Temporomandibular Disorders

Temporomandibular Disorders
Guidelines for Classification, Assessment,
and Management

The American Academy of Orofacial Pain

Edited by
Charles McNeill, DDS

Quintessence Publishing Co, Inc

Chicago, Berlin, London, Tokyo, Sao Paulo, Moscow
<+no
A5 / o*

/W3
Library of Congress Cataloging-in-Publication Data

American Academy of Orofacial Pain.

Temporomandibular disorders : guidelines for classification,
assessment, and management / The American Academy of
Orofacial Pain
edited by Charles McNeill. —2nd ed.
p. cm.
Rev. ed. of: Craniomandibular Disorders. 1990.
Includes bibliographical references.
ISBN 0-86715-253-2
1. Temporomandibular joint—Diseases. I. McNeill, Charles,
date. II. American Academy of Craniomandibular Disorders.
Craniomandibular Disorders. III. Title.
RK470.A48 1993
617.5'22—dc20 92-37493

Second Edition

© 1993 by Quintessence Publishing Co, Inc, Carol Stream, Illinois.

All rights reserved.

This book or any part thereof may not be reproduced, stored in a

retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without prior written permission of the publisher.

Previous edition copyrighted 1990, Craniomandibular Disorders:

Guidelines for Evaluation, Diagnosis, and Management.

Editor: Carol L. Rose

Designer and Production: Jennifer A. Sabella

Composition: Focus Graphics, St. Louis, MO

Printing and Binding: Port City Press, Baltimore, MD
Printed in the USA on recycled paper.
 Contents

Preface 7
Committee Members 9
1 Introduction 11
Definition of TMD 11
History of TMD 11
Anatomy of the masticatory system 13

2 Epidemiology 19
TMD 19
Chronic pain disorders 21
Headache 22

3 Etiology 27
Trauma 28
Anatomic factors 29
Pathophysiologic factors 30
Psychosocial factors 31

4 Diagnostic Classification 39
Diagnostic process 39
Differential diagnosis of orofacial pain 42
Diagnostic classification system for TMD 46
 Contents

5 Assessment 61
Screening evaluation 61
Comprehensive history 61
Comprehensive physical examination 63
Imaging 66
Behavioral and psychosocial evaluation 68
Additional clinical tests 68
Proposed additional documentation 71

6 Management 81
Patient education and self-care 82
Cognitive behavioral intervention 83
Psychotherapy 84
Pharmacotherapy 85
Physical therapy 87
Orthopedic appliance therapy 89
Occlusal therapy 92
Surgery 94

Addendum 109
Health care benefits 109
Professional recommendations 111

Glossary 115

6
 Preface

This document represents the recommen¬ more accurately refers to the joint and
dations of the American Academy of Oro¬ muscle problems in the area in which
facial Pain (AAOP), formerly known as dentists have formal training, expertise,
the American Academy of Cranioman- clinical experience, licensing, and profes¬
dibular Disorders (AACD), for the classi¬ sional and legal responsibility.4 The term
fication, assessment, and management of is compatible with the terminology used
temporomandibular disorders (TMD). It by the American Dental Association’s
is a revision of the first edition of Cranio- TMD guidelines, numerous state dental
mandibular Disorders: Guidelines for associations’ recently established TMD
Evaluation, Diagnosis, and Management guidelines, and the International Head¬
published by the AACD in 1990.1 Those ache Society’s classification for headache,
guidelines were an update of two prior cranial neuralgias, and facial pain. Also,
position papers on the same subject.2-3 temporomandibular disorders is the term
The AAOP is composed of persons with recognized by a larger percentage of the
academic credentials, advanced education lay public and faculty and staff at multi¬
and training, or extensive clinical experi¬ specialty medical centers and academic
ence in the field of orofacial pain and institutions. Lastly, it is the term that
specifically in TMD. is used by Index Medicus to classify
Currently the term temporomandibular peer-reviewed medical and dental litera¬
disorders is used interchangeably with the ture.4
term craniomandibular disorders. However, The AAOP continues to recognize an
the term temporomandibular disorders is increasing need for appropriate practice
considered the preferred term by most guidelines, and, therefore, has published
North American authorities in the field. this second edition in response to the
The term temporomandibular disorders recent advances in the field. This docu¬
is specific for the orofacial region and ment provides dentists, physicians, allied

7
 Preface

health professionals, researchers, and the References

insurance industry with a current up¬
1. American Academy of Craniomandibular
dated review of the classification, assess¬
Disorders: McNeill C (ed) Craniomandibu¬
ment, and management of patients with
lar disorders: Guidelines for evaluation, di¬
TMD. The major objective is to provide
agnosis, and management. J Craniomandib
guidelines based on knowledge gained Disord Oral Facial Pain. Chicago, Quintes¬
from research in the basic and clinical sence Publishing Co, 1990.
sciences and on clinical practice experi¬
2. McNeill C, Danzig WM, Farrar WB, Gelb
ence. Literature is cited from refereed H, Lerman M, Moffett BC, Pertes R, Sol-
professional journals from the allied berg WK, Weinberg L: Craniomandibular
health fields in support of the guide¬ (TMJ) disorders—The state of the art. J
lines. Proposed theories or clinical Prosthet Dent 1980;44:434-437.
techniques that are not yet supported 3. McNeill C: Craniomandibular (TMJ) disor¬
scientifically are duly noted in this pub¬ ders—The state of the art, Part II: Accepted
lication. Because knowledge in this field diagnosis and treatment modalities. J Pros¬
is rapidly growing and changing with ad¬ thet Dent 1983;49:393-397.
ditional scientific research, these guide¬ 4. McNeill C (ed): Current Controversies in
lines will continue to require periodic Temporomandibular Disorders. Chicago,
updating. Quintessence Publishing Co, 1992.

8
 AAOP “Guidelines” Committee Members
1990-1992

Charles McNeill, DDS, Chairman

James R. Fricton, DDS, MS Eric K. Milliner, MD

Joseph A. Gibilisco, DDS, MSD Jeffrey P. Okeson, DMD
Steven B. Graff-Radford, DDS Harold T. Perry, DDS, PhD
Tore L. Hansson, DDS, Odont Dr John D. Rugh, PhD
James A. Howard, DDS Donald A. Seligman, DDS
 ONE

Introduction

Definition of TMD movement and TMJ sounds that are most

frequently described as clicking, popping,
Temporomandibular disorders (TMD) is a grating, or crepitus.
collective term embracing a number of Common patient complaints include
clinical problems that involve the mastica¬ jaw ache, earache, headache, and facial
tory musculature, the temporomandibular pain. Nonpainful masticatory muscle hy¬
joint (TMJ) and associated structures, or pertrophy and abnormal occlusal wear
both. The term is synonymous with the associated with oral parafunction such as
term craniomandibular disorders. Tempo¬ bruxism (jaw clenching and tooth grind¬
romandibular disorders have been identi¬ ing) may be related problems. Pain or
fied as a major cause of nondental pain in dysfunction due to nonmusculoskeletal
the orofacial region and are considered to causes such as otolaryngologic, neuro¬
be a subclassification of musculoskeletal logic, vascular, neoplastic, or infectious
disorders.1 Although TMD was viewed as disease in the orofacial region is not con¬
one syndrome, current research supports sidered a primary temporomandibular dis¬
the view that TMD are a cluster of related order even though musculoskeletal pain
disorders in the masticatory system that may be present. However, TMD often
have many common symptoms.2-3 coexist with other craniofacial and orofa¬
The most frequent presenting symp¬ cial pain d’sord^rs.
tom is pain, usually localized in the mus¬
cles of mastication, the preauricular area,
and/or the TMJ. The pain usually is ag¬ History of TMD
gravated by chewing or other jaw func¬
tion. In addition to complaints of pain, A historical review of TMD reveals a no¬
patients with these disorders frequently table evolutionary process given consider¬
have limited or asymmetric mandibular able impetus following the publication in

11
Introduction

1934 of a paper by Costen, an otolaryn¬ ization of intracapsular structures. Far¬

gologist.4 Costen observed that patients rar28 challenged the neuromuscular ori¬
with pain in or near the ear, tinnitus, ented concepts and reemphasized the joint
dizziness, a sensation of ear pressure or condition, especially disc interference dis¬
fullness, and difficulty in swallowing orders, as demonstrated by arthrography
(known as Costen’s Syndrome) seemed to and supported by the surgical findings of
improve by altering the vertical dimen¬ McCarty.29 Wilkes30 also described ar¬
sion of the occlusion. Because malocclu¬ ticular disorders stating the importance
sion was perceived to be the underlying of arthrographic soft tissue imaging and
cause, treatment for TMD and a variety surgery. These imaging techniques, espe¬
of other orofacial pain phenomenon shift¬ cially MRI, and arthroscopy31-34 plus
ed from medicine to dentistry. Dental increasing experience in clinical manage¬
occlusionists contended shortly thereaf¬ ment, provided information for more spe¬
ter that occlusal disharmony rather than a cific articular diagnoses.
closed bite was the primary etiologic fac¬ At this time multidisciplinary knowl¬
tor,5 and various restorative techniques to edge was leading to more refined differ¬
balance or stabilize the occlusion resulted ential diagnoses and the realization that
during the period from the late 1930s to orofacial pain patients may suffer from a
the post-World War II era. variety of disorders including systemic-
Studies were expanding in the fields of related problems and articular, neuromus¬
neuromuscular physiology6*7 and joint bio¬ cular, neurologic, neurovascular, and
mechanics including dysfunction, remod¬ behavioral disorders. Parallel to the de¬
eling, and degenerative processes.8-10 velopment of knowledge in TMD, there
Other clinical investigators were empha¬ has been an expansion of knowledge in
sizing different approaches to the man¬ the basic mechanisms of pain and major
agement of head, neck, and orofacial pain advances in the neurophysiology and neu¬
and TMD. Regional and referred pain of ropharmacology of pain.
myofascial origin was considered to be a It became evident that diagnostic and
major influence in these conditions.11-13 management guidelines were of para¬
Conversely, the gnathologic approach, as mount importance in the 1980s, a decade
described by McCollum and Stuart,14 em¬ characterized by a proliferation of TMD
phasized the importance of occlusion and devices, both diagnostic and therapeutic.
the TMJs. Accordingly, in 1982 the American Den¬
The role of occlusion in TMD gained tal Association (ADA) held a conference
in popularity from the late 1950s with an on the examination, diagnosis, and man¬
emphasis on occlusal equilibration or ad¬ agement of TMD.3 The need for an im¬
justment.15-17 In the 1960s the quality of proved classification system that would
clinical investigation and basic scientific permit proper comparison of epidemio¬
research was becoming increasingly so¬ logic, diagnostic, and treatment data was
phisticated18-20 and there was a gradual stressed. It was also recognized that some
de-emphasis of the role of occlusion in patients developed a lingering, chronic,
TMD etiology. painful illness with an unpredictable treat¬
After 1970, advances in imaging tech¬ ment response to modalities usually found
niques that included tomography, arthrog¬ effective in managing biomechanical,
raphy,21*22 computed tomography (CT),2 3 structural dysfunctions. The complexity
and, later, magnetic resonance imaging of managing a chronic orofacial pain dis¬
(MRI),24-27 resulted in improved visual¬ order was acknowledged and the use of

12
 History of TMD

multidisciplinary and interdisciplinary bone (Fig 1-1). Separating these two bones
management programs became common. from direct contact is the interposed ar¬
ticular disc (sometimes inappropriately
referred to as “meniscus”). The healthy
Anatomy of the articular portion of the disc is composed
Masticatory System of dense fibrous connective tissue, devoid
of any nerves or vessels; conversely, the
Craniomandibular articulation occurs in posterior attachment of the disc is richly
the temporomandibular joints, two of the vascularized and innervated.35-37 The
most complex joints of the body. Each disc is also attached to the condyle both
TMJ provides for hinging movement in medially and laterally by collateral liga¬
one plane, which is a criterion for a gin- ments. These ligaments permit rotational
glymoid joint. At the same time, however, movement of the disc on the condyle
the TMJ provides for gliding movements, during opening and closing of the mouth.
which is a criterion for an arthrodial joint. This so-called condyle-disc complex trans¬
Thus, the TMJ is technically considered lates out of the fossa during extended
a ginglymoarthrodial joint.2 The TMJ is mouth opening (Fig 1-2).2 Therefore, in
formed by the mandibular condyle fitting the normal joint, rotational movement
into the mandibular fossa of the temporal occurs between the condyle and the infe-

ACL

Fig 1-1 Temporomandibular joint. Diagram showing the anatomic components: RT, retrodiscal
tissues; SRL, superior retrodiscal lamina (elastic); IRL, inferior retrodiscal lamina (collagenous);
ACL, anterior capsular ligament (collagenous); SLP and ILP, superior and inferior lateral ptery¬
goid muscles; AS, articular surface; SC and IC, superior and inferior joint cavity; DL, discal
(collateral) ligament. Figure reproduced with permission from Okeson JP: Management of
Temporomandibular Disorders and Occlusion, ed 3. St Louis, CVMosby Co, 1992, fig 1-14.

13
Introduction

Fig 1-2 Normal functional movement of the condyle and disc during the full range of opening
and closing. Note that the disc is rotated posteriorly on the condyle as the condyle is translated out
of the fossa. The closing movement is the exact opposite of opening. Figure reproduced with
permission from Okeson JP: Management of Temporomandibular Disorders and Occlusion, ed 3.
St Louis, CV Mosby Co, 1992, fig 1-27.

rior surface of the disc during early open¬ Unlike most synovial joints, the ar¬
ing (the inferior joint space) and transla¬ ticulator surfaces of the TMJs are lined
tion takes place in the space between the with dense fibrous connective tissue, not
superior surface of the disc and the fossa hyaline cartilage.38 This is an impor¬
(the superior joint space) during later tant feature because fibrous connective
opening. Movement of the joint is lubri¬ tissue has a greater ability to repair
cated by synovial fluid, which also acts as a itself than does hyaline cartilage. This
medium for transporting nutrients to and implies that the management of arthrit¬
waste products from the articular surfaces. ic conditions of the TMJ may be dif-

14
 Anatomy of the Masticatory System

Fig 1-3 Central trigeminal sensory pathways. Dorsal view of spinal, brain stem, thalamic, and
cortical pain temperature/touch pathways. The ascending trigeminal tract (lemniscus) is the
primary pain/temperature pathway while the dorsal central trigeminal tract conveys most of the
touch impulses.

ferent from that of other synovial which predominantly elevate the mandi¬
joints.39 ble (mouth closing); the digastric muscles,
Movement and stability of the TMJs is which assist in mandibular depression
achieved by a group of skeletal muscles (mouth opening); the inferior lateral ptery¬
referred to as the muscles of mastication. goid muscles, which assist in protruding
Although the muscles of mastication are the mandible; and the superior lateral ptery¬
the primary muscles that provide man¬ goid muscles, which provide stabilization
dibular movement, other associated mus¬ for the condyle and disc during func¬
cles of the head and neck furnish sec¬ tion.40-42 The masticatory muscles are
ondary support during mastication. The recruited in a variety of functional behav¬
masticatory muscles include the masseter, iors that includes talking, swallowing, and
medial pterygoid, and temporal muscles, masticating.43 A number of muscle be-

15
Introduction

haviors are also apparently nonfunctional tion of the temporomandibular joint. Ann
(parafunctional), defined under the broad Otol 1934;43:1-15.
term of bruxism, and include grinding, 5. Schuyler CH: Fundamental principles in
clenching, or rhythmic chewing-like, emp¬ the correction of occlusal disharmony, nat¬
ty-mouth movements.44’45 ural and artificial. J Am Dent Assoc 1935;
Motor innervation of the muscles of 22:1193-1202.

mastication as well as sensory innerva¬ 6. Moyers RE: An electromyographic analy¬

tion to the oral structures and the face are sis of certain muscles involved in temporo¬
mandibular movement. Am J Orthod 1950;
supplied by the trigeminal cranial nerve
36:481-515.
(CV). Sensory fibers of the trigeminal
nerve extend to synapses in the trigemi¬ 7. Perry HT: Implications of myographic re¬
nal spinal nucleus of the brain stem. It is search. Angle Orthod 1955;25:179.

important to appreciate that the anatomy 8. Moffett BC, Johnson LC, McCabe JB, et
of this spinal nucleus extends caudally al: Articular remodeling in the adult hu¬
down into the region where cervical nerves man temporomandibular joint. Am J Anat
1964;115:119-130.
1 through 3 enter the central nervous
system. Neurons from the trigeminal as 9. Blackwood HJJ: Cellular remodeling in ar¬
well as facial (CVII), hypoglossal (CIX), ticular tissue. J Dent Res 1966;45:480-
and vagus (CX) cranial nerves share in the 489.

same neuron pool as neurons from the 10. Carlsson GE, ObergT: Remodeling of the
upper cervical spine (cervical nerves 1, 2, temporomandibular joint. Oral Sci Rev
3) (Fig 1-3).46-49 This convergence of the 1974;4:53-86.

trigeminal and cervical nerves is an ana¬ 11. Travell J, Rinzler SH: The myofascial gen¬
tomic and physiologic explanation for the esis of pain. Postgrad Med 1952; 11:425-
source of referred pain from the cervical 434.
region to the trigeminal region.50 The 12. Schwartz LL: Pain associated with the tem¬
clinician needs to be aware of this com¬ poromandibular joint. J Am Dent Assoc
mon referral pattern so as to avoid mis¬ 1955;51:394-397.
directed diagnosis and treatment. 13. Laskin DM: Etiology of the pain-dysfunc¬
tion syndrome. J Am Dent Assoc 1969;79:
147-153.

References 14. McCollum BB, Stuart CE: A research re¬

port. South Pasadena, Calif, Scientific Press,
1955.
1. Bell WE: Orofacial pains. Classification,
Diagnosis, Management. 4th ed. Chicago, 15. Shore NA: Occlusal Equilibration and Tem¬
Year Book Medical Publishers, 1989, pp poromandibular Joint Dysfunction. Phila¬
101-113. delphia, JB Lippincott Co, 1959, pp 201—
270.
2. Bell WE: Temporomandibular Disorders.
Classification, Diagnosis, Management. 3rd 16. Ramfjord SP: Dysfunctional temporoman¬
ed. Chicago, Year Book Medical Publishers, dibular joint and muscle pain. J Prosthet
1990, pp 166-176. Dent 1961;11:353-374.
3. Griffiths RH: Report of the President’s 17. Krough-Poulson WG, Olsson A: Occlusal
Conference on Examination, Diagnosis and disharmonies and dysfunction of the sto-
Management of Temporomandibular Dis¬ matognathic system. Dent Clin North Am
orders. J Am Dent Assoc 1983;106:75-77. Nov 1966;627—63 5.
4. Costen JB: A syndrome of ear and sinus 18. Thilander B: Innervation of the temporo¬
symptoms dependent upon disturbed func- mandibular joint capsule in man. Trans

16
 References

Royal School Dent (Stockholm and Umea) and mandibular condyle. In Solberg WK,
1961;7:9-67. Clark GT (eds) Temporomandibular Joint
19. Kawamura Y, Majima T: Temporomandib¬ Problems: Biologic Diagnosis and Treat¬
ular joint’s sensory mechanisms control¬ ment. Chicago, Quintessence Publ Co,
ling activities of the jaw muscles. J Dent 1980, pp 145-168.
Res 1964;43:150. 30. Wilkes CH: Arthrography of the temporo¬
20. Storey AT: Sensory functions of the tem¬ mandibular joint. Minn Med 1978;61:645-
poromandibular joint. Can Dent Assoc J 652.
1968;34:294-300. 31. Kino K: Morphological and structural ob¬
21. Dolwick MR, Katzberg RW, Helms CA, servations of the synovial membranes and
Bales DJ: Arthrotomographic evaluation their folds relating to the endoscope find¬
of the temporomandibular joint. J Oral ings in the upper joint cavity of the human
Maxillofac Surg 1979;37:793-799. temporomandibular joint (in Japanese). J
22. Katzberg RW, Dolwick MF, Helms CA, Stomatol Socjpn 1980;47:98-134.
Hopens T, Bales DJ, Coggs GC: Arthroto- 32. Ohnishi M: Clinical applications of the
mography of the temporomandibular joint. arthroscope in temporomandibular joint
AJR 1980;134:995-1003. diseases. Bull Tokyo Med/Dent Univ 1980,
23. Helms CA, Katzberg RW, Manzione JV: pp 141-150.
Computed tomography. In Helms CA, 3 3. Murakami K-I, Matsuki M, Iizuka T, Ono
Katzberg RW, Dolwick MF (eds) Internal T: Diagnostic arthroscopy of the TMJ:
Derangements of the Temporomandibular Differential diagnosis in patients with lim¬
Joint. San Francisco, Radiology Research ited jaw opening. J Craniomand Pract 1986;
Foundation, 1983, pp 135-166. 4:118-126.
24. Helms CA, Morrish RB, Kircos LT, Katz¬ 34. Sanders B: Arthroscopic surgery of the
berg RW, Dolwick WF: Computed tomog¬ temporomandibular joint: Treatment of in¬
raphy of the meniscus temporomandibular ternal derangement with persistent closed
joint: Preliminary observations. Radiology lock. Oral Surg Oral Med Oral Pathol 1986;
1982;145:719-722. 62:361-372.

2 5. Harms SE, Wilk RM, Wolfford LM, Chiles 35. Fried L: Anatomy of the Head, Neck, Face
DG, Milan SB: The temporomandibular and Jaws. Lea and Febiger, Philadelphia,
joint: Magnetic resonance imaging using 1980, pp 43-83; 173-186.
surface coils. Radiology 1985;157:133-136. 36. Scapino RP: The posterior attachment: Its
26. Helms CA, Kaban LB, McNeill C, Dobson structure, function, and appearance in TMJ
T: Temporomandibular joint: Morphol¬ imaging studies. Part I. J Craniomandib
ogy and signal intensity characteristics of Disord Facial Oral Pain 1991;5:83-95.
the disc at MR imaging. Radiology 1989; 37. Scapino RP: The posterior attachment: Its
172:817-820. structure, function, and appearance in TMJ
27. Helms CA, Doyle GW, Orwig D, McNeill imaging studies. Part 2. J Craniomandib
C, Kaban L: Staging of internal derange¬ Disord Facial Oral Pain 1991;5:155-166.
ments of the TMJ with magnetic resonance 38. Dubrul E: The craniomandibular articula¬
imaging: Preliminary observations. J Cra- tion. In Sicher’s Oral Anatomy. 7th ed. St
niomandib Disord Facial Oral Pain 1989;3: Louis, CV Mosby Co, 1980, Chap 4, pp
93-99. 147-209.
28. Farrar WB: Diagnosis and treatment of 39. Meikle MC: Remodeling. In Sarnat BG,
anterior dislocation of the articular disc. Laskin DM (ed) The Temporomandibular
NYJ Dent 1971;41:348-351. Joint: A Biological Basis for Clinical Prac¬
29. McCarty W: Diagnosis and treatment of tice. 4th ed. WB Saunders Co, Philadel¬
internal derangements of the articular disc phia, 1992, pp 93-107.

17
Introduction

40. McNamara JA: The independent functions 45. Rugh JD, Harlan J: Nocturnal bruxism and
of the two heads of the lateral pterygoid temporomandibular disorders. Adv Neurol
muscles. AmJ Anat 1973;138:197-206. 1988;49:329-341.
46. Kerr FWL: Structural relation of the tri¬
41. Meyenberg K, Kubik S, Palla S: Relation¬
geminal spinal tract to upper cervical roots
ships of the muscles of mastication to the
and the solitary nucleus in the cat. Exp
articular disc of the temporomandibular
joint. Helv Odont Acta 1986;30:1-20. Neurol 1961 ;4:134.
47. Kerr FWL: Facial, vagal and glossopha¬
42. Wilkinson TM: The relationship between
ryngeal nerves in the cat: Afferent connec¬
the disk and the lateral pterygoid muscle in
tions. Arch Neurol 1962;6:264.
the human temporomandibular joint. J
48. Kerr FWL: The divisional organization of
Prosthet Dent 1988;60:715-724.
afferent fibers of the trigeminal nerve. Brain
43. Hylander WL: Functional anatomy. In 1963 ;86:721.
Saranat BG and Laskin DM (eds), The 49. Sessle BJ: The neurobiology of facial and
Temporomandibular Joint: A Biological
dental pain: Present knowledge, future di¬
Basis for Clinical Practice. 4th ed. Phila¬ rections. J Dent Res 1987;66:962-981.
delphia, WB Saunders Co, 1992, pp 60-92.
50. Giunta JL, KronmanJH: Orofacial involve¬
44. Glaros AG, Rao SM: Effects of bruxism: A ment secondary to trapezius muscle trau¬
review of the literature. J Prosthet Dent ma. Oral Surg Oral Med Oral Pathol 1985;
1977;38:149-157. 60:368-369.

18
 TWO

Epidemiology

Epidemiology is the study of the factors the findings, therefore, cannot easily be
that govern the frequency and distribu¬ generalized to more global communities.
tion of disease or physiologic states in a
community.1 Its focus is on the total pop¬
ulation rather than the individual,2 and its TMD
purpose is disease classification and pre¬
vention.3 Epidemiologic studies can be Cross-sectional epidemiologic studies of
descriptive or analytic. Descriptive inves¬ specific nonpatient populations show that
tigation usually involves retrospective approximately 75% of those populations
evaluation of the number of cases with have at least one sign of joint dysfunction
any disease or associated factor. These (movement abnormalities, joint noise, ten¬
findings are reported as prevalence. Ana¬ derness on palpation, etc) and approx¬
lytic investigation usually involves pro¬ imately 33% have at least one symptom
spective longitudinal evaluation of the (face pain, joint pain, etc).4-5 The results
number of cases acquiring a disease or an from epidemiologic studies vary consid¬
associated factor over a specified time erably from study to study because of
period. These findings are reported as differences in descriptive terminology, in
incidence. Few reports on the incidence of data collection, in analytic approaches
TMD and the associated signs and symp¬ (eg, single-factor versus multiple-factor
toms are available, so the emphasis in this analysis), and in the individual factors
chapter will be, by default, on prevalence. selected for study.
However, the majority of studied popula¬ Some signs appear to be relatively com¬
tions are cross-sectional samples and are mon in healthy populations: joint sounds
not necessarily representative of broader or deviation on mouth opening occur in
populations. Thus, few are strict epide¬ approximately 50% of healthy nonpatient
miologic studies of total populations and populations. Other signs are relatively

19
Epidemiology

rare: mouth opening limitations only oc¬ or showed less or no clicking over the
cur in approximately 5%.6 Signs and symp¬ examination period even though most did
toms of TMD generally increase in not have any treatment interventions. Fur¬
frequency and severity beginning in the thermore, while TMJ clicking is fairly
second decade of life.7-9 The incidence of common, the progression to a potentially
joint sounds in young adults in their late more serious nonreducing disc status is
teens can be as high as 17.5% over a relatively uncommon.27 It is unfortunate
2-year period.10 The majority of 3,428 that the incidence of disc displacement
patients in a recent study were between without reduction is not currently known
the ages of 15 and 45 years (mean, 32.9 and, further, that the progression from
years); this suggests that older subjects locking to osteoarthrosis or significant
are less bothered by their symptoms.11 disability is variable. Because MRI has
Prevalence of nonspecific measures of made documentation of disc derangement
overall symptom levels (eg, Helkimo in¬ without invasive procedures available, the
dices) was reported to be almost equal in question of disability potential is clini¬
men and women in Scandinavian nonpa¬ cally important to avoid overtreatment of
tient surveys of adults12-16 and younger benign chronic nonreducing disc displace¬
populations.17-21 In contrast, when indi¬ ment. The internal derangement-osteo¬
vidual symptoms were evaluated sepa¬ arthrosis-disability continuum is thus less
rately, women were found to have slightly predictable and more complex than was
more headache, TMJ clicking, TMJ ten¬ previously proposed by'Rasmussen.33-34
derness, and muscle tenderness than were The prevalence of a specific temporo¬
men.8*9’22-24 These differences between mandibular disorder is difficult to deter¬
men and women found in epidemiologic mine because of the lack of a universally
studies only partially explain the recent accepted classification scheme with diag¬
clinical tabulations stating a women-to- nostic criteria. However, different inves¬
men ratio of 3:1 to 9:1 in persons seeking tigators have used combinations of signs
care for TMD.11-25-26 Temporomandibu¬ and symptoms to indirectly deduce the
lar disorders are often remitting, self- prevalence of differentiated diagnoses. A
limiting, or fluctuating over time as recent study of patients seeking treat¬
suggested by recent patient studies.27-28 ment for TMD in a private dental prac¬
While knowledge of the natural history tice described 31% with internal derange¬
or course of TMD is limited, there is ment, 39% with arthritis, and 30% with a
increasing evidence that progression to muscle disorder.35 Schiffman et al30 used
chronic and disabling intracapsular TMJ specifically tested diagnostic criteria on a
disease is an uncommon occurrence.29 general population and found 3 3 % with
Despite the large percentages of the TMD and 41% with masticatory muscle
population having signs or symptoms (see disorders but only 7% of the total popula¬
Fig 2-1), only 5% to 7% are estimated to tion had a disorder severe enough to be
be in need of treatment.3-4-30-32 These comparable to a clinic population. Thus,
estimates are supported by a recent study prevalence values of patients may over¬
that indicated that only 7% of a patient state the clinical significance of indi¬
population with nonproblematic TMJ vidual problems because patients with
clicking showed progression to a prob¬ mild transient signs and symptoms not
lematic clicking status over a 1- to 7.5- requiring treatment are no doubt in¬
year period.28 The majority of the pa¬ cluded.
tients with TMJ clicking remained stable To overcome the shortcomings of past

20
 TMD

34.2 years and 33.8 years, respectively, and, of those seeking treatment, 85.4% were women.
(Figure adapted with permission, originally appeared as Fig 4.1 in Howard.11)

studies of prevalence, a universally ac¬ Chronic Pain Disorders

cepted classification scheme with case defi¬
nitions such as is proposed in these guide¬ Although most TMD appear to be mild
lines is mandatory.36 In addition, the and self-limiting, a significant number of
development of an impairment-disability TMD patients develop a chronic pain syn¬
scale is recommended to allow compara¬ drome.36 Chronic pain syndromes are de¬
tive cross-study estimates. Finally while fined as persistent pain that lasts more
broad-based symptom scales (eg, the Hel- than 6 months with associated behavioral
kimo indices) have been useful in the past, and psychosocial factors.37-38 There is in¬
recent advances in disorder classification creasing recognition of the need for epi¬
mandate that future epidemiologic stud¬ demiologic studies of the prevalence and
ies, using working definitions that in¬ impact of chronic and recurrent pain.39
clude patterns of signs and symptoms, One comprehensive survey examining
focus on more narrowly defined disease chronic pain prevalence among adults in
groups. North America suggests that there is val-

21
Epidemiology

ue in comparing different pain condi¬ tem. Many studies have found recurrent
tions.40-41 In this study, various pain headache to occur in as many as 70% of
conditions were found to share common TMD patients,47-48 compared to approx¬
features such as age distribution and as¬ imately 20% of a general population.49-51
sociation with psychologic stress. The It has been estimated that one in three
findings also indicate that having had a persons suffers from severe headache at
pain condition in the preceding 12 months some stage in his or her life.52 Currently,
is common in the adult North American 5% to 10% of the North American popu¬
population, with 73% experiencing head¬ lation has sought medical advice for se¬
ache, 56% experiencing back pain, 46% vere headache.41-53 There is also a high
experiencing stomach pain, and 27% ex¬ prevalence in children; 7 5 % of Scandina¬
periencing dental pain. Another study on vian children report histories of signifi¬
the prevalence of pain found that by 70 cant head pain by age 15.54
years of age, 34% have experienced sig¬ Because headache is a major cause of
nificant headache, abdominal pain, or chest suffering and absenteeism from work or
pain.42 Headaches, facial pain, and most school,40-41 epidemiologic studies of
other chronic pains are more prevalent headache are needed to clarify the rela¬
among women.8-9-24 tionship with TMD. Temporomandibular
Chronic pain involves long-term noci¬ disorders do not necessarily cause head¬
ceptive input with complex central and ache and there is need for study of the
peripheral nervous system changes at lev¬ possibility that TMD aggravates head¬
els of both perception and reaction.43 ache in those patients predisposed to head¬
Patient response to chronic pain is differ¬ ache. An association between the pres¬
ent from acute pain response.44 Ongoing ence of headache and TMD has been well
peripheral pathology is potentiated by documented,47-49-55-60 but this associa¬
neuropsychologic factors, such as social tion has not yet shown to be a causal
situations, attitudes, and emotional prob¬ relationship and may be coincidental in
lems, and may cause an enhanced percep¬ many cases. Clarification of the role of
tion of continuous pain. Some patients the musculoskeletal system in producing
with chronic pain are able to cope with headache is not currently available. Thus,
this continuous unpleasant perception and it is important to emphasize that head¬
manage to live productive lives.45 When ache per se should not be considered a
their coping mechanisms break down, temporomandibular disorder unless the
however, patients may become depressed, pain is clearly related to clinical signs and
disabled, and dependent on the pain re¬ symptoms that involve the masticatory
gardless of the original event that started musculoskeletal system.
the pain problem. These patients have
complex pain and are often victims of
multiple unsuccessful treatments, which References
include multiple drug misuse and surgical
interventions for pain.46
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RM (eds): Dorland’s Illustrated Medical
Dictionary. 23rd ed. Philadelphia, WB
Headache Saunders Co, 1960.
2. Zwemer TJ (ed): Boucher’s Clinical Dental
Headache can be a symptom of many Terminology. St Louis, CV Mosby Co,
disorders affecting the masticatory sys¬ 1982.

