A Female Psoriatic Arthritis Patient Involving the TMJ
Giovanni Falisi ,1Roberto Gatto ,1Carlo Di Paolo ,2Alberto De Biase ,2
Carlo Franceschini ,2Annalisa Monaco ,1Sofia Rastelli ,1and Gianluca Botticelli 1
1Department of Life Health and Environmental Sciences, University of L’Aquila, L’Aquila 67100, Italy
2Università degli Studi di Roma La Sapienza, Rome 00161, Italy
Correspondence should be addressed to Gianluca Botticelli; email@example.com
Received 18 December 2020; Revised 26 January 2021; Accepted 1 February 2021; Published 11 February 2021 Academic Editor: Gianrico Spagnuolo
Copyright © 2021 Giovanni Falisi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Psoriatic arthritis (PsA) is an inﬂammatory chronic arthritis associated with psoriasis. Currently, data about gender diﬀerences in clinical manifestation and therapeutic outcomes of PsA are limited. Frequently, women manifest a peripheral disease while men have an axial localization. Moreover, women display higher disease activity and physical activity limitations, if compared to men. Although the involvement of the temporomandibular joint (TMJ) is quite rare, it can seriously impact the quality of life.
The morpho-functional peculiarities of TMJ require a multidisciplinary approach to perform a correct diagnosis and a successful treatment. Here, we report a case of a woman aﬀected by PsA involving TMJ treated by combining pharmacological therapy and an occlusal splint. The coordination between diﬀerent specialties led to a complete remission of clinical symptoms and a regression of lesions.
Psoriasis is a chronic inﬂammatory relapsing and remitting pathology interesting skin but also nails, hair scalp, mucosae, and joints (5% to 42%) [1–3]. The epidemiological studies in literature report around 1 to 3% of incidence with prevalence in Caucasian ethnicity . About 25% of patients with psori- asis develop a rheumatological form, the PsA [5, 6].
The gender prevalence of PsA is still under debate: a higher ratio of female to male was observed by Love et al., who considered an Iceland population . Nossent and Gran found instead a male prevalence of the PsA . However, the growing attention to the inﬂuence of the gender on the path- ophysiology and management of diseases  stimulated researchers to investigate about any diﬀerence between the two genders in PsA [10–12]. There are growing evidences that the phenotype of the disease is diﬀerent between male and female but further studies are needed [10, 13]. Sex diﬀer- ences in PsA include a more frequent axial involvement in men  and a predominant peripheral arthritis with higher disability scores in women .
Ovarian hormones and pain response: a review of clinical and basic science studies .
Indeed, women present multiple articular lesions, a sig- niﬁcant lowering of the functionality and higher fatigue in the daily movements [11, 12, 15]. An important diﬀerence between genders is the response to therapy .
In addition, literature shows how the average age of diag- nosis of the female gender is lower than male, and the begin- ning of the therapy usually overlaps with the peak of the reproductive age [15–17]. Another age peak is the postmen- opausal age range, indicating a link with the impact of the hormonalﬂuctuations .
Also, theﬂuctuations and the hormonal peaks occurring during speciﬁc therapies, as, for example, ovarian hyperstim- ulation in reproductive techniques (ART) protocols, signiﬁ- cantly impact on the course and onset of psoriasis .
Indeed, ART protocols include the administrations of follicular-stimulating hormones and gonadotropin antago- nist, determining an important hormonal ﬂuctuations and changes in the homeostasis of the female body system [16, 17, 19–22].
Volume 2021, Article ID 6638638, 6 pages https://doi.org/10.1155/2021/6638638
The psoriasis symptomatology and the form aﬀecting the joints have a higher negative impact on the emotional and psychological life of women than in men .
The most common variety of psoriasis manifestation aﬀects the skin and its annexes, but secondary manifestations in the oral cavity and temporomandibular joint (TMJ) can represent a challenging diagnosis.
Temporomandibular disorders (TMDs) are more fre- quent in psoriatic patients than in the general population [23, 24].
TMJ, as all the other complex joints can be aﬀected by a form of PsA, is with negative implications to the patients’
quality of life .
Here, we report a case, according to the CAse REport (CARE) guidelines , of a manifestation of PsA in the TMJ in a female patient including the peculiar diagnosis and treatment needed for this manifestation.
