to simplify treatment. J Prosthet Dent 1972;28:629–36.

51. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique.

J Craniomandib Disord 1992;6:301–55.

52. Lausten LL, Glaros AG, Williams K. Inter-examiner reliability of physical assessment methods for assessing temporomandibular disorders. Gen Dent


53. John MT, Dworkin SF, Mancl LA. Reliability of clinical temporomandibular disorder diagnoses. Pain


54. Reissmann DR, John MT, Schierz O, Wassell RW.

Functional and psychosocial impact related to specific temporomandibular disorder diagnoses. J Dent 2007;35:643–50.

55. Ohrbach R, Dworkin SF. Five-year outcomes in TMD:

relationship of changes in pain to changes in physical and psychological variables. Pain 1998;74:315–


56. Gatchel RJ, Garofalo JP, Ellis E, Holt C. Major psychological disorders in acute and chronic TMD: an initial examination. J Am Dent Assoc

1996;127:1365–70, 1372, 1374.

57. Parker MW, Holmes EK, Terezhalmy GT. Personality characteristics of patients with temporomandibular disorders: diagnostic and therapeutic implications.

J Orofac Pain 1993;7:337–44.

58. Wright AR, Gatchel RJ, Wildenstein L, Riggs R, Buschang P, Ellis E, 3rd. Biopsychosocial differences

between high-risk and low-risk patients with acute TMD-related pain. J Am Dent Assoc 2004;


59. Phillips JM, Gatchel RJ, Wesley AL, Ellis E, 3rd.

Clinical implications of sex in acute

temporomandibular disorders. J Am Dent Assoc 2001;132:49–57.

60. McCreary CP, Clark GT, Merril RL, Flack V, Oakley ME. Psychological distress and diagnostic subgroups of temporomandibular disorder patients. Pain


61. Garofalo JP, Gatchel RJ, Wesley AL, Ellis E, 3rd.

Predicting chronicity in acute temporomandibular joint disorders using the research diagnostic criteria.

J Am Dent Assoc 1998;129:438–47.

62. Yap AU, Tan KB, Chua EK, Tan HH. Depression and somatization in patients with temporomandibular disorders. J Prosthet Dent 2002;88:479–84.

63. Meldolesi G, Picardi A, Accivile E, Toraldo di Francia R, Biondi M. Personality and psychopathology in patients with temporomandibular joint pain-dysfunction syndrome. A controlled

investigation. Psychother Psychosom 2000;69:322–8.

64. Birket-Smith M. Somatization and chronic pain. Acta Anaesthesiol Scand 2001;45:1114–20.

65. Fricton J, Dubner RB. Orofacial Pain and

Temporomandibular Disorders. New York: Raven Press, 1995.

66. Dworkin SF. Perspectives on the interaction of biological, psychological and social factors in TMD.

J Am Dent Assoc 1994;125:856–63.

67. Al-Ani MZ, Davies SJ, Gray RJ, Sloan P, Glenny AM.

Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev 2004;CD002778.

68. Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders.

Cochrane Database Syst Rev 2003;CD003812.

69. Dimitroulis G. Temporomandibular disorders: a clinical update. BMJ 1998;317:190–4.

70. Greene CS, Laskin DM. Long-term evaluation of conservative treatment for myofascial

pain-dysfunction syndrome. J Am Dent Assoc 1974;89:1365–8.

71. Greene CS, Laskin DM. Long-term evaluation of treatment for myofascial pain-dysfunction syndrome:

a comparative analysis. J Am Dent Assoc 1983;107:235–8.

72. Yanagi Y, Asaumi J, Maki Y, Murakami J, Hisatomi M, Matsuzaki H et al. Incidentally found and unexpected tumors discovered by MRI examination for

temporomandibular joint arthrosis. Eur J Radiol 2003;47:6–9.

73. Brown RS, Johnson CD, Fay RM. The misdiagnosis of temporomandibular disorders in lateral pharyngeal


space infections – two case reports. Cranio 1994;12:194–8.

74. Orhan K, Orhan AI, Oz U, Pekiner FN, Delilbasi C.

Misdiagnosed fibrosarcoma of the mandible mimicking temporomandibular disorder: a rare condition. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e26–9.

75. Reiter S, Gavish A, Winocur E, Emodi-Perlman A, Eli I.

Nasopharyngeal carcinoma mimicking a

temporomandibular disorder: a case report. J Orofac Pain 2006;20:74–81.