22
 References

3. Solberg WK: Epidemiology, Incidence, and bution of symptoms according to age and
Prevalence of Temporomandibular Disor¬ sex as judged from investigation by ques¬
ders: A Review. The President’s Confer¬ tionnaire. Acta Odontol Scand 1972;30:
ence on the Examination, Diagnosis, and 597-613.
Management of Temporomandibular Dis¬
13. Helkimo M: Studies on function and dys¬
orders. Chicago, American Dental Asso¬
function of the masticatory system. I: An
ciation, 1983, pp 30-39.
epidemiological investigation of symptoms
4. Rugh JD, Solberg WK: Oral health status of dysfunction in Lapps in the North of
in the United States. Temporomandibular Finland. Proc Finn Dent Soc 1974;70:37-
disorders. J Dent Educ 1985;49:398-404. 49.
5. Schiffman E, Fricton JR: Epidemiology of 14. Helkimo M: Studies of function and dys¬
TMJ and craniofacial pain. In Friction JR, function of the masticatory system. II: In¬
Kroening RJ, Hathaway KM (eds) TMJ dex for anamnestic and clinical dysfunction
and Craniofacial Pain: Diagnosis and Man¬ and occlusal state. Swed Dent J 1974;67:
agement. St Louis, IEA Publ, 1988, pp 1- 101-121.
10.
15. Hansson T, Nilner M: A study of the oc¬
6. Huber MA, Hall EH: A comparison of the currence of symptoms of diseases of the
signs of temporomandibular joint dysfunc¬ temporomandibular joint, masticatory mus¬
tion and occlusal discrepancies in a symp¬ culature, and related structures. J Oral Re-
tom-free population of men and women. habil 1975;2:313-324.
Oral Surg Oral Med Oral Pathol 1990;70:
16. Swanljung O, Rantanen T: Functional dis¬
180-183.
orders of the masticatory system in south¬
7. Egermark-Eriksson I, Carlsson GE, Mag- west Finland. Community Dent Oral Epi¬
nusson T: A long-term epidemiologic study demiol 1979;7(3):177—182.
of the relationship between occlusal factors
17. Egermark-Eriksson I, Carlsson GE, Inger-
and mandibular dysfunction in children and
vall B: Prevalence of mandibular dysfunc¬
adolescents. J Dent Res 1987;67:67-71.
tion and orofacial parafunction in 7-, 11-,
8. Agerberg G, Bergenholz A: Cranioman- and 15-year old Swedish children. Eur J
dibular disorders in adult populations of Orthod 1981;3(3):163—172.
West Bothnia, Sweden. Acta Odontol Scand
18. Nilner M, Lassing S A: Prevalence of func¬
1989;47:129-140.
tional disturbances and diseases of the sto¬
9. Salonen L, Hellden L: Prevalence of signs ma tognathic system in 7-14 year olds. Swed
and symptoms of dysfunction in the mas¬ Dent J 1981;5:173-187.
ticatory system: An epidemiologic study in
an adult Swedish population. J Cranio- 19. Nilner M: Prevalence of functional distur¬
bances and diseases of the stomatognathic
mandib Disord Facial Oral Pain 1990;4:
system in 15-18 year olds. Swed Dent J
241-250.
1981;5:189-197.
10. Wanman A, Agerberg G: Temporoman¬
dibular joint sounds in adolescents, a longi¬ 20. Heft MW: Prevalence of TMJ signs and
tudinal study. Oral Surg Oral Med Oral symptoms in the elderly. Gerontology 1984;
Pathol 1990;69:2-9. 3:125-130.

11. Howard JA: Temporomandibular joint dis¬ 21. Magnusson T, Egermark-Eriksson I, Carls¬
orders, facial pain and dental problems of son G: Five year longitudinal study of signs
performing artists. In Sataloff R, Brand- and symptoms of mandibular dysfunction
fonbrener A, Lederman R (eds) Textbook in adolescents. J Craniomand Pract 1986;
of Performing Arts Medicine. New York, 4:339-343.
Raven Press, 1991, pp 111-169. 22. Solberg WK Woo MW, Houston JB: Prev¬
12. Agerberg G, Carlsson GE: Functional dis¬ alence of mandibular dysfunction in young
orders of the masticatory system. I. Distri¬ adults. J Am Dent Assoc 1979;98:25-34.

23
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23. Pullinger A, Seligman DA, Solberg W: 33. Rasmussen CO: Clinical findings during
Temporomandibular disorders. Part I: the course of temporomandibular arthrop¬
Functional status, dentomorphologic fea¬ athy. Scand J Dent Res 1981;89:283-288.
tures, and sex differences in a nonpatient 34. Nitzan DW, Dolwick MF: An alternative
population.} Prosthet Dent 1988;59:228- explanation for the genesis of closed-lock
235. symptoms in the internal derangement pro¬
24. Agerberg G, Inkapool I: Craniomandibu- cess. J Oral Maxillofac Surg 1991 ;49:810—
lar disorders in an urban Swedish popula¬ 815.
tion. J Craniomandib Disord Facial Oral 35. Pullinger A, Seligman DA: Overbite and
Pain 1990;4:154-164. overjet characteristics of refined diagnos¬
25. McNeill C: The optimum temporoman¬ tic groups of temporomandibular patients.
dibular joint condyle position in clinical Am J Orthod Dentofac Orthop 1991;100:
practice. Int J Periodont Rest Dent 1985; 401-415.
5(6):53-76. 36. LeResche L, Dworkin SF, Sommers EE,
26. Centore L, Bianchi P, McNeill C: The Truelove EL: An epidemiologic evaluation
relationship between nonorganic multiple of two diagnostic classification schemes for
physical complaints and narcissism. J Dent temporomandibular disorders. J Prosthet
Res 1989;68(special issue):abstr 317. Dent 1991;65:131-137.
2 7. Pullinger A, Seligman D: TMJ osteoarthro¬ 3 7. Sanders SH: Chronic pain: Conceptualiza¬
sis: A differentiation of diagnostic sub¬ tion and epidemiology. Ann Behav Med
groups by symptom history and demo¬ 1985;7:3-5.
graphics. J Craniomandib Disord Facial 38. Merskey H: Classification of chronic pain-
Oral Pain 1987;1:251-256. descriptions of chronic pain syndromes and
28. Randolph CS, Greene CS, Moretti R, definitions of pain terms. Pain 1986;(suppl
Forbes D, Perry HT: Conservative man¬ 3): 1 —2 2 5.
agement of temporomandibular disorders:
39. National Institute of Health Consensus
A post treatment comparison between pa¬
Development Conference. The Integrated
tients from a university clinic and from
Approach to the Management of Pain. NIH
private practice. Am J Orthod Dentofac
Consensus Development Conference State¬
Orthop 1990;98:77-82.
ment. Vol 6 No. 3, Washington, DC, US
29. Nickerson JW, Boering G: Natural course Government Printing Office, 1986.
of osteoarthrosis as it relates to internal
40. Sternbach RA: Pain and “hassles” in the
derangement of the temporomandibular
United States: Findings of the Nuprin pain
joint. Oral Maxillofac Surg Clin North Am
report. Pain 1986;27:69-80.
1989;1:1-19.
41. Sternbach RA: Survey of pain in the United
30. Schiffman E, FrictonJR, Haley D, Shapiro
States: The Nuprin Pain Report. Clin J
BL: The prevalence and treatment needs of
Pain 1986;2:49-53.
subjects with temporomandibular disorders.
J Am Dent Assoc 1989;120:295-304. 42. Dworkin SF, Burgess JA: Orofacial pain of
31. Dworkin SF, LeResche LR, Von Korff, psychogenic origin: Current concepts and
Howard J, Truelove E, Sommers E: Epi¬ classification.} Am Dent Assoc 1987; 115:
demiology of signs and symptoms in tem¬ 565-571.
poromandibular disorders: I. Clinical signs 43. Fields HL: Pain. New York, McGraw Hill
in cases and controls. J Am Dent Assoc Book Co, 1987, pp 145-158.
1990;120:273-281.
44. Hagberg C, Hellsing G, Hagberg M: Per¬
32. Greene CS, Marbach JJ: Epidemiologic ception of cutaneous electrical stimulation
studies of mandibular dysfunction: A criti¬ in patients with craniomandibular disor¬
cal review. J Prosthet Dent 1982;48(2): ders. J Craniomandib Disord Facial Oral
184-190. Pain 1990;4:120-125.

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45. Turk DC, Rudy TE: Towards a compre¬ 5 3. Campbell JK: Headache in adults: An over¬
hensive assessment of chronic pain patients. view. J Craniomandib Disord Facial Oral
Behav Res Ther 1987;25:237-249. Pain 1987;1:11-15.

46. Brena SF, Chapman SL: Management of 54. Bille, B: Migraine in school children. Acta
Patients with Chronic Pain. New York, SP Pediatr 1962;51:13-147.
Medical and Scientific Books (a division of 55. Heloe B, and Heloe LA: Frequency and
Spectrum Publications, Inc), 1982, pp 25- distribution of myofascial pain-dysfunction
27. syndrome in a population of 2 5-year-olds.
47. Magnusson T, Carlsson GE: Comparison Community Dent Oral Epidemiol 1979;
between two groups of patients in respect 7:357-360.
to headache and mandibular dysfunction. 56. Isberg A, Widmalm S-E, Ivarsson R: Clini¬
Swed Dent J 1978;2:85-87. cal, radiographic, and electromyographic
study of patients with internal derange¬
48. Andrasik F, Holyroyd KA, Abell T: Preva¬
ment of the temporomandibular joint. Am
lence of headache within a college student
J Orthod 1985;88:453-460.
population: A preliminary analysis. Head¬
ache 1979;19:384-387. 57. Wanman A, Agerberg G: Headache and
dysfunction of the masticatory system in
49. Magnusson T, Carlsson GE: Recurrent
adolescents. Cephalgia 1986;6:247-255.
headaches in relation to temporomandibu¬
58. Forssell H: Mandibular dysfunction and
lar joint pain-dysfunction. Acta Odontol
headache. Thesis. Turku, Finland, Univer¬
Scand 1978;36:333-338.
sity of Turku. Finn Dent Soc 1985;81
50. Rieder C: The incidence of some occlusal (suppl 2).
habits and headaches/neckaches in an ini¬
59. Schokker RP, Hansson TL, Ansink BJJ:
tial survey population. J Prosthet Dent
Craniomandibular disorders in patients with
1976;35:445-451.
different types of headache. J Cranioman¬
51. Turner D, Stone A: Headache and its treat¬ dib Disord Facial Oral Pain 1990;4:47-51.
ment: A random sample survey. Headache 60. Schokker RP, Hansson TL, Ansink BJJ:
1979;19:74-77. The result of treatment of the masticatory
5 2. National Institute of Health Ad Hoc Com¬ system of chronic headache patients. J Cra¬
mittee on Classification of Headache. JAMA niomandib Disord Facial Oral Pain 1990;
1962;179:717-718. 4:126-130.

25
 ■ .

■
 THREE

Etiology

Most of the etiologic factors discussed in Many factors can affect the dynamic
this chapter can be considered to have balance or equilibrium between the com¬
merely an association with TMD. These ponents of the masticatory system.3 There
contributing factors thought to be clini¬ are numerous factors driving the equilib¬
cally relevant await future research to rium either toward normal or adaptive
document their etiologic significance. Be¬ physiologic health and function or
cause TMD are diverse and often multi¬ toward dysfunction and pathology. Bone
factorial, a universal etiology of TMD remodeling, TMJ soft tissue metaplasia,
does not exist. and muscle hypoactivity or hyperactivity
Factors that increase the risk of TMD are all adaptive physiologic responses to
are called predisposing. Factors that cause insult or change. Hyperactivity (hyper¬
the onset of TMD are called initiating. function) of the masticatory muscles, for
Factors that interfere with healing or en¬ example, from parafunction can affect the
hance the progression of TMD are called dynamic balance by biomechanically over¬
perpetuating. Individual factors, under loading the system contributing to long¬
different circumstances, may serve any or term adaptive reactions.3 Loss of struc¬
all of these roles.1-2 Long-term successful tural integrity, altered function, or
management usually depends on identi¬ biomechanical overloading in the system
fying the possible contributing factors can compromise adaptability and increase
and is often proportionate to the thor¬ the likelihood of dysfunction or pathol¬
oughness and accuracy of the initial ogy. Direct extrinsic trauma to any com¬
assessment. Thus, a comprehensive diag¬ ponent of the masticatory system can spon¬
nostic approach requires clinicians to taneously initiate loss of structural
understand all potential contributing fac¬ integrity and concomitant altered func¬
tors relevant to TMD and chronic orofa¬ tion thereby reducing the adaptive capac¬
cial pain. ity in the system. In addition, there are

27
Etiology

other contributing anatomic, systemic also been implicated as an etiologic fac¬

pathophysiologic, and psychosocial fac¬ tor.1*
tors that may sufficiently reduce the adap¬ Hyperextension injury with no direct
tive capacity of the masticatory system blow to the face is suggested as a possible
and cause TMD. cause of TMD.6-13 There is some evi¬
dence that TMD signs and symptoms are
higher with hyperextension-flexion inju¬
Trauma ry than in a noninjury controlled popula¬
tion,6 but a direct causal relationship has
At this time, there is evidence to support yet to be established.14 Braun et al6 have
trauma as an etiologic factor for a subset emphasized that most of the evidence in
of TMD. In fact, overt trauma and ad¬ hyperextension-flexion injuries is anec¬
verse loading from parafunction may cause dotal. Thus, the condition of mandibular
injury to the masticatory structures and sprain at the time of a motor vehicular
are often implicated as etiologic factors accident, without a direct blow to the
leading to TMD signs and systems. Overt mandible, resulting in hyperextension of
trauma that produces injury to the head, the mandibular capsule, ligaments, and
neck, or jaw can result from an impact masticatory muscles is questionable.5’14
injury.4-6 An injury while eating, yawn¬ Studies have shown that some patients
ing, singing, or from prolonged mouth with TMD have a cervical trauma history
opening or extensive stretching, as may prior to the onset of TMD.6 However,
occur during long dental appointments, some of these studies do not separate
may lead to or aggravate TMD signs or cervical hyperextension-hyperflexion in¬
symptoms. According to Pullinger and juries from other forms of cervical trau¬
Seligman7-8 38% to 79% of adults in dif¬ ma and the specific effects of this type
ferent diagnostic groups have a history of of injury on the TMJ are not discussed.
trauma compared to only 12% to 18% of This is an area of uncertainty in which
nonpatients. Another study reported that much misinformation is being provided
a physical event was found in half the to attorneys and patients without scien¬
number of patients with nonreducing disc tific studies to support the claims. This
displacement, compared with only 27% area is in need of clinical study and re¬
in the muscle disorder group.9 Katzberg search.
et al10 reported trauma as a cause of TMJ Another form of trauma has been hy¬
pain in 26% of pediatric TMD patients. pothesized to originate from sustained
Blows and abuse involving being struck in and repetitious adverse loading of the
the mandible by a fist or an object precip¬ masticatory system through postural im¬
itating TMJ noise and pain occur more balances or from oral and parafunctional
often in women than in men.11 Sports habits. It has been suggested that postural
injuries including glancing or direct blows habits such as forward head position or
in contact sports can initiate TMD most phone-bracing may create muscle and
often in the age range of 15 to 30 years. joint strain and lead to musculoskeletal
Iatrogenic trauma includes routine den¬ pain, including headache, in the TMD
tal procedures such as extraction of patient.15
teeth and cementation of crowns and Parafunctional habits such as teeth
fixed protheses especially on the man¬ clenching, tooth grinding, lip biting, and
dibular arch.4 Oral intubation for the ad¬ abnormal posturing of the jaw are com¬
ministration of general anesthesia has mon and usually do not result in TMD

28
 Trauma

symptoms. However, parafunctional hab¬ past injuries to the teeth are examples of
its have been suggested as initiating and/ possible structural factors.
or perpetuating factors in certain sub¬ The dental profession historically has
groups of TMD patients.16-27 The avail¬ viewed malocclusion as a primary eti-
able research and clinical observations ologic factor for TMD. Occlusal features
generally support this assumption; how¬ such as working and nonworking poste¬
ever, the exact role of parafunctional hab¬ rior contacts and discrepancies between
its in TMD remains somewhat unclear the retruded contact position (RCP) and
because few studies have directly assessed intercuspal position (ICP) have been com¬
these behaviors. Experimentally induced monly identified as predisposing, initiat¬
parafunction has been shown to cause ing, and perpetuating factors. However,
pain similar to that reported by patients reviews of the literature and recent stud¬
with TMD.28>29 The intensity and fre¬ ies do not strongly support the role of
quency of parafunctional jaw activity may anatomic etiologic factors.32^31 Skull
be exacerbated by stress and anxiety, sleep studies42-44 and studies of patients with
disorders, and medications (neuroleptics, osteoarthrosis45-50 have correlated loss
alcohol, and other substances)26; and in¬ of molar support with TMJ osteoarthrosis.
tense and persistent parafunction can oc¬ However, the incidence of both osteo¬
cur in patients with neurologic disorders, arthrosis and tooth loss increases with
such as cerebral palsy, and extrapyramidal age and, when age is controlled, the asso¬
disorders, such as orofacial dyskinesia and ciations vanish.51 Studies of living nonpa¬
epilepsy.30 tient populations do not provide evidence
Parafunctional habits have been most of an association between TMD and lost
frequently assessed by indirect means such molar support.52-59 Further, a literature
as self-report, questionnaires, reports by review did not reveal substantial evidence
a sleeping partner, or tooth wear. These that moderate changes (approximately 4
indirect measures of parafunctional hab¬ to 6 mm) in occlusal vertical dimension
its have provided conflicting reports as to (OVD) cause masticatory muscle hyper¬
the relationship between TMD symp¬ activity or TMD symptoms.60 Although
toms and the presence of parafunctional occlusal guidance has been mentioned
habits. The limitations of these measures as influential for TMD signs and symp¬
have recently been noted by Marbach et toms,21 the majority of studies have
al.31 Continued research with more direct not provided evidence for this associa¬
measurements of parafunction, ie, porta¬ tion.32*61-65
ble electromyography, sleep laboratory, Extensive overbite (vertical overlap of
and direct observation, will be necessary anterior teeth) was associated with joint
to clarify the specific role of parafunc¬ sounds62 and broad masticatory muscle
tion. tenderness,66 but most studies do not sup¬
port these associations.63*65*67-73 Reduced
overbite, in particular skeletal anterior
Anatomic Factors open bite, however, has been associated
with osteoarthrosis,46*74*75 and with rheu¬
Anatomic factors comprise maladaptive matoid arthritis.45*46
biomechanical relationships that can be Extensive overjet (horizontal overlap
genetic, developmental, or iatrogenic in of anterior teeth) is mentioned as associ¬
origin. Severe skeletal malformations, in¬ ated with TMD symptoms67*71 and osteo¬
terarch and intra-arch discrepancies, and arthrosis,74 but other studies fail to pro-

29
Etiology

vide evidence of overjet associations to Pathophysiologic Factors

TMD.37>62>63>65’68-70’72’73’76-78 Recently,
however, Seligman and Pullinger40 have All pathophysiologic factors primarily re¬
shown that overjet greater than 5 mm is flect systemic conditions and generally
very uncommon in a healthy nonpatient should be managed by the patient’s pri¬
population. mary physician or other medical special¬
Crossbite per se is not associated with ist. These can include degenerative,
TMD.37-39-62-70-72-76-79-81 However, while endocrine, infectious, metabolic, neoplas¬
a recent study has not found any evidence tic, neurologic, rheumatologic, and vas¬
that anterior or posterior bilateral cross¬ cular disorders. These factors can act
bite is associated with TMD, unilateral simultaneously on a central and local lev¬
maxillary posterior lingual crossbite was el .82>83 The interacting tissues may be
found to be more common in TMD pa¬ nonadjacent and dissimilar. For example,
tients.40 degenerative muscle changes can result
There is a suggestion that those oc¬ from intracapsular disease.84 It has been
clusal factors that are more prevalent in suggested that alterations in synovial flu¬
patients (large overjet, minimal overbite id viscosity and inadequate lubrication
and anterior skeletal open bite, unilateral may initiate clicking and derangement of
posterior crossbite, occlusal slides great¬ the TMJ.85 Synovial fluid analyses have
er than 2 mm, lack of firm posterior tooth attempted to correlate biochemical signs
contact) are possibly the result of condy¬ of inflammation with pain revealing abnor¬
lar positional changes following intra- mal concentrations of plasma proteins.86-87
capsular alterations associated with dis¬ Other studies have evaluated the degra¬
ease but are not the cause of the disease.40 dation of various enzymes, other meta¬
However, examination of isolated occlusal bolic by-products, as well as the type of
factors, the valuative technique in the vast pain transmitters causing pain, inflam¬
majority of past studies, is artificial and mation, and degeneration in the TMJ.88-89
misleading and no doubt partially ac¬ Joint laxity has been cited as a possible
counts for past confusion. Furthermore, contributing factor to TMD.90-91 Sys¬
whether considered individually or simul¬ temic joint laxity has been shown to be
taneously, little evidence is available that significantly more prevalent in patients
occlusal and other associated factors that with articular disorders than with other
are traditionally implicated in TMD eti¬ TMD or with normal controls. Also, sys¬
ology (ie, Angle malocclusions, deep over¬ temic joint laxity is significantly more
bite, minimal overjet, severe attrition, an¬ prevalent in female than male adoles¬
terior and bilateral posterior crossbite, cents.92 Research has yet to demonstrate
condyle position, discrepancy between that the differences in populations can
RCP and ICP, and unilateral RCP con¬ predict the potential of TMD.93 Further¬
tacts) merit that association. Thus, stud¬ more, physiologic response appears to be
ies to date suggest that occlusion is likely variable and individual;94
to be of secondary importance as a factor, Of great concern to the diagnostician is
exacerbating symptoms once TMD has the distinction between pathologic and
become established for other reasons. Fu¬ adaptive responses to disease. Histologic
ture scientifically controlled longitudinal studies suggest that cartilage thickness is
epidemiologic studies are required to val¬ a response to functional loading95-98 and
idate a relationship between occlusion usually smooths radiographically observed
and TMD. bony irregularities through articular-sur-

30
 Pathophysiologic Factors

face soft tissue remodeling.99-100 Even to patients with lower back pain and
when cartilage was absent, loss of the headache.112 However, one recent study
fibrous connective-tissue covering of the found that TMD patients were not signif¬
articular bone was not observed. Thus, icantly different from other pain patients
maintenance of an intact articular surface or healthy controls in personality type,
is to be expected, even in the face of response to illness, attitudes toward
osteoarthrosis.57 This allows for both pos¬ health care, or ways of coping with
tural stability and histologic compatibil¬ stress.113
ity between the articulating components. It is important to note that anxiety and
Morphologic change, therefore, while depression may not only result from and
mostly irreversible, usually achieves and predispose patients to TMD, but that
maintains stability and should be consid¬ patients may present with mental disor¬
ered adaptive. The proper goal of treat¬ ders unrelated to TMD.114-115 Mental dis¬
ing arthrosis in this light should not be to orders are syndromes of psychologic or
restore normal morphology but to en¬ organic origin that impair adaptive func¬
courage the body’s adaptive response to tioning in areas of emotion, perception,
pathophysiologic processes. cognition, behavior, and/or interperson¬
al adjustment. The clinical features of
mental disorders have been outlined by
Psychosocial Factors the American Psychiatric Association’s
DSM-IIIR.116 Diagnostic criteria for psy¬
Psychosocial factors include individual, in¬ chotic syndromes, mood disturbances,
terpersonal, and situational variables that anxiety disorders, organic mental dis¬
impact the patient’s capacity to function orders, and somatoform disorders are
adaptively. As a group, TMD and orofa¬ described. Somatization disorders, con¬
cial pain patients are significantly dis¬ version disorders, psychogenic pain dis¬
similar both culturally and economically orders, hypochondriasis, and atypical so¬
so the relevant psychosocial factors pres¬ matoform disorders are classified among
ent with tremendous diversity. However, the somatoform disorders. While the re¬
individual TMD patients may have per¬ lationship of mental disorders to TMD
sonality characteristics or emotional con¬ awaits research documentation, clinical
ditions that make managing or coping reports suggest that the psychologic con¬
with life situations difficult.35-41-101-105 flicts and emotional distress of pre-exist¬
There is evidence that some patients with ing psychiatric conditions may contrib¬
TMD experience more anxiety than do ute to the etiology and exacerbation of or
healthy control groups and that the TMD be intensified in response to TMD condi¬
symptoms may be only one of several tions.117-119
somatic manifestations of emotional dis¬ Environmental contingencies can great¬
tress.106-108 These patients often have ly complicate treatment by affecting an
a history of other stress-related disor¬ individual’s perception of and responses
ders.109 Depression and anxiety related to to pain and disease. Some patients may
other major life events may alter the pa¬ experience a lessening of distress to the
tient’s perception of and tolerance for extent that psychogenic symptoms de¬
physical symptoms, causing them to seek crease or resolve pre-existing psychologic
more care.24-105-110-111 Chronic TMD pa¬ and interpersonal conflicts. This primary
tients have been found to have psychoso¬ gain of symptom formation is to be dis¬
cial and behavioral characteristics similar tinguished from the secondary gain of so-

31
Etiology

cial benefits experienced by patients once 3. Parker MW: A dynamic model of etiology
a disorder is established.120-123 Second¬ in temporomandibular disorders. J Am
Dent Assoc 1990;120:283-289.
ary gain includes being exempt from or¬
dinary daily responsibilities, being com¬ 4. Harkins SJ, Marteney JL: Extensive trau¬
pensated monetarily from insurance or ma: A significant precipitating factor in
litigation, using the rationalization of temporomandibular dysfunction. J Pros¬
thet Dent 1985:271-272.
“being ill” to avoid unpleasant tasks, and
gaining attention from family, friends, or 5. Burgess J: Symptom characteristics in
health care workers.124 TMD patients reporting blunt trauma
The use of alcohol, minor tranquilizers, and/or whiplash injury. J Craniomandib
Disord Facial Oral Pain 1991;5:251-257.
narcotics, barbiturates, and other phar¬
maceuticals contributes substantially to 6. Braun BL, Di Giovanna A, Schiffman E,
the chronicity of many TMD patients. Bonnema J, Fricton J: A cross-sectional
Every clinical assessment should pay care¬ study of temporomandibular joint dys¬
function in post-cervical trauma patients.
ful attention to possible concurrent alco¬
J Craniomandib Disord Facial Oral Pain
holism or addiction in this patient group.
1992;6:24-31.
The chemical dependency problems and
pharmacologically induced depressions 7. Pullinger AG, Seligman DA: TMJ osteo¬
arthrosis: A differentiation of diagnostic
among TMD and chronic pain patients
subgroups by symptom history and de¬
are frequently overlooked aspects that
mographics. J Craniomandib Disord Fa¬
account for refractory responses to oth¬
cial Oral Pain 1987;1:251-256.
erwise excellent treatment approaches.
8. Pullinger AG, Seligman DA: Trauma his¬
Thus, psychosocial factors may predis¬
tory in diagnostic groups of temporo¬
pose certain individuals to TMD and may
mandibular disorders. Oral Surg Oral
also perpetuate TMD once symptoms
Med Oral Pathol 1991;71:529-534.
have become established. A careful con¬
9. Isacsson G, Linde C, Isberg A: Subjective
sideration of psychosocial factors is there¬
symptoms in patients with temporomandi¬
fore important to the diagnostic evalua¬
bular joint disk displacement versus pa¬
tion and treatment of every TMD pa¬
tients with myogenic craniomandibular
tient. disorders. J Prosthet Dent 1989;61:70-77.
10. Katzberg R, Tallents R, Hayakawa K,
Miller T, Goske M, Wood B: Internal
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38
 FOUR

Diagnostic Classification

Diagnostic Process Disorders (AACD) has collaborated with

these organizations to include TMD in
The first well-known classification of the diagnostic classification.3
headache was proposed by the Ad Hoc A TMD classification system that is
Committee on Classification of Head¬ integrated with an existing medical diag¬
ache (AHCCH)1 of the National Institute nostic classification system facilitates com¬
of Neurological Diseases and Blindness. munication and shared responsibility
This classification provided general guide¬ among dentists, physicians, and allied
lines for categorizing headaches based on health care providers. Because of the mul¬
clinical symptomatology. Because of short¬ titude of disease entities that present with
comings in the AHCCH system, the similar pain patterns in the head and neck
International Headache Society (IHS) es¬ region, dentists must consider diseases
tablished a committee in 1987 to reclas¬ unrelated to the masticatory system in
sify headaches. This committee devel¬ their differential diagnosis. Likewise, phy¬
oped more specific criteria to provide sicians evaluating craniofacial pain must
greater uniformity and reproducibility in also consider odontogenic pain and TMD
headache diagnosis. This system was pub¬ in their differential diagnosis.
lished as the first edition of Classification The diagnostic process is a clinical skill
and Diagnostic Criteria for Headache Disor¬ in which both art and science are wed.4
ders, Cranial Neuralgias and Facial Pain The goals of the process are to determine
(see Flowchart).2 This was the first major the primary and any secondary physical
attempt to reclassify headache syndromes or mental diagnoses, the contributing fac¬
since the AHCCH’s criteria were pub¬ tors, and the level of complexity of the
lished in 1962. The American Academy patient’s problem(s) including the prog-
of Orofacial Pain (AAOP), formerly the nosis(es).5-6 A problem list that identifies
American Academy of Craniomandibular conditions or problems that may be

39
Diagnostic Classification

International Headache Society Recommended Diagnostic

Classification* for
Classification for Headache Disorders,
11 Headache or facial pain associated
Cranial Neuralgias, and Facial Pain* **
with disorders of cranium, eyes,
ears, nose, sinuses, teeth, mouth,
1. Migraine headache or other facial or cranial structures
2. Tension-type headache 11.1 Cranial bones including
3. Cluster headache and chronic mandible
paroxysmal hemicrania 11.2 Neck
4. Miscellaneous headaches, unasso¬ 11.3 Eyes
ciated with structural lesion
11.4 Ears
5. Headache associated with head
11.5 Nose and sinuses
trauma
11.6 Teeth and related oral
6. Headache associated with vascular
structures
disorders
11.7 Temporomandibular joint
7. Headache associated with non-
vascular intracranial disorders 11.8 Masticatory muscles
8. Headache associated with
substances or their withdrawal
9. Headache associated with non-
cephalic infection
10. Headache associated with
metabolic disorder
11. Headache or facial pain associated
with disorder of cranium, neck,
eyes, ears, nose, sinuses, teeth,
mouth, or other facial or cranial
structures
12. Cranial neuralgias, nerve trunk
pain, and deafferentation pain
13. Headache not classifiable

* Cephalgia, vol 8, supplement 7, 1988, Norwegian University Press, Publications Expediting Inc, or PO Box 2459
Tolyen 0609 Oslo 6, Norway.

** Adapted from American Academy of Craniomandibular Disorders, C. McNeill (ed): Craniomandibular Disorders:
Guidelines for Evaluation, Diagnosis, and Management. Chicago, Quintessence PubI Co, 1990.
 Diagnostic Process

Recommended Diagnostic Classification** for

11.1 Cranial bones including the mandible
11.1.1 Congenital and developmental disorders
11.1.1.1 Aplasia
11.1.1.2 Hypoplasia
11.1.1.3 Hyperplasia
11.1.1.4 Dysplasia
11.1.2 Acquired disorders
11.1.2.1 Neoplasia
11.1.2.2 Fracture

Recommended Diagnostic Classification** for

11.7 Temporomandibular joint disorders
11.7.1 Deviation in form
11.7.2 Disc displacement
11.7.2.1 Disc displacement with reduction
11.7.2.2 Disc displacement without reduction
11.7.3 Dislocation
11.7.4 Inflammatory conditions
11.7.4.1 Synovitis
11.7.4.2 Capsulitis
11.7.5 Arthritides
11.7.5.1 Osteoarthrosis
11.7.5.2 Osteoarthritis
11.7.5.3 Polyarthritides
11.7.6 Ankylosis
11.7.6.1 Fibrous
11.7.6.2 Bony

Recommended Diagnostic Classification** for

11.8 Masticatory muscle disorders
11.8.1 Myofascial pain
11.8.2 Myositis
11.8.3 Spasm
11.8.4 Protective splinting
11.8.5 Contracture
11.8.6 Neoplasia__

41
Diagnostic Classification

responsible for each of the presenting intensity, pain-related disability, depres¬

complaints of the patient, as well as other sion, and nonspecific physical symptoms.
factors that may contribute to the com¬
plexity of the tentative diagnoses, usually
facilitates the process. The diagnostic pro¬ Differential Diagnosis of
cess involves ruling out specific disorders Orofacial Pain
from a diagnostic classification that in¬
cludes all possible disorders that can cause Orofacial pain can be associated with pa¬
similar symptoms. It is important to rule thology or disorders related to intracra¬
out serious, life-threatening intracranial nial and extracranial structures (includ¬
or extracranial disorders or diseases early ing TMD) and neurovascular, neuropathic,
in the diagnostic process as these condi¬ and psychogenic pain disorders (Fig 4-1).
tions may require immediate care. Atten¬
tion is then directed toward odontogenic,
Intracranial and Extracranial
TMD, and other sources of pain until the
correct diagnosis(es) is(are) established Structures
using inclusive diagnostic criteria. The Disorders of the intracranial structures,
process of differential diagnosis is critical eg, neoplasm, aneurysm, abscess, hemor¬
because an incorrect or omitted diagnosis rhage or hematoma, and edema should be
is one of the most frequent causes of considered first in the differential diag¬
treatment failure. nosis because they can be life threatening
Establishing the correct diagnosis in and may require immediate attention. The
patients with chronic TMD and orofacial characteristics of serious intracranial dis¬
pain is particularly difficult because of the orders include new or abrupt onset of
complex interrelationship of somatic and pain or progressively more severe pain,
psychosocial factors in the etiology of interruption of sleep by pain, and pain
chronic pain syndromes. Many disorders precipitated by exertion or positional
in this category have similar signs and change (ie, coughing, sneezing). Also,
symptoms and there is a high frequency weight loss, ataxia, weakness, fever with
of multiple diagnoses. If the source of pain, and neurologic signs or symptoms
painful symptoms is uncertain, the ap¬ (eg, seizure, paralysis, vertigo) and neu¬
propriate diagnosis is “pain, cause rologic deficits are characteristic of intra¬
unknown or undetermined.” Although in¬ cranial disorders.9 Besides masticatory
dividual clinicians are successful in diag¬ structures and TMD, other extracranial
nosing the more simple TMD problems, structures and disorders should also be
a team approach is often required for suspected as the source of orofacial pain.
diagnosing and managing complex chron¬ This includes disorders of the dental pulp,
ic TMD problems, especially when psy¬ periodontium, mucosa, tongue, salivary
chologic disorders may be present.7 To glands, lymph tissues, sinuses, eyes, ears,
facilitate this approach, Dworkin8 sug¬ nose, and throat. When doubt exists about
gested a multiaxial diagnostic system that
a specific diagnosis, consultation with an
develops concurrent physical, mental, and appropriate specialist is essential.
social conditions into two axes. Axis I
includes the TMD clinical diagnoses, and
axis II provides assessment and classifica¬ Neurovascular Disorders
tion of nonpathophysiologic components Neurovascular disorders associated with
of TMD pain conditions in terms of pain orofacial pain include migraine headache,

42
 Differential Diagnosis of Orofacial Pain

Differential Diagnosis of Orofacial Pain

Intracranial structures
• Neoplasm, aneurysm, abcess, hemorrhage, hematoma, edema
Extracranial structures
• Temporomandibular disorders, other craniofacial disorders, cervical disorders
Neurovascular disorders
• Migraine, migraine variants, cluster headache, paroxymal hemicrania, cranial
artertis, carotidynia

Neuropathic pain disorders

• Paroxysmal neuralgias
Trigeminal, glossopharyngeal, nervus intermedius, superior laryngeal neuralgias
• Continuous pain disorders
Deafferentation pain syndromes (peripheral neuritis, postherpetic neuralgia,
posttraumatic and postsurgical neuralgia)
• Sympathetic maintained pain

Psychogenic pain disorders

• Psychotic syndromes, mood disturbances, anxiety disorders, organic disorders,
somatoform disorders