2. Case Description
2.1. The Patient: Reason of Attention, Medical, and Pain History. A female Caucasian patient, age 65, came to the attention of the dental clinic of University of L’Aquila com- plaining about a pain referred to the right ear. After a thor- ough otolaryngological examination, the ear did not present any inﬂammatory or infectious disease and medical attention was focused on the TMJ. The pain history revealed that the patient suﬀered from occasional pain to the right ear during the last 18 months, which became more frequent and acute in the days preceding the visit.
The patient referred that the pain was more acute upon waking up in the morning; it improved during the day and worsened only during mastication of solid and chewy food.
The patient also referred that in the past 10 years, she noticed articular sounds coming from her temporomandibu- lar joint. In addition, the patient revealed to suﬀer from a cutaneous form of plaque psoriasis on the hair scalp (Figure 1) and to be under control of the rheumatologist.
The prescribed pharmacological medication for the psoriasis included no-steroidal anti-inﬂammatory drugs (NSAIDs).
Furthermore, the symptomatology began to appear two months after the suspension of the pharmacological medica- tion when awaiting for the clinical analysis report for the new therapy for psoriasis.
2.2. Extra- and Intraoral Situation and TMJ Functional Examination. The extraoral examination did not reveal any facial asymmetry. The intraoral examination revealed a class 2 division malocclusion, according to the Angle classiﬁcation . The 4.6, 4.7 and 3.6, 3.7 elements were missing, deter- mining the loss of the vertical posterior dimension.
The TMJ functional exam highlighted a limited jaw opening with a right laterodeviation at the maximum mouth opening. The maximum jaw opening was measured by means of a mechanical caliber and was 32 mm (Figure 2).
Following is the clinical examination form of DC/TMD:
The patient referred pain in the right side of her face pre- cisely at the level of the right TMJ without presenting any headache
Taking as a referral, the dental element 1.1, the patient presented 2 mm of overjet, 4 mm of over bite, and interinci- sive midline deviated to the right
The mandible was deviated to the right during opening and closing mandibular movements
Maximum opening with pain at 32 mm Right lateral movement of 7 mm Left lateral movement of 3 mm Protrusion of 3 mm
Crepitus sounds at the right side of the TMJ during phases of opening, closing, and lateral movements
Pain during palpation at the right TMJ
The physical examination of the TMJ conﬁrmed the pres- ence of joint noises (crepitus) during jaw opening, protru- sion, and lateral movements.
2.3. Pain Self-Perception, End-Feel Test, and Radiographic Evidence. The self-perception of the pain symptomatology was evaluated by means of the visual analog scale (VAS) . At rest position, the VAS value was 6, while at the pal- pation, the VAS was 7.
The end-feel movement test was negative since no increased forced opening was appreciable.
The preliminary stratigraphy showed bone-remodeling signs on both condylar surfaces of the TMJ. The right tempo- romandibular joint has a greater remodeling than the left side, compatible with the symptoms reported by the patient. In addition, both the articular eminence of the zygomatic process and the upper surface of the condyle appeared ﬂattened, resulting in a reduction of the intra-articular space (Figure 3).
2.4. Diagnosis and Treatment. The clinical and radiological information together with the medical history led to the diag- nosis, according to the Diagnostic Criteria for Temporoman- dibular Disorders (DC/TMD) , of degenerative joint disease (ICD-9715.18) with right joint arthralgia (ICD-9 524.62).
Figure 1: Psoriasis lesion on the patient’s hair scalp.
The treatment, as recommended , was the causal therapy, and therefore, the patient was sent to the attention of the rheumatologist for the appropriate therapy (Brodalu- mab 210 mg, subcutaneous injection).
In addition, a stabilization appliance bite was prescribed as coadjuvant therapy to reduce the articular load on the TMJ.
Currently, there are several diﬀerent occlusal splints available that have diﬀerent clinical indications, making it hard for the clinician to choose the adequate one. At the moment, the scientiﬁc guidelines suggest more conservative treatments planned on the speciﬁc diagnosis.
The appliance chosen for this patient is an anterior repo- sitioning stabilization splint.
The characteristics of this type of splint are a full upper teeth occlusal coverage with point-like contacts and the presence of an anterior pivot to allow mandibular protrusion.