76. Albino JEN. Management of temporomandibular disorders. National institutes of health technology assessment conference statement. J Am Dent Assoc 1996;127:1595–606.

77. Greene CS. An evaluation of unconventional methods of diagnosing and treating temporomandibular disorders. Oral Maxillofac Surg Clin North Am 1995;7:167–73.

78. Shipman WG, Greene CS, Laskin DM. Correlation of placebo responses and personality characteristics in myofascial pain-dysfunction (MPD) patients.

J Psychosom Res 1974;18:475–83.

79. Greene CS, Laskin DM. Meprobamate therapy for the myofascial pain-dysfunction (MPD) syndrome:

a double-blind evaluation. J Am Dent Assoc 1971;82:587–90.

80. Laskin DM, Greene CS. Influence of the doctor-patient relationship on placebo therapy for patients with myofascial pain-dysfunction (MPD) syndrome. J Am Dent Assoc 1972;85:892–4.

81. Greene CS, Laskin DM. Splint therapy for the myofascial pain – dysfunction (MPD) syndrome: a comparative study. J Am Dent Assoc 1972;84:624–8.

82. Goodman P, Greene CS, Laskin DM. Response of patients with myofascial pain-dysfunction syndrome to mock equilibration. J Am Dent Assoc


83. Dworkin SF. Behavioral and educational modalities.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:128–33.

84. Turner JA, Holtzman S, Mancl L. Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain 2007;127:276–86.

85. Dworkin SF, Turner JA, Wilson L, Massoth D, Whitney C, Huggins KH et al. Brief group cognitive- behavioral intervention for temporomandibular disorders. Pain 1994;59:175–87.

86. de Leeuw R, Boering G, Stegenga B, de Bont LG.

Clinical signs of TMJ osteoarthrosis and internal derangement 30 years after nonsurgical treatment.

J Orofac Pain 1994;8:18–24.

87. Stohler CS. Phenomenology, epidemiology, and natural progression of the muscular

temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:77–81.

88. Magnusson T, Egermark I, Carlsson GE. A longitudinal epidemiologic study of signs and symptoms of

temporomandibular disorders from 15 to 35 years of age. J Orofac Pain 2000;14:310–9.

89. Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: disease or illness?

J Prosthet Dent 1994;72:29–38.

90. Di Fabio RP. Physical therapy for patients with TMD: a descriptive study of treatment, disability, and health status. J Orofac Pain 1998;12:124–35.

91. Feine JS, Widmer CG, Lund JP. Physical therapy: a critique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:123–7.

92. Feine JS, Lund JP. An assessment of the efficacy of physical therapy and physical modalities for the control of chronic musculoskeletal pain. Pain 1997;71:5–23.

93. Sturdivant J, Fricton JR. Physical therapy for

temporomandibular disorders and orofacial pain. Curr Opin Dent 1991;1:485–96.

94. Chapman CE. Can the use of physical modalities for pain control be rationalized by the research evidence? Can J Physiol Pharmacol 1991;69:


95. Michelotti A, de Wijer A, Steenks M, Farella M.

Home-exercise regimes for the management of non-specific temporomandibular disorders. J Oral Rehabil 2005;32:779–85.

96. Dionne RA. Pharmacologic treatments for temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:134–42.

97. Lindfors E, Magnusson T, Tegelberg A. Interocclusal appliances – indications and clinical routines in general dental practice in Sweden. Swed Dent J 2006;30:123–34.

98. Pierce CJ, Weyant RJ, Block HM, Nemir DC. Dental splint prescription patterns: a survey. J Am Dent Assoc 1995;126:248–54.

99. Gray RJ, Davies SJ. Occlusal splints and

temporomandibular disorders: why, when, how?

Dent Update 2001;28:194–9.

100. Major PW, Nebbe B. Use and effectiveness of splint appliance therapy: review of literature. Cranio 1997;15:159–66.

101. Wright E, Anderson G, Schulte J. A randomized clinical trial of intraoral soft splints and palliative treatment for masticatory muscle pain. J Orofac Pain 1995;9:192–9.

102. Pettengill CA, Growney MR Jr., Schoff R, Kenworthy CR. A pilot study comparing the efficacy of hard and soft stabilizing appliances in treating patients with temporomandibular disorders. J Prosthet Dent 1998;79:165–8.