Fig 4-1 The diagnostic process involves ruling out specific disorders that may be responsible for
each of the presenting complaints of the patient. From a diagnostic classification this includes
disorders of the intracranial and extracranial structures, neurovascular disorders, neuropathic pain
disorders, and psychogenic pain disorders.

migraine variants, cluster headaches, cra¬ tic criterion to separate migraine without
nial arteritis, and carotidynia. The usual aura from episodic tension-type head¬
description of vascular pain is a throbbing, ache. The site of pain in migrainous head¬
pulsating, or beating pain. Migraine head¬ aches is most frequently in the orbital,
aches can be subdivided into migraine frontal, or temporal regions, but facial
with aura (classic) and migraine without migrainous headaches also occur. The term
aura (common migraine). Migraine with mixed muscular-vascular (combination)
aura headaches characteristically are one¬ headache is being eliminated in favor of
sided and have a prodromal vasoconstric¬ both migraine and tension-type headache
tion phase with visual aberrations. This is being individually coded for patients with
followed by vasodilation of the affected coexisting conditions.2 However, recent¬
arteries resulting in throbbing (pulsating) ly a vascular-supraspinal-myogenic mod¬
pain lasting 4 to 72 hours with frequently el for pain in migraine has been proposed
accompanying nausea and/or vomiting based on the theory that headache inten¬
and phonophobia and photophobia.10 Mi¬ sity is determined by the sum of nocicep¬
graine without aura headaches are similar tion from cephalic arteries and pericra¬
to classic migraines, but proceed into a nial myofascial tissues converging on the
headache without prodromata. At least same neurons and integrated with supra¬
five attacks are required as a diagnos¬ spinal effects (usually facilitating) of

43
Diagnostic Classification

somatovisceral afferents on nucleus cau- misdiagnosed as a muscular disorder when

dalis neurons.11 Migraine with aura vari¬ the temporal artery is involved. The dan¬
ants include ophthalmoplegic, retinal, ger of delayed diagnosis is that when there
basilar, and hemiplegic migraines. Oph¬ is involvement with the ophthalmic ar¬
thalmoplegic and hemiplegic migraines tery, subsequent blindness can occur. Ca¬
are severe variations of classic migraine. rotidynia is a vascular disorder character¬
The symptoms are accompanied by ocu¬ ized by throbbing pain in the distribution
lar motor nerve palsy and/or partial or of the external carotid artery, usually in
complete paralysis of motor function. Reti¬ the neck and face.15 Palpation of the ar¬
nal migraine is described as repeated at¬ tery may reproduce the symptoms and
tacks of monocular scotoma or blindness project ipsilateral pain to the head. Other
lasting less than an hour. headaches that can resemble migraine
Cluster headache, also known as Hor¬ headaches may be related to many differ¬
ton’s headache or histaminic neuralgia, ent causes of vasodilation with associated
and chronic paroxysmal hemicrania are throbbing pain (ie, altitude sickness, over¬
similar to migrainous pain but are much exertion, dehydration, dialysis, certain
more intense and of shorter duration than allergens, caffeine, alcohol, and certain
is migraine pain. The pain is usually re¬ chemicals).
ported as unilateral, excruciating, throb¬
bing pain behind the eyes that occurs in
clusters of days to weeks with periods of
Neuropathic Pain Disorders
remission of months to years. The head¬ Neuropathic pain disorders can be di¬
aches can be provoked by alcohol, hista¬ vided into two main categories of painful
mine, or nitroglycerine. Cluster head¬ conditions: paroxysmal and continuous.16
ache frequently presents characteristic The paroxysmal conditions causing oro¬
autonomic effects, ie, nasal congestion, facial pain include trigeminal neuralgia,
lacrimation, conjunctival injection, edema glossopharyngeal neuralgia, nervous in-
of the eyelids and face on the affected termedius neuralgia, and superior laryn¬
side, that are commonly referred to as geal neuralgia.17 Occipital neuralgia is
Horner’s syndrome.12-13 Cluster headaches not listed because the characteristic pain
are 10 to 50 times less common than are is located in the back of the cranium
migraine headaches and are found at least above the nuchal line rather than in the
5 to 6 times more frequently in men than orofacial region. The common paroxys¬
in women.14 Chronic paroxysmal hemi¬ mal pain attack follows a distinct uni¬
crania are similar to cluster headaches but lateral course and is described as electric¬
they are shorter lasting, more frequent, like, stabbing, or shooting pain. Attacks
occur mostly in women, and remit imme¬ occur intermittently lasting for seconds
diately in response to indomethacin ad¬ to minutes with remissions for days,
ministration. months, or even years. Stimulation of a
Headaches associated with other vas¬ trigger zone within the distribution of the
cular disorders that can be related to oro¬ affected nerve sets off a volley of pain
facial pain include cranial arteritis and attacks. Trigeminal neuralgia (tic doulou¬
carotidynia. Cranial arteritis (temporal ar¬ reux) commonly involves the maxillary
teritis) is a giant-cell inflammatory dis¬ and/or mandibular division of the fifth
ease of the carotid artery system (vas¬ cranial nerve which causes pain in the
culitis) and is rarely seen in people under area of the distribution of either division
50 years of age. The problem can easily be of the trigeminal nerve.18 Glossopharyn-

44
 Differential Diagnosis of Orofacial Pain

geal neuralgia is less common than is tri¬ pain initiated by trauma of a major pe¬
geminal neuralgia. Cutaneous trigger ripheral nerve.23 Because disruption of
points are less common but, if present, the normal pathway that connects the
are localized around the ear. Ordinary neural elements of the dental pulp to the
functions like coughing, chewing, swal¬ central nervous system occurs routinely
lowing, and talking may trigger pain. The with pulp extirpation during endodontic
pain is generally located in the ear, tonsil¬ procedures and dental extraction, deaf¬
lar area, throat, and pharynx.19 Nervus ferentation is an important consideration
intermedius (geniculate) neuralgia is rare in the differential diagnosis of unrelent¬
and is described as a lancinating “hot ing odontogenic pain.
poker” in the ear.20 The trigger area is Sympathetically maintained pain refers
usually in the external auditory canal. to a specific group of painful disorders
Superior laryngeal neuralgia is also a rare precipitated by an injury to peripheral
disorder characterized by severe pain in tissues and sustained by neural mecha¬
the lateral aspects of the throat, subman¬ nisms that include sympathetic efferent
dibular region, and underneath the ear, activity.24 The existence of this condition
precipitated by swallowing, shouting, or has been unequivocally demonstrated by
turning the head.2 sympathetic blockade (stellate ganglion
The continuous neuropathic pain dis¬ block) producing immediate and com¬
orders associated with orofacial pain are plete relief of pain.25 There appears to be
primarily deafferentation pain syndromes (pe¬ some evidence that atypical odontalgia
ripheral postherpetic neuralgia, posttrau- may be a sympathetically maintained
matic and postsurgical neuralgia) and sym¬ pain.26 The term reflex sympathetic dystro¬
pathetically maintained pain conditions. The phy has been used when the sympathet¬
pain is usually described as a persistent, ically maintained pain is accompanied by
ongoing, unremitting burning sensation. progressive autonomic dysfunction, ie,
Patients frequently report abnormal sen¬ changes in cutaneous temperature, color,
sations (dyesthesias) that are exacerbated texture, and perspiration followed by tro¬
by movement or touch. Deafferentation phic changes in the skin, muscle, and
pain can occur as a result of inflamma¬ bone.27
tion, compression, distortion, demyeli-
nation, infarction, or paralysis of a nerve
Psychogenic Pain Disorders
trunk. Referred pains and other central
excitatory effects do not occur.21 One com¬ Stressful life events, such as conflicts
mon neuropathic pain condition, post¬ in home or work relationships, financial
herpetic neuralgia, is usually a constant, problems, and cultural readjustment may
intense, unilateral burning pain with hy¬ contribute to illness and chronic pain.28-29
peresthesia that occurs after clearing of These stressors may heighten tensions,
the herpes zoster virus from a peripheral insecurities, and dysphoric effects that
nerve or dorsal root ganglion.22 Post- may in turn lead to increased adverse
traumatic and postsurgical (anesthesia do¬ loading of the masticatory system as psy¬
lorosa) neuralgias are described as a con¬ chic “stress,” which is converted to mus¬
tinuous tingling, numbness, twitching, or cle “tension” and increased parafunctional
prickly sensation. This deafferentation behaviors. Once established, these ad¬
pain results from damage to the nerve by justment reactions (often with mixed
trauma or surgery. The term causalgia has disturbance of emotions and conduct)
been used in the past for deafferentation can further exacerbate the physical

45
Diagnostic Classification

condition in a reverberating circuit Diagnostic Classification

of somatopsychic-psychosomatic prob¬
lems.30-31 System for TMD
Depression, anxiety, and prolonged neg¬ Defining most TMD that produce mus¬
ative feelings are common among chronic culoskeletal pain and dysfunction has been
pain patients and may make the persistent difficult due to the lack of clear etiologic
pain more difficult to tolerate or man¬ factors and knowledge regarding the nat¬
age.28-32 Individuals who unconsciously ural progression of TMD, as well as the
tend toward somatic expressions of emo¬ lack of homogeneity of the patient popu¬
tions and conflicts are thought to be at lation. However, as previously mentioned,
higher risk of developing psychogenic so¬ the American Academy of Orofacial Pain
matic symptoms, including TMD, through has developed a well-defined diagnostic
increased autonomic nervous system classification for TMD that is to be added
arousal, chronic muscle tension, and neu- to the Classification and Diagnostic Cri¬
roendocrinologic activation.33-34 Nega¬ teria for Headache Disorders, Cranial
tive cognitive factors, such as counter¬ Neuralgias and Facial Pain by the Inter¬
productive thoughts or attitudes, can national Headache Society (IHS).3 This
make resolution of the illness more diffi¬ effort will help to emphasize the role of
cult.35-36 Confusion and misunderstand¬ TMD in headache and orofacial pain.
ing are commonly seen in chronic pain With the TMD diagnostic classification
patients because they often have received integrated within the existing medical di¬
many opposing and varied opinions, di¬ agnostic system, it is hoped that more
agnoses, and treatment suggestions. This accurate differential diagnoses can be es¬
confusion reduces motivation and in¬ tablished. However, some confusion still
creases anger or noncompliance. Also, exists, particularly in distinguishing the
patients with persistent pain often muscle pain disorders (tension headache,
have unrealistic expectations and may mixed muscular-vascular headache, myo¬
expect complete or immediate pain re¬ fascial pain, fibromyalgia, and mastica¬
lief.32 tory muscle disorders).39
It is to be emphasized that mental dis¬ Temporomandibular disorders are list¬
orders and TMD are not mutually exclu¬ ed in the diagnostic classification of the
sive conditions.37 On the one hand, indi¬ IHS under the 11th major classification,
viduals with psychiatric disturbances may namely, headache or facial pain associated
have bonafide TMD. Conversely, the lack with disorders of the cranial bones, neck,
of clear organic findings in patients with eyes, ears, nose, sinuses, teeth, mouth, or
persistent symptoms of TMD is insuffi¬ other facial or cranial structures (see Flow¬
cient to impute a psychogenic origin to chart). Temporomandibular disorders are
these complaints. The diagnosis of psy¬ divided into disorders of the cranial bones
chogenic pain requires the presence of including the mandible (IHS Classifica¬
specific signs and symptoms and should tion 11.1), temporomandibular joint dis¬
never be based on the exclusion of organ¬ orders (IHS Classification 11.7), and
ic disease alone. When psychosocial fac¬ masticatory muscle disorders (IHS Clas¬
tors are prominent in the patient’s pre¬ sification 11.8). The International Clas¬
sentation, collaboration with a mental sification of Diseases, 9th Revision,
health professional should be an integral Clinical Modification Codes (ICD.9.CM),
dimension of assessment and manage¬ required by medical insurance, are given
ment.38 for each specific TMD.40

46
 Diagnostic Classification System forTMD

Disorders of the Cranial Bones development of the cranial bones and man¬
and Mandible dible, eg, Treacher-Collins syndrome.42
Condylar hypoplasia can be secondary to
Disorders of the cranial bones and man¬ trauma.
dible include aplasia (agenesis), hypoplasia, Hyperplasia (ICD.9.CM 526.89) Hy¬
hyperplasia, dysplasia, neoplasia, and frac¬ perplasia is the overdevelopment of the
ture (see Flowchart). Lesions and disor¬ cranial bones or mandible, which can be
ders of the jaws can be of either odon¬ congenital or acquired. It is a nonneoplas¬
togenic or nonodontogenic origin and tic increase in the number of normal cells.
can be of generalized or metastatic na¬ It can occur as a localized enlargement,
ture. Most disorders of the cranial bones ie, condylar hyperplasia or coronoid hy¬
and mandible are congenital or develop¬ perplasia, or as an overdevelopment of
mental disorders and are rarely accom¬ the entire mandible or side of the face 43
panied by orofacial pain. They are pri¬ Excessive size of the mandible is termed
marily disorders that cause problems with mandibular prognathism, which results in
esthetics or function. Acquired disorders protrusion of the chin with no abnormality
such as neoplasia (eg, osteomyelitis, mul¬ of condylar size, shape, or function.
tiple myeloma, Pagets’ disease) and man¬ Dysplasia (ICD.9.CM 526.89) Fibrous
dibular fracture can be a source of pain. dysplasia is a benign slow-growing swell¬
ing of the mandible and/or maxilla char¬
Congenital or Developmental acterized by the presence of fibrous con¬
Disorders nective tissue44 with a characteristic
Aplasia (ICD.9.CM 754.0) Aplasia is whorled pattern and containing trabecu¬
a faulty or incomplete development of the lae of immature nonlamellar bone.45 Ra¬
cranial bones or mandible. Almost all apla¬ diographically the lesion may appear var¬
sia of the mandible belong to the group of ied, from an opaque ground-glass to a
anomalies commonly known as hemifa¬ lucent appearance, depending on the ratio
cial microsomia or first and second bran¬ of fibrous tissue to bone. There is usually
chial arch syndromes. The most common no displacement of teeth, the cortical bone
developmental defect is the lack of growth remains intact, and the occlusion of the
of the condyle, usually resulting from dental arches remains undisturbed. The
incomplete development of the primor- disease occurs particularly in children and
dium of the condyle embryologically; in young adults and usually becomes inac¬
this case there is little to no articular fossa tive when they reach skeletal maturity.
and a rudimentary or absent eminence.
The auditory apparatus is frequently af¬ Acquired Disorders
fected. The complete congenital absence Neoplasia (ICD.9.CM 213.1 [benign];
(agenesis) of the mandible or maxilla is 170.1 [malignant]) Neoplasia is a new,
extremely rare.41 abnormal, and uncontrolled growth of
Hypoplasia (ICD.9.CM 526.89) Hy¬ the cranial bones or mandible. Neoplasia
poplasia is the incomplete development includes benign, malignant, and meta¬
or underdevelopment of cranial bones or static tumors. Benign tumors, ie, osteo¬
mandible that is congenital or acquired. ma, chondroma, osteoblastoma, chondro¬
The growth is considered to be normal blastoma, ameloblastoma, and synovial
although proportionately reduced. It is chondromatosis are most commonly found
less severe in degree than is aplasia. Many in the TMJ. Malignant tumors, ie, osteo¬
craniofacial anomalies include incomplete sarcoma, Ewing’s sarcoma, chondrosar-

47
Diagnostic Classification

coma, fibrosarcoma, adenocarcinoma do condylar positions on opening and closing

exist but are exceedingly rare. Approx¬ of the mandible.51
imately 1% of malignant neoplasia metas¬
tasize to the jaws.46’47 Diagnostic criteria
Fracture (ICD.9.CM 802.21 [condy¬
lar process]) Extrinsic traumatic force 1. Complaint of faulty or compromised
can injure all related bony components of joint mechanics (eg, joint noise, in¬
the masticatory system (ie, temporal bone, termittent locking, or dislocation)
maxilla, zygoma, sphenoid bone, and man¬ 2. Reproducible joint noise usually at
dible) possibly causing the following: frac¬ same position during opening and
ture, dislocation, contusion, and/or lacera¬ closing mandibular movements
tion of articular surfaces, ligaments, and 3. Radiographic evidence of mild struc¬
disc, with or without hemarthrosis intraar- tural bony abnormality or loss of nor¬
ticularly. Sequelae could include adhe¬ mal shape may also exist
sions, ankylosis, or joint degeneration.48

Disc Displacement (ICD.9.CM 524.63)

Joint Disorders
Articular disc displacement is the most
Temporomandibular joint disorders can be common TMJ arthropathy and is charac¬
divided into articular disorders related to terized by several stages of clinical dys¬
deviation inform, articular disc displacement, function that involve the'condyle-disc re¬
dislocation, inflammatory conditions, arthri- lation. It is characterized by an abnormal
tides, and ankylosis3 (see Flowchart). These relation or misalignment of the articular
subclassifications are similar to disorders disc and condyle.52-56 Although poste¬
in other synovial joints in the body even rior57 and mediolateral58-60 displacements
though the articular surfaces of the tem¬ of the articular disc have been described,
poromandibular joint are covered with the usual direction for displacement is in
noninnervated, avascular fibrous connec¬ an anterior or anteromedial direction.61*62
tive tissue as opposed to hyaline cartilage. The causes of disc displacement are not
agreed upon; however, it is postulated
Deviation in Form (ICD.9.CM 524.69) that in a majority of cases the disc is
Deviation in form is described as painless permitted to be displaced by stretched or
mechanical dysfunction or altered func¬ torn ligaments that bind the disc to the
tion due to irregularities or aberrations in condyle.63 A recent study associated an
form of intracapsular soft and hard artic¬ increased horizontal angle of the mandib¬
ular tissues. It can occur because of devel¬ ular condyle and internal derangement of
opmental or acquired conditions, which the TMJ. The condylar angle was in¬
include physiologic remodeling related creasingly larger with more advanced
to adverse loading.49*50 When a develop¬ pathologic changes.64 Disc displacement
mental process causes an anatomic devia¬ is subdivided into disc displacement with
tion in form or an acquired remodeling reduction or disc displacement without
process causes a loss of integrity in the reduction.
articular surfaces, a mechanical interfer¬ Disc Displacement With Reduction Disc
ence clinically manifested as joint sounds displacement with reduction is described
on function may result. The condition is as an abrupt alteration or interference of
nonpainful and the resultant asymptom¬ the disc-condyle structural relation dur¬
atic joint sounds usually occur at the same ing mandibular translation with mouth

48
 Diagnostic Classification System for TMD

opening and closing. From a closed mouth Diagnostic criteria

position the “temporarily” misaligned disc
reduces or improves its structural rela¬ 1. Pain, when present, is precipitated by
tion with the condyle when mandibular joint movement.
translation occurs with mouth opening, 2. Reproducible joint noise occurs usu¬
which produces a joint noise (sound) de¬ ally at variable positions during open¬
scribed as clicking or popping. Disc dis¬ ing and closing mandibular move¬
placement with reduction usually is char¬ ments.
acterized by what is termed reciprocal 3. Soft tissue imaging reveals displaced
clicking, a reciprocal noise that is heard disc that improves its position during
during the opening movement and again jaw opening.
just before the teeth occlude during the
closing movement. The closing noise is Disc Displacement Without Reduction
usually of less magnitude and is thought Disc displacement without reduction is
to be produced by the displacement, once described as an altered or misaligned
again, of the disc. The momentary jam¬ disc-condyle structural relation that is
ming or misalignment of the disc has maintained during mandibular transla¬
been theorized to be due to articular sur¬ tion. Thus, the disc is nonreducing or
face irregularity, disc-articular surface ad¬ “permanently” displaced and does not
herence, synovial fluid degradation, disc- improve its relation with the condyle on
condyle incoordination as a result of translation; in fact, the relation may be¬
abnormal muscle function, increased mus¬ come worse. It sometimes is referred to as
cle activity across the joint, or disc defor¬ a “closed lock”. When acute, it is usually
mation. Because disc displacement with painful and is characterized by sudden
reduction is so common, it is reasonable and marked limited jaw motion because
to consider the disorder as a physiologic of a jamming or fixation of the disc sec¬
ondary to disc adhesion, deformation, and/
adaptation that develops an important
or dystrophy.70 It is manifested clinically
equilibration of force distribution and
as a straight line deviation to the affected
does not necessarily represent a patho¬
side on opening, a marked limited lat-
logic response.65-68 Thus, TMJ dysfunc¬
erotrusion to the contralateral side, and a
tion (asymptomatic clicking) itself does
lack of joint noise. Disc displacement with¬
not warrant treatment.69
out reduction is often associated with overt
Pain, if present, is precipitated by joint
trauma and, when acute, the accompany¬
movement and usually occurs at the time
ing pain is exacerbated by function. As
of the disc reduction. Painful disc dis¬
the condition becomes chronic, the pain
placement with reduction is thought to
is markedly reduced from the acute stage
be due to gross injury that results in
to the point of becoming nonpainful in
stretching or tearing of the disc ligaments
many cases, and the opening range may
and/or capsule of the joint. As the condi¬
approach normal dimensions over time.
tion becomes more chronic or as the disc
If chronic, there usually is a history of
becomes further displaced, it begins to
joint noise and/or limitation of mandibu¬
interfere later in the translating (open¬
lar opening.71-72
ing) movement. Previously used terms
for this condition include internal de¬ Diagnostic criteria (acute)
rangement, anterior disc displacement,
1. Pain precipitated by function.
reciprocal disc, and disc-condyle incoor¬
dination. 2. Marked limited mandibular opening.

49
Diagnostic Classification

3. Straight line deviation to the affected Diagnostic criteria

side on opening.
1. Inability to close the mandible.
4. Marked limited laterotrusion to the
2. Pain, if present, occurs at time of
contralateral side.
dislocation with mild residual pain
5. Soft tissue imaging reveals displaced after the episode.
disc without reduction.
3. Radiographic evidence reveals con¬
dyle well beyond the eminence.
Diagnostic criteria (chronic)
Inflammation (ICD.9.CM 727.09)
1. Pain, when present, is markedly re¬
Primary inflammatory conditions of the
duced from acute stage. TMJ are relatively uncommon and are
2. History of joint noise and/or limita¬ associated primarily with rheumatologic
tion of mandibular opening. disease. Inflammatory conditions, includ¬
3. Slight limited mandibular opening, if ing synovitis or capsulitis, frequently oc¬
at all. cur secondary to trauma, irritation, or
4. Slight limited laterotrusion to the con¬ infection and often accompany other TMJ
tralateral side. disorders.73 Synovitis is described as an
inflammation of the synovial lining of the
5. Soft tissue imaging reveals displaced
TMJ that can be due to infection, an
disc without reduction.
immunologic condition'secondary to car¬
tilage degeneration, or trauma. Synovitis
Dislocation (ICD.9.CM 830.1 [open]) is characterized by localized pain that is
Temporomandibular joint dislocation, also exacerbated by function and superior and/
known as open-lock or subluxation, de¬ or posterior joint loading. Many times
scribes a condition in which the condyle there will be a fluctuating swelling (due to
is positioned anterior to the articular em¬ effusion) that decreases the ability to oc¬
inence and is unable to return to a closed clude on the ipsilateal posterior teeth.
position. It is manifested clinically as an Capsulitis, an inflammation of the cap¬
inability to close the jaw. Dislocation may sule related to sprain of capsular liga¬
be the result of (1) a physical jamming of ments, is difficult, if not impossible, to
the disc-condyle complex beyond the ar¬ differentiate from synovitis but may also
ticular eminence that is maintained by exhibit pain on joint distraction. Previ¬
muscle activity; (2) a true hyperextension ously used terms include arthritis, ar¬
of the disc-condyle complex beyond its thralgia, discitis, and retrodiscitis.
normal maximum translation position; or
Diagnostic criteria
(3) failure of the disc to rotate about the
condyle during jaw closure due to disc 1. Localized pain at rest exacerbated by
distortion and attachment elongation. The function, especially with superior and/
duration of dislocation can be prolonged or posterior joint loading.
and patients are only able to normalize 2. Limited range of motion secondary
jaw function with manipulation by a cli¬ to pain. When present, fluctuating
nician. There usually is a clinical history swelling (due to effusion) decreases
of excessive range of motion that is not ability to occlude on ipsilateral poste¬
painful, but pain can occur at the time of rior teeth. An MRI may give a bright
dislocation with residual pain following signal if fluid is present (T2 weight¬
the episode. ing).

50
 Diagnostic Classification System for TMD

Arthritides bony change (subchondral sclerosis,

Arthritides of the TMJ include localized osteophytic formation) and joint space
osteoarthrosis, osteoarthritis, and general¬ narrowing
ized poly arthritides.7*
Osteoarthrosis (ICD.9.CM 715.38) Os¬ Osteoarthritis (ICD.9.CM 524.62
teoarthrosis is defined as a degenerative, [arthralgia]) Osteoarthritis (OA) is a de¬
noninflammatory condition of the joint generative condition accompanied by sec¬
characterized by structural changes of the ondary inflammation (synovitis) of the
joint surfaces secondary to excessive strain TMJ. Typically the disease is slowly pro¬
in the remodeling mechanism.75 The on¬ gressive but OA can have remissions and
set is insidious and usually not associated cartilage regeneration82 characterized by
with systemic disease. Osteoarthrosis is deterioration of the articular cartilage
no longer considered a part of aging or and secondary new bone formation. Os¬
simply a wear-and-tear process. Some re¬ teoarthritis is frequently localized to the
searchers believe that it is due to a physi¬ temporomandibular joint in question but
ologic imbalance between the stress ap¬ may be a part of a generalized condi¬
plied to a joint and the ability of the tion.83*84 Clinical findings include point
physiologic “shock absorbers” —soft tis¬ tenderness on palpation, crepitus, limited
sue, cartilage, and bone—to deal success¬ range of motion with deviation on open¬
fully with the stress of loading.76*77 As ing to the affected side, and radiographic
degeneration occurs there is a deteriora¬ evidence of structural bony changes. The
tion and abrasion of the articular cartilage articular changes are associated with (1)
and remodeling of underlying bone.78-80 external or overt jaw trauma, (2) repeti¬
The process accelerates as proteoglycan tive adverse loading, (3) infection, or (4)
depletion, collagen fiber network disin¬ an idiopathic degenerative process. Al¬
tegration, and fatty degeneration weaken though coarse crepitus can be diagnostic,
the functional capacity of the articular confirmation of the diagnosis is based on
cartilage. Previous terms commonly used joint imaging and pain. One rare idio¬
were osteoarthritis, arthritis, degenera¬ pathic degenerative condition termed con-
tive joint disease, and arthrosis defor¬ dylysis occurs spontaneously, primarily in
mans. Osteoarthrosis is characterized clin¬ adolescent females.85-87 Normal condy¬
ically by an absence of pain, probable lar development proceeds until the sud¬
crepitus, and usually a limited range of den lytic event occurs causing the con¬
motion and deviation to the affected side dyle to become progressively smaller and
on opening secondary to degeneration.81 in some cases even disappear. Condylysis
At the later stages of osteoarthrosis there is not usually associated with ankylosis,
is radiographic evidence of structural bony erosive changes in the fossae, or a positive
changes; however, early cartilage degen¬ serologic test.
eration would only be detectable with
biopsy or possibly with arthroscopy.63 Diagnostic criteria
1. Pain with function due to the inflam¬
Diagnostic criteria mation
1. Crepitus 2. Point tenderness on palpation
2. Limited range of motion causes devi¬ 3. Crepitus or multiple joint noises
ation to the affected side on opening 4. Limited range of motion with devia¬
3. Radiographic evidence of structural tion on opening to the affected side

51
Diagnostic Classification

5. Radiographic evidence of structural (Anterior open bite and abnormal serol¬

bony change (subchondral sclerosis ogy findings may also be present.)
osteophytic formation) and joint space
narrowing
Ankylosis (ICD.9.CM 524.61)
Ankylosis is defined as a restricted man¬
Polyarthritides (ICD.9.CM 714.9 [un¬ dibular movement with deviation to the
specified]) Joint inflammation and struc¬ affected side on opening that often results
tural change caused by a generalized sys¬ as a long-term sequela of trauma includ¬
temic polyarthritic condition are referred ing mandibular fracture.88 It implies a
to as polyarthritides. Temporomandibular firm, unyielding restriction due to either
joint polyarthritides include rheumatoid intra-articular fibrous or bony ankylosis
arthritis, juvenile rheumatoid arthritis and is not associated with pain. Fibrous
(Still’s disease), spondyloarthropathies (an¬ adhesions within the TMJ are thought to
kylosing spondylitis, psoriatic arthritis, occur mainly in the superior compart¬
infectious arthritis, Reiter’s syndrome), ment of the TMJ. They produce a de¬
and crystal-induced disease (gout, hyper¬ creased movement of the disc-condyle
uricemia). Other rheumatologically re¬ complex. Adhesions can occur secondary
lated diseases that may affect the TMJ to joint inflammation that results from
include autoimmune disorders and other external trauma or systemic conditions
mixed connective tissue diseases (sclero¬ such as a polyarthritic disease. Bony an¬
derma, Sjogren’s syndrome, lupus erythe¬ kylosis results from the union of the bones
matosus).70 Polyarthritides are charac¬ of the TMJ by proliferation of bone cells;
terized by pain during acute and subacute this causes complete immobility of that
stages, possible crepitus, limited range of joint. No radiographic findings other than
motion secondary to pain and/or degen¬ absence of ipsilateral condylar translation
eration, and bilateral radiographic evi¬ on opening are found with fibrous an¬
dence of structural bony changes. This kylosis. Bony ankylosis is characterized
group of arthritides comprises multiple by radiographic evidence of bone prolif¬
diagnostic categories that are best diag¬
eration with marked deviation to the af¬
nosed with the aid of serology and man¬
fected side and marked limited laterotru-
aged by rheumatologists. Dental man¬ sion to the contralateral side.
agement relates to secondary complaints.
Bilateral resorption of condylar struc¬
Diagnostic criteria (fibrous)
tures can result in an anterior open bite in
many cases. 1. Limited range of motion on opening
2. Marked deviation to the affected side
Diagnostic criteria 3. Marked laterotrusion to the contra¬
1. Pain during acute and subacute stages lateral side
2. Point tenderness on palpation during 4. Radiographic findings that reveal ab¬
acute stage sence of ipsilateral condylar transla¬
tion on opening
3. Crepitus
4. Limited range of motion secondary
to pain and/or degeneration Diagnostic criteria (bony)
5. Radiographic evidence of structural 1. Extreme limited range of motion on
bony change opening when condition is bilateral

52
 Diagnostic Classification System forTMD

2. Marked deviation to the affected side the commonly held view that musculoskel¬
when condition is unilateral etal pain is maintained by some form of
3. Marked limited laterotrusion to the tonic muscular hyperactivity. Their stud¬
contralateral side when condition is ies show that the activity of agonist mus¬
unilateral cles is often reduced by pain with small
4. Radiographic evidence of bone pro¬ increases in the level of antagonist muscle
activity. As a result, maximum voluntary
liferation and absence of condylar
translation contraction, force production, and the
range and velocity of movement are often
reduced.
Fibromyalgia, also termed myofascitis,
Masticatory Muscle Disorders
myofibrositis, or fibrositis, is often con¬
Masticatory muscle disorders are analo¬ fused with myofascial pain; however, it
gous to muscle disorders that can occur in should not be considered a specific mas¬
other areas of the head, neck, body, and ticatory muscle disorder even though there
extremities. They include myofascial pain, may be concurrent masticatory muscle
myositis, spasm, protective splinting, con¬ pain.39 Fibromyalgia is manifested as a
tracture, and neoplasia3 (see flowchart). generalized, continuous, aching pain and
The mechanisms that cause pain to origi¬ is associated with tenderness in many sites
nate in skeletal muscles are still not well over the body, sleep disturbances, and
understood. Overuse of a normally pro- depression. It may also be associated with
fused muscle or ischemia of a normally generalized fatigue, chronic headache,
working muscle may cause pain.89-91 Sym¬ anxiety, subjective swelling, irritable bowel
pathetic and fusimotor reflexes can pro¬ syndrome, and modulation of the symp¬
duce changes in the blood supply and toms by activity or the weather. Descrip¬
muscle tone; furthermore, different psy¬ tors include pain in three of four quad¬
chologic or emotional states can alter mus¬ rants for at least 3 months, tenderness in
cle tone. Neurons that mediate pain from 11 of 18 specific spots, and association
skeletal muscle are subject to strong modu¬ with normal EMG activity.95-98
latory influences. The nociceptive endings
can be sensitized very easily by endoge¬ Myofascial Pain (ICD.9.CM 729.1)
nous substances (bradykinin, serotonin, Myofascial pain is characterized by a re¬
prostaglandin [PGE2], neuropeptides and gional, dull, aching pain and presence of
substance P). These painful muscle con¬ localized tender spots (trigger points) in
ditions not only result in increased sensi¬ muscle, tendons, or fascia that reproduce
tivity of peripheral nociceptors, but also pain when palpated and may produce a
produce hyperexcitability in the central characteristic pattern of regional referred
nervous system.90 pain and/or autonomic symptoms on
On examination the jaw-closing mus¬ provocation.99-102 Myofascial pain can be
cles of the large majority of TMD pa¬ confused with muscle contraction head¬
tients are tender to palpation and approx¬ ache or tension headache and previously
imately 40% of TMD patients report pain used terms include myalgia, trigger-point
on chewing.92 Traditionally it has been pain, and myofascial pain dysfunction syn¬
hypothesized that these symptoms are as¬ drome. Palpation of the “active” trigger
sociated with increased postural electro¬ points causes reproducible alteration of
myographic (EMG) activity.93 However, pain to a more extensive area that may or
Lund and co-workers94 have questioned may not include the muscle containing