The mandibular repositioning is three-dimensional because other than a sagittal movement, we will have an increase in the vertical and transversal dimension (DITRA) Figures 4 and 5 .
The time of application should not exceed one continu- ous hour per day and should be worn always during rest time either day or night.
The splint must be checked every 15 days to control the evolution of the patient’s symptomatology.
2.5. Follow-Up. At the ﬁve-month follow-up, the patients referred a considerable lowering of the pain symptomatol- ogy. The VAS value at rest position was 2. In addition, the maximum mandibular opening improved to 40 mm. The mobility of the condyles also improved, as showed by the follow-up magnetic nuclear resonance (MNR) (Figure 6).
Figure 2: Limited open mouth measured by means of a mechanical calliper. Presence of laterodeviation towards the right side.
Figure 3: Stratigraphy of right TMJ. The arrows indicate the erosive changes on the surface of the condyle with interruption of cortical lining. When the articular eminence and the condyles are in contact, the joint space is narrow. Condyles and articular eminence appear bothﬂattened.
2.6. Ethics. The patient gave her written informed consent, in accordance with the Helsinki Declaration on the Ethical Principles for Medical Research Involving Human Subjects for the publication of her case report.
Psoriasis can manifest in three forms: type I, type II, and PsA.
Among these three forms, the latter increases the burden of the disease .
Cases of TMD due to PsA are reported in literature, but coherent statistical studies on its frequency are not available yet. Generally, the PsA forms aﬀecting the TMJ are consid- ered rare [1, 31–34].
However, an increased attention to the medical history of patients with rheumatologic disease is bringing up the num- ber of diagnosed cases of PsA-TMD.
The female gender is generally more exposed to develop TMDs, and the disturbs aﬀecting this joint signiﬁcantly decrease the quality of life of the patients, due to the second- ary symptomatology such as general orofacial pain, head-
ache, myalgia at masticatory muscle level, and sleep disorders [35–37].
Christidis et al. reported the higher expression in women at masseter levels of the serotonin receptor, increasing the sensitivity of the female sex to the pain in the TMJ- masseter region .
This condition, in combination with a peculiar sensitivity to pain stimulation due to the sex hormonal peaks and changes , expose the female gender to a higher burden in case of manifestation of TMJ arthropathy.
PsA negatively aﬀects the quality of life of women , and the development of this form in the TMJ, as rare as it can be, results in a worsening of the clinical conditions.
Indeed, the complexity of the PsA requires regular follow-ups and long-life treatments that might need adjust- ments over the time, generating frustration in the aﬀected patients .
The diagnosis of PsA-TMD is based on a careful medical history assessment, on an accurate physical examination of the TMJ and the masticatory muscles and on the radiological evidences.
The clinical signs of a TMJ aﬀected by PsA are repre- sented by limited functionality, muscular pain, clicking or crepitation sounds, and altered opening derangement .
Figure 4: Reposition appliance DITRA.
Figure 5: Pivot mandibular advancement.
Figure 6: Representative MNR scan at 5-month follow-up. The erosive lesions on the condyle surfaces regressed, and interruption of cortical lining disappeared.
The radiological signs obtained using magnetic reso- nance or CT scans reveal an alteration of the morphology of the condyles and of the mandibular fossa, with signs of erosion, bone remodeling, and osteoarthritis .
The radiographic image of the examined patient showed a greater anatomical structural alteration of the right condyle.
There is a direct proportionality between the structural mod- iﬁcations of the TMJ and the symptoms reported by the patient.
The therapy is causal  and therefore should be aimed at controlling the disease; for this reason, the rheumatologist should be alerted of the diagnosis to modulate the right phar- macological therapy to control the disease.
As reported by Wilson et al., the pharmacological plan should include the administration of NSAIDs and steroids . In addition, coadjuvant therapies, such as physiotherapy, may help in the pain reduction and the functionality recovery . Another therapy option for the treatment of PsA-TMD is surgery, which should be reserved to those cases where pharmacological therapy is not successful.
In the presented case, beyond the causal therapy, an occlusal appliance bite was prescribed and added as coadju- vant therapy.
The preferred therapy in TMDs consists in the use of sta- bilization splints as in the short term; it is the one that shows clear improvements in symptoms.