103. Nevarro E, Barghi N, Rey R. Clinical evaluation of maxillary hard and resilient occlusal splints. J Dent Res 1985;64:313.

104. Okeson JP. The effects of hard and soft occlusal splints on nocturnal bruxism. J Am Dent Assoc


105. Wright EF. Manual of Temporomandibular Disorders.

Ames, IA: Blackwell Munksgaard, 2005:xvi, 338.

106. Moufti MA, Lilico JT, Wassell RW. How to make a well-fitting stabilization splint. Dent Update 2007;

34:398–400, 402–4, 407–8.

107. Magnusson T, Adiels AM, Nilsson HL, Helkimo M.

Treatment effect on signs and symptoms of

temporomandibular disorders – comparison between stabilisation splint and a new type of splint (NTI). A pilot study. Swed Dent J 2004;28:11–20.

108. Davies SJ, Gray RJ. The pattern of splint usage in the management of two common temporomandibular disorders. Part II: the stabilisation splint in the treatment of pain dysfunction syndrome. Br Dent J 1997;183:247–51.

109. Forssell H, Kalso E, Koskela P, Vehmanen R, Puukka P, Alanen P. Occlusal treatments in temporomandibular disorders: a qualitative systematic review of

randomized controlled trials. Pain 1999;83:549–60.

110. Turp JC, Komine F, Hugger A. Efficacy of stabilization splints for the management of patients with

masticatory muscle pain: a qualitative systematic review. Clin Oral Investig 2004;8:179–95.

111. Marbach JJ, Raphael KG. Future directions in the treatment of chronic musculoskeletal facial pain: the role of evidence-based care. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:170–6.

112. Wassell RW, Adams N, Kelly PJ. Treatment of temporomandibular disorders by stabilising splints in general dental practice: results after initial treatment.

Br Dent J 2004;197:35–41; discussion 31.

113. Molin C. From bite to mind: TMD – a personal and literature review. Int J Prosthodont 1999;12:279–88.

114. Forssell H, Kirveskari P, Kangasniemi P. Effect of occlusal adjustment on mandibular dysfunction.

A double-blind study. Acta Odontol Scand 1986;44:63–9.

115. Forssell H, Kirveskari P, Kangasniemi P. Response to occlusal treatment in headache patients previously treated by mock occlusal adjustment. Acta Odontol Scand 1987;45:77–80.

116. Vallon D, Ekberg EC, Nilner M, Kopp S. Short-term effect of occlusal adjustment on craniomandibular disorders including headaches. Acta Odontol Scand 1991;49:89–96.

117. Tsukiyama Y, Baba K, Clark GT. An evidence-based assessment of occlusal adjustment as a treatment for temporomandibular disorders. J Prosthet Dent 2001;86:57–66.

118. Dolwick MF, Dimitroulis G. Is there a role for temporomandibular joint surgery? Br J Oral Maxillofac Surg 1994;32:307–13.

119. Dimitroulis G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005;34:231–7.

120. Dolwick MF. The role of temporomandibular joint surgery in the treatment of patients with internal derangement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:150–5.

121. Kunjur J, Anand R, Brennan PA, Ilankovan V. An audit of 405 temporomandibular joint arthrocentesis with intra-articular morphine infusion. Br J Oral Maxillofac Surg 2003;41:29–31.

122. Brennan PA, Ilankovan V. Arthrocentesis for

temporomandibular joint pain dysfunction syndrome.

J Oral Maxillofac Surg 2006;64:949–51.

123. McCain JP, Sanders B, Koslin MG, Quinn JH, Peters PB, Indresano AT. Temporomandibular joint

arthroscopy: a 6-year multicenter retrospective study of 4831 joints. J Oral Maxillofac Surg 1992;50:926–30.

124. Reston JT, Turkelson CM. Meta-analysis of surgical treatments for temporomandibular articular disorders. J Oral Maxillofac Surg 2003;61:3–10;

discussion 10–12.

125. Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. Int J Oral Maxillofac Surg


126. Ethunandan M, Wilson AW. Temporomandibular joint arthrocentesis -more questions than answers?

J Oral Maxillofac Surg 2006;64:952–5.

127. Schiffman EL, Look JO, Hodges JS, Swift JQ, Decker KL, Hathaway KM et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res 2007;86:58–63.




Related subjects :