53
Diagnostic Classification

the trigger points.103-104 Inactivation of muscle. Because chemical substances pro¬

the trigger-point area with injection of duced in response to tissue damage and
local anesthetics, ice, or vapocoolant spray inflammation are presumably the princi¬
followed by stretch or transcutaneous elec¬ pal cause of pain, elevated serum enzyme
trical nerve stimulation (TENS) relieves levels should be found; conversely, with
the larger area of pain. The pathogenesis interstitial inflammation without muscle
of myofascial pain is not well understood. cell damage there is no rise in serum
There is evidence that a localized isch¬ enzyme levels.90 Clinically, the patient
emia may cause the characteristic trigger- may exhibit a limited range of motion.
point sensitivity. Recently, interest has Ossification of a muscle can occur sec¬
focused on the central nervous system, ondary to inflammation, which results in
including the sympathetic nervous sys¬ myositis ossificans. The inflammation may
tem, as a mediator of myofascial pain. occur in the tendinous attachments of the
muscle as well; this type of inflammation
Diagnostic criteria
is termed either tendinitis or tendomyo-
1. Regional pain, usually dull sitis.
2. Localized tenderness in firm bands of
Diagnostic criteria (delayed onset muscle
muscle and/or fascia
soreness)
3. Reduction in pain with local muscle
anesthetic injection or vapocoolant 1. Increased pain with mandibular move¬
spray to trigger point followed by ment
stretch 2. Onset following prolonged or unac¬
customed use (up to 48 hours after¬
(A reproducible alteration of pain com¬
ward)
plaints with palpation at specific tender
areas may also occur.)
Diagnostic criteria (generalized myositis)
Myositis (ICD.9.CM 728.81) 1. Pain, usually acute, in localized area
Myositis is usually due to local causes 2. Localized tenderness over entire re¬
such as infection or injury. To help ex¬ gion of the muscle
plain the clinical variations in painful mus¬
3. Increased pain with mandibular move¬
cle conditions, the term myositis is
ment
divided into two types of inflammatory
responses. The first condition, which is 4. Moderately to severly limited range
primarily theoretical, is referred to as a of motion due to pain and swelling
painful condition due to intermittent over¬ 5. Onset following injury or infection
use that results in interstitial inflamma¬
tion and is referred to as delayed onset Myospasm (ICD.9.CM 728.85)
muscle soreness. There is no swelling, Myospasm (acute trismus or cramp) is
increased EMG activity, or trigger points an acute disorder and is an involuntary,
and referral of pain with delayed onset sudden, tonic contraction of a muscle.
muscle pain. The second condition is re¬ A muscle in spasm is acutely shortened,
ferred to as an extensive, clinically recog¬ grossly limited in range of motion, and
nizable, inflamed muscle. painful. Spasm is a continuous muscle
The second type of myositis is a con¬ contraction (fasciculation) and can, there¬
stant, acutely painful, generalized inflam¬ fore, be differentiated from protective
mation and swelling, usually of the entire muscle splinting by needle or fine wire

54
 Diagnostic Classification System forTMD

EMG verification of sustained in¬ fibrosis of the supporting tendons, liga¬

voluntary muscle contraction even at ments, or muscle fibers themselves. Mus¬
rest.105’106 cle contracture is usually caused by trau¬
Diagnostic criteria ma but can result from infection or any
disorder that results in hypomobility. It is
1. Acute pain not painful in general. Experiments sug¬
2. Continuous muscle contraction (fas- gest that there is a close relation between
ciculation) lowered adenosine triphosphate (ATP)
3. Increased EMG activity even at rest concentrations and the occurrence of con¬
tracture.109
(as measured with fine wire EMG)
Diagnostic criteria
Protective Muscle Splinting
(ICD.9.CM 728.89) 1. Limited range of motion
Protective muscle splinting is defined as 2. Unyielding firmness on passive stretch
restricted or guarded mandibular move¬ 3. History of trauma or infection
ment due to co-contraction of muscles as
a means of avoiding pain caused by move¬ Neoplasia (ICD.9.CM 171.0)
ment of the parts.107 Protective splinting Masticatory muscle neoplasia is defined
is a central-nervous-system-induced re¬ as a new, abnormal, or uncontrolled
sponse characterized by a limited range of growth of muscle tissue. It can be malig¬
motion, rigidity of jaw on manipulation, nant or benign and may or may not be
and pain. This problem can be further dif¬ associated with pain. A myxoma is an
ferentiated into (1) protective splinting to example of a muscle neoplasm.
avoid a painful dysfunction, such as pain¬
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Dent Rest 1977;85:434-443. 91. Mense S: Considerations concerning the
neurobiological basis of muscle pain. Can
79. Castelli WA, Nasjleti CE, Diaz-Perez R,
J Physiol Pharmacol 1991;69:610-616.
Caffesse RG: Histopathologic findings in
temporomandibular joints of aged indi¬ 92. Dworkin SF, Huggins KH, Le Resche L,
viduals.} Prosthet Dent 1985;53:415-419. Von KorffM, Howard J, Truelove E, Som¬
mers E: Epidemiology of signs and symp¬
80. Stegenga B, de Bont LGM, Boering G,
toms in temporomandibular disorders.
Van Willigen JD: Tissue responses to de¬
Clinical signs in cases and controls. J Am
generative changes in the temporoman¬
Dent Assoc 1990;120:273-281.
dibular joint: A review. J Oral Maxillofac
Surg 1991;49:1079-1088. 93. Dahlstrom L, Carlsson SG, Gale EN,
Jansson TG: Stress-induced muscular ac¬
81. Rasmussen OC: Clinical findings during
tivity in mandibular dysfunction: Effect
the course of temporomandibular ar¬
of biofeedback training. J Behav Med
thropathy. Scand J Dent Res 1981 ;89:
1985;8:191-200.
283-288.
94. Lund JP, Donga R, Widmer CG, Stohler
82. Bland JH, Cooper SM: Osteoarthritis: A
CS: The pain-adaptation model: A dis¬
review of the cell biology involved and
cussion of the relationship between chron¬
evidence for reversibility. Semin Arthritis
ic musculoskeletal pain and motor activ¬
Rheum 1984;14:106-133.
ity. Can J Physiol Pharmacol 1991 ;69:
83. Blackwood HJJ: Arthritis of the mandibu¬ 683-694.
lar joint. Br Dent J 1963; 115:317-376.
95. Goldenberg DL: Clinical features of fi¬
84. Toller P: Osteoarthritis of the mandibu¬ bromyalgia. In Fricton JR, Awad EA (eds)
lar condyle. Br DentJ 1973; 134—223. Advances in Pain Research and Therapy.
85. Rabey GP: Bilateral mandibular condyly- Vol 17. Myofacial Pain and Fibromyalgia.
sis—a morphanalytic diagnosis. BritJ Oral New York, Raven Press Ltd, 1990, pp
Surg 1977/1978; 15:121-134. 139-163.
86. Caplan HI, Benny RA: Total osteolysis of 96. Wolfe F, Smythe HA, Yunus MB, Bennett
the mandibular condyle in progressive sys¬ RM, Bombardier C, Goldenberg DL, Tug-
temic sclerosis. Oral Surg 1978;46:362- well P: The American College of Rheu¬
366. matology, 1990: Criteria for the classifica¬
87. Lanigan DT, Myall RWT, West RA, tion of fibromyalgia. Arthritis Rheum
McNeill RW: Condylysis in a patient with 1990;33:160-172.

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Diagnostic Classification

97. Bennett RM: Recognizing fibromyalgia. 104. Fricton J, Kroening R, Haley D, Siegert
Patient Care, July 1989: pp 60-83. R: Myofascial pain syndrome of the head
and neck: A review of clinical characteris¬
98. Bennett RM: Etiology of the fibromyal¬
gia syndrome: A contemporary hypothe¬ tics of 168 patients. Oral Surg Oral Med
sis. Intern Med Specialist 1990; 11:48—61. Oral Pathol 1982;60:615-623.

99. Shiftman A. Myofascial pain associated 105. Layzer RB: Diagnostic implications of
with unilateral masseteric hypertrophy in clinical fasiculations and cramps. In Row¬
a condylectomy patients. J Craniomand land LP (ed) Human Motor Neuron Dis¬
Pract 1984;2:373-376. eases. New York, Raven Press Ltd, 1982
pp 23-27.
100. Clark GT: Muscle Hyperactivity, Pain
and Dysfunction. In Klineberg I, Sesale B 106. Roth G: The origin of fasciculations. Ann
(eds) Orofacial Pain and Neuromuscular Neurol 1982;12:542-547.
Dysfunction: Mechanisms and Clinical 107. Tveteras K, Kristensen S: The aetiology
Correlates. Sydney, Pergamon Press, 1985, and pathogenesis of trismus. Clin Oto¬
pp 103-111. laryngol 1986;11:383-387.
101. Solberg WK: Temporomandibular disor¬ 108. Revington PJ, Peacock TR, Kingscote
ders: Masticatory myalgia and its man¬ AD: Temporomandibular joint dysfunc¬
agement. Br Dent J 1986;160:351-356. tion: A case of hysterical trismus. Br Dent
102. Fricton JR: Myofascial pain syndrome: J 1985;158:55-56.
Characteristics and epidemiology. In Fric¬ 109. Sahlin K, Eldstrom L, Sigholm H, Hultl-
ton JR, Awad EA (eds) Advances in Pain man E: Effects of lacjic acid accumulation
Research and Therapy. Vol 17. Myofacial and ATP decrease on muscle tension and
Pain and Fibromyalgia. New York, Raven relaxation. Am J Physiol 1981 ;240:C 121—
Press Ltd, 1990, pp 107-127. C126.
103. Travell JG, Simons DG: Myofascial Pain
and Dysfunction: The Trigger Point Man¬
ual. Baltimore, Williams and Wilkins,
1983, pp 63-158.

60
 FIVE

Assessment

Collection of baseline records and other facial pain may require behavioral and
diagnostic data is fundamental to the prop¬ psychosocial assessment. Occasionally, to
er management of TMD. The extent to confirm a clinical impression, additional
which any or all of the elements of evalua¬ diagnostic tests for a specific diagnosis
tion are pursued depends on the magni¬ may be required (such as diagnostic injec¬
tude of the presenting complaints and the tions, biopsies, and hematologic testing).
potential for the problem to progress phys¬
ically or psychosocially. However, it is
Screening Evaluation
important for all clinicians to realize that
many clinical signs important in the dif¬
Screening for TMD is recommended as
ferential diagnosis of specific TMD sub¬
an essential part of the routine dental
sets are not measured with high reliabili¬
examination.2 The screening consists of a
ty.1 In particular, assessment of pain on
questionnaire, brief history, and exam¬
muscle palpation and identification of spe¬
ination (Figs 5-1 and 5-2). The aim of
cific TMJ sounds have only modest to
screening is to determine the presence or
marginal reliability.
absence of TMD signs and symptoms. If
A screening evaluation is appropriate
significant findings are identified and re¬
for all routine dental patients; whereas a
corded, a comprehensive history taking
comprehensive evaluation, ie, history and
and clinical examination should be con¬
physical examination, is needed for pa¬
ducted.2-3
tients presenting with signs or symptoms
suggestive of TMD. Radiographic stud¬
ies and soft tissue imaging of the TMJ and Comprehensive History
associated structures may be necessary
for evaluation of articular disorders. Fur¬ The history should parallel the tradition¬
ther, patients suffering from chronic oro¬ al medical history and review of systems.

61
Assessment

Recommended Screening Questionnaire for TMD

1. Do you have difficulty, pain, or both when opening your mouth, for instance,
when yawning?
2. Does your jaw get "stuck," "locked," or "go out"?
3. Do you have difficulty, pain, or both when chewing, talking, or using your jaws?
4. Are you aware of noises in the jaw joints?
5. Do your jaws regularly feel stiff, tight, or tired?
6. Do you have pain in or about the ears, temples, or cheeks?
7. Do you have frequent headaches and/or neckaches?
8. Have you had a recent injury to your head, neck, or jaw?
9. Have you been aware of any recent changes in your bite?
10. Have you previously been treated for a jaw-joint problem? If so, when?

Fig 5-1 All patients should be screened for TMD through a questionnaire that includes these
questions. The decision to actually complete a comprehensive history and clinical exam will
depend on the number of positive responses and the apparent seriousness of the problem for the
patient, ie, a positive response to any question may be sufficient to warrant a TMD exam if it is a
concern to the patient or is viewed as clinically important by the clinician. -

A comprehensive history includes (1) iden¬ cial paralysis, and/or cranial nerve defi¬
tification of the chief complaint; (2) a cits), it is critical to rule out intracranial
history of the present illness; (3) a medi¬ pathology as the cause. Space-occupying
cal history; (4) a dental history; and (5) a lesions such as a tumor, hematoma, and
personal history (Fig 5-3). The chief com¬ arteriovenous malformation must be con¬
plaints) or the purpose of the patient’s sidered.
visit should be stated succinctly. The chief The relevant medical history may in¬
complaint is the one symptom that the clude previous surgeries, hospitalizations,
patient states as the most bothersome and traumas, illnesses, developmental and ac¬
the one most desired to be changed. Be¬ quired anomalies, and medications used.
cause patient complaints are often nu¬ Contributing factors also should be as¬
merous, they should be prioritized ac¬ sessed. For instance, the quality of the
cording to the patient’s concerns. The patient’s sleep pattern is important be¬
history of the present illness is a narrative cause it may relate to depression and mus¬
report of each symptom or complaint: culoskeletal pain. The dental history
date of onset, onset event, character, in¬ should include previous dental disease,
tensity, duration, frequency, location, re¬ treatment, and attitude. A habit history
missions, change over time, modifying also identifies potential contributing fac¬
factors including those that alleviate, ag¬ tors such as bruxism (clenching or grind¬
gravate, or precipitate individual episodes ing), repetitive chewing (eg, excessive gum
of pain, and previous treatment results. chewing), and abnormal jaw and tongue
Any interrelationships among symptoms postural habits (eg, nail biting and lateral
should be noted. When neurologic signs tongue bracing).3
or symptoms are present (eg, numbness, The personal history of TMD patients
visual disturbances, dizziness, vertigo, fa¬ is important because it often identifies

62
 Comprehensive History

Recommended Screening Examination Procedures forTMD

1. Measure range of motion of the mandible on opening and right and left
laterotrusion. (Note any incoordination in the movements.)
2. Palpate for preauricular or intrameatal TMJ tenderness.
3. Auscultate and/or palpate for TMJ sounds (ie, clicking or crepitus).
4. Palpate for tenderness in the masseter and temporalis muscles.
5. Note excessive occlusal wear, excessive tooth mobility, buccal mucosal ridging, or
lateral tongue scalloping.
6. Inspect symmetry and alignment of the face, jaws, and dental arches.

Fig 5-2 All patients should be screened for TMD using this or a similar cursory clinical
examination. The need for a comprehensive history and clinical examination will depend on the
number of positive findings and the clinical significance of each finding. Any one positive finding
may be sufficient to warrant a TMD exam.

psychosocial contributing factors; how¬ ing a sensory and motor evaluation of the
ever, many patients are hesitant to discuss cranial nerves, and an intraoral evaluation
fully their personal history. They may be including an occlusal analysis3 (Fig 5-4).
reluctant to share information on previ¬
ous or current psychiatric counseling, de¬
pression, anxiety, impaired social and oc¬ General Inspection of the
cupational activities, pending litigation Head and Neck
or disability claims, family relationships,
Inspection of the head and neck includes
and other personal matters. Open commu¬
visual and manual inspection of each ana¬
nication is necessary to complete the his¬
tomic structure to help rule out tumors,
tory and to ensure comprehensive treat¬
infections, and other pathology. Clini¬
ment. If this proves difficult, either
cians should be aware of unusual asym¬
because the patient becomes very dis¬
metry, size, color, consistency, shape, pos¬
tressed or because the patient describes
ture, involuntary movement, or tenderness
significant problems, consultation with a
that might suggest an infectious, edema¬
relevant mental health specialist must be
tous, neoplastic, degenerative, obstruc¬
considered.
tive, or dysfunctional process.

Comprehensive Physical Evaluation of the TMJ and

Examination Cervical Spine
Physical examination for TMD consists Measure and record mandibular opening
of observation and documentation of a and lateral movements. Two vertical open¬
general inspection of the head and neck, ing measurements are suggested: full ac¬
an evaluation of the functional status of the tive opening by the patient (unassisted)
TMJs and cervical spine, an evaluation of and range of motion with passive (as¬
the masticatory and cervical muscles, a sisted) stretch applied by the clinician.
cursory neurovascular evaluation includ¬ The localization of pain with active move-

63
Assessment

Comprehensive History Format for TMD Patients

Chief complaint
History of present illness
Date and event of onset
Location of signs and symptoms
Character, intensity, duration, frequency of signs and symptoms
Remissions or change over time
Modifying factors (alleviate, precipitate, or aggravate)
Previous treatment results
Medical history
Current or pre-existing relevant physical disorders or disease (specifically systemic
arthritides or other musculoskeletal/rheumatologic conditions)
Previous treatments, surgeries, and/or hospitalizations
Trauma (specifically to head, face, or neck)
Medications (prescription, nonprescription)
Allergies
Alcohol and other substances of abuse
Dental history
Current or pre-existing relevant physical disorders or disease
Previous treatments including patient's attitude toward treatment
History of trauma to the jaw, teeth, or supporting tissues (including iatrogenic trauma)
Parafunctional history, both diurnal and nocturnal
Personal history
Social, behavioral, and psychologic
Occupational, recreational, and family
Litigation, disability, or other secondary gain issues

Fig 5-3 The sequence of a comprehensive history should parallel the traditional medical history and
review of systems format including the patient’s chief complaint(s), the history of each complaint or
present illness, medical and dental histories, and finally a personal history.

ment or passive stretching of the jaw and of joint end-feel should be evaluated and
the quality and symmetry of jaw move¬ noted. Observe active range of head and
ments should be noted. Document the cervical spine movement and note pain re¬
presence and location of audible joint sponses to extension, flexion, rotation and
sounds, palpable clicking, or interference side bending movements. Evaluate cervical
with jaw movement. Any manipulated or joint noises and neurosensory signs or
altered jaw position that eliminates, allevi¬ symptoms in the neck and shoulders.
ates, or aggravates the joint pain, sounds,
or incoordination should be noted. Palpate
the TMJ for tenderness and swelling over Masticatory and Cervical
the lateral (pre-auricular) and posterior
(intrameatal) aspects of the joint capsule
Muscle Evaluation
in the closed mouth position and during Tenderness, swelling, enlargement, and
condylar translation. The amount and type unusual texture are noted from palpation

64
 Comprehensive Physical Examination

Comprehensive TMD Physical Examination Procedures

General inspection of the head and neck

Note unusual asymmetry, size, shape, color, consistency, posture, and involuntary
movement or tenderness
Evaluation of the TMJ and cervical spine
Palpate the TMJ preauricularly and intrameatally
Measure range of motion, quality of movement, and association with pain
Auscultate and/or palpate for joint noises in all movements
Guide mandible movement noting pain, end feel, and joint noise.
Masticatory and cervical muscle evaluation
Note tenderness, swelling, enlargement, and unusual texture
Neurovascular evaluation
Vascular compression of temporal and carotid arteries
Cranial nerve signs and symptoms
Intraoral evaluation
Hard and soft tissue conditions or disease
Occlusal analysis, both static and dynamic

Fig 5-4 Physical examination for TMD consists of observation and documentation of a general
inspection of the head and neck, an evaluation of the functional status of the TMJs and cervical
spine, an evaluation of the masticatory and cervical muscles, a neurovascular evaluation, and an
intraoral evaluation including an occlusal analysis.

of the following masticatory muscles: tem¬ important to rule out giant cell arteritis
poralis, deep and superficial masseter, me¬ and carotidynia. Neuropathies of the cra¬
dial pterygoid, and suprahyoids. Recent nial nerves are manifested as disturbances
studies confirm that an algometer or pain- of smell, sight, hearing, equilibrium, taste,
threshold meter can be reliably used to and response to touch on the face (ie,
measure muscle tenderness.4-6 The same numbness, dysesthesia, and paresthesia).
inspection of the following cervical mus¬ The motor function of the head and neck
cles or muscle groups is performed: sterno¬ is mediated through the following nerves:
cleidomastoid, suboccipital, paravertebral trigeminal (masticatory muscles), facial
(scalenus), posterior deep cervical, and up¬ (muscles of expression), glossopharyngeal
per trapezius. Evaluation of the cervical (uvula and soft palate), hypoglossal
musculature, nerves, and spine is recom¬ (tongue), and accessory (trapezius) crani¬
mended due to the high percentage of oro¬ al nerves.10 Paralysis, gross weakness, at¬
facial pain patients who also have cranio¬ rophy, or spasticity of these muscles re¬
cervical disorders.7-9 If further study of quires further evaluation by a neurologist.
the cervical region is needed, a referral to
an appropriate specialist is necessary.
Intraoral Evaluation
Neurovascular Evaluation A complete dental and soft tissue exam¬
Compression testing of the temporal and ination is recommended to identify the
carotid arteries for pain provocation is dental, periodontal, salivary gland, or oth-

65
Assessment

er intraoral pathoses that are suspected of diograph due to image distortion of the
causing the presenting complaints. Clini¬ bony articular structures and superim¬
cians should be particularly aware of fac¬ position of other structures.13 Although
tors such as tongue and mucosal ridging, gross degenerative or traumatic changes
abnormal tooth wear, increased tooth mo¬ and the amplitude of condylar translation
bility, and tenderness of the teeth to per¬ can be assessed by this technique, condy¬
cussion that may be related to oral habits. lar position cannot14-16; it can be assessed
Assess mandibular stability according to only by fluoroscopy.17
the pattern and distribution of occlusal Corrected cephalometric tomography
contacts on closure. Document anterior is a more accurate method for radiographic
tooth relations, including overbite and examination of patients suspected of hav¬
overjet, tooth-contact guidance patterns, ing articular disorders.13’18-20 High spa¬
crossbite, vertical dimension of the oc¬ tial resolution of skeletal structures is
clusion, and any other significant occlusal obtained in multiple projections. Cor¬
features that may be present. rected tomography detects gross bony
changes at various lateral to medial sec¬
tions; thus, axially corrected tomography
Imaging is preferred to transcranial projections.
In normal subjects, condyle position is
Imaging of the TMJ and craniofacial struc¬ often centered, but considerable variability
tures may be necessary to rule out struc¬ is observed. Therefor^, radiographs to
tural disorders of the head, neck, and jaw. assess condyle position by means of joint
Panoramic radiographs are recommended space measurements are contraindicated
to screen for gross tooth, periodontal, for diagnostic purposes.15*21-28 Further,
mandibular, or maxillary pathology. Spe¬ condylar position in the fossa is not a
cial radiographic techniques such as peri¬ diagnostic aid for articular disc displace¬
apical radiographs, sialography, sinus ment.29’30
series, radionuclide studies, and angiog¬ Computerized tomography (CT) is val¬
raphy may be needed to rule out specific uable as an adjunct imaging technique for
dental and other craniofacial pathology. assessment of bony abnormalities of the
The extensive technology available for TMJ (ie, developmental anomalies, trau¬
TMJ imaging provides clinicians with mul¬ ma, and neoplastic conditions).31-35 At
tiple options. present CT has little role in the eval¬
uation of disc displacement because of
the technical difficulty in depicting the
Radiography
disc.36-38 Direct sagittal CT imaging does
Radiography of the TMJ structures is provide improved resolution; however, the
prescribed primarily when clinical exam¬ imaging position is difficult for some pa¬
ination suggests some form of joint pa¬ tients.
thology.11 Further radiographic studies In emission scintigraphy a radiolabeled
should assist the diagnostic and treat¬ material that is concentrated by the body
ment process.12 They may include to¬ in areas of rapid bone turnover is admin¬
mographic films as well as lateral istered. A bone scan is positive if there is
pharyngeal, transorbital and modified approximately a 10% increase in osteo¬
Townes, and panoramic views of the jaws. blastic activity well in advance of any
Transcranial radiography of the TMJ joint radiographic evidence of change. Emis¬
has a limited purpose as a screening ra¬ sion imaging has high sensitivity for early

66
 Imaging

stages of bony remodeling.39-40 In planar

Magnetic Resonance Imaging
scintigraphy, the area of interest is scanned
with a gamma camera 2 to 4 hours after Magnetic resonance imaging (MRI) tech¬
administration of the radioactive mate¬ nology is advancing at such a rapid pace
rial. The areas with increased uptake of that many diagnostic radiologists limit
the radiolabeled material appear as “hot their clinical interest to this area. This
spots” on the scan. imaging process is revealing pathoses and
Single-photon emission computed to¬ anomalous structures previously unde¬
mography (SPECT) is similar to a CT tected and unsuspected. Magnetic reso¬
scan except that the radiation source is nance imaging is being increasingly uti¬
inside the area of interest rather than lized in the investigation of TMD.37-51-55
being external. While SPECT is a sensi¬ Presently MRI technology affords the cli¬
tive indicator of bone activity, it cannot nician interested in observing disc func¬
discriminate between normal bone re¬ tion the opportunity to view both right
modeling and degenerative processes. As and left joint functions simultaneously
in CT, the receptor or camera is moved and to interpret not only film plates but
about the patient, producing a tomo¬ also a video that demonstrates bilaterally
graphic slice in any plane desired. the symmetrical and asymmetrical excur¬
Structures under and over the plane of sions of the mandible, disc function, joint
interest are in effect removed from the space, muscles of mastication, and nerve
image.41-42 and vascular anatomy. Magnetic resonance
imaging eliminates previous concern of
ionizing radiation exposure and the pro¬
Soft Tissue Imaging
cess is painless.
Temporomandibular joint arthrography The indications for MRI of the TMJ
is a radiographic technique in which disc are the same as those for arthrogra¬
radiopaque contrast medium is injected phy; however, increasing utilization of
into the inferior joint space, into the su¬ MRI is lessening the use of arthrography.
perior and inferior joint spaces, or into In general, a patient should have an imag¬
both joint spaces followed by the intro¬ ing study when the results may alter treat¬
duction of air (double contrast arthrogra¬ ment strategy. This can occur when the
phy).43 Tomography is then used to de¬ diagnosis of articular soft tissue prob¬
termine the position of the articular disc lems, especially in a nonreducing dis¬
relative to the condyle.43-50 Arthrogra¬ placed disc with clinically restricted
phy can also reveal the functional dynam¬ condylar motion, is in question or when
ics of the disc and condyle when used with the diagnosis must be documented for
fluoroscopy and videotaping. Because of third-party payers, for medicolegal rea¬
the invasiveness of the procedure, radia¬ sons, and preoperatively for disc surgery.
tion, and discomfort with this imaging It is important to note, however, that
method, TMJ arthrography is limited to MRI also reveals abnormal soft tissue
selected TMD cases of disc displacement conditions in asymptomatic joints.48
when the dynamic imaging results will It has been demonstrated that between
alter the course of treatment. Arthrogra¬ 25% and 38% of MRI of the TMJ in
phy is the imaging study of choice for the asymptomatic volunteers reveal disc
diagnosis of disc perforation, although displacement.56-58 Thus, MRI results
there is a 20% false-positive rate with the alone should not dictate treatment
technique.31 strategy.

67
Assessment

list of psychological and behavioral issues

Behavioral and Psychosocial
has recently been published and may be
Assessment used by the dentist to identify factors that
may warrant further evaluation from a
Basic assessment of TMD patients, espe¬ mental health professional66 (Fig 5-5).
cially those suffering from chronic pain, If warranted, the initial psychological
should include behavioral and psychoso¬ assessment may be followed by evaluation
cial evaluation consideration. In some with a mental health care professional. In
cases, stress-related muscle hyperactivity addition to the tests mentioned, the men¬
may be the primary contributing factor. tal health care professional may use
In other cases, emotional problems such other testing instruments such as the
as anxiety and depression can result from MMPI, Hamilton Depression Scale, West
unresolved signs and symptoms. Thus, it Haven-Yale Multidimensional Pain In¬
is strongly advised that the dental history ventory, DSP & SCL-90 Scale, Beck De¬
include questions to evaluate behavioral, pression Inventory, McGill Pain Ques¬
social, emotional, and cognitive factors tionnaire, Multiaxial Assessment of Pain,
that may initiate, sustain, or result from Millon Behavioral Health Inventory, and
the patient’s condition. Illness Behavior Questionnaire.67-74 It is
Comprehensive psychological invento¬ important to realize that these invento¬
ries such as the Minnesota Multiphasic ries should be used in the context of a
Personality Inventory (MMPI) are not careful history and clinical examination.75
necessary for routine screening.59 The
utility of most psychological tests in the
dental office is limited, as the tests require Additional Clinical Tests
interpretation in the context of an exten¬
sive psychosocial history and usually re¬ Various diagnostic studies are available
quire considerable training and experience for use in selected cases to assist in con¬
to interpret.60 However, prior to undertak¬ firming a physical TMD diagnosis, such
ing TMD management the dentist should as biopsy, laboratory tests, and diagnostic
screen specifically for oral habits, depres¬ anesthetic injections. Mounted study casts
sion, anxiety, stressful life events, lifestyle can be of value, not only as a baseline
changes, secondary gain, and overuse of record for tooth and jaw relations, but
health care. Although in most simple cases also for evaluation of the effects of brux-
this can be accomplished during the ini¬ ism to the occlusal surface of the teeth.
tial interview and examination by the den¬
tist, further assessment is recommended
if significant factors are identified. Anxi¬
Biopsy
ety and depression can usually be identi¬ Intra-articular biopsies are useful for
fied by simply asking the patient about benign or malignant tumors of bones, car¬
these conditions.61 Some psychological tilage or synovium (eg, chondroma, chon¬
aspects of illness can be identified in TMD drosarcoma, synovial osteochondromato¬
patients by using pain diaries or self- sis). As previously mentioned, definitive
assessment instruments such as the diagnosis of temporal arteritis is usually
Holmes and Rahe Scale for life changes.62 dependent on biopsy of the temporal ar¬
Two recendy developed tests, IMPATH63 tery. These tests should not be considered
and the TMJ Scale,64-65 are designed for routine procedures but rather are used
use by dentists assessing TMD. A check¬ to supplement knowledge gained during

68
 Additional Clinical Tests

Checklist of Psychological and Behavioral Factors

1. Inconsistent, inappropriate, and/or vague reports of pain

2. Overdramatization of symptoms
3. Symptoms that vary with life events
4. Significant pain of greater than 6 months' duration
5. Repeated failures with conventional therapies
6. Inconsistent response to medications
7. History of other stress-related disorders
8. Major life events, eg, new job, marriage, divorce, death
9. Evidence of drug abuse
10. Clinically significant anxiety or depression
11. Evidence of secondary gain

Fig 5-5 These psychosocial and behavioral considerations should be assessed as part of the
patient exam and history. The significance of these factors depends on the particular patient. In
general, the more factors identified, the greater is the indication that the patient should be referred
to a mental health professional; however, any one of these factors may be sufficiently problematic to
warrant a more extensive psychosocial evaluation.

history-taking, examination, and imag¬ rheumatoid factor (RhF). However, none

ing. Soft tissue biopsy would be of prima¬ of these findings alone is diagnostic. Like¬
ry importance for intraoral lesions and wise, in rheumatic disease the RhF may or
suspected neoplasia within the mastica¬ may not be positive (and if positive, is not
tory muscles. specific) and an anemia is commonly pres¬
ent. In the spondylarthropathies Human
Lymphocyte Antigen-B27 (HLA-B27), a
Laboratory Tests histocompatibility antigen, may be present
Laboratory diagnostic testing for TMD in 20% to 50% of the patients but is again
may include hematologic, urine, and syn¬ poorly specific for the disease.76-77 The
ovial fluid analyses to identify hematolog¬ uric acid test is considered to be diagnos¬
ic, rheumatologic, metabolic, or other tic for gouty arthritis.78 Leucocytosis may
abnormalities suggestive of systemic dis¬ be a sign of an acute infectious process but
ease. However, hematologic studies are is again not specific for an articular infec¬
rarely diagnostic of disorders that present tious process. Hematologic laboratory
as TMD, but they may be helpful in tests that contradict the clinical diagnosis
screening for some conditions, especially or that substantially change the intended
certain vascular, rheumatic, or infectious therapy should be viewed with caution.
diseases. In almost all cases, a blood study Analysis of synovial fluid tests for a
that is sensitive for a particular disease is variety of extracellular matrix (ECM) deg-
poorly specific. For example, in vascular radative enzymes, inflammatory by¬
disease like temporal arteritis, one will products, and known pain mediators may
commonly find an elevated erythrocyte be used as biochemical markers for the
sedimentation rate (ESR), antinuclear an¬ degradation that occurs with TMJ pa-
tibodies (ANA), an anemia, and a negative thosis.79-82 A study by Quinn and Ba-

69
Assessment

zan83 evaluated three factors, Prostaglan¬ nopalatine or stellate ganglion blocks) for
din E2 (PCE2), Leukotriene B4 (LTB4), diagnosis of sympathetic mediated pain
and Platelet-activating Factor (PAF) by should be referred to an appropriately
injecting 1.5 cc of saline followed by aspi¬ trained anesthesiologist.85 Myofascial trig¬
ration and assay. The analysis was cor¬ ger point injections can result in absent or
related with arthroscopic evaluation of decreased pain in the trigger point area
the joint. Another study correlated ker- and the referred pain location(s).86 Pro¬
atan sulfate levels in the synovial fluid and caine is the local anesthetic of choice for
arthroscopic examination findings.84 the injection of myofascial trigger points
There seems to be a good correlation of because of the low potential for adverse
the degree of synovial pathosis to the effects in muscles. Diagnostic anesthesia
level of those factors. The prime flaw in of the TMJ can be achieved by a direct
this type of research, a major drawback of lateroposterior and slightly inferior in-
any research involving invasive methods, tracapsular approach to the joint, a poste¬
is the lack of controls. Another use of rior meatal intracapsular approach, or an
articular fluid aspiration would be in the extracapsular block of the auriculotem¬
instance when articular infection is sus¬ poral nerve at the posterior aspect of the
pected and cultures are needed. In gout neck of the condyle. Bupivacaine (.25%)
(urate crystals) and pseudogout (calcium produces prolonged anesthesia for muscle
pyrophosphate dihydrate crystals), the ar¬ and joint diagnostic injections, but can
ticular fluid can be used to analyze poten¬ possibly produce toxicity in muscle tissue.
tial crystal formation. These two arthri- However, the long duration of its thera¬
tides, however, are rare in the TMJ. At peutic effect can be very beneficial for ad¬
this point synovial fluid analysis is pri¬ junctive pain management and outweighs
marily a research tool and has little clini¬ the reported risk of muscle toxicity.
cal application toward diagnosis and man¬ The interpretation of diagnostic local
agement, but future clinical value is anesthetic blocks is a challenging process
promising because the detection of bio¬ requiring considerable study and caution,
chemical markers may precede any detec¬ particularly in a patient who may have
tion of morphologic change in the TMJ. been overtreated and/or who may have de¬
veloped an iatrogenic condition. Unfortu¬
nately, when well-intended treatment pro¬
Diagnostic Anesthetic Injections
cedures fail, the patient’s distress
Diagnostic injections include neural increases. To patients the temporary re¬
blockade (somatic and sympathetic nerve duction in their distress (not necessarily
blocks), trigger point injections, and pain relief) following an anesthetic block
TMJ injections. Neural blockade can be becomes so welcome and encouraging that
used to determine if the pain is due to they may succeed in persuading the clini¬
pathosis peripheral to the point of the cian to perform an irreversible procedure.
block. Lidocaine (1% to 2% without epi¬ Thus, temporary relief of pain that may re¬
nephrine) is recommended for diagnostic sult following a local anesthetic block or
nerve blocks because it produces a prompt, infiltration does not always indicate that
longer-lasting, and more extensive anes¬ nerve ablation or surgical intervention will
thesia. Neural blockade is of particular result in lasting relief. Diagnostic anes¬
prognostic value prior to neurolytic block¬ thetic injections are valued test procedures
ade or surgical sympathectomy (neurol¬ but they must be evaluated with the his¬
ysis). Sympathetic nerve blocks (ie, sphe¬ torical, clinical, and laboratory findings.