The repositioning splint used, since it is built in a slight protrusion position, causes a lowering of the activity of the masseters by reducing the vertical muscular load which could increase intra-articular pressure, with a consequent improve- ment in symptoms. In addition, the main function of the occlusal splint is to carry out a protective activity on the joint structures, because the nocturnal phase parafunctional mus- cular phenomena could occur leading to an increase in the symptomatological set.
Indeed, the TMJ is a peculiar joint, allowing not only the simple mouth opening and closure, but also contributing to other movements such as swallowing, chewing, sucking, breathing, phonatory acts, and facial mimicry [41, 43, 44].
Hence, the mechanical stress due to the physiological move- ments makes the TMJ a delicate and complex structure to be approached.
Intervening on occlusal interferences helped in the improvement of the TMJ functionality and conﬁrmed how a patient aﬀected by such complex disease can beneﬁt from a therapeutic multidisciplinary approach.
Dental operators and the specialists of TMJ should be involved in a global view of the treatment of female psoriatic patients, and conversely, they should pay attention when fac- ing this special category of patients.
The availability of targeted treatment for the systemic disease in association with an appropriate supportive therapy to the joint positively improves the quality of life of women aﬀected by PsA on the TMJ.
Data Availability Data are available on request.
Conflicts of Interest
The authors declare no conﬂict of interest.
 T. Badel, L. Krapac, and D. Zadravec,“Psoriatic arthritis and temporomandibular joint involvement–literature review with a reported case,” Acta Dermatovenerologica Croatica, vol. 22, no. 2, pp. 114–121, 2014.
 S. Bianchi, S. Bernardi, M. A. Continenza et al.,“Scanning elec- tron microscopy approach for evaluation of hair dyed with Lawsonia inermis powder: in vitro study,” International Jour- nal of Morphology, vol. 38, no. 1, pp. 96–100, 2020.
 V. Chandran and S. Raychaudhuri, “Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis,”
Journal of Autoimmunity, vol. 34, pp. 314–321, 2010.
 E. Christophers, “Psoriasis-epidemiology and clinical spec- trum,” Clinical and Experimental Dermatology, vol. 26, no. 4, pp. 314–320, 2001.
 F. Alinaghi, M. Calov, L. E. Kristensen et al.,“Prevalence of psoriatic arthritis in patients with psoriasis: a systematic review and meta-analysis of observational and clinical stud- ies,” Journal of the American Academy of Dermatology, vol. 80, no. 1, pp. 251–265.e19, 2019.
 M. Diani, S. Perego, V. Sansoni et al.,“Diﬀerences in osteoim- munological biomarkers predictive of psoriatic arthritis among a large Italian cohort of psoriatic patients,” International Journal of Molecular Sciences, vol. 20, no. 22, p. 5617, 2019.
 T. Love, B. Gudbjornsso, J. E. Gudjonsson, and H. Valdimarsson, “Psoriatic arthritis in Reykjavik, Iceland:
prevalence, demographics, and disease course,” Journal Reu- matol, vol. 34, pp. 2082–2088, 2007.
 J. Nossent and J. Gran,“Epidemiological and clinical character- istics of psoriatic arthritis in northern Norway,” Scandinavian Journal of Rheumatology, vol. 38, no. 4, pp. 251–255, 2009.
 V. Regitz-Zagrosek, “Sex and gender diﬀerences in health,”
EMBO Reports, vol. 13, no. 7, pp. 596–603, 2012.
 E. Generali, C. A. Scirè, L. Cantarini, and C. Selmi, Sex diﬀer- ences in the treatment of psoriatic arthritis : a systematic litera- ture review, Vol. 18, IMAJ, 2016.
 D. Colombo, N. Cassano, G. Bellia et al.,“Gender medicine and psoriasis,” World Journal Dermatology, vol. 3, no. 3, pp. 36–44, 2014.
 T. J. Braaten, C. Zhang, A. P. Presson, B. Breviu, D. Clegg, and J. A. Walsh, “Gender diﬀerences in psoriatic arthritis with fatigue, pain, function, and work disability,” Journal of Psoria- sis and Psoriatic Arthritis, vol. 4, no. 4, pp. 192–197, 2019.
 K. Nas, E. Capkin, A. Z. Dagli et al.,“Gender speciﬁc diﬀer- ences in patients with psoriatic arthritis,” Modern Rheumatol- ogy, vol. 27, no. 2, pp. 345–349, 2017.