70
 Additional Clinical Tests

Mounted Study Casts have potential to be clinically useful, re¬

search on their reliability and validity for
Articulated or mounted dental casts can
TMD diagnosis has yet to be completed.
facilitate detailed examination of both the
All diagnostic tests should be subjected to
static and functional relations of the teeth
testing for safety as well as for efficacy.
and jaws and serve as a baseline record for
Efficacy of a diagnostic test should be
the effects of bruxism. They are of partic¬
established through studies that deter¬
ular importance as a baseline record when
mine the sensitivity, specificity, and posi¬
orthopedic appliance therapy is contem¬
tive and negative predictive values of the
plated because appliances can potentially
test.88-89 The sensitivity is the probability
cause an irreversible alteration in the tooth that the test will identify disease when it is
and jaw relations. However, acute muscle known to be present. The specificity of a
and joint pain and joint edema can de¬ test is its ability to correctly identify a
crease the accuracy of the mountings and, patient who is free of a specific disease.
thus, occlusal analysis with mounted study The sensitivity and specificity of a test
casts is most reliable after acute disease should generally be better than 70%. At
processes are resolved.87 this time these important characteristics
Mandibular position measurement de¬ are known for only a very few diagnostic
vices that allow for the comparison of tests for TMD.90-95
articulator condylar differences in vari¬ The primary concern is that with the
ous occlusal positions are an adjunct to use of many tests, a lack of scientific data
mounted study casts. They provide mea¬ can lead to many false-positive diagnoses
surements between the condylar positions and some false-negative diagnoses. There
in the intercuspal position and the re- are immediate and implied future health
truded contact position in all three planes and financial costs related to treating a
of space. Even with the most careful rec¬ false-positive diagnosis and the delayed
ords and mountings, however, mounted costs of not treating a false-negative diag¬
casts are at best an approximation of the nosis. Until well-controlled clinical trials
true dynamics of the mandible. The clini¬ with new diagnostic tests are performed
cian should note that although mounted on the subgroups of TMD patients and
casts can be valuable for the study of the are compared to control groups, tests
teeth, associated structures, and occlusal should be considered experimental and
relations as an aid for dental treatment should be interpreted with extreme cau¬
planning, they do not provide direct in¬ tion.90*92 It is hoped that as research
sight into the etiology of TMD, Thus, continues a number of procedures will
because the relationship between occlu¬ become accepted for specific clinical situ¬
sion and TMD is not strongly correlated, ations in the future.
mounted casts should not be used to diag¬
nose TMD per se.
Mandibular Movement Recording
Because impairment of jaw movement is
one of the signs of TMD, it is not surpris¬
Proposed Additional ing that quantification of jaw movement
Documentation has been considered important. Facebows
using simple pens as recorders (pantogra-
Numerous tests have been proposed for phy) have long been used for recording
use in patients with TMD. Although many mandibular border movements lateral to

71
Assessment

the condyles. Electronic systems may en¬ the evaluation or diagnosis of TMD. This
hance mandibular movement recording is consistent with conclusions reached dur¬
procedures, but their use for diagnosis ing scientific conferences of the Neurosci¬
depends on whether the dentist obtains ence Group of the International Associa¬
diagnostically relevant information from tion for Dental Research,105 a workshop
the jaw tracking. This is an important of the National Institute of Dental Re¬
question in view of the sparse and unrep¬ search (NIH, April 3 to 4, 1989), and
licated scientific evidence linking jaw scientific programs dealing with diagnosis
tracking to TMD diagnosis.92-93-96’97 Pre¬ of TMD by the American Academy of
cise tracking movements of the entire Craniomandibular Disorders (Washing¬
mandible in three dimensions requires a ton, DC, April 13 to 15, 1989) and the
minimum of six measurements (six de¬ European Academy of Craniomandibular
grees of freedom), and the data analysis Disorders (Zurich, Switzerland, October
generated by such a system (especially 8 to 10, 1987).
during functional movements such as
chewing) is a very complex task.98 Instru¬
Thermography
ments that measure movements at the
incisors do not fulfill these requirements The diagnosis of neurologic and mus¬
and are not adequate for describing molar culoskeletal abnormalities by thermogra¬
and condylar movements or maximal man¬ phy is based on thermal asymmetry be¬
dibular movements.99 Presently, there is tween normal and abnormal sites. The
insufficient scientific documentation to applicability of thermography to the di¬
suggest that jaw tracking devices are use¬ agnosis of TMD has been addressed with
ful in the diagnosis of TMD.94 Further¬ conflicting results.106-107 The concept is
more, subjects are not able to consistently that if normal pain-free subjects have sym¬
reproduce functional jaw movements even metrical thermograms,108 then asymmet¬
after training.100-101 rical thermograms might suggest the pres¬
ence of TMD. Some studies indicate that
TMD patients have increased thermal
Electromyography
emission on the symptomatic side,109-110
Electromyography (EMG) can be useful especially the affected joint.111 However, a
for studies of reflex activity and nerve study by Finney et al112 suggests that
conduction and for the assessment of para- TMD patients have decreased thermal
functional behavior. Parafunctional activ¬ emission on the symptomatic side. The
ity can be monitored and in some in¬ variability of normal facial surface tem¬
stances can be recorded outside of the perature between sides may be consider¬
dental office by means of diurnal or noc¬ able.113 A recent comprehensive review
turnal electronic measuring techniques. found that there is conflicting evidence
The measurement of other functional and on the direction of temperature shift over
postural acts by surface EMG is less use¬ the painful site and high within-patient
ful because variations in means exceed and between-patient variability.95 Stud¬
the very differences one seeks to establish ies demonstrate that the results of ther¬
between “normal” and “abnormal” sub¬ mography can vary greatly according to
ject groups.92-102-104 A recent compre¬ technique and instrument position. The
hensive review of the scientific literature94 results of clinical investigations suggest
concluded that there is not yet sufficient that thermographic “hot spots” in the
evidence to support the use of EMG for back are unassociated with active trigger

72
 Proposed Additional Documentation

points and “cold patches” on the face or 3. Clark GT, Seligman DA, Solberg WK,
head are not prognostic for head¬ Pullinger AG: Guidelines for the exam¬
ache.114-115 Presently, there is little scien¬ ination and diagnosis of temporomandib¬
tific evidence to suggest that thermogra¬ ular disorders. J Craniomandib Disord
phy is useful in the diagnosis of Facial Oral Pain 1989;3:7-14.
TMD.116-117 4. Schiffman E, Fricton J, Haley D, Tylka D:
A pressure algometer for myofascial pain
syndrome: Reliability and validity testing.
In Dubner R, et al (eds) Proceedings of
Mediate Auscultation
the Fifth World Congress on Pain. Vol 3.
Sonography is the technique of recording Amsterdam, Elsevier, 1988, pp 407-413.
and graphically representing sound. In 5. Ohrbach R, Gale EN: Pressure pain
Doppler ultrasonography (the application thresholds, clinical assessment, and dif¬
of the Doppler effect to ultrasonic scan¬ ferential diagnosis: reliability and validity
ning), ultrasound echoes are converted to in patients with myogenic pain. Pain 1989;
amplified audible sound waves as the ul¬ 39:157-169.
trasonic transmissions bounce off moving 6. List T, Helkimo M, Karlsson R: Influence
tissues within the TMJ. The clinical sig¬ of pressure rates on the reliability of a
nificance and reproducibility of sounds pressure threshold meter. J Cranioman¬
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178.
clear.101-118 One study compared clinical
findings and arthrographic data to Dop¬ 7. Clark GT: Examining temporomandibu¬
pler ultrasonographic findings.119 Al¬ lar disorder patients for craniocervical
though this and other longitudinal data dysfunction. J Craniomand Pract 1984;
2:56-63.
are available,120-121 more information is
needed before the clinical significance of 8. Clark GT, Green EM, Dornan MR, Flack
these sounds can be better understood.122 VF: Craniocervical dysfunction levels in a
patient sample from a temporomandibu¬
Recent comprehensive reviews concluded
lar joint clinic. J Am Dent Assoc 1987;
that there is no clinical advantage of 115:251-256.
using sonography or Doppler methods
9. S j aastad O, F redriksen TA, Plaffenrath V:
over a conventional stethoscope or di¬
Cervicogenic headache: Diagnostic crite¬
rect auscultation to document joint ria. Headache 1990;30:725-726.
sounds.92-94-123
10. Tanaka, TT: Recognition of the pain for¬
mula for head, neck, and TMJ disorders.
V: The general physical examination. J
Calif Dent Assoc 1984;12:43-49.
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1991;70(special issue):abstr 843. 109. Berry DC, Yemm R: Variations in skin
98. Gibbs C, Lundeen H: Jaw movements and temperature on the face in normal sub¬
forces during chewing and swallowing and jects and in patients with mandibular
their clinical significance. In Lundeen H, dysfunction. BrJ Oral Surg 1971 ;8:242—
Gibbs C (eds) Advances in Occlusion. 247.
Boston, John Wright, 1982, pp 2-32. 110. Berry DC, Yemm R: A further study of
99. Balkhi KIM, Tallents RH, Goldin B, Cata¬ facial skin temperature in patients with
nia JA: Error analysis of a magnetic jaw¬ mandibular dysfunction. J Oral Rehabil
tracking device. J Craniomandib Disord 1974;1:255-264.
Facial Oral Pain 1991;5:51-56.
111. Steed PA: The utilization of contact liq¬
100. dos Santos J Jr, Ash MM Jr, Warshawsky uid crystal thermography in the evalua¬
P: Learning to reproduce consistent func¬ tion of temporomandibular dysfunction. J
tional jaw movement. J Prosthet Dent Craniomand Pract 1991;9:120-128.
1991;65:294-302.
112. Finney JW, Holt CR, Pearce KB: Ther¬
101. Toolsen GA, Sadowsky C: An evaluation mographic diagnosis of temporomandibu¬
of the relationship between temporoman¬ lar joint disease and associated neuro¬
dibular joint sounds and mandibular move¬ muscular disorders. Postgrad Med Special
ment. J Craniomandib Disord Facial Oral Rep, Proceedings of the Academy of Neu¬
Pain 1991;5:187-196. romuscular Thermography. March, 1986,
102. Lund JP, Widmer CG: Evaluation of the pp 93-95.
use of surface electromyography in the 113. Johansson A, Kopp S, Haraldson T: Re¬
diagnosis, documentation and treatment producibility and variation of skin surface
of dental patients. J Craniomandib Dis¬ temperature over the temporomandibu¬
ord Facial Oral Pain 1989;3:125-137. lar joint and masseter muscle in normal
103. Rugh JD, Davis SE: Accuracy of diagnos¬ individuals. Acta Odontol Scand 1985;43:
ing MPD using electromyography. J Dent 309-313.
Res 1990;69(special issue):273, abstr 1319. 114. Swerdlow B, Dieter JN: The vascular “cold
104. Schroeder H, Siegmund H, Santibanez patch” is not a prognostic index for head¬
H-G, Kluge A: Causes and signs of tem¬ ache. Headache 1989;29:562-568.
poromandibular joint pain and dysfunc¬
115. Swerdlow B, Dieter JN: An evaluation of
tion: An electromyographical investiga¬
the sensitivity and specificity of medical
tion. J Oral Rehabil 1991;18:301-310.
thermography for the documentation of
105. International Association of Dental Re¬ myofascial trigger points. Pain 1992;48:
search. Newsletter. Vol 3, No. 6, 1987. 205-213.
106. Pogrel MA, Yen CK, Taylor RC: Infrared 116. Graft BM, Pullinger A, Sickles EA, Lee
thermography in oral and maxillofacial JJ: Electronic thermography of normal
surgery. Oral Surg Oral Med Oral Pathol facial structures: A pilot study. Oral Surg
1989;67:126-131. Oral Med Oral Pathol 1989a;68:346-3 51.

78
 References

117. Gratt BM, Sickles EA, Graff-Radford SB, 121. Heffez L, Blaustein D: Advances in so¬
Solberg W: Electronic thermography in nography of the temporomandibular joint.
the diagnosis of atypical odontalgia: A Oral Surg Oral Med Oral Pathol 1986;62:
pilot study. Oral Surg Oral Med Oral 486-495.
Pathol 1989b;68:472—481. 122. Greene CS, Laskin DM: Long term status
118. HardesonJD, OkesonJP: Comparison of of TMJ clicking in patients with myofas¬
three clinical techniques for evaluating cial pain dysfunction. J Am Dent Assoc
joint sounds. J Craniomand Pract 1990;8: 1988;117:461-465.
307-311. 123. Widmer CG: Temporomandibular joint
sounds: A critique of techniques for re¬
119. Davidson SL: Doppler auscultation. J Cra- cording and analysis. J Craniomandib Dis¬
niomandib Disord Facial Oral Pain 1988; ord Facial Oral Pain 1989;3:213-217.
2:128-132.

120. GayT, Bertolamie CN: Arthrophonome-

try of the TMJ. J Dent Res 1986;65(spe-
cial issue):abstr 851.

79
 S I X

Management

Management goals for patients with TMD py, medications, and orthopedic appli¬
are similar to those for patients with oth¬ ances are endorsed for the initial care of
er orthopedic or rheumatologic disor¬ nearly all TMD.4
ders, namely, decreased pain, decreased The majority of patients suffering with
adverse loading, restored function, and TMD achieve good relief of symptoms
restored normal daily activities. These with conservative therapy.5’6 Long-term
goals are best achieved by a well-defined follow-up of TMD patients shows that
program designed to treat the physical more than 50% of the patients have few
and/or psychological disorder(s) and to or no symptoms after conservative treat¬
decrease or remove all contributing fac¬ ment. From a study of 154 patients, it was
tors. The management options and se¬ concluded that most TMD patients have
quence of treatments for TMD described minimal recurrent symptoms 7 years af¬
here are consistent with treatment of oth¬ ter conservative treatment procedures.2
er musculoskeletal disorders. A study of 90 patients with clinically doc¬
As in many musculoskeletal conditions, umented TMD who were followed for 10
the signs and symptoms of TMD may be years revealed that more than 90% had
transient and self-limiting, resolving with¬ relief of symptoms after conservative treat¬
out serious long-term effects.1-3 Little is ment.7 In a recent study of 110 TMD
known about which signs and symptoms patients, 85.5% reported that they expe¬
will progress to more serious conditions rienced no pain or much less pain at 2.0 to
in the natural course of TMD. For these 8.5 years after conservative treatment.8
reasons, a special effort should be made In many patients with disc displacement,
to avoid aggressive, nonreversible thera¬ painless and satisfactory function are pos¬
py, such as complex occlusal therapy or sible although the disc remains displaced.9
surgery. Conservative treatment such as In fact, patients with disc displacement
behavioral modification, physical thera¬ of the temporomandibular joint may go

81
Management

through a natural progression of healing a team of clinicians may be needed. A

and remodeling.10-11 treatment team is needed because it is
It is strongly suggested that the use of difficult for an individual clinician to ad¬
the terms phase I and phase II treatment dress the multitude of contributing fac¬
of TMD be discontinued. Phase I therapy tors that may be present in complex chron¬
usually referred to behavior modification, ic pain patients.12
counseling, pharmacotherapy, physical Traditionally, most treatment of TMD
therapy, and/or orthopedic appliances. In has been unique and varied according to
the past, phase II therapy traditionally the clinician’s favorite theory of causa¬
referred to some form of definitive oc¬ tion.6 As a result, success of treatment
clusal therapy, ie, equilibration, restora¬ was often compromised by limited ap¬
tive therapy, full-mouth reconstruction, proaches that only addressed part of the
prosthodontic therapy, orthodontic ther¬ problem. With a team, various aspects of
apy and/or orthognathic surgery, or sur¬ the problem can be addressed by different
gery. The disturbing concern with phase specialists, which enhances the overall
1/phase II terminology is that to some, if potential for success. Teams can be inter¬
not to many, dentists the concept of two disciplinary (one setting) or multidisci¬
phases of treatment means that after com¬ plinary (multiple settings). Management
pleting phase I treatment, phase II treat¬ goals are best achieved by using the opti¬
ment is automatically planned. But the mal combination and sequence of treat¬
scientific literature does not support the ment options in the context of the overall
need for a two-phase approach because management program. All management
definitive occlusal therapy is not required programs should be time limited. Treat¬
for most TMD cases. The need for fol¬ ment options include (1) patient education
low-up or second-phase occlusal therapy and self-care, (2) cognitive intervention,
is a historical belief system that dentists (3) psychotherapy, (4) pharmacotherapy,
have developed, in part, from previous (5) physical therapy, (6) orthopedic appli¬
predoctoral and postdoctoral programs, ance therapy, (7) occlusal therapy, and (8)
and, in the main, from continuing educa¬ surgery. Each of these modalities will be
tion courses. Although the literature does discussed in detail separately, but in prac¬
not support a direct correlation between tice they should be used in combination
occlusion and TMD, and thus the need depending on the needs of the patient.
for phase II TMD therapy, it does not
exclude occlusal therapy as valid for
the proper treatment of numerous dental
conditions. Patient Education and
Despite the success of conservative care, Self-Care
some patients with TMD do not improve.
Reasons for this vary but these patients The success of a self-care program de¬
generally fall into two groups: (1) patients pends on patient motivation, coopera¬
with pain and dysfunction caused by ma¬ tion, and compliance. The clinician must
jor structural changes in the joint, and take the time to explain the clinical find¬
(2) patients with a chronic pain syndrome ings, diagnostic data, treatment options,
complicated by multiple contributing fac¬ and prognosis to the patient. The time
tors. In the first situation, TMJ surgery spent on patient reassurance and educa¬
may be indicated. In the second situation, tion is a significant factor in developing a
a chronic pain management program with high level of rapport and treatment com-

82
 Patient Education and Self-Care

pliance. This requires attentive listening described in detail, further enhancement

on the part of the clinician and sufficient of the doctor-patient relationship and
time for the patient to present his concerns. compliance results. Emphasis on patient
A careful explanation of the problem and self-control should remain a paramount
treatment plan, using terminology the theme. A program of moist heat or ice or
patient can understand, is important to both to the affected areas, massage of the
successful management. affected muscles, and gentle range of mo¬
A successful self-care program may al¬ tion exercises can decrease tenderness and
low healing and prevent further injury to pain and increase range of motion. Heat
the musculoskeletal system and is often is commonly applied with hot compresses,
enough to control the problem.6-13 In¬ moist heating pads, hydrocollators, and
struction in a self-care routine should disposable hot packs. These applications
include the following: rest of the mus¬ transmit heat by conduction and are only
culoskeletal system through voluntary lim¬ useful for superficial heating (1 to 5 mm
itation of mandibular function, habit in depth). Heat stimulates analgesia, mus¬
awareness and modification, and a home cle relaxation, and improvement in the
physiotherapeutic program. An explana¬ physiologic state of the tissue. Cold, used
tion of the advantages of resting the af¬ primarily for its local analgesic and anti¬
fected muscular and articular structures, inflammatory effects in muscle tissue, is
much the same as an athlete must rest or applied to the affected area by ice that is
immobilize an injured joint, is most help¬ moved along the direction of the muscle
ful. This explanation should emphasize fibers for several minutes. Because cold
function modification (ie, avoidance of is uncomfortable, however, it is best to
heavy mastication, gum chewing, wide warm the area afterward. Alternate appli¬
yawning, singing) and habit awareness cation of heat, ice, and heat again may be
(ie, avoidance of clenching, bruxing, most effective. Because the temperature
tongue thrusting, poor sleeping posture, differential is greater with cold, a shorter
object biting, and playing certain musical application may produce a greater re¬
instruments).14 Habit change can be ac¬ sponse. Heat should not be used for acute
complished when the patient becomes injury (less than 72 hours), acute inflam¬
more aware of the habit, knows how to mation, or infection. Cold should not be
correct it, and has the motivation to cor¬ used over areas with poor circulation (as
rect it. When this knowledge is combined found in patients with diabetes) or over
with a commitment to conscientious moni¬ open wounds.
toring, some habits will change. A simple
form of feedback, such as visual reminders
adapted to the patient’s daily activities,
should be discussed and implemented (eg,
Cognitive Behavioral
small stickers strategically placed at home, Intervention
in the automobile, and at work). The
feedback objects should remind the pa¬ Approaches to changing maladaptive hab¬
tient to be aware of the habit and then to its and behavior is an important part of
help modify it. Progress with habit mod¬ the overall treatment program for TMD
ification should be addressed at all ap¬ patients.16 Although simple habits may be
pointments with the patient. modified when the patient is made aware
A home physiotherapeutic program is of them, changing persistent habits may
also beneficial.15 When such a program is require a structured program that is facil-

83
Management

itated by a clinician trained in behavioral than is any single behavioral treatment

modification.17-19 Significant modifica¬ procedure. Use of behavioral therapies
tion in the patient’s lifestyle is often nec¬ in conjunction with dental therapies ap¬
essary to alter the contributing factors. If pears to enhance the overall therapeutic
a more structured approach is indicated, effects.26
strategies for behavior modification such
as a habit reversal program, lifestyle coun¬
seling, progressive relaxation, hypnosis, Psychotherapy
and biofeedback should be considered.
Treatment should be individualized to The plethora of emotional and interper¬
best fit the patient’s problems, prefer¬ sonal connotations associated with the
ences, and lifestyle. functions of the mouth and jaw make
Biofeedback is a structured therapy these anatomic sites the ideal focus for
based on the theory that when an individ¬ the symbolic portrayal of psychological
ual receives information about a desired conflicts.27*28 For some TMD patients,
change and is supported for making the symptoms may serve as a somatic meta¬
change, the change is more likely to oc¬ phor that both expresses and resolves pre¬
cur.20 In general, biofeedback training existing or concurrent psychological con¬
uses equipment to measure biological ac¬ flicts.29’30 Chronic pain behaviors may
tivity (eg, surface electromyograph to mea¬ both enact and inhibit aggressive, depen¬
sure muscle activity). The equipment is dent, and sexual impulses that the patient
designed with a “feedback” loop so that a both wishes and fears.31’32 Thus, symp¬
patient can receive immediate informa¬ toms may be a compromise formation
tion (feedback). A number of controlled that decreases anxiety and conflict while
studies have demonstrated that relaxation facilitating the patient’s unconscious, in¬
training, with or without the use of sur¬ voluntary best effort to function adap¬
face electromyographic (EMG) biofeed¬ tively.33 These primary gains of symptom
back, can decrease diurnal (daytime) ton¬ formation may be offset by the limita¬
ic muscle activity.18 The use of nocturnal tions and discomfort that accompany
EMG biofeedback has been reported to TMD and orofacial pain conditions.
be effective in controlling nighttime brux- When TMD and orofacial pain are
ism.21-23 However, such studies have gen¬ symptoms of a true conversion disorder
erally been of short duration, and the or are integrally part of the patient’s char-
short-term biofeedback therapy has not acterologic defensive and coping style,
been followed by measurable long-term treatment efforts with pharmacologic or
decreases in bruxing behavior.24*25 Be¬ cognitive-behavioral management alone
cause nocturnal EMG biofeedback with¬ are likely to prove insufficient.29 These
out a more comprehensive stress man¬ patients should be referred to a mental
agement program appears to decrease health professional skilled in gaining ac¬
bruxism only temporarily, its use may cess to and resolving psychological con¬
be limited to short-term management of flicts. The goal of psychotherapeutic in¬
acute conditions. tervention is to translate the meaning of
Comprehensive stress management and the somatic symptom into its psychologi¬
counseling programs that involve a com¬ cal and interpersonal equivalents, and then
bination of EMG biofeedback, progres¬ to help the patient resolve the original
sive relaxation, and self-directed changes conflicts. These efforts often extend be¬
in lifestyle appear to be more effective yond the resolution of the original TMD

84
 Psychotherapy

or orofacial pain symptoms.34-36 The role tropic medications, including the ben¬
of the dentist is to insure continuity of zodiazepines (eg, central nervous system
treatment by providing supportive in¬ [CNS] depression), are likely to outweigh
volvement and routine dental care. At the the therapeutic benefits. Rarely indicated
same time, invasive or irreversible dental for specific TMD, anticonvulsant medi¬
procedures are to be assiduously avoided.37 cations may be prescribed by appropri¬
Careful coordination of treatment by the ately trained clinicians for diagnostic and
dentist and mental health professional therapeutic reasons for orofacial pain syn¬
will assure that such patients receive opti¬ dromes of neuropathic origin; however,
mal care.38*39 careful monitoring is essential for patient
safety. For proper management of TMD
patients with chronic pain secondary to
Pharmacotherapy pre-existing or concurrent psychiatric dis¬
orders, psychoactive medications should
Both clinical experience and controlled be prescribed by a psychiatrist in con¬
experimental studies show that pharma¬ junction with comprehensive care for the
cotherapy can be a powerful catalyst to patient’s overall mental health needs.
patient comfort and rehabilitation when The most effective pharmacologic
used as part of a comprehensive manage¬ agents for the management of TMD in¬
ment program.40 Although there is a ten¬ clude analgesics, nonsteroidal anti-inflam¬
dency for clinicians to rely on a single matory drugs (NSAID), corticosteroids,
“favorite” agent, no one drug has a proven muscle relaxants, and antidepressants 45-47
efficacy for the entire spectrum of TMD. The analgesics and corticosteroids are
To avoid unexpected complications and indicated for acute TMD pain, the non¬
adverse drug interactions and to achieve steroidal anti-inflammatory agents and
maximal efficacy, it is important to be¬ muscle relaxants may be used for both
come familiar with a spectrum of drugs acute and chronic conditions, and the
that may be prescribed for orofacial pain. tricyclic antidepressants are primarily in¬
Of concern with TMD pharmacother¬ dicated for chronic orofacial pain man¬
apy are the problems that can occur with agement.48’49
drug misuse or abuse. Because opioid
narcotics produce tolerance and depen¬
Analgesics
dence, continued analgesic usage in the
TMD patient needs careful considera¬ Analgesics, either opiate or nonopiate
tion.41-43 The use of “prn” (as needed) preparations, are used to reduce pain
pain-contingent drug prescribing is still associated with TMD. The nonopiate an¬
common despite clear warnings in the algesics are a heterogeneous group of
literature that this approach is ineffective compounds that share certain therapeu¬
and may lead to abuse with some patients. tic actions and side effects.50 They are
Therefore, dependence-producing phar¬ effective for mild to moderate pain asso¬
maceuticals should only be used on a ciated with TMD. Aspirin (salicylate),
time-contingent basis.44 Every other ave¬ which prevents prostaglandin synthesis,
nue of treatment should be pursued rath¬ is the prototype for these compounds. All
er than relying on narcotic medication salicylate drugs are antipyretic, analgesic,
for TMD patients. and anti-inflammatory, but there are im¬
For patients with chronic orofacial pain portant differences in their effects. If the
including TMD pain, the risks of psycho¬ patient is sensitive to aspirin, a nonacety-

85
Management

lated aspirin, choline magnesium trisal- where conservative treatment has been
cylate (Trilisate) may be effective.51 The unsuccessful.52’53 It is thought that the
therapeutic effect of opioid narcotics acts drug effect causes more rapid resolution
on specific opiate receptor sites in the of symptoms, thus avoiding surgery in
central nervous system. These drugs have some cases. Conversely, it has been re¬
central nervous system depression quali¬ ported that injection of corticosteroids
ties and addiction liabilities and depend¬ into the TMJ does not result in sustained
ing on their potency may be used short¬ improvement and that repeated injections
term for moderate to severe acute pain. are not effective in treating degenerative
TMJ arthritis and may even accelerate
joint degeneration.45 Still others report
Nonsteroidal Anti-Inflammatory significant short-term improvement with
Drugs intracapsular injection of corticosteroids
in patients with rheumatoid arthritis54
Nonsteroidal anti-inflammatory drugs and with no long-term sequelae.55
(NSAID) are effective against mild to
moderate inflammatory conditions and
postoperative pain. Their chief clinical Muscle Relax ants
application is as anti-inflammatory drugs Muscle relaxants are prescribed to help
in the treatment of musculoskeletal dis¬ prevent the increased muscle activity as¬
orders. These drugs provide only symp¬ sociated with TMD.56 Mephenesin is the
tomatic relief and do not arrest the prototype for the majority of the oral
progression of pathologic tissue injury skeletal muscle relaxants —the propane¬
except possibly in active inflammatory diols (eg, carisoprodol [Soma], methocar¬
joint disease. Nonsteroidal anti-inflam¬ bamol [Robaxin], and chemically related
matory drugs can be divided into two chloroxazome [Paraflex, Parafon]). Exper¬
groups of compounds: (1) the indoles (of imentally, muscle relaxants depress spinal
which indomethacin [Indocin] is the pro¬ polysynaptic reflexes preferentially over
totype), which include sulindac (Clinoril) monosynaptic reflexes. These compounds
and tolmetin sodium (Tolectin); and (2) affect neuronal activity associated with
propionic acid derivatives with a shorter muscle stretch reflexes, primarily in the
half-life (eg, ibuprofen [Motrin], naprox¬ lateral reticular area of the brainstem.
en [Naprosyn], and fenoprofen [Nalfon]). The oral doses of all of these drugs are
well below the amount required to elicit
muscle relaxant activity experimentally;
Corticosteroids
thus, some investigators conclude that
Although effective because of their anti¬ their muscle relaxant activity is related
inflammatory effects, corticosteroids are only to their sedative effect.57 Another
not commonly prescribed for systemic commonly prescribed muscle relaxant, cy-
use in the treatment of inflammation as¬ clobenzaprine (Flexeril), is similar to the
sociated with TMD except for acute, gen¬ structurally related tricyclic antidepres¬
eralized muscle and joint inflammation sants in its effects. It is reported to act
associated with polyarthritides. Intracap- primarily at the brain stem level with the
sular TMJ injection of corticosteroids net effect of reduced tonic autonomic
(ie, methylprednisolone) has been rec¬ motor activity.58 Some central skeletal
ommended on a limited basis in cases of muscle relaxants are available in combi¬
acute exacerbation of severe joint pain nation with analgesics (eg, carisoprodol

86
 Pharmacotherapy

with phenacetin and caffeine [Soma Com¬ generation of tissues. In most cases,
pound], chlorzoxazone with acetamino¬ physical therapy is used as an adjunct to
phen [Parafon Forte], methocarbamol with other treatments. Referral to and close
aspirin [Robaxisal]). cooperation with licensed professional
therapists are recommended. Although
Antidepressan ts well-controlled clinical trials have not been
completed, physical therapy is well rec¬
The tertiary tricyclic antidepressants, par¬ ognized as an effective, conservative meth¬
ticularly amitriptyline (Elavil), have anal¬ od of treatment for TMD.15-63-66
gesic properties independent of an anti¬
depressant effect and are prescribed for
chronic pain patients who have pain, de¬
Posture Training
pression, and sleep disturbance.59-61 The The goal of posture training involves the
therapeutic benefit of these drugs is re¬ prevention of untoward muscle activity
lated to their ability to increase the avail¬ of the head, neck, and shoulders, as well as
ability of the biogenic amine serotonin at the mandible and tongue. The aim should
the synaptic junctions in the central ner¬ be to maintain orthostatic posture to pre¬
vous system. The tricyclic antidepres¬ vent increased cervical and shoulder mus¬
sants are beneficial in dosages as low as 10 cle activity and possible protrusion of the
mg in the treatment of muscle contrac¬ mandible. The posture of the tongue also
tion headache and musculoskeletal pain.62 effects the posture and function of the
They decrease the number of awaken¬ muscles attached to it. The more anterior
ings, increase stage IV (delta) sleep, and the head is to the spinal column the great¬
markedly decrease time in rapid eye move¬ er is its effective weight. Except during
ment (REM) sleep. For these reasons, function, the mandible should be in a
they may have potential in the treatment relaxed (rest) position so that there is
of certain types of nocturnal bruxism. In separation between the maxillary and man¬
dosages of 10 through 75 mg, the tri¬ dibular teeth (prevents occlusal contact)
cyclics are beneficial in the treatment of and the tongue should rest gently on the
chronic orofacial pain and various oral anterior palate (prevents lateral tongue
dysaesthesias, which include glossodynia bracing). Although posture training is a
and idiopathic intraoral burning. When common physical therapeutic approach,
used as antidepressants, which requires its relationship to TMD is not well un¬
an increase in therapeutic dosage, these derstood and needs further study.
drugs should only be prescribed by clini¬
cians who have had special training in the
Exercise
diagnosis and treatment of depression.
Clinical experience suggests that an ac¬
tive exercise program is important to the
Physical Therapy development and maintenance of normal
muscle and joint comfort, function, and
Physical therapy helps to relieve mus¬ stability. One of the objectives of an exer¬
culoskeletal pain and to restore normal cise program is to teach the patient how
function by altering sensory input; to avoid activities that are injurious to the
reducing inflammation; decreasing, co¬ synovial joints involved. In addition, ex¬
ordinating, and strengthening muscle ac¬ ercise may be recommended to stretch
tivity; and promoting the repair and re¬ and relax muscles,67 increase joint range

87
Management

of motion, increase muscle strength, de¬ Another technique incorporates the pa¬
velop normal coordination arthrokine- tient’s voluntary maximal lateral excur¬
matics, and stabilize the TMJs. Three sive jaw movement to the nonaffected
types of exercise are generally recom¬ side followed by opening through the
mended: (1) repetitive exercises to estab¬ lateral border movement.70 Arthrographic
lish coordinated, rhythmic muscle func¬ studies indicate that manipulation does
tion; (2) isotonic exercises to increase not produce complete anatomic reduc¬
range of motion; and (3) isometric exer¬ tion of the disc but does increase disc
cises to increase muscular strength. They mobilization.71 Following mobilization,
are prescribed to achieve specific goals therapy to maintain the reduced condyle-
and are changed or modified as the pa¬ disc relation should be considered, such
tient progresses. Most patients will not as orthopedic appliance therapy, relax¬
exercise if it increases pain; therefore, the ation therapy, and exercises.
therapist must initially help the patient to The application of continuous passive
achieve some symptom relief with physi¬ motion for postsurgical therapy has re-
cal agents or modalities. A maintenance cendy been implemented by oral and max¬
level of exercise is recommended to ensure illofacial surgeons.72’73 It is reasonable to
long-term resolution once the patient has suggest that there are the same indica¬
reached the goals of the treatment. tions and advantages for its use following
TMJ surgery as with orthopedic surgery
in general.
Mobilization
Mobilization techniques are indicated for
Physical Agents or Modalities
decreased range of motion and pain due
to muscle contracture, disc displacement Physical agents or modalities for TMD
without reduction, and fibrous adhesions management include electrotherapy and
in the joint. In some cases repeated ma¬ ultrasound modalities, anesthetic agents,
nipulation by the therapist can restore a and acupuncture. Electrotherapy devices
more physiologic length of resting mus¬ that produce thermal, histochemical, and
cle or improve joint function to permit a physiologic changes in the muscles and
more normal range of motion.68 Muscle joint are divided into high-voltage stimu¬
relaxation and pain reduction are often lation (electrogalvanic stimulation [EGS]),
required before mobilization can be ef¬ low-voltage stimulation (transcutaneous
fective. Thus, a combination of heat, cold, electrical nerve stimulation [TENS]), and
ultrasound, and electrical stimulation is microvoltage stimulation. Electrogalvanic
often employed before or in conjunction stimulation uses a high-voltage, low-
with mobilization. Acute disc displace¬ amerpage, monophasic current of vary¬
ment without reduction at tipies can be ing frequencies. This modality produces
effectively reduced by manipulation of a reduction of muscle pain and activity
the mandible, again usually after the use and enhances healing.74 Transcutaneous
of physical agents and at times with the electrical nerve stimulation uses a low-
use of local anesthetic injections.69 The voltage, low-amperage, biphasic current
mandible is gripped firmly with the clini¬ at varying frequencies and is designed
cian’s thumbs on the occlusal surfaces of primarily for sensory counter stimulation
the posterior teeth, the unaffected side is in painful disorders.75 Like EGS, this mo¬
securely braced, and the affected side is dality decreases muscle pain and hyper¬
forced downward, forward, and inward. activity and also can be an aid in muscle

88
 Physical Therapy

re-education. If significant motor stimu¬ Once muscle pain cycles are interrupted
lation occurs concurrently, this may im¬ with local anesthetic injections, relief may
pair the analgesic effect and even exacer¬ last beyond the duration of the anesthet¬
bate acute pain.76 Microcurrent electrical ic. Procaine (1.0% to 2.0% without epi¬
stimulation is reputed to apply a micro¬ nephrine diluted to 0.5% with sterile sa¬
voltage at the approximate electrochemi¬ line) is recommended for trigger point
cal spectrum that occurs neurophysiolog- injections because it is thought to be the
ically at the synaptic junction. It has been least myotoxic local anesthetic.87
used primarily for pain relief. To date, Acupuncture has also been used for the
only clinical evidence has suggested the treatment of chronic pain. The therapeu¬
use of electrical stimulation for the treat¬ tic effects of acupuncture on pain and
ment of pain related to TMD. dysfunction are usually explained by neu¬
Ultrasound is a frequently used physi¬ ral and humoral pathways.88 In a ran¬
cal treatment modality in physical medi¬ domized study comparing acupuncture
cine for musculoskeletal problems. With and conventional treatment modalities in
ultrasound, the high-frequency oscilla¬ the management of TMD,89 the patients
tions of the transducer head are convert¬ surveyed favored conventional therapy;
ed to heat when transmitted through the however, there was no statistical differ¬
tissue. This can heat to a depth of 5 cm ence in pain relief or improvement in
and may decrease the convalescence peri¬ function. Another random, controlled
od associated with painful joint disorders. study had the same positive results as
Ultrasound is used to produce deep heat acupuncture.90 Further study of this ap¬
in the joints, to treat joint contracture by proach for TMD is indicated.
increasing the stretch of the extracapsu-
lar soft tissue, to decrease chronic pain,
muscle contraction, and tendonitis, and to Orthopedic Appliance Therapy
facilitate resorption of calcium deposits
with bursitis.77-82 The potentially critical Orthopedic appliances, commonly re¬
parameters of ultrasound such as duration ferred to as interocclusal splints, orthot-
of treatment, number of sessions, exposure ics, nightguards, or bruxism appliances,
time per session, frequency, and intensity are routinely used in the treatment of
need further systematic study.83 TMD. Removable acrylic resin appliances
Anesthetic agents can also be beneficial that cover the teeth have been used to alter
to TMD therapy. Application of vapo- occlusal relationships and to redistribute
coolant sprays followed by muscle stretch¬ occlusal forces,91-92 to prevent wear and
ing decreases muscle soreness and mobility of the teeth,93-94 to reduce brux¬
tightness and is thought to inactivate myo¬ ism and parafunction,22-95 to treat mastica¬
fascial trigger points.84-85 The spray is tory muscle pain and dysfunction,26-96-99
applied to the affected area from approx¬ and to alter strucmral relationships in the
imately an 18-inch working distance in a TMJ.68-100-103
sweeping motion in the direction of the The reduction of painful symptoms with
muscle fibers. The eyes, ears, and nasal appliance therapy has been well docu¬
mucosa must be protected. Local anes¬ mented. Many studies have found resolu¬
thetic injections, alone or in conjunction tion of symptoms after insertion of an
with muscle stretching or mobilization, appliance.26-99-104-107 Clark26 reviewed
also have been shown to be useful for the design, theory, and effectiveness of
myofascial trigger point management.86 orthopedic appliances for specific symp-

89
Management

toms and found a 70% to 90% rate of patients.96 Recent EMG studies have doc¬
clinical success. Although the treatment umented a short-term reduction in eleva¬
effect was predictable, the physiologic tor muscle activity and a short-term in¬
basis of the treatment response has not crease in suprahyoid muscle activity.118’119
been well understood. The occlusal surface of the appliance
The complications that can occur with should be adjusted to provide a stable
the excessive or incorrect use of any ap¬ physiologic mandibular posture by creat¬
pliance include caries, gingival inflamma¬ ing bilateral, even posterior occlusal con¬
tion, mouth odors, speech difficulties, tacts for the opposing teeth on closure.
tooth-contact relation changes, and psy¬ Anterior guidance is usually provided by
chologic dependence on the appliance. acrylic guide ramps in the canine or ante¬
Serious complications include major ir¬ rior areas of the appliance to separate the
reversible changes in the interocclusal or opposing posterior teeth from the ap¬
interarch relation as a result of long-term pliance in all lateral, lateroprotrusive, and
use of all appliances, and particularly with protrusive excursions of the mandible.
the partial-arch coverage appliances.108 Clinical experience suggests that the oc¬
Appliances must not be designed to allow clusal surface of the appliance should be
or provide for tooth movement during adjusted initially and periodically to com¬
active treatment of TMD signs and symp¬ pensate for changes in the maxilloman¬
toms. There are many useful types of dibular relation as pain, muscle activity,
appliances; but two major types of ap¬ inflammation, edema, dr soft tissue struc¬
pliances, stabilization appliances and an¬ tural relations change.
terior positioning appliances, are com¬ The protocol should be monitored on a
monly used for TMD management. timely basis for the initial period until the
maxillomandibular relation stabilizes.120
In acute cases, the appliance is usually
Stabilization Appliances
best worn full time for a specified period
Stabilization appliances, also termed “flat of time. As resolution occurs, use of the
plane”, “gnathologic”, or “muscle relax¬ appliance only at night can be considered.
ation splints”, should cover all of the man¬ Recently a study suggested that nocturnal
dibular or maxillary teeth. They are appliance use only was more successful in
designed to provide joint stabilization, patients with muscle disorders, whereas
protect the teeth, redistribute forces, re¬ patients with articular disorders benefit-
lax the elevator muscles, and decrease ted from continuous appliance use (24-
bruxism.22>26-91>97>106.i07,109-115 Wearing hour wear).121 Eventually, intermittent
the appliance increases the patient’s aware¬ use at night during periods of increased
ness of jaw habits and helps alter the stressful life events should suffice, if the
posture of the mandible to a more open, appliance is needed at all. Ideally, the
relaxed (rest) position. Electromyo¬ patient should eliminate full-time use of
graphic monitoring of the masseter mus¬ an appliance. Patients not showing a posi¬
cle has shown a short-term decrease in tive response within 3 to 4 weeks should
the level of bruxism activity when an ap¬ be reevaluated. Failure to show an initial
pliance is worn.22-116-117 In another study, positive response does not mandate more
appliance therapy decreased muscle ac¬ aggressive or prolonged therapy; rather,
tivity in approximately 50% of the treated other factors should be considered: chron¬
patients; however, it increased muscle ac¬ ic pain behavior, noncompliance, mis¬
tivity in approximately 30% of the diagnosis, or degree of tissue pathology.

90
 Orthopedic Appliance Therapy

If a stabilizing appliance is fabricated with when it is worn full time at the beginning
a soft resilient material, it should be used of treatment. However, part-time use at
on a temporary basis when worn full night is effective for preventing intermit¬
time or it should only be worn part time. tent disc displacement without reduction
Full-time wear can result in uncontrolled on awakening, with less potential for the
changes in tooth position due to the di¬ occlusal consequences of full-time use.
mensional instability of the soft appli¬ The appliance should initially be adjusted
ance. The efficacy of resilient appliances for occlusal stability in as minimal an
for decreasing bruxism and TMD signs anterior mandibular position as possible
and symptoms is not clear.116-122-123 (2 mm or less) to decrease the pain and
dysfunction. Once joint pain and dys¬
Anterior Positioning Appliances function (ie, intermittent locking) are de¬
creased, the appliance should be adjusted
Anterior positioning appliances, also to, or replaced with, a stabilization ap¬
termed mandibular orthopedic reposition¬ pliance to allow posterior repositioning
ing appliances (MORAs), are used to de¬ of the mandible to the approximate pre¬
crease joint pain, joint noise (clicking), and treatment occlusal position. The appli¬
associated secondary muscle symptoms ance should be adjusted back to this more
in TMD.101-102-124-128 Anterior position¬ physiologic stable position within a 6- to
ing appliances may effect the TMJ in two 12-week period. This approach is strong¬
ways: (1) they may decrease adverse load¬ ly recommended to avoid or minimize the
ing (compression) in the joint, and (2) they need for unnecessary restorative, pros-
may alter the structural condyle-disc re¬ thodontic, or orthodontic therapy.
lation. The primary indication for ante¬ Although short-term success with
rior positioning appliance therapy is acute anterior positioning appliances is
joint pain associated with joint noise, inter¬ good,103-126-134 long-term use is not en¬
mittent locking, and/or structural bony couraging.129-134 Because constant long¬
changes.102-125-129-134 Prior to this ap¬ term use of an anterior positioning ap¬
proach, the occlusal consequences should pliance can create iatrogenic occlusal
be determined and discussed with the pa¬ problems, anterior positioning should be
tient because mandibular repositioning attempted only in selected cases of articu¬
can result in irreversible changes in the oc¬ lar pain and if the patient understands the
clusion (ie, posterior open bite). For a num¬ possible treatment consequences. If ante¬
ber of patients a stabilization appliance can rior positioning is not a viable option, a
accomplish many of the same goals as can stabilization splint with adjunctive thera¬
an anterior positioning appliance with less py for pain relief and improved function is
risk of irreversible consequences and, thus, indicated.135 Although clicking is not usu¬
should be considered first. ally eliminated, it may be decreased, and
Anterior positioning appliances are fab¬ asymptomatic dicks, by themselves, do not
ricated for either dental arch to cover the warrant treatment. If the anterior position¬
occlusal surfaces of all teeth with occlusal ing appliance approach does not affect sat¬
indentations, guide ramps, or both that isfactorily the patient’s internal derange¬
cause the mandible to temporarily ad¬ ment and significant pain or limited range
vance or protrude into a therapeutic (ie, of motion continues, arthroscopy or sur¬
less painful) condyle-disc-fossa relation. gical repair of the disc may be necessary
An anterior positioning appliance is most or definitive changes in the occlusion
efficient for decompression of the joint with dental treatment may be required.

91
Management

as biologically successful adaptation and

Occlusal Therapy
are not necessarily pathognomic.141 Thus,
The topic of occlusion continues to re¬ any occlusomorphologic explanations for
main an enigma to those interested in TMD should be resisted until the TMD
studying therapeutic concepts and TMD have stabilized and there is reasonable
pathophysiology related to occlusal dis¬ assurance that further occlusal changes
crepancies. It is difficult to establish any will not occur.120*142
significant cause and effect relationships When considering occlusal changes in
due to the many variables involved, some the TMD patient, the clinician is advised
of which are difficult, if not impossible, to to proceed cautiously, using the least in¬
exclude clinically.48’136 To be sure, there vasive procedures possible, with constant
are many valid reasons for treatment of patient reassessment.143 Occlusal alter¬
the occlusion for numerous dental condi¬ ation in TMD patients should be mini¬
tions (ie, lack of interarch/intra-arch tooth mized (ie, the pretreatment intercuspal
stability; tooth mobility; fremitus; occlu¬ relationship and condylar position should
sion-related tooth or restoration fracture; be preserved whenever possible) after they
tooth sensitivity; altered or compromised have received treatment for TMD. There
masticatory function, swallowing, or is no evidence that anterior guidance is
speech; and compromised supporting tis¬ superior to other forms of guidance for
sues due to adverse loading). Although treating TMD symptoms related to noc¬
dental treatment may be necessary for turnal bruxism, as studied with ortho¬
patients with TMD, it is believed to be pedic appliances,144-145 or that it would
infrequently necessary for the purpose of provide the optimum joint loading for all
direct treatment for TMD. TMD articular conditions.146’147 In gen¬
Primary occlusal therapy should be used eral, there is a lack of evidence that the
with caution because there is little evi¬ composition of an idealized occlusion
dence that natural occlusal morphologic through complex occlusal therapy is nec¬
variation is a cause of TMD.137’138 Be¬ essary for TMD management.138’148
cause most occlusal features previously
associated with TMD now appear to have
minimal scientific relationship to clinical
Occlusal Adjustment
signs and symptoms, the appropriateness Occlusal adjustment for TMD has been
of treatment emphasis on the correction recommended as beneficial,149 but more
of chronic malocclusion is becoming ques¬ recently this treatment has been shown
tionable.137’138 Yet, in spite of the fact that not to be as effective as the more conser¬
a strong correlation between occlusal mor¬ vative modalities in reducing TMD symp¬
phology and TMD treatment outcome toms and headache.150 For that reason,
has not been shown,139 dentists continue occlusal adjustment as an irreversible
to consider occlusal therapy necessary for treatment modality should rarely be con¬
definitive treatment of TMD.140 Recent¬ sidered as a primary component of TMD
ly it has been cited that treatment di¬ treatment. Limited occlusal adjustment
rected to the correction of a chronic or may be appropriate in primary treatment
adapted malocclusion or occlusal varia¬ stages when intercuspal position (ICP)
tion may be appropriate because it can relationships provoke acute symptomatol¬
be a symptom rather than a cause of ogy,151 ie, when acute symptoms result
TMD.137’138 A wide variety of segments from interferences following recent re¬
of the stomatognathic system may occur storative dental treatments. Occlusal ad-

92
 Occlusal Therapy

justment may also be considered for of change with treatment carries some
enhanced mandibular stability and for re¬ risk in TMD patients142; however, the
distribution of adverse loading forces in risk in TMD patients as a group appears
cases where a specific TMD disturbance to be minimal.159 Altered occlusal rela¬
has resulted in an unstable occlusal rela¬ tions can advantageously redistribute load¬
tion. For example, a skeletal anterior open ing forces but disturb existing stable
bite development may occur following an conditions elsewhere in the masticatory
aggressive TMJ arthritic condition.137-152 system.111 It is possible, therefore, that
With regard to bruxism, there is no evi¬ symptoms may be exacerbated if the de¬
dence that prophylactic selective grind¬ mand for adaptation is beyond the adap¬
ing of occlusal surfaces is beneficial or tive capacity of the tissues or if the TMD
that it eliminates bruxism.1-105 Occlusal patient is already functioning at the limit
adjustment is never indicated for preven¬ of his or her adaptive range.
tion of TMD.153 There may be an indica¬
tion for occlusal adjustment, however, in
Orthodontic-Orthognathic Therapy
conjunction with a coexisting dental treat¬
ment need, such as stabilization of post- When major occlusal alterations are con¬
orthodontic-postorthognathic therapy or sidered to be advantageous dentally, ortho¬
finalization of reconstructive dental ther¬ dontic therapy is often the treatment of
apy.154 choice because it is less invasive than is
extensive reconstructive therapy. Fixed,
removable, functional, and extraoral ap¬
Restorative Therapy pliances are all capable of improving
Some questions have been posed regard¬ occlusal and mandibular stability.160-161
ing the benefits of occlusal restorative Frequently, orthodontic therapy is rec¬
care for TMD patients.155 As with other ommended to provide occlusal support
kinds of irreversible treatment, restora¬ following anterior repositioning therapy.
tive therapy should never be primary but However, this has not proven to be as
may follow initial resolution of TMD successful on a longitudinal basis when
symptoms and dysfunctional instability. compared to anterior positioning splint
However, once stability and symptom res¬ therapy alone.129-162 Orthodontic thera¬
olution are achieved, restorative therapy py, even with the normally healthy pa¬
can be considered in those patients who tient, but in particular with the TMD
are likely to benefit from reduction of patient, presents some risk of destabi¬
adverse loading and improvement of oc¬ lizing the stomatognathic system during
clusal force redistribution, as suggested treatment.163 Hence, the orthodontic di¬
by studies of Hannam,156 Hylander,157 agnosis and treatment plan must reflect
and Faulkner et al.158 However, the scien¬ possible influences of occlusal insta¬
tific basis for the belief that occlusal fac¬ bilities created daring treatment with
tors influence loading within the TMJ or pre-existing joint pathology, trauma
cause TMD is weak at best. With this in associated disease, and anatomic varia¬
mind there are, however, instances when tions.26*16^166
However, recent retrospective clinical
the dental consequences of TMD results
in functional mandibular instability that studies have reported no greater preva¬
lence of TMD signs or symptoms in highly
must be addressed.
selective samples ofpostorthodontic sub¬
Extensive restorative therapy should be
jects than in untreated subjects of similar
undertaken with caution because the speed

93
Management

ages.167-181 Furthermore, other studies major structural mandibular deformities,

comparing postorthodontic patients with discrepancies, or instabilities. However,
and without premolar extractions found orthognathic surgery should only be con¬
no differences in posttreatment condylar templated in TMD patients following
position,182-185 overbite,184 discrepancy careful evaluation after all symptoms have
between intercuspal position and retruded been reasonably resolved and the maxil¬
contact position,186 mandibular posi¬ lomandibular relation has been stabilized.
tion,187 or in overall TMD symptomatol- Surgical treatment for skeletal asymme¬
Qgy 181,188,189 tries and growth anomalies with the spe¬
A recent study concluded that it cannot cific intent of alleviating pain associated
be ruled out that some patients acquire a with TMD is very questionable at this
more posterior location of the condyle time. But in those TMD patients with
during correction of any Class II, Divi¬ severe skeletal malocclusion who may ben¬
sion I malocclusion with extraction only efit from greater dental-skeletal stability,
of maxillary premolars, but the preva¬ orthognathic surgery in conjunction with
lence was similar to controls shortly after orthodontic therapy is often the method
therapy.190 A few studies have found a of choice.175’194-196
higher incidence of joint sounds (click¬
ing) on a longitudinal basis, especially
with premolar extraction; however, it was Surgery
possibly explained by the original growth
pattern more than by the extractions be¬ Temporomandibular surgery has become
cause the clicking predated the actual an effective treatment for specific articu¬
treatment.176-191 There are some longi¬ lar disorders. However, the complexity of
tudinal studies that, in fact, show that available techniques, potential for com¬
subjects with a history of orthodontic plications, frequency of behavioral and
treatment tend to have a lower prevalence psychosocial contributing factors, and the
of TMD signs and symptoms than do availability of nonsurgical approaches,
control groups who have not had orth¬ make TMJ surgery an approach that
odontic therapy.170-188’192 should be used only in selected cases.
Although as a group there is little evi¬ The decision to treat the patient sur¬
dence that orthodontically treated pa¬ gically depends on the degree of pathol¬
tients have greater prevalence of TMD ogy or anatomic derangement present
symptoms, the individual response to the within the joint, the repairability of that
dental instabilities associated with orth¬ condition, the results of appropriate non¬
odontic treatment may be quite different. surgical therapy, and the extent of impair¬
Thus, the practitioner must be alert for, ment that the joint pathology creates for
and be prepared to deal with, the onset or the patient. The appropriate duration and
exacerbation of signs and symptoms for complexity of nonsurgical therapy before
whatever reason they may occur during considering surgery are determined by a
orthodontic tooth movement.160 This po¬ combination of factors including the ex¬
tential clearly mandates a pretreatment pected prognosis compared with the ac¬
screening examination of all orthodontic tual patient improvement, the degree of
patients for asymptomatic signs.193 impairment, and the patient’s compliance
Orthognathic surgery may be consid¬ with the program. Patients with compli¬
ered in conjunction with orthodontic or cating factors such as litigation, depres¬
restorative treatment for correction of sion, or uncontrolled nocturnal bruxism

94
 Surgery

may have a poor surgical prognosis. In

Arthroscopy
addition, the clinician must have a full
knowledge and appreciation of the poten¬ Arthroscopy holds promise for histopath¬
tial complications and the potential for ologic and biochemical sampling of the
surgical failure. Once this information is joint tissues199 and as a modality for treat-
available, a realistic discussion of the prog¬ ing painful joint hypomobility secondary
nosis, the patient’s expectations, and to a persistent nonreducing displaced disc
the complicating factors can help a pa¬ or arthrosis.200-203 Arthroscopic revision
tient to make the correct decision about of previous open surgery has also been
surgery. helpful in alleviating postoperative pain
Preoperative and postoperative non- and intracapsular fibrosis.204 At this time,
surgical management must be integrated the arthroscope is used mainly to examine
into the overall surgical treatment plan.197 the upper joint space, and surgery is lim¬
This therapy is directed toward decreas¬ ited to biopsies, minor debridement and
ing the functional load placed on the lavage, and incising minor adhesions with¬
joint, eliminating or modifying contrib¬ in the upper joint space.205 Recent evi¬
uting factors such as oral parafunctional dence reveals that reduction of symptoms
habits, and providing appropriate psy¬ following arthroscopic surgery is not due
chologic and medical support. The fol¬ to improved disc position or joint sounds
lowing criteria adapted from The Ameri¬ and that any inferred long-term benefits
can Association of Oral and Maxillofacial are still undetermined at this time.206-207
Surgeons198 should be addressed before Postoperative MRI scans reveal that fol¬
proceeding with TMJ surgery: (1) docu¬ lowing arthroscopic procedures a vast ma¬
mented TMJ internal derangement or jority of patients have persistent anterior
other structural joint disorder with ap¬ displacement but increased disc mobili-
propriate imaging; (2) positive evidence ty.208-212 Further, it has been suggested

to suggest that the symptoms and objec¬ that simple irrigation or lavage (arthro-
tive findings are a result of a structural centesis) with or without intra-articular
disorder; (3) pain and/or dysfunction of corticosteroids and manipulation may be
such magnitude as to constitute a disabil¬ as effective as arthroscopic lavage.213
ity to the patient; (4) prior unsuccessful
nonsurgical treatment; (5) prior manage¬
Arthrotomy
ment, to the extent possible, of bruxism,
oral parafunctional habits, other medical Open surgical intervention of the TMJ
or dental conditions, and other contrib¬ (arthrotomy) usually is required for bony
uting factors that may affect the outcome or fibrous ankylosis, neoplasia, severe
of surgery; and (6) patient consent after chronic dislocations, persistent painful
a discussion of potential complications, disc derangement, and severe osteoarthro¬
goals to achieve, success rate, timing, post¬ sis refractory to conservative modalities
operative management, and alternative ap¬ of treatment. Surgery is less often indi¬
proaches including no treatment. These cated in displaced condylar fractures, agen¬
conditions maximize the potential for a esis of the condyle, and severe, painful,
successful outcome but cannot guarantee chronic arthritides. Surgery is seldom, if
it. Surgical management may include ever, indicated in inflammatory joint dis¬
closed surgical procedures (arthroscopy) orders (synovitis or capsulitis), condyly-
and open surgical procedures (arthrot- sis, and nonpainful degenerative arthritis.
omy). Thus, arthrotomy is generally indicated

95
Management

for the patient with advanced disease who There can be more postsurgical sequelae,
meets the surgical criteria or who has including marked occlusal changes, with
disease refractory to or not amenable to these procedures. The outcome criteria
arthroscopic surgical techniques. of assessing surgery results are based on
Open joint surgical procedures may the patient’s report of decreased intensity
range from discoplasty, discal reposition¬ or infrequency of pain, increased jaw func¬
ing, or discectomy with or without re¬ tion and range of motion (vertical incisal
placement to arthroplasty, which includes opening to at least 3 5 mm), and the ability
high condylectomy. Discoplasty and disc for the patient to return to a normal
repositioning with plication has been re¬ lifestyle, which includes a normal diet.
ported to have an 80% to 90% success
rate.214 Discectomy (meniscectomy) is per¬
formed with215-216 or without autogenous
or homologous replacement.217 However, References
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uation of treatment for myofascial pain-
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Relationship between orthodontic treat¬ closed lock. Oral Surg Oral Med Oral
ment, condylar position, and internal de¬ Pathol 1986;62:361-372.
rangement in the temporomandibular
201. Sanders B, Buoncristiani R: Diagnostic
joint. Am J Orthod Dentofac Orthop
and surgical arthroscopy of the temporo¬
1992;101:48-53.
mandibular joint: Clinical experience with
191. Smith A, Freer TJ: Post-orthodontic oc¬ 137 procedures over a two year period. J
clusal function. Aust DentJ 1989;34:301- Craniomandib Disord Facial Oral Pain
309. 1987;1:202-213.
192. Egermark I, Thilander B: Cranioman- 202. Forman D: Success with temporoman¬
dibular disorders with special reference to dibular joint arthroscopic surgery. In
orthodontic treatment: An evaluation from Controversies in Dentistry. Dent Clin
childhood to adulthood. Am J Orthod North Am 1990;34:135-140.
Dentofac Orthop 1992;101:28-34.
203. Clark GT, Moody DG, Sanders B: Arthro¬
193. Solberg WK, Seligman DA: Temporo¬ scopic treatment of temporomandibular
mandibular orthopedics: A new vista in joint locking resulting from disc
orthodontics. In Johnston LA Jr (ed) New derangement: Two-year results. J Oral
Vistas In Orthodontics, Philadelphia, Lea Maxillofac Surg 1991;49:157-164.
and Ferbiger, 1985, pp 148-183. 204. Blaustein D, Heffez L: Diagnostic arthros¬
194. Athansiou AE, Melsen B, Eriksen J: Con¬ copy to the temporomandibular joint.
cerns, motivation and experiences of or¬ Part II: Arthroscopic findings of arthro-
thognathic surgery patients: A retrospec¬ graphically diagnosed disc displacement.
tive study of 152 patients. Int J Adult Oral SurgOralMed Oral Pathol 1988;65:
Orthod Orthognathic Surg 1989;4:47— 135-141.
55. 205. American Association of Oral and Max¬
195. Ochs M, La Banc JP, Dolwick MF: The illofacial Surgeons. Position paper on
diagnosis and management of concomi¬ TMJ Arthroscopy, 1988.
tant dentofacial deformity and temporo¬ 206. Nitzan D, Dolwick MF: An alternative
mandibular disorders. Oral Maxillofac explanation for the genesis of closed-lock
Surg Clin North Am 1990;2:669-690. symptoms in the internal derangement
196. Proffit WR, White RP: Surgical-orth¬ process. J Oral Maxillofac Surg 1991 ;49:
odontic treatment. Chicago, Mosby Year¬ 810-815.
book, 1989, pp 664-665. 207. Montgomery MT, van Sickels JE, Harms
197. American Society of Temporomandibu¬ SE: Success of temporomandibular joint
lar Joint Surgeons: Guidelines for diag¬ arthroscopy in disk displacement with and
nosis and treatment of disorders of the without reduction. Oral Surg Oral Med
temporomandibular joint and related mus¬ Oral Pathol 1991;71:751-759.
culoskeletal disorders. Dallas, 1990. 208. Moses JJ, Sartoris D, Glass R, Tanaka T,
198. American Association of Oral and Max¬ Poker I: The effect of arthroscopic surgi-

105
Management

cal lysis and lavage of the superior joint temporalis pedicle flap as an interposi-
space on TMJ disc position and mobility. tional graft in temporomandibular joint
J Oral Maxillofac Surg 1989;47:674-678. arthroplasty: A preliminary report. J Oral
Maxillofac Surg 1990;48:1049-1056.
209. Gabler MJ, Greene CS, Palacios E, Perry
HT: Effect of arthroscopic temporoman¬ 219. Pogrel MA, Kaban LB: The role of a
dibular joint surgery on articular disc po¬ temporalis fascia and muscle flap in tem¬
sition. J Craniomandib Disord Facial Oral poromandibular joint surgery. J Oral Max¬
Pain 1989;3:191-202. illofac Surg 1990;48:14-19.

210. Nitzan DW, Dolwick MF, Heft MW: Ar¬ 220. Dolwick MF, Aufdemorte TB: Silicone-
throscopic lavage and lysis of the temporo¬ induced foreign body reaction and lymph-
mandibular joint: A change in perspective. adenopathy after temporomandibular joint
J Oral Maxillofac Surg 1990;48:798- arthroplasty. Oral Surg Oral Med Oral
801. Pathol 1985;59:449-452.

211. Perrott DH, Alborzi A, Kaban LB, Helms 221. Westesson PF, Eriksson L, Linstrom C:
CA: A prospective evaluation of the effec¬ Destructive lesions of the mandibular con¬
tiveness of temporomandibular joint ar¬ dyle following diskectomy with tempo¬
throscopy. J Oral Maxillofac Surg 1990; rary silicone implant. Oral Surg Oral Med
48:1029-1032. Oral Pathol 1987;63:143-150.

212. Moses JJ, Topper DC: A functional ap¬ 222. Heffez L, Mafee MF, Rosenberg H, Lan-
proach to the treatment of temporoman¬ ger B: CT evaluation of TMJ disc re¬
dibular joint internal derangement. J Cra¬ placement with a proplast-teflon lami¬
niomandib Disord Facial Oral Pain 1991; nate. J Oral Maxillofac Surg 1987;45:657-
5:19-27. 665.
223. Florine BL, Gatto DJ, Wade ML, Waite
213. Nitzan DW, Dolwick MF, Martinez GA:
Temporomandibular joint arthrocente- DE: Tomographic evaluation of tempo¬
sis: A simplified treatment for severe, lim¬ romandibular joints following discoplasty
ited mouth opening. J Oral Maxillofac or placement of polytetrafluoroethylene
Surg 1991;49:1163-1167. implants. J Oral Maxillofac Surg 1988;48:
183-188.
214. McCarty WL, Farrar WB: Surgery for
internal derangements of the temporo¬ 224. Valentine JD: Light and electron micro¬
mandibular joint. J Prosthet Dent 1979; scopic evaluation of proplast II TMJ disc
42:191-196. implants. J Oral Maxillofac Surg 1989;47:
689-696.
215. Tucker MR, Kennedy MC, Jacoway JR:
Autogenous auricular cartilage implanta¬ 225. RyanDE: Alloplastic implants in the tem¬
tion following discectomy in the primate poromandibular joint. Oral Maxillofac
temporomandibular joint. J Oral Maxil¬ Clin North Am 1989;1:427-441.
lofac Surg 1990;48:38-44. 226. Wagner JD, Mosby EL: Assessment of
216. HartogJM, Slavin AB, Kline SN: Recon¬ proplast-teflon disc replacements. J Oral
struction of the temporomandibular joint Maxillofac Surg 1990;48:1140—1144.
with cryo preserved cartilage and freeze- 227. Food and Drug Administration: Safety
dried dura: A preliminary report. J Oral Alerts Department of Health and Human
Maxillofac Surg 1990;48:919-925. Services. Rockville, Maryland, 1990, 1991.
217. Lekkas C, Honee GLJM: The anatomical 228. Poswillo DE: Experimental investigation
effects of surgically repositioning the disc of the effects of intra-articular hydrocor¬
in the temporomandibular joint of rats: tisone and high condylectomy in the man¬
An experimental study. J Oral Rehabil dibular condyle. Oral Surg Oral Med Oral
1990;17:249-255. Pathol 1970;30:161-173.
218. Herbosa EG, Rotskoff KS: Composite 229. Nickerson JW Jr, Veaco NS: Condylot-

106
 References

omy in surgery of the temporomandibu¬ omy in the management of temporoman¬

lar joint. Oral Maxillofac Surg Clin North dibular joint disorders. In Worthington P,
Am 1989;1:303-327. Evans J (eds) Controversies in Oral and
Maxillofacial Surgery. Philadelphia, Saun¬
230. Nickerson JW Jr: The role of condylot- ders, 1992.