 V. T. Martin,“Ovarian hormones and pain response: a review of clinical and basic science studies,” Gender Medicine, vol. 6, pp. 168–192, 2009.
 A. B. Gottlieb, C. Ryan, and J. E. Murase,“International Jour- nal of Women’ s Dermatology Clinical considerations for the
management of psoriasis in women,” International Journal of Women's Dermatology, vol. 5, no. 3, pp. 141–150, 2019.
 S. Bianchi, G. Macchiarelli, G. Micara, C. Aragona, M. Maione, and S. A. Nottola,“Ultrastructural and morphometric evalua- tion of aged cumulus-oocyte-complexes,” Italian Journal of Anatomy and Embryology, vol. 118, 2013.
 S. Bianchi, G. Macchiarelli, G. Micara et al.,“Ultrastructural markers of quality are impaired in human metaphase II aged oocytes: a comparison between reproductive and in vitro aging,” Journal of Assisted Reproduction and Genetics, vol. 32, no. 9, pp. 1343–1358, 2015.
 C. I. Tejeda, V. Voss, and J. N. Salvemini,“Known history of pustular psoriasis with reactivation from in vitro fertilization therapy,” JAAD case reports, vol. 5, no. 6, pp. 543–545, 2019.
 I. Giusti, S. Bianchi, S. A. Nottola, G. Macchiarelli, and V. Dolo,“Clinical electron microscopy in the study of human ovarian tissues,” EuroMediterranean Biomedical Journal, vol. 14, pp. 145–151, 2019.
 M. A. A. Khalili, M. Maione, M. G. G. Palmerini, S. Bianchi, G. Macchiarelli, and S. A. A. Nottola, “Ultrastructure of human mature oocytes after vitriﬁcation,” European Journal of Histochemistry, vol. 56, no. 3, p. 38, 2012.
 S. A. Nottola, S. Cecconi, S. Bianchi et al.,“Ultrastructure of isolated mouse ovarian follicles cultured in vitro,” Reproduc- tive Biology and Endocrinology, vol. 9, no. 1, p. 3, 2011.
 M. G. Palmerini, S. A. Nottola, W. A. S. Tunjung et al.,“EGF- FSH supplementation reduces apoptosis of pig granulosa cells in co-culture with cumulus-oocyte complexes,” Biochemical and Biophysical Research Communications, vol. 481, no. 1-2, pp. 159–164, 2016.
 G. Gioco, R. Patini, G. Troiano et al.,“Oral manifestations of psoriasis: a systematic review,” Proceedings (MDPI), vol. 35, no. 1, p. 25, 2019.
 E. Dervis and E. Dervis,“The prevalence of temporomandibu- lar disorders in patients with psoriasis with or without psori- atic arthritis,” Journal of Oral Rehabilitation, vol. 32, no. 11, pp. 786–793, 2005.
 R. Freitas de Souza, C. H. Lovato da Silva, M. Nasser, Z. Fedorowicz, and M. A. Al-Muharraqi,“Interventions for the management of temporomandibular joint osteoarthritis,” Cochrane Database of Systematic Reviews, vol. 2012, no. 4, arti- cle CD007261, 2012.
 J. J. Gagnier, G. Kienle, D. G. Altman et al.,“The CARE guide- lines: consensus-based clinical case reporting guideline devel- opment,” Journal of Medical Case Reports, vol. 7, no. 1, p. 223, 2013.
 J. F. Gravely and D. B. Johnson,“Angle’s classiﬁcation of mal- occlusion: an assessment of reliability,” British Journal of Orthodontics, vol. 1, no. 3, pp. 79–86, 1974.
 G. A. Hawker, S. Mian, T. Kendzerska, and M. French,“Mea- sures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill pain ques- tionnaire (MPQ), short-form McGill pain questionnaire (SF- MPQ), chronic pain grade scale (CPGS), short form-36 bodily pain scale (SF),” Arthritis Care and Research, vol. 63, no. S11, pp. S240–S252, 2011.
 C. C. Peck, J.-P. Goulet, F. Lobbezoo et al.,“Expanding the tax- onomy of the diagnostic criteria for temporomandibular disor- ders,” Journal of Oral Rehabilitation, vol. 41, no. 1, pp. 2–23, 2014.