107
 Addendum

Health Care Benefits plaints, the patient is considered to be

suffering from a specific medical problem
classified according to the symptoms. The
Reimbursement
designation of a broad, nonspecific cate¬
Temporomandibular disorders and oro¬ gory of symptoms classified as “TMJ” per¬
facial pain are of increasing concern to haps has led carriers to consider benefit
the general public, clinicians, and research¬ coverage for treatment of these symptoms
ers. New and improved methods of diag¬ as if they were caused by a single entity
nosis and treatment of TMD now enable with one treatment appropriate in all cases.
patients to benefit from this advanced Temporomandibular disorders need to
technology. This surge of interest in the be covered under the patient’s medical
clinical management of these disorders policy on the same basis as are other joint
by physicians, dentists, psychologists, disorders, not under dental or orthodon¬
physical therapists, and biofeedback thera¬ tic policies, regardless of who provides
pists has incurred hesitancy among third- the service, as mandated by the Minneso¬
party payers who provide health care bene¬ ta Accident and Health Insurance Stat¬
fits. There is confusion by these third- utes.1 Consistent with these statutes, ten
party payers as to whether the services other states have legally mandated cover¬
should be covered under a patient’s medi¬ age for nonsurgical and surgical care for
cal or dental policy. It is unfortunate that TMD on the same basis as for other joints
patients who complain of head, neck, and under their medical policies (Kentucky,
orofacial pains are classified by major med¬ Maryland, Nevada, New Mexico, North
ical insurers as suffering from “TMJ” Dakota, Oregon, Tennessee, Texas, Wash¬
when treatment of the symptoms is provid¬ ington, West Virginia).2 Recendy, a federal
ed by a dentist. When the same patient is appeals court in Connecticut upheld a low¬
treated by a physician for the same com¬ er court decision ordering a health insur-

109
Addendum

ance company to cover a TMD claim un¬ port and broad-based agreement on their
der a medical insurance plan.3 Other state usefulness, and the criteria for the various
insurance commissioner offices are receiv¬ diagnostic and treatment modalities need
ing information on TMD and orofacial to be periodically reassessed. Guidelines
pain from dental care councils of state assure credibility to providers and insur¬
dental associations and the American Den¬ ance companies, minimize controversy,
tal Association.4-5 In general, dentists and and ensure access to high-quality, cost-
insurance companies have reacted posi¬ effective care. Insurance companies should
tively to the use of these guidelines. be encouraged to use the guidelines as a
Although there continues to be a need point of reference for prior authoriza¬
for further work in those states with a tions of claims but not to use them liter¬
mandate, progress has been made. As other ally. Each case needs to be reviewed on an
states attempt to address these same is¬ individual basis with use of expert consul¬
sues, a number of recommendations can tants.
be made to enhance patient access to
quality and cost-effective care. Changes
Impairment and Disability
are best accomplished with a coordinated
effort among the university programs, The decision on the need for treatment
the state dental associations, and health intervention should depend ultimately on
care providers. The state dental associa¬ three factors—symptom intensity-dura¬
tions need to work with medical insur¬ tion, disability, and progression—rather
ance companies to improve reimburse¬ than on the presence of a symptom. Such
ment for treatment of these disorders and an approach would give a legitimate esti¬
to support legislative efforts to mandate mate of the problem of TMD in the gen¬
coverage for both surgical and nonsurgi- eral population and become a useful goal
cal care. Legislation that covers only par¬ for health care insurance coverage.6 The
tial care, such as surgery only, for these Commission for Evaluation of Pain of the
problems should be avoided because of United States Department of Health and
the divisive effect that it can have on a Human Services7 has defined all aspects
patient receiving quality surgical and non- of pain and has urged that these not be
surgical care. Care should include treat¬ overlooked when evaluating a person for
ments consistent with those used for oth¬ impairment. The Commission describes
er joints and muscles in the body whether pain specialists as physicians, psycholo¬
administered by physicians, dentists, or gists, dentists, and other health profes¬
other health care providers. sionals who evaluate and treat complex
The state dental associations also need chronic pain problems.8 Nearly every
to coordinate development of regional community, major medical facility, and
practice parameters for the diagnosis, eval¬ health education institution has, as a part
uation, and treatment of these disorders. of its care component, a facility referred
These guidelines should be developed us¬ to as a “pain center.”9’10
ing a broad local representation of aca¬ Of concern is that lack of treatment,
demic and private dentists from various inappropriate treatment, or overzealous
specialties and be relatively consistent with treatment of a condition with poor results
national guidelines, eg, the AAOP pub¬ may contribute to or develop into a chronic
lished guidelines. The guidelines should pain syndrome. Chronic pain behavior in
identify selective treatments and diag¬ turn can become fixed in the patient’s life
nostic tests that have both scientific sup¬ and can result in the development of de-

110
 Health Care Benefits

pendent relationships, emotional distur¬ proposed AAOP TMD ratings are inclu¬
bances, physical disabilities, and behav¬ sive of most jaw and facial symptoms
ioral and psychosocial disorders. These except for gross motor weaknesses and
patients often present with frustrating sensory loss associated with the tri¬
medical complications that result in un¬ geminal nerve or disorders of the facial
necessary diagnostic testing, complex nerve.
treatments, multiple surgical procedures,
improper utilization of long-term medi¬
cations, and dependency on or abuse of
the health care system. The past decade Professional
has seen an impressive increase in the Recommendations
number of pain management centers or
pain clinics that deal with these prob¬
lems. Professional Responsibility
Impairment cannot be considered per¬ The information contained in this docu¬
manent until maximum rehabilitation has ment may be useful as a diagnostic and
been achieved in the attending practi¬ management guide, but the ultimate val¬
tioner’s best clinical judgment.7 It is ue of this information for the individual
particularly important to understand the patient depends on the clinician who col¬
distinction between a patients medical lects the history, examination, and other
impairment, which is an alteration of diagnostic data and interprets the find¬
health status assessed by medical means, ings to arrive at a diagnosis. The clini¬
and the patient’s disability, which is an cian’s most important task and greatest
alteration of the patient’s capacity to meet responsibility is to use good clinical judg¬
personal, social, or occupational demands, ment to treat the individual patient and
or to meet statutory or regulatory re¬ avoid approaching all clinical problems as
quirements and is assessed by nonmedical if they were the same. The emphasis should
means.6 be on conservative therapy that facilitates
In accordance with the American Medi¬ the musculoskeletal system’s natural heal¬
cal Association Guides to the Evaluation of ing capacity. All dentists are licensed to
Permanent Impairment,11 disability and per¬ treat temporomandibular disorders. Each
manent impairment ratings may be evalu¬ practitioner should assess his or her own
ated on either of two conditions: (1) loss knowledge, skill, and ability and should
of nerve function and (2) conditions that work within his or her own limitations. It
cause interferences in mastication and is the responsibility of the practitioner to
deglutition (chewing and swallowing). evaluate those patients who have condi¬
However, these guidelines do not consid¬ tions that require greater expertise than
er limited impairment caused by TMD: they possess and refer them to those who
(1) the diet is limited to semi-solid or soft have the capability to provide effective
foods, 5%; (2) the diet is limited to liquid care.
food, 5% to 10%; (3) ingestion of food Dentists who choose to manage TMD
requires tube feeding, 10% to 15%. must use a diagnostic classification stated
The issue of TMD impairment and in terms of established concepts of physi¬
disability merits farther evaluation and ology and pathology such as presented in
has been tentatively addressed by an ad these guidelines. Even though the pro¬
hoc insurance committee of the American posed biomedical classification system can
Academy of Orofacial Pain (AAOP). The lead to an appropriate diagnostic label for

111
Addendum

the condition, clinicians should treat pa¬ EduaJtiorutl Responsibility

tients, not diseases. The weakness of a
purely biomedical model is its failure to It is unfortunate that in the past many
consider the total patient by ignoring predoc to ral dental educational programs
issues of a behavioral, psychologic, or have not trained their students adequately
social nature. It is recommended that the in effective management of orofacial pain
clinician consider the biopsychosocial and more specifically IMD.14 Training
characteristics of the patient’s envi¬ in the management ot chronic pain syn¬
ronment when identifying contributing dromes in both medical and dental schools
factors in as much as there may be impor¬ has been lacking. Although TMD is a
tant predisposing, initiating, or per¬ collection of medical conditions, many
petuating factors that are not addressed physicians, including neurologists, or¬
in the biomedical model. Understanding thopedic surgeons, rheumatologists, and
the illness behavior as well as the phys¬ otolaryngologists have not been well
ical process will result in the more appro¬ trained to treat complex chronic pain1'
priate and successful therapy for the pa¬ and often prefer not to treat T.MD pa¬
tient. tients. However, recently a comprehen¬
Proposed treatment should have been sive core curriculum for professional ed¬
proven through controlled research to be ucation in pain was published by The
both appropriate and effective for the International Association for the Study of
specific disorders) being treated.1- Pro¬ Pain Task Force on Professional Educa¬
posed treatment should have specific val¬ tion.16
ue for the disorder as opposed to re¬ Because of their educational concen¬
sponses due to nonspecific factors such as tration and interest in the anatomy, func¬
placebo effects, positive aspects of the tion, and pathophysiology of the jau and
doctor-patient relationship, spontaneous facial structures, dentists will continue to
remissions, and overtreatment.13 This assume the responsibility of diagnosing
should be reflected in concise and cost- and treating T.MD and orofacial pain. A
effective treatment plans that avoid use of review ot the scientific literature reveals
excessive or untested diagnostic tests, over- that the majority of basic science and
zealous use of treatments, and open-ended clinical research in this area is accom¬
durations of care. plished by dentists and is presently prolif¬
In conclusion, dentistry has accepted erating at a rapid rate both in quantity
the responsibility to provide care for pa¬ and quality. In light of this, many referrals
tients with temporomandibular disorders to dentists and dental clinics specializing
and orofacial pain. Previous experience in 1 MD and orofacial pain come from
has shown that we can be successful in physicians and other health care profes¬
treating these patients and gain the re¬ sionals.
spect of patients, other health care pro¬ -As part of this increasing interest and
viders, and the insurance industry. How¬ responsibility, most dental schools have
ever, to attain these goals, we need to be established predoctoral educational pro¬
aware that the future is dependent on us grams and some have established postdoc¬
increasing our scientific knowledge in the toral residency programs in the evaluation
area, expanding education in this field, and management of these disorders.17 Ed¬
and striving to provide the highest quality ucational guidelines for training programs
and most cost-effective care for our pa¬ in dental schools have been established to
tients. offer uniformity in clinical practice based

112
 Professional Pecommendations

on generally accepted practice parame¬ tional process is to permit dentists to

ters.,^-21
provide the best possible care for their
A majority of practicing dentists treat¬ patients.
ing'! ML) patients, however, have not had
formal training or credentialing in the
diagnosis and management of'! MD and Academy Responsibility
orofacial pain. And, unfortunately, con¬
77iis document should be referenced in
tinuing education programs, which pro¬
the time frame in which it has been writ¬
liferated over the last decade, dissemi¬
ten. 7 he American Academy of Orofacial
nated 7 MD information with a wide range
Pain anticipates the need to continually
of scientific integrity and inconsistency in
revise these published guidelines with in¬
terminology, diagnostic criteria, and man¬
put from all who support or take excep¬
agement protocol.22 The establishment
tion to the information provided. While
of definitive guidelines for the presenta¬
it is the hope of the Academy that these
tion of continuing education in 7 MD has
practice guidelines will improve the qual¬
been difficult due to the wide variety of
ity of patient care,25 this is not a standard
course lengths, course objectives, faculty,
of care document. The standard of care
and location of courses. Therefore, the
must be established locally. However, it is
responsibility for training dentists into
hoped that it will serve as a nucleus for
the next century in this complex and im¬
discussions on the standard of care by all
portant area must, in large part, be met by
interested parties. We are reluctant to
more effective continuing education pro¬
label this as a “state of the art” document
grams. 7he overall goal should be an
because the “state of the art” is in a
effort to organize, coordinate, and unify
constant state of flux due to the fact that
philosophies and clinical techniques. This
the field is ever changing for the benefit
attempt should establish scientifically
of all.
based programs that include the integra¬
tion and correlation of related basic and
clinical sciences and dental techniques.23
Course content should be scientifically References
valid and presented in an academically
honest context.24 Participants have the 1. Minnesota Accident and Health Insurance
right to expect information to be accurate Statutes Dental Procedures. Chap 62A.043,
and documentable in refereed journals. 1987(Supp!>.
7 his is not to say that new or scientifically 2. American Dental Association: Department
undocumented information should never of State Government Affairs. J Am Dent
be presented, but it should be identified Assoc 1991;122:83-84.
as such. Clinical programs should be mul¬ 3. Spaeth D: Co .rt orders insurer to pay TMJ
tidisciplinary, when appropriate, and based claim. An*. Deni Assoc News 1991;22:9.
on an acceptable diagnostic classification 4. California Dental Association Council on
system. Professional excellence is depen¬ Dental Care: Guidelines for the assess¬
dent on the quality of the education of ment of clinical quality and professional
health care providers. Continuing educa¬ performance: TMJ and MPD Guidelines.
tion facilities must attempt to integrate California Dental Association, 1989.
their programs with degree- or creden¬ 5. American Dental Association, Council on
tial-granting institutions in all the health Dental Care Programs: Prepayment plan
sciences. 7 he ultimate goal of this educa¬ benefits for temporomandibular joint dis-

113
Addendum

orders. J Am Dent Assoc 1982; 105:485— 15. Pilowsky I: An outline curriculum on pain
488. for medical schools. Pain 1988;33:1-2.

6. Pullinger AG, Moneiro AA: Functional im¬ 16. Fields HL: Core curriculum for profes¬
pairment in TMJ patient and nonpatient sional education in pain. Task force on
groups according to a disability index and professional education. International As¬
symptom profile. J Craniomand Pract 1988; sociation for the Study of Pain, Seattle,
6:156-165. IASP Publ, 1991.
17. Gonty AA: Teaching a comprehensive oro¬
7. Commission for Evaluation of Pain: United
facial pain course in the dental curriculum.
States Department of Health and Human
J Dent Educ 1990;54:319-322.
Services, Social Security Administration,
Office of Disability, March 1984, p 134. 18. Attanasio R, Mohl ND: Curriculum guide¬
lines for the development of predoctoral
8. Phillips DJ, Walters PJ, Rogal OJ, Stack
programs in temporomandibular disorders.
BC, Weiner LB, Klemons IM: Recommend¬
J Dent Educ 1992;56:646-649.
ed guide to the evaluation of permanent
impairment of the temporomandibular 19. Attanasio R, Mohl ND: Curriculum guide¬
joint. J Craniomand Pract 1989;7:13-17. lines for the development of postdoctoral
programs in temporomandibular disorders
9. International Association for the Study of and orofacial pain. J Dent Educ 1992;56:
Pain: Task force on guidelines for disen¬ 650-658.
able characteristics for pain treatment fa¬
20. Attanasio R, Mohl ND: Suggested curricu¬
cilities. IASP, Seattle, Washington, 1990.
lum guidelines for the development of pre¬
10. Brena SF, Sanders SH: The business of doctoral programs in TMD and orofacial
pain management programs: How to plan pain. J Craniomandib Disord Facial Oral
and successfully operate a pain manage¬ Pain 1992;6:113-116.
ment facility. Am Pain Soc Bull 191; 1:4-6.
21. Attanasio R, Mohl ND: Suggested curricu¬
11. American Medical Association: Guides to lum guidelines for the development of post¬
the Evaluation of Permanent Impairment. doctoral programs in TMD and orofacial
2nd ed. Chicago, American Medical Asso¬ pain. J Craniomandib Disord Facial Oral
ciation, 1984. Pain 1992;6:126-134.
12. Mohl ND, Ohrbach R: The dilemma of 22. Rugh JD, Solberg WK: Oral health status
scientific knowledge versus clinical man¬ in the United States temporomandibular
agement of temporomandibular disorders. disorders. J Dent Educ 1985;49:398-405.
J Prosthet Dent 1992;67:113-120. 23. McNeill C, Falace D, Attanasio R: Con¬
13. Greene CS: A critique of non-convention- tinuing education for TMD and orofacial
al treatment concepts and procedures for pain: A philosophical overview. J Cranio¬
TM Disorders. In Laskin D, Greenfield W, mandib Disord Facial Oral Pain 1992;6:
Gale E, Rugh J, Neff P, Ailing C, Ayer WF 135-136.
(eds) The President’s Conference on the 24. Association of University TMD Orofacial
Examination, Diagnosis and Management Pain Centers, Planning Session, San Fran¬
of Temporomandibular Disorders. Am Dent cisco, American Association of Dental Re¬
Assoc, 1983, pp 177-181. search Meeting, 1989.
14. McNeill C, Mohl ND, Rugh JD, Tanaka 25. Crall JJ: The role of health services re¬
TT: Temporomandibular disorders: Diag¬ search in developing practice policy: De¬
nosis, management, education, and re¬ velopment of practice guidelines. J Dent
search. J Am Dent Assoc 1990; 120:253-263. Educ 1990;54:693-694.

114
 Glossary

A through membranes that takes the system

from its normal resting state to one of muscle
abrasion of teeth Pathologic wearing away contraction.
of teeth from mastication or bruxism in con¬
trast to chemical erosion. active mandibular opening Mandibular
range of motion achieved by motion imparted
abscess Localized collection of pus within
by voluntary contraction of the controlling
tissues or preformed cavities.
muscles and relaxation of antagonist muscles.
acoustic meatus External cartilaginous and
active resistive stretch Motion voluntarily
internal bony auditory canal.
imparted against resistance of muscle, ten¬
acoustic neuroma Benign tumor within the dons, capsule, or intra-articular structures.
auditory canal arising from the eighth cranial
(acoustic) nerve [CN VIII].
acupuncture Traditional Chinese practice
of inserting needles into specific points along
acquired disorder Postnatal aberration,
the “meridians” of the body to induce anesthe¬
change, or disturbance of normal develop¬
sia, for alleviating pain or for prevention. There
ment or condition that relates to the individu¬
is experimental evidence that the procedure
al and is not bound to hereditary transmission
produces an analgesic effect because it causes
from parents to offspring. the release of enkephalin, a naturally occur¬
acromegaly Chronic metabolic condition ring endorphin that has opiatelike effects.
characterized by a gradual and marked elon¬
acute [ant: chrome] Having rapid onset, se¬
gation and enlargement of bones of the face,
vere symptoms, or short course.
jaws, and extremities, accompanied by en¬
largement of the lips and thickening of the soft acute malocclusion Malocclusion with sud¬
tissues of the face, which afflicts middle-aged den onset, related to joint pain, inflammation,
persons and is caused by overproduction of and/or protective muscle splinting.
growth hormone. acute pain Unpleasant sensation with dura¬
activation of muscles Energy release in tion of pain related to the normal healing time
muscle caused by the passage of molecules of the initiating or causal factors.

115
Glossary

adaptive capacity [syn: adaptive potential, agenesis Failure of development of a part in

adaptive response] Relative ability to adjust to the absolute sense. Nonappearance of the pri-
a change in the environment. More specifically, mordium in the embryo,
the correlation between the change in structure agonist [ant: antagonist] Muscle principally
and the change in function of tissues dependent responsible for a particular movement.
upon the conditions of their local environment.
algometer Instrument for measuring degree
adenocarcinoma Malignant adenoma arising of sensitivity to pressure pain.
from the epithelium of a glandular organ.
allodynia Pain that occurs without noxious
adenoma Neoplasm arising from glandular stimulus at the anatomic site of the pain.
epithelium.
alloplastic implant Nonbiologic material
adenopathy Swelling or enlargement of any implanted surgically to augment or replace
gland, especially a lymph node. tissue.
adenosine triphosphate [ATP] Enzyme found alveolar Pertaining to a tooth socket, sup¬
in muscle cells, responsible for producing en¬ porting bone, and associated connective tis¬
ergy. sue.
adherence Binding or sticking of opposing ameloblastoma Tumor of the jaw arising from
surfaces. the enamel organ, of low grade malignancy.
adhesion Molecular attraction between two analgesia Absence of normal sense of pain.
surfaces in contact. The abnormal joining or
analgesic Agent that alleviates or reduces pain
union of adjacent structures, or any band that
without loss of consciousness.
connects them, as may occur in an inflamma¬
tory process or as the result of injury.
anamnestic Pertaining to past medical history.

capsular adhesions Fibrosis of the capsular anatomic Pertaining to morphology, the struc¬
ture of an organism.
structures.
extracapsular adhesion Fibrosis of tissue ad¬ anesthesia Partial or complete loss of sensa¬
tion with or without loss of consciousness.
jacent to capsule such as muscles or ligaments,
ie, collateral ligament fibrous, adhesion of anesthesia dolorosa [syn: postsurgical neu¬
coronoid process and temporalis muscle, or ralgia] Loss of sensation of a part but with
other muscle of mastication adhering to adja¬ paradoxical pain.
cent cranial structures. aneurysm Localized, abnormal dilation of a
intracapsular adhesions Fibrous bands or ad¬ blood vessel, usually an artery.
hesions between intra-articular surfaces, in¬ Angle’s classification of malocclusion Clas¬
cluding the surrounding capsule. sification of dental malocclusion based on the
adhesiotomy Surgical separation of adhesions. relationship of the maxillary and mandibular
adhesive capsulitis Adhesions between cap¬ molar and incisor teeth.
sule/disc/fossa/condyle resulting in reduced Class I Minor dental irregularities but a cor¬
joint space volume and causing restricted trans¬ rect anteroposterior relationship of the maxil¬
lation or rotation. In the TMJ the disc posi¬ lary to the mandibular teeth.
tion may be normal but with reduced mobility.
Class //Mandible and its teeth are in a poste¬
Diagnosis determined with arthrography.
rior or retruded relationship to the maxillary
adjunctive therapy An addition to the princi¬ teeth.
pal procedure or primary course of therapy.
division 1 Maxillary anterior teeth have a
affect In psychology, the emotional reactions normal or excessive forward inclination, of¬
associated with an experience. ten with excessive horizontal overjet.
afferent neural pathway Nerve impulses division 2 Maxillary incisors are upright or
transmitted from the periphery toward the inclined backward, often with an excessive
central nervous system. overbite.

116
 Glossary

Class III Mandible and its teeth are posi¬ ic and persistent apprehension manifested by
tioned too far forward in relationship to the autonomic hyperactivity such as sweating, diz¬
maxilla.
ziness, heart palpitations, musculoskeletal hy¬
anhydrosis Absence of or reduced sweating. peractivity, and irritability.
ankylosing spondylitis Ossification of liga¬ aplasia Incomplete or arrested development
ments that results in bony encasement of the of a structure due to failure of normal devel¬
joint, primarily in spine, onset suggestive of opment of the embryonic primordium.
rheumatoid arthritis with gradual progressive apnea Temporary cessation of breathing.
movement restriction of the affected joints.
aponeurosis Flat, fibrous sheath of connec¬
Represents 15 % of cases of arthritis that begin
tive tissue that attaches muscle to bone or
before the age of 16 years, with HLA B27
other tissue.
antigen almost always found. More common
in men with onset most often between 9 to 12 appliance Device or prosthesis to provide or
years of age. facilitate a particular function or therapy.

ankylosis Immobility or fixation of a joint as arch length discrepancy Inadequate dental

a result of fibrous or bony union that may be arch circumference to accommodate the mes¬
congenital or the result of disease, trauma or ial to distal dimensions or the interproximal
surgery. contact points of the natural teeth.

bony ankylosis [.syn: synostosis] Imaging evi¬ arteriovenous malformation Altered mor¬
phology, weakening or distension of an artery
dence of reduced joint space with osseous
or vein.
union and lack of translatory movement.
arteritis Inflammation of an artery, usually of
fibrous ankylosis [syn: pseudoankylosis] Fi¬
the intima or internal layers.
brous adhesions and capsular fibrosis.
arthralgia Pain in and around a joint.
anorexia Diminished appetite, aversion to
food. arthritis [pi., arthritides] Inflammation of a
joint and peri-articular tissues, usually accom¬
anorexia nervosa Personality disorder usu¬
panied by pain.
ally occurring in young women, characterized
by extreme aversion to food and resulting in arthritis deformans [unfavorable term} See
extreme weight loss and amenorrhea. arthrosis.
antagonist [ant: agonist] Muscle whose func¬ arthrocentesis Puncture of a joint space by
tion is opposite the agonist or prime mover. using a needle, followed by removal of fluid.

antegonial notching Depression or concav¬ arthrodial Gliding joint movement.

ity at the inferior aspect of the body of the arthrogram Visualization of a joint by radi¬
mandible at the junction with ramus, near the ography following injection of a radiopaque
insertion of the masseter muscle. contrast agent into the joint space to deter¬
anterior [ant: posterior] Toward the front. mine the location and integrity of intra-artic-
ular soft tissue structures including disc
anterior positioning appliance Intraoral de¬
position, soft tissue contours, presence of per¬
vice that guides the mandible to a position
forations, joint motion, intra-articular free
forward of maximum intercuspation.
bodies, and adhesive capsulitis.
antinuclear antibody [ANA] Anti-DNA an¬ single contrast Injection of a radiopaque
tibody of serum lupus erythematosus and oth¬
contrast agent.
er connective tissue disorders.
double contrast Injection of a small amount
antipyretic Fever-reducing medication. of radiopaque contrast agent followed by in¬
anxiety Feeling of apprehension, uncertain¬ flation of the joint with air.
ty, or dread of a future threat or danger, ac¬ single space Injection of a radiopaque con¬
companied by tension or uneasiness. trast agent into either the upper or the lower
anxiety disorder [syn: panic disorder] Chron¬ synovial bursa of the TMJ.

117
Glossary

double space Injection of a radiopaque con¬ articulation Union between two or more
trast agent into both the upper and lower bones.
synovial bursa of the TMJ. articulator Mechanical device for attachment
arthrogryposis Fixation of a joint in a flexed of dental casts that allows movement of the
or contracted position that may be related to casts into various eccentric relationships.
innervation, muscles, or connective tissue.
asymmetry Lack of symmetry, unequal in
arthrokinematics See arthrokinetics. size, shape, movement, or function.
arthokinetics [syn: arthrokinematics] Joint ataxia Impaired ability to coordinate move¬
motion. ment, neuromuscular dysfunction.
depression of mandible Downward move¬
attrition Wearing away by friction or rub¬
ment of the mandible.
bing. A wearing away of teeth in the normal
distraction of mandible Separation of sur¬ course of use.
faces of the temporomandibular joint by exten¬
attrition bruxism Tooth grinding with fric¬
sion without injury or dislocation of the parts.
tional wear of opposing teeth in excursive
elevation of mandible Upward movement of movements, in contrast to tooth clenching.
the mandible.
atypical facial pain Continuous, unilateral,
lateral excursion of mandible Eccentric move¬
deep, aching pain, sometimes with a burning
ment by condylar translation to the contra¬
component. Unfavorable term as the underly¬
lateral side.
ing cause for the symptoms may just not have
laterotrusion of mandible Movement of the been discovered, and the symptom complex
mandible away from the median or toward the should be referred to as facial pain of unknown
side. origin.
mediotrusion of mandible Movement of the
atypical odontalgia [unfavorable term] See
mandible toward the median or center.
idiopathic odontalgia.
protrusion of mandible Eccentric movement
atrophy [ant: hypertrophy] Progressive de¬
with bilateral forward condylar translation.
cline or wasting away of tissue, eg, bone re¬
retrusion of mandible Bilateral condylar trans¬ sorption, muscle disuse atrophy.
lation in a posterior direction.
auditory nerve Sensory cranial nerve (CN
arthropathy Any disease or disorder that af¬ VIII) with cochlear (hearing) and vestibular
fects a joint. (equilibrium) fibers.
arthroplasty Surgical repair or plastic recon¬
aura Subjective sensation or phenomenon that
struction of a joint.
precedes and marks the onset of a paroxysmal
arthroscopy Direct visualization of a joint attack.
with an endoscope.
auricle [syn: pinna] Portion of the external ear
arthrosis Trophic degeneration of a joint. outside the head that connects to the external
arthrotomography Tomographic radiographs auditory meatus, the portion of the external
taken following the injection of radiopaque ear contained within the head.
contrast medium into a joint. auriculotemporal nerve Sensory branch of
arthrotomy Surgical incision of a joint, the mandibular division of the trigeminal nerve.
articular Pertaining to a joint. Innervates the external acoustic meatus, the
lateral aspect of the temporomandibular joint
articular capsule Fibrous connective enve¬ capsule, the parotid sheath, and the skin of the
lope of tissue that surrounds a synovial joint. auricle.
articular disc See disc.
auriculotemporal neuralgia Paroxysmal pain
articulate In dentistry, the state of the teeth with refractory periods of the auriculotem¬
being brought together into occlusion. poral branch of the trigeminal nerve.

118
 Glossary

auscultation Listening for sounds within the biomechanical Action of intrinsic or extrin¬
body, a diagnostic method. sic forces on the body, in particular the loco¬
autogenous graft Graft transferred from motor system.
one part of a patient’s body to another. block anesthesia Regional anesthesia result¬
autoimmune disorder Disease in which the ing from nerve block by injecting into or near
body produces a disordered immunologic re¬ a nerve trunk.
sponse against itself, causing tissue injury, eg,
border movements Movements of the man¬
rheumatoid arthritis, scleroderma.
dible at the boundary or margin of the enve¬
autonomic nervous system Regulates invol¬ lope of movement. Determined by the joint
untary vital functions including cardiac mus¬ anatomy, joint capsule, ligaments, and associ¬
cle, smooth muscle, and glands, including sali¬ ated muscles.
vary, sweat, and gastric glands. Comprised of
sympathetic and parasympathetic divisions.
bracing [syn: clenching] Static, prolonged
position of the mandible maintained by mas¬
avascular Lacking in blood vessels or having ticatory and tongue muscle activity, not neces¬
a poor blood supply.
sarily involving contact of the teeth.
avascular necrosis [AVN] Bone infarction
bradykinin Plasma kinin that is a potent vaso¬
not associated with asepsis but with circula¬
dilator and incites pain.
tory impairment (vascular occlusion) leading
to bone necrosis and collapse of joint surface brain stem Connects cerebral hemispheres
into underlying infarction. with the spinal cord, comprised of the medulla
oblongata, pons, and the midbrain.

bruxism Diurnal or nocturnal parafunctional

B activity including clenching, bracing, gnash¬
ing, and grinding of the teeth. In absence of
balancing occlusal contact [unfavorable term]
subjective awareness, can be diagnosed from
See nonworking occlusal contact.
presence of clear wear facets that are not
behavior Actions or reactions under specific generated by masticatory function.
circumstance.
bruxism appliance Intraoral device for
behavior modification Psychotherapy that controlling or reducing bruxism activity and
attempts to modify observable patterns of be¬ associated discomfort or damage to the denti¬
havior by the substitution of a new response to
tion.
a given stimulus.
bulimia Craving for food, often resulting
benign Mild, nonprogressive character of an
in episodes of continuous, binge eating fol¬
illness that may disturb function without en¬
lowed by periods of depression and self-depri¬
dangering the life of the individual, nonmalig-
vation.
nant character of a tumor.
benign masseteric hypertrophy Nonmalig- bulimia nervosa Personality disorder usually
seen in young women, a variety of anorexia
nant increase in size or bulk of masseter mus¬
nervosa with bouts of overeating followed by
cles of unknown etiology, usually bilateral.
intentional, self-induced vomiting. Charac¬
bilaminar zone [unfavorable term] See retro- terized by chemical erosion of teeth from
discal tissue. stomach acids and may result in bilateral en¬
bilateral [ant: unilateral] Pertaining to or largement of the parotid glands.
having two sides.
bursa Sac-like cavity found in connective tis¬
biofeedback training Utilizing equipment to sue at places where friction would otherwise
feed back a visual or auditory representation develop. Lined with synovial membrane and
of a measured physiologic activity or autonomic filled with viscous synovial fluid.
function, used in therapy to voluntarily modify
physiologic activity or autonomic function. bursitis Inflammation of a bursa.

119
Glossary

c cephalgia [syn: headache] Pain or ache in the

head.
calcium pyrophosphate dihydrate crystals cephalogram Radiogram of the head.
Present in synovial fluid of joint affected by
cerebral palsy Motor function disorder caused
active attack of gout.
by a permanent, nonprogressive brain defect
capsulitis Inflammatory response of capsule or lesion present at birth or shortly thereafter.
and associated capsular ligament and disc at¬ Deep tendon reflexes are exaggerated, fingers
tachments in response to mechanical irrita¬ are often spastic, and speech may be slurred.
tion or systemic disease. cervical Pertaining to the neck.
carotid artery Principal artery of the neck, cervicalgia Pain of the structures of the neck,
the paired common carotid, divides at the may be referred pain from noncervical origin.
upper border of the thyroid cartilage into the
cervicogenic Originating in the structures of
external and internal carotid arteries.
the neck.
carotodynia Pain in the distribution of the
chief complaint [CC] Purpose of patient’s
branches of the external carotid artery, usually
visit, most bothersome, most desired to be
related to pressure on the artery.
changed.
cast In dentistry, a model or representation
chondritis Inflammation of cartilage.
of the teeth and supporting bone, usually made
of stone or plaster. chondroblastoma Benign tumor, derived from
precursors of cartilage cells, that may contain
caudal [syn: inferior, ant: cephalic] Inferior, scattered areas of calcification and necrosis.
toward the tail.
chondroma Benign cartilaginous tumor.
causalgia [syn: reflex sympathetic dystro¬
phy] Deafferentation pain initiated by trauma chondromalacia Softening of cartilage that
may be accompanied by swelling, pain, and
or surgical procedure.
degeneration.
central nervous system [CNS] Brain and spi¬
chondrosarcoma Malignant tumor of car¬
nal cord, processes information to and from the
tilaginous cells or their precursors that may
peripheral nervous system and is the network of
contain nodules of calcified hyaline cartilage.
coordination and control of the entire body.
chronic [ant: acute] Developing slowly and
centric occlusion [CO] [syn: maximum in-
persisting for a long time.
tercuspal position] That position of the man¬
dible relative to the maxilla where the greatest chronic pain Enduring and relatively con¬
degree of tooth contact is achieved on articu¬ stant condition that has become a component
lation of the teeth. of the patients’ daily routine. May have associ¬
ated unpleasant sensory, perceptual, and emo¬
centric relation [CR] See centric relation
tional experiences with associated behavioral
occlusion.
and psychosocial responses. Persistent pain
centric relation occlusion [CRO] [syn: cen¬ beyond 6 months or the normal time for heal¬
tric relation, retruded contact position] Po¬ ing of an acute injury or pain that persists
sition of the mandible relative to the maxilla, when other aspects of disorder-disease have
defined when normal joint anatomy exists, resolved.
such that on pure rotation (hinge closure) the
chronic paroxysmal hemicrania Rare form of
mandibular condyle is functioning in its most
headache centered around the eye and radiating
physiologic position. Determined at the point
to the cheek or temple with attacks lasting 5 to
of initial tooth contact on this arc of physi¬
60 minutes with 4 to 12 attacks per day for years
ologic closure, not necessarily coincident with
without remission. Like cluster headache, may
centric occlusion.
have associated conjunctival congestion and
cephalic [syn: rostral, ant: caudal] Toward clear nasal discharge, with the headache con¬
the head, structure of the head. sistently remaining on the same side.

120
 Glossary

claudication Pain in muscle resulting from condylysis condylolysis] Resorption or

inadequate blood supply. dissolution of condyle.
clenching [syn: bracing] Exertion of mastica¬ congenital disorder Developmental disor¬
tory force, primarily of the elevator muscles, der present at birth.
in static occlusal relationship that is not asso¬
ciated with normal functions such as biting, conjunctiva Mucous membrane covering
chewing, swallowing, or speech. May be diur¬ the anterior surface of the eyeball and lining
the eyelids.
nal or nocturnal and the patient may not be
aware of the muscle activity. conjunctival injection Dilation of the vas-
clicking joint noise Distinct snapping or pop¬ cularature of the conjunctiva.
ping sound emanating from the TMJ during connective tissue Tissue of mesodermal ori¬
joint movement or with joint compression. gin that supports and connects other tissues
cluster headache [syn: Horton’s syndrome, and includes elastic or collagenous fibrous
histamine cephalgia] Severe unilateral head connective tissue, bone, and cartilage. Con¬
and face pain, often accompanied by involun¬ nective tissues are highly vascular with the
tary lacrimation, with localized extracranial exception of cartilage.
vasodilatation in the periorbital region con¬ connective tissue disorder [syn: mixed con¬
tributing to the pain and conjunctival conges¬ nective tissue disease, collagen disease]
tion. The paroxysmal pain occurs in bouts or Group of diseases of connective tissue that
clusters, sometimes with clockwork regulari¬ share common anatomic and pathologic fea¬
ty, with the attacks usually occurring during tures. The etiology of these diseases is un¬
the night, lasting 30 to 120 minutes. known and they are grouped on the basis of
cognitive behavioral therapy Therapy fo¬ common clinical signs and symptoms.
cused on changing attitudes, perceptions, and continuous passive motion [CPM] Cyclic
patterns of thinking. motion imparted to a body part by another
collateral ligament Supportive ligament on individual or machine that moves an articula¬
the lateral aspect of the temporomandibular tion through a determined range of motion.
joint capsule. contracture Abnormal, usually permanent,
compression of joint Pressing together of condition of a joint caused by the loss of the
joint surfaces. normal elasticity of the skin or connective
tissue surrounding a joint or by atrophy and
computed tomography [CT] Tomographic
shortening of the muscles.
method that employs a narrowly collimated
radiographic beam that passes through the contraction Shortening, tightening, or re¬
body and is recorded by an array of scintilla¬ duction in size or length of a muscle fiber.
tion detectors. The computer calculates tissue contralateral [ant: ipsilateral] Originating in
absorption, demonstrating the densities of vari¬ or affecting the opposite side.
ous structure. contrast medium Radiopaque material in¬
condyle Rounded, articular end of a bone. jected prior to imaging examination that ren¬
condylar fracture Fracture of the head or ders certain tissues or spaces opaque.
neck of the mandibular condyle that may be contributing factor Condition or action
intracapsular or extracapsular and may be dis¬ that contributes to ine occurrence of or aggra¬
placed or nondisplaced. vation of a disease or disorder.
condylectomy Surgical removal of a portion contusion of joint Traumatic condition not
of the superior mandibular condylar head. sufficient to cause condylar fracture, charac¬
condyloid Pertaining to the condylar process. terized by acute synovitis, effusion, and possi¬
ble hemarthrosis.
condylotomy [syn: subcondylar osteotomy]
Surgical sectioning of the condylar neck with¬ conversion disorder Repressed emotional
out removal or recontouring of the condyle. conflicts that are converted into sensory, mo-

121
 %
Glossary

tor, or visceral symptoms with no underlying the scalp and along facial and temporal arte¬
organic cause. The conversion reaction often ries, headache, and jaw claudication. May lead
becomes evident through a hysterical mani¬ to blindness. Age related onset, uncommon
festation of symptoms resembling those of an before the age of 60 years. Cranial manifesta¬
organic disease. tion of giant cell arteritis.
coping mechanisms Cognitive and behav¬ cranial nerves [CN] Twelve pairs of nerves
ioral efforts to manage specific tasks, prob¬ that have their origin in the brain.
lems, or situations. craniocervical Relating to both the cranium
coronal [syn-. frontal] Vertical plane, perpen¬ and the neck.
dicular to sagittal plane, dividing the body craniofacial Relating to both the face and
into front to back portions. the cranium.
coronoid hyperplasia Benign overgrowth of craniomandibular Paired articulation of
the coronoid process of the mandible that may the mandible to the cranium.
result in limited opening.
craniomandibular disorder [CMD] [unfavor¬
coronoid process Process on the anterosupe- able term] See temporomandibular disorder.
rior surface of the mandibular ramus that serves
cranium Skull or bones of the head that en¬
as the attachment of the temporalis muscle.
case the brain.
coronoid process impingement Hyperplas¬
crepitation [syn-. grating, crepitus] Noise or
tic growth disturbance resulting in progres¬
vibration produced by rubbing bone or irreg¬
sive, gradual restriction of mouth opening
ular cartilage surfaces together, as found with
caused by obstruction of the hyperplastic co¬
arthrosis.
ronoid process by the zygomatic process. Re¬
striction is more pronounced if opening is crossbite Condition in which normal labio-
attempted from a protruded or translatory lingual or buccolingual relationship between
condylar position. Relative impingement can the maxillary and mandibular teeth is reversed.
also occur without hyperplasia of coronoid cutaneous Relating to the skin.
when there has been shortening of the condy¬
lar head with superior positioning of the con¬
dylar articular surface. D
corrected cephalometric tomography To¬
mography of structures of the head, in partic¬ deafferentation pain Pain perceived in a lo¬
ular the condyle of the mandible, with the calized area resulting from the loss or disrup¬
radiographic section oriented to the precise tion of sensory nerve fibers.
location and angulation of the structure of debridement Excision of devitalized tissue
interest. and foreign matter from a diseased area or
Costen’s syndrome Syndrome of dizziness, wound.
tinnitus, earache, stuffiness of the ear, dry decompression of a joint Removal or re¬
mouth, burning in the tongue and throat, lease of pressure.
sinus pain, and headaches that an otolaryngol¬
deflection on mandibular opening Eccen¬
ogist in 1934 attributed to overclosure of the
tric displacement of mandible on opening,
bite and posterior displacement of the mandi¬
away from a centered mandibular midline path,
bular condyle.
without correction to midline position on full
cranial [syn: cephalic, superior] In the direc¬ opening.
tion of the head, pertaining to the structures
degeneration Tissue deterioration with soft
of the head.
tissue, cartilage, and bone converted into or
cranial arteritis [syn-. giant cell arteritis] replaced by tissue of inferior quality. Failure of
Condition characterized by fever, anorexia, articulation to adapt to loading forces, result¬
loss of weight, leucocytosis, tenderness over ing in impaired function.

122
 Glossary

deglutition The act of swallowing. disc derangement See internal derange¬

delayed onset muscle soreness Pain caused ment.
by intermittent overuse, resulting in intersti¬ disc displacement Abnormal position of the
tial inflammation. intra-articular disc relative to the mandibular
delta sleep Nonrapid eye movement, Stage condyle and the temporal fossa.
IV sleep. reducing Condyle re-establishes a normal
demyelination Loss of myelin from the sheath anatomic relationship with the disc during
of a nerve. condylar translation or rotation.

dental Pertaining to a tooth or teeth. nonreducing Condyle fails to re-establish a

normal anatomic relationship with the disc
dentition Arrangement of the natural teeth
during condylar translation or rotation.
in the dental arch.
disc interference disorder See internal
depression of mandible Downward move¬ derangement.
ment; a component of normal mandibular
opening. discal repositioning surgery Arthrotomy
with intent of re-establishing normal disc-to-
depressive state Psychiatric mood disorder. condyle anatomic relationship.
derangement A disturbed arrangement; a discectomy [syn\ meniscectomy] Arthrotomy
mechanical disorder. with removal of intra-articular disc.
developmental disorder See acquired dis¬ disclusion [syn: disocclusion] Separation of
order, congenital disorder. mandible from maxilla in excursive movements
deviation in form Irregularities or aberra¬ through tooth-guided contact.
tions in the form of intracapsular, soft, and discoplasty Correction or improvement in
hard articular tissue. the contour or position of a disc.
deviation on mandibular opening Eccen¬ disease Illness, sickness, body function disor¬
tric displacement of mandible on opening, der, or pathologic alterations characterized by
away from centered mandibular midline path, identifiable group of signs and symptoms.
with correction to midline position on full
disk [unfavorable term\ See disc.
opening.
dislocation of condyle Anterior displace¬
diagnosis Determining the nature of a dis¬
ment of mandibular condyle away from the
ease from a study of the signs and symptoms.
temporal component, lacking contact with
differential diagnosis Differentiation of two normal articulating surface but located within
or more diseases with similar symptoms to the joint capsule.
determine which is the correct diagnosis.
disorder Disturbance of function, structure,
digingylmoarthroidal Paired joint that is both or both.
a hinged (ginglymoid) and a gliding (arthro¬ displacement Removal from the normal or
dial) joint. usual position or place.
disability Alteration of the patient’s capacity distal [ant: proximal] Away from the origin.
to meet personal or social demands or occupa¬
distraction of the condyle Separation or
tional tasks. Failure to meet statutory or regu¬
downward movement of the condylar head
latory requirements. Assessed by nonphysical
from the normal articular contact zone.
measures such as social adjustment or psycho¬
logical assessment. diurnal [ant: nocturnal] Pertaining to or oc¬
curring in the daylight hours.
disc [syn: articular disc, intra-articular
disc] Intra-articular, plate-like fibrocarti¬ dizziness Sensation of faintness or inability
laginous structure in the TMJ consisting of an to maintain normal balance, sometimes with
anterior band, intermediate zone, and poste¬ associated mental confusion, nausea, and
rior band. weakness.

123
Glossary

Doppler effect The apparent change in the edema Abnormal accumulation of fluid in
frequency of a wave resulting from relative cells, tissue, or cavities.
motion of the source and the receiver. efferent neural pathway Neural impulse trans¬
Doppler ultrasonography The application mitted away from the central nervous system.
of the Doppler effect to ultrasonic scanning efficacy Maximum ability of a drug or treat¬
with ultrasound echoes converted to (ampli¬ ment to produce a result, regardless of dosage
fied) sound or graphic waves. or frequency.
dysarthrosis Deformity or malformation of a effusion Escape of fluid from blood vessels or
joint whereby there is impairment of joint lymphatics, usually into a body cavity or tissue.
motion.
Ehlers-Danlos syndrome Autosomal domi¬
dyscrasia Morbid condition referring to an nant inherited disorder of dermal collagen, lax
imbalance of the component parts. joints, and skin elasticity.
dysesthesia Disagreeable or impaired (ab¬ elastic tissue Connective tissue composed
normal) sensation. of approximately 30% elastin, a yellow fibrous
dysfunction Collective term for signs and mucoprotein.
symptoms of abnormal or altered function. electrogalvanic stimulation [EGS] Electro¬
dyskinesia Motor function disorder with im¬ therapy utilizing direct current, or galvanism,
pairment of voluntary movement, character¬ resulting in muscle fiber contraction. Galva¬
ized by spontaneous, imprecise, involuntary, nism is also used for iontophoresis and the
irregular movements with stereotype patterns. application of the current is used as a pain-
May involve grimacing, muscle tremors, and relieving modality.
sudden twitches as occur from the adverse electromyography [EMG] The preparation
effect of phenothiazine derivative medications. or study of the graphic recording of the intrin¬
dysostosis Abnormal condition character¬ sic electrical process that accompanies muscle
ized by defective ossification, especially de¬ contraction.
fects in the ossification of fetal cartilages. electrotherapy Use of electricity in treating
dysphoria Disquiet, restlessness, malaise. disease: with direct current, galvanism; with
dysplasia Pathologic abnormality of develop¬ alternating current, faradism.
ment or replacement of cells with alteration in elevator masticatory muscles Paired masse-
the size, shape, and organization. ter, medial pterygoid, and temporalis muscles.
dystonia Abnormal tonicity, usually in refer¬ eminence [syn\ tubercle] Prominence or pro¬
ence to muscle tissue, that may result in al¬ jection of a bone.
tered movement and posture. emission scintigraphy Imaging process in
focal dystonia Localized dystonia character¬ which radiolabeled material is administered
ized by momentary sustained contracture of that is concentrated by the body in areas of
involved muscles. rapid bone turnover.
dystrophy Developmental change in muscles endocrine Internal secretion from a gland
resulting from defective nutrition, not involv¬ directly into the systemic circulatory system.
ing the central nervous system, with fatty
endogenous Produced or originating from
degeneration and increased size but decreased
within a tissue or organism.
strength.
endoscope Instrument for examining the in¬
terior of a body cavity.
E end-feel Quality of resistance felt in trajec¬
tory between full active opening and full pas¬
eccentric Jaw relation or position that is sive opening, determined by gentle manipula¬
peripheral or away from a centered or centric tion to increase range of motion (passive
jaw position. resistive stretch).

124
 Glossary

epidemiology Science concerned with defin¬ extrinsic Originating outside of a part where
ing and explaining the interrelationships of it is found or on which it acts.
factors that determine disease frequency and
extrinsic trauma Trauma originating from
distribution.
outside an organ system or individual.
epilepsy Group of neurologic disorders char¬
extrusion Process of forcing out of a normal
acterized by recurrent episodes of convulsive
position.
seizures, sensory disturbance, abnormal be¬
havior, and loss of consciousness.
equilibration of occlusion Adjustment of F
the dentition to evenly distribute the vertical
and excursive forces of occlusion. facebow Device used in dentistry for regis¬
erosion of teeth Wearing away of dentition, tering the relationship between the dentition
especially by chemical means. and the facial skeleton, including the tempor¬
omandibular joint articulation, used to mount
erythrocyte sedimentation rate [ESR] Rate a dental cast on an articulator.
at which red blood cells settle out in a tube of
unclotted blood, expressed in millimeters per facet Small, smooth area on a hard surface.
hour. Elevated sedimentation rate indicates facial Pertaining to the face or anterior part
the presence of inflammation, but is not spe¬ of the head from forehead to chin.
cific for any disorder. facial cranial nerve [CN VII] Mixed sensory
etiologic factors Factors that may be involved and motor nerve that innervates the scalp,
in, or cause, the development of a disease. forehead, eyelids, muscles of facial expression,
eustachian tube Opening from the middle platysma muscle, submaxillary and subman¬
dibular salivary glands, and the afferent fibers
ear cavity into the pharynx.
from taste buds of the anterior two thirds of
Ewing’s sarcoma Malignant tumor that de¬ the tongue.
velops from bone marrow; most frequently in
facial neuralgia [unfavorable term] See atypi¬
adolescent boys.
cal facial neuralgia.
exacerbating factor Factor that increases the
factitious disorder Sign, symptom, or dis¬
seriousness of a disease or disorder as marked
order produced artificially; not natural.
by greater intensity in the signs or symptoms.
fascia Collagenous connective tissue that en¬
excursion of mandible Movement of the man¬
closes structures and separates them into vari¬
dible away from the median or centric occlu¬
ous groups.
sion position.
fasciculation Continuous muscle contraction.
lateral excursion Movement of the mandible
to the side. fibrillation Involuntary recurrent contraction
of individual muscle fibers.
protrusive excursion Movement of the mandi¬
ble forward. fibrocartilage Type of cartilage in interver¬
tebral discs, pubic symphy sis, and mandibular
extension of joint [ant-, flexion] A motion
symphysis, as well as on certain regions of the
that increases the joint angle.
TMJ.
external Away from the center of the body,
fibromyalgia [syn: fibrositis, myofibrositis]
outside a structure.
Nonarticular rheumatism with diffuse mus¬
external auditory meatus Portion of the ex¬ culoskeletal aches and stiffness and exagge¬
ternal ear contained within the head. rated tenderness at multiple known anatomic
extracapsular [ant: intracapsular] Outside sites, associated with nonrestorative sleep.
or external to the capsule, fibrosarcoma Sarcoma that contains con¬
extracranial Outside or external to the cra¬ nective tissue, develops suddenly from small
nium. nodules on the skin.

125
Glossary

fibrosis Abnormal proliferation of fibrous con¬ cranial arteries. Characterized by fever, an¬
nective tissue, occurs in the formation of scar orexia, loss of weight, leucocytosis, and ten¬
tissue to replace normal tissue lost through derness over the scalp and along facial and
injury or infection. temporal arteries. May lead to blindness. Av¬
fibrositis [syn: fibromyalgia myofibrositis] erage age of onset is 70 years, uncommon
See fibromyalgia. before the age of 60 years, with 65% of re¬
ported cases in women,
fibrous Composed of or containing fibers of
connective tissue. ginglymoid Hinging joint with one convex
and one concave surface, with movement in
fibrous dysplasia Abnormal fibrous replace¬
one plane of space.
ment of osseous tissue with onset usually dur¬
ing childhood. gliding See translation.

flexion [ant: extension] A motion that re¬ glossodynia [syn: glossalgia] Painful or burn¬
duces the joint angle. ing tongue.

flexion-extension injury Traumatic, exag¬ glossopharyngeal neuralgia Severe, parox¬

gerated movement of joints through extreme ysmal, lancinating pain of the branches of the
range of motion with hyperflexion and then glossopharyngeal nerve [CN IX] radiating to
hyperextension, resulting in ligamentous the throat, ear, teeth, and tongue. Rare, uni¬
sprain, muscular strain, inflammation, and lateral condition, usually in men over age of 5 0
subsequent reflex muscle splinting. years, that is triggered by movement in the
tonsillar region by swallowing or coughing.
fluoroscopy Radiographic technique for vi¬
Branches to the carotid, artery can trigger
sualizing the contours and function of an or¬
vasovagal response including altered respira¬
gan or joint, providing immediate dynamic
tion, blood pressure, and cardiac output.
images.
gnathic Pertaining to the jaw.
fossa [pi, fossae] Hollow, pit, concavity, or
depression, especially on the surface of the gnathologic Pertaining to the dynamics of
end of a bone. the jaw.
freeway space Interocclusal distance or sep¬ gout Disorder of purine metabolism charac¬
aration between the arches when the mandible terized by hyperuricemia and the deposition
is in its physiologic rest position. of monosodium urate crystals in joints, result¬
ing in acute attacks of arthritis with red, hot,
fremitus Vibration.
and swollen joints, especially the big toe.
frontal [syn: coronal] Vertical plane, perpen¬ Occurs primarily in men over the age of 30
dicular to sagittal plane, dividing the body years.
into front to back portions.
grating joint sound See crepitation.
grinding of teeth [syn: gritting] See attrition
G bruxism.

genetic Pertaining to reproduction, birth,

origin, or heredity. H
geniculate neuralgia [syn: nervous inter-
hard tissue Skeletal tissue including bone,
medius neuralgia, Ramsay Hunt’s syn¬
hyaline cartilage, and fibrocartilage.
drome] Painful disturbance of the sensory
portion of the facial nerve characterized by headache See cephalgia.
lancinating pain deep to the ear. hemarthrosis Bloody effusion into cavity of a
giant cell arteritis [syn: cranial arteritis] joint.
Inflammation that fragments and distorts the hematoma A swelling or mass of blood con¬
arterial internal elastic lamina resulting in fined to a tissue or space, caused by a break in a
obliteration of the lumen. Not restricted to blood vessel.

126
 Glossary

hemifacial microsomia Condition in which hypermobility [ant: hypomobility] Exces¬

one side of the face is abnormally small and sive mobility.
underdeveloped, yet normally formed. hypermobility syndrome Inherited ar¬
hemorrhage Abnormal internal or external thropathy with traumatic synovitis associated
discharge of blood. with joint laxity; common in children but
seldom persists into adult life.
herpes zoster Acute infection caused by the
varicella zoster virus characterized by painful hyperplasia Overdevelopment of tissue or
vesicular skin eruptions that follow the path¬ structure with an increase in the number of
way of cranial or spinal nerves inflamed by the normal cells.
virus. hypertonicity of muscle Excess muscular tonus.
hinge axis Articulation about a single hori¬ hypertrophy [ant: atrophy] Increase in size
zontal axis; for the mandible, a pure rotary of an organ or structure that does not involve
movement on opening. tumor formation. Increase in size or bulk is
not from an increase in number of cells.
histaminic cephalgia See cluster headache.
hyperuricemia Abnormal amount of uric acid
history of present illness [HPI] Narrative
in the blood, found in gout but also in many
report of each symptom or complaint includ¬
other conditions.
ing date of onset, duration, and character of
the present illness. hypochondriasis Somatoform disorder
marked by the preoccupation with and anxiety
homologous Corresponding or alike in criti¬
over one’s health with exaggeration of normal
cal attributes, similar in structure but not
sensations. Misinterpretation of normal phys¬
necessarily in function.
ical signs and minor complaints as a serious
Horner’s syndrome Neurologic condition illness or disease.
characterized by unilateral miosis, ptosis, and hypoglossal cranial nerve [CN XII] Mixed
facial anhydrosis, usually resulting from a cer¬ nerve carrying afferent proprioceptive im¬
vical sympathetic lesion. pulses as well as efferent motor impulses to the
Horton’s headache See cluster headache. intrinsic and extrinsic muscles of the tongue,
human leukocyte antigen-B27 [HLA-B27] with communication to the vagus nerve [CN
Genetic marker usually present in individuals X].
with ankylosing spondylitis. hypomobility [ant: hypermobility] Reduced
humoral Relating to or arising from any of or restricted mobility.
the body fluids. hypoplasia Incomplete or defective develop¬
ment or underdevelopment of a tissue or struc¬
hyaline cartilage Type of cartilage found on
ture. Implies fewer than the usual number of
the articular surfaces of bones. Forms a temp¬
cells.
late for endochondral bone formation.
hysterical trismus Severe restriction of man¬
hyperesthesia Increased sensitivity to senso¬
dibular motion due to acute psychologic distress.
ry stimuli.
hyperextension Position of maximum or ex¬
treme extension of a joint. I
hyperextension-hyperflexion injury Trau¬
ma that results in a combination of hyperex¬ iatrogenic Unfavorable response or condi¬
tension and then hyperflexion of a joint and tion caused by medical personnel, diagnostic
associated soft tissues. tests, or treatment procedures,
hyperflexion Position of maximum or ex¬ idiopathic Pain, disease, or disorder of un¬
treme flexion of a joint. known origin or pathology,
hyperfunction of muscle Increased function idiopathic odontalgia Tooth pain without
obvious pathology and of unknown etiology.
of muscle.

127
Glossary

illness behavior Person experiencing symp¬ intermaxillary [unfavorable term] See inter-
toms seeks validation of and advice for treat¬ occlusal.
ment of the suspected disorder and adopts the internal [ant: external] Toward the center of
sickness role. the body, within a structure.
imaging Representation or visual reproduc¬ internal derangement Localized mechani¬
tion of a structure for purpose of diagnosis cal fault interfering with smooth joint move¬
such as radiographs, ultrasound, CT, and MRI. ment, including elongation, tear, or rupture of
the capsule or ligaments causing altered disc
impairment Alteration of health status as¬
sessed by medical means. position or morphology.
interocclusal Between the opposing dental
incidence Number of new cases that occur
arches.
during a specified period of time.
interstitial Pertaining to the space between
incisor The four front teeth of each arch,
tissues.
used for cutting.
intra-arch Located within an arch.
infarct An area of tissue that undergoes ne¬
crosis following cessation of blood supply. intra-articular Located within a joint.

infection Invasion of a tissue by pathogenic intracapsular [ant: extracapsular] Located

microorganisms that reproduce and multiply, within the confines of the capsule of a joint.
causing disease by local cellular injury, secre¬ intracranial [ant: extracranial] Within the
tion of toxin, or antigen-antibody reaction in cranium or skull.
the host.
intrameatal Within the auditory canal or me¬
infectious arthritis Acute inflammatory atus.
condition of a joint caused by bacterial or viral
intraoral Within the oral cavity.
infection.
intrinsic [ant: extrinsic] Originating from or
inferior [syn\ caudal, ant-, superior] Tail-
situated within an organ or tissue.
ward.
intrinsic trauma [syn: microtrauma, ant: ex¬
inflammation Protective response of tissue
trinsic trauma] Trauma originating from
to irritation or injury that may be accom¬
within an organ system or individual.
panied by redness, heat, swelling, and pain.
Process initiates with increased vascular per¬ ionizing radiation Radiation created by dis¬
meability with exudate of fluid from vessels. locating negatively charged electrons from
atoms by the application of an electrical cur¬
initiating factors Factors that cause the on¬
rent.
set of a disease or disorder.
iontophoresis Introduction of various ions
insidious onset [ant: acute onset] Develop¬ into tissues through intact skin by means of
ment that is gradual, subtle, or imperceptible. direct electrical current.
insomnia Wakefulness, inability to sleep dur¬ ipsilateral [syn: homolateral, ant: contra¬
ing the period when sleep should occur. lateral] On the same side of the body.
interarch Between two adjacent arches, as isotonic exercises Active exercise without
between the maxillary and mandibular dental appreciable change in the force of muscle
arches. contraction, with shortening of the muscle.
intercuspal position [ICP] [syn: centric oc¬ isokinetic exercises Dynamic muscle activ¬
clusion] Mandibular position with maximum ity performed at a constant angular velocity.
interdigitation of opposing teeth.
isometric exercises Active exercise per¬
interdisciplinary Multiple clinical special¬ formed against stable resistance, without
ties in one setting. change in the length of the muscle.

128
 Glossary

J luxation Displacement of articular surfaces

from normal position but with continued con¬
jaw Either or both bony structures, the max¬ tact.
illa or mandible, in which the teeth are set.
lysis Dissolution or loosening,
jaw tracking [unfavorable term] See mandi¬
lytic Pertaining to lysis.
bular movement recording.
juvenile rheumatoid arthritis [JRA] Repre¬
sents 15% of cases of arthritis that begin be¬ M
fore the age of 16 years, with rheumatoid
factor found in 70% of cases. More common magnetic resonance imaging [MRI] Non-
in women with onset most often between 12 to invasive, nonionizing imaging method that
15 years of age. utilizes the signals from resonating hydrogen
juxtaposed Positioned adjacently or side by nuclei after they have been subjected to a
side. charge in a magnetic field. Their relaxation
and resultant resonant frequency is detected,
measured, and converted by a computer into
K an image.
malformation Failure of proper or normal
kinesiograph Instrument use to record and development, a primary structural defect that
provide graphic representation of movement. results from a localized error of morphogene¬
sis.
kinesiology The science or study of move¬
ment and the active and passive structures malinger To feign an illness, usually to es¬
involved. cape responsibility, provoke sympathy, or gain
compensation.
malocclusion [See also Angle’s Classifica¬
L tion] Abnormal contact or position of the
teeth of the maxillae with the teeth of the
lacrimadon Secretion of tears by the lacrimal mandible.
glands.
mandible Horseshoe shaped lower jaw, con¬
larynx Air passageway connecting the phar¬ sisting of the horizontal body joined at the
ynx with the trachea; the organ of voice. symphysis and two vertical rami with the
latent disease Dormant disease; existing as a anterior coronoid process and the posterior
potential disease or disorder. condylar process, separated by the mandib¬
ular notch. The superior border of the body,
lateral [ant: medial] Away from the midline of
the alveolus, contains sockets for the lower
the body.
teeth.
lavage The process of washing out or irri¬
mandibular movement recording Kinesio-
gating a cavity.
graphic recording of the movement of the
leukocytosis Abnormal increase in the num¬ mandible.
ber of circulating white blood cells. mandibular orthopedic repositioning ap¬
ligament Flexible band of fibrous tissue, pliance [MORA] Interocclusal appliance, usu¬
slightly elastic and composed of parallel collag¬ ally covering only the posterior mandibular
enous bundles, binding joints together and teeth, that may be used to alter mandibular
connecting various bones and cartilages. position.
locking of joint [unfavorable term] See non¬ mastication Process of chewing food in prep¬
reducing disc. aration for deglutition.
lupus erythematosus See systemic lupus masticatory muscles Muscles responsible
erythematosus. for masticatory motion including the paired

129
Glossary

ness, altered consciousness, confusional states,

masseter, temporalis, lateral pterygoid, and
and subsequent headache.
medial pterygoid muscles,
classic migraine with aura Headache with
maxilla Upper jawbone, superior maxilla,
associated premonitory sensory, motor, or vi¬
maxillofacial Pertaining to the maxilla and sual symptoms.
the face.
hemiplegic migraine Oculomotor nerve pal¬
maxillomandibular Pertaining to the maxilla sy and partial to complete paralysis of motor
and mandible. function.
maximum intercuspation That position of ophthalmoplegic migraine Nonthrobbing
the mandible relative to the maxillae where the orbital or periorbital pain that radiates to the
greatest degree of tooth contact is achieved on hemicranium, often accompanied by vomit¬
articulation of the teeth, ing, lasting 1 to 4 days. Frequently accom¬
medial [ant: lateral] Toward the midline of panied by ipsilateral ptosis and sometimes by
the body. pupillary dilatation.
mediate auscultation Listening to sounds retinal migraine Repeated attacks of monocu¬
with the use of an instrument. lar scotoma or blindness lasting less than 1 hour.
meniscectomy [unfavorable term] See discec¬ common migraine without aura Condition in
tomy. which no focal neurologic disturbance pre¬
mental disorder Disorder of mind or intel¬ cedes the headache.
lect, of psychologic or organic origin, that mixed connective tissue disease See con¬
impairs adaptive functioning in area of emo¬ nective tissue disorder. '
tional perception, cognitive behavior, or in¬ mobilization of a joint Restoration of mo¬
terpersonal relationships. tion to a joint.
metaplasia Conversion of one tissue type monosynaptic reflex Simplest and fastest re¬
into a form that is not normal for that tissue. flex involving one motor and one sensory neu¬
metastatic Shifting of a disease or its local ron with one synapse, eg, muscle stretch reflex.
manifestation from one part of the body to mood disturbance Disturbance of the emo¬
another. In cancer the appearance of neo¬
tional state of an individual.
plasms in parts of the body remote from the
morphology Form or structure of an organ¬
seat of the primary tumor,
ism.
micrognathia Abnormal smallness of the
jaw, especially the lower jaw. motor neuron A neuron carrying impulses
that initiate muscle contraction.
microtrauma [syn: intrinsic trauma] Minor
trauma that may cause problems if repetitive, multidisciplinary Different specialties in mul¬
as distinguished from macrotrauma or gross tiple clinical settings.
trauma. multifactorial Resulting from the combined
midline of teeth Interproximal contact zone action of several factors.
between the central incisor teeth of the maxil¬ multiple myeloma Malignant neoplasm of
lary or mandibular dental arch. bone marrow.
migraine headache Paroxysmal, recurrent, multiple sclerosis Chronic, slowly progres¬
intense headache, frequently unilateral and sive disease of the central nervous system of
often accompanied by disordered vision and unknown etiology, characterized by demyeli-
gastrointestinal disturbances. Headache vari¬ nated glial patches called plaques.
ants classified by descriptive characteristics muscle Tissue comprised of contractile fi¬
rather than by known physiologic mechanisms. bers that effect movements of an organ or part
basilar migraine Disturbance of brain stem of the body. Muscle types include striated
function with dramatic but slowly evolving skeletal and cardiac muscles and smooth, non-
neurologic events, often involving total blind¬ striated visceral muscles.

130
 Glossary

digastric muscle Origin at the digastric notch trapezius muscle Origin on the superior nu¬
of the mastoid process with insertion on the chal line of the occipital bone, spinous process
mandible near the symphysis, raises the hyoid of the seventh cervical and all the thoracic
bone and base of the tongue and depresses the vertebrae with insertion on the clavicle and
mandible. scapula. Elevates the shoulder and rotates the
lateral (external) pterygoid muscle Origin at scapula.
the lateral pterygoid plate and greater wing of muscle cramp [unfavorable term] See myo¬
the sphenoid with insertion at the fovea of the spasm.
condyle and capsule of the temporomandibu¬ muscular dystrophy Group of genetically
lar joint. Muscle of mastication that translates transmitted diseases characterized by progres¬
the mandible and is active on mouth opening sive atrophy of symmetric groups of skeletal
and near final mouth closure. muscles without evidence of degeneration of
masseter muscle Origin of the superficial mas- neural tissue.
seter on the zygomatic process and arch with musculoskeletal Relating to the muscles and
insertion on the ramus and the angle of the skeleton.
lower jaw. Origin of the deep masseter on the
myalgia Pain in a muscle.
zygomatic arch with insertion on the upper
half of the ramus and the coronoid process of myelin Fatty substance that forms a major
the lower jaw. Powerful muscle of mastication component of the sheath that surrounds and
that elevates the mandible. insulates the axon of some nerve cells.
medial pterygoid muscle Origin on the maxil¬ myoclonus Clonic spasm or twitching that
lary tuberosity and medial surface of the lat¬ results from the contraction of one or more
eral pterygoid plate with insertion on the me¬ muscle groups.
dial surface of the ramus and angle of the myofascial Pertaining to muscle and its at¬
mandible. Muscle of mastication that elevates taching fascia.
and protrudes the mandible and is active in myofascitis Inflammation of muscle and its
mandibular movements during speech. fascia.
scalene muscles Origin on the transverse pro¬ myofibrositis See fibromyalgia,
cess of the cervical vertebrae with insertion on
myogenous Having origin in muscle.
the ribs. Acts to stabilize the cervical vertebra
or incline the neck to the side. miosis Contraction of the sphincter of the
iris, causing the pupil to constrict.
sternocleidomastoid muscle Rotates and ex¬
tends the head and flexes the vertebral col¬ myositis Inflammation of muscle tissue.
umn. Origin on the sternum and clavicle with myositis ossificans Ossification of a hema¬
insertion on the mastoid process and superior toma, usually after injury, located in but not
nuchal line of the occipital bone. involving muscle.
suboccipital muscles Muscles situated below myospasm [syn: acute trismus, muscle
the occipital bone that act to stabilize the cramp] Spasmodic contraction of a muscle.
cervical vertebrae and head position.
myxoma Neoplasm derived from connective
suprahyoid muscles Digastric, geniohyoid, my¬ tissue, composed of a mucoid matrix.
lohyoid, and stylohyoid, all attach to the upper
part of the hyoid bone and act to stabilize and
elevate the hyoid bone and depress the mandi¬ N
ble.
temporal muscle Origin on the temporal fossa natural history of disorder The natural
with the insertion on the coronoid process and sequence, duration, transitional stages, and
anterior aspect of the ramus. Muscle of mas¬ nature of change of a disease or disorder
tication that elevates and retrudes the mandi¬ over time, without external interference such
ble. as trauma or treatment.

131
Glossary

neoplasm [syn: tumor] Abnormal growth of nonworking occlusal contact Tooth con¬
new tissue, benign or malignant. tact on the contralateral side during guided
lateral excursive movement of the mandible.
nervous intermedius neuralgia [syn: genicu¬
late neuralgia, Ramsay Hunt’s syndrome] nuchal line Bony ridge at the nape or back of
See geniculate neuralgia. the skull.
neuralgia [syn: neurodynia] Pain of severe
throbbing or stabbing character in the distri¬
bution of a nerve.
o
neuritis Inflammation of a nerve that may occipital neuralgia Neuralgia of the greater
cause neuralgia, hyperesthesia, anesthesia, pa¬ occipital nerve, a continuation of the dorsal
ralysis, muscular atrophy, and impaired re¬ ramus of the second cervical nerve that emerges
flexes. onto the scalp between the sternocleidomas¬
neurolepsis Altered state of consciousness, as toid and trapezius muscles, midway between
induced by a neuroleptic medication, charac¬ the occipital protuberance and the mastoid
terized by quiescence, reduced motor activity, process.
anxiety, and indifference to the surroundings. occlusal adjustment Equilibration or grind¬
neurologic Pertaining to the nervous system ing of the occluding surfaces of teeth.
and its disorders. occlusal appliance See interocclusal appli¬
neurolysis Destruction of nerve tissue or loos¬ ance.
ening of adhesions surrounding a nerve. occlusal guidance Tooth-determined guid¬
neuromuscular Concerning both nerves ance of the mandible in eccentric movements,
and muscles. when the teeth remain in contact.

neuropathy Disease of the nerves charac¬ occlusal vertical dimension [OVD] The ver¬
terized by inflammation and degeneration of tical position of the mandible relative to the
the peripheral nerves. maxilla and facial skeleton when the teeth are
interdigitated.
neuropathic pain Pain resulting from a neu¬
rologic disorder or disease. occlusion Alignment of the mandibular and
maxillary teeth when the jaw is closed or in
neurovascular Concerning both the nervous functional contact.
and vascular systems.
ocular Pertaining to the eye.
nightguard appliance Interocclusal appli¬
odontogenic Derived from or produced in
ance traditionally worn only at night to reduce
the teeth or tissues that produce the teeth.
adverse effects of bruxism.
open bite Abnormal dental condition in which
nociceptive Capable of receiving and trans¬
the anterior teeth do not contact when the
mitting painful sensation.
posterior teeth are brought into occlusion.
nocturnal [ant: diurnal] Pertaining to or oc¬
opthalmic Pertaining to the eye.
curring in the hours of darkness.
oral Pertaining to the mouth,
noninnervated Tissue that is lacking in a
sensory or motor nerve supply. organic Related to the organs of the body,

noninvasive Denoting diagnostic or thera¬ orofacial Relating to the mouth and face.
peutic procedures that do not require pene¬ orthodontic Pertaining to the prevention of
trating the skin or entering a cavity or organ of and correction of irregularities and malocclu¬
the body. sion of the teeth.
nonsteroidal anti-inflammatory drug orthognathic Pertaining to malposition of
[NSAID] Class of anti-inflammatory medica¬ the bones of the jaws.
tions that also provide analgesia, useful in the orthopedic Relating to form and function of
treatment of musculoskeletal disorders. the locomotor structures, especially the ex-

132
 Glossary

tremities, spine, and associated structures in¬ otolaryngology Division of medical science