 D. T. Meshkova, P. Di Giacomo, F. Panti, A. D'Urso, E. Serritella, and C. Di Paolo,“Application of a systematic pro-
tocol in the treatment of TMDs with occlusal appliances: eﬀec- tiveness and eﬃciency in a longitudinal retrospective study with medium-term follow-up,” Journal of International Society of Preventive and Community Dentistry, vol. 9, no. 4, pp. 372– 382, 2019.
 L. Lamazza, F. Guerra, M. Pezza et al.,“The use of etanercept as a non-surgical treatment for temporomandibular joint psor- iatric arthritis : a case report,” Australian Dental Journal, vol. 54, no. 2, pp. 161–165, 2009.
 M. Stodółkiewicz, M. Turska, and J. Szkutnik, “Assessment of the incidence of temporomandibular disorders in patients diagnosed with psoriasis,” Journal of Pre-Clinical Clinical Rea- search, vol. 13, no. 3, pp. 110–113, 2019.
 U. Garagiola, P. Cressoni, M. Grazia, P. Kenzo, and G. Farronato,“Temporomandibular joint dysfunction as the ﬁrst articular sign in psoriatic arthritis : case report,” journal of Interdisciplinary Clinical Dentistry, vol. 1, pp. 1–9, 2020.
 V. Crincoli, M. ComiteDi, M. Beatrice, D. Bisceglie, L. Fatone, and G. Favia, “Temporomandibular disorders in psoriasis patients with and without psoriatic arthritis : an observational study,” International Journal of Medical Sciences, vol. 12, no. 4, pp. 341–348, 2015.
 T. Cutilli, S. Scarsella, D. Di Fabio et al.,“Cervical injury related to mandibular fractures. A retrospective study of 315 cases,” Cranio - J. Craniomandib. Pract, vol. 37, pp. 188–195, 2017.
 T. Kim, J. Shin, J. Lee et al.,“Gender diﬀerence in associations between chronic temporomandibular disorders and general quality of life in Koreans : a cross-sectional study,” PLoS One, vol. 10, no. 12, article e0145002, 2015.
 A. Rampello, M. Saccucci, G. Falisi, F. Panti, A. Polimeni, and C. Di Paolo,“A new aid in temporomandibular joint disorders’
therapy: the universal neuromuscular immediate relaxing appliance,” Journal of Biological Regulators and Homeostatic Agents, vol. 27, no. 4, pp. 1011–1019, 2013.
 N. Christidis, I. Kang, B. E. Cairns et al.,“Expression of 5-HT3 receptors and TTX resistant sodium channels (Na(V)1.8) on muscle nerve ﬁbers in pain-free humans and patients with chronic myofascial temporomandibular disorders,” The Jour- nal of Headache and Pain, vol. 15, p. 63, 2014.
 K. Vincent, C. J. Stagg, C. E. Warnaby, J. Moore, S. Kennedy, and I. Tracey,““Luteal Analgesia”: progesterone dissociates pain intensity and unpleasantness by inﬂuencing emotion regulation networks,” Frontiers in Endocrinology, vol. 9, pp. 1–12, 2018.
 A. U. Kulkarni, P. K. Gadre, P. A. Kulkarni, and K. S. Gadre,
“Diagnosing psoriatic arthritis of the temporomandibular joint : a study in radiographic images,” BMJ Case Reo, vol. 2013, no. jul03 1, article bcr2013010301, 2013.
 E. Ortu, D. Pietropaoli, G. Mazzei, R. Cattaneo, M. Giannoni, and A. Monaco,“TENS eﬀects on salivary stress markers: a pilot study,” International Journal of Immunopathology and Pharmacology, vol. 28, no. 1, pp. 114–118, 2015.
 A. W. Wilson, J. S. Brown, and R. A. Ord,“Psoriatic arthropa- thy of the temporomandibular joint,” Oral Surgery, Oral Medi- cine, and Oral Pathology, vol. 70, no. 5, pp. 555–558, 1990.
 B. Bordoni and M. Varacallo, Anatomy, head and neck, tempo- romandibular joint, Stat Pearls; StatPearls Publishing, 2020.
 S. Tecco, A. Nota, S. Caruso et al.,“Temporomandibular clin- ical exploration in Italian adolescents,” Cranio, vol. 37, no. 2, pp. 77–84, 2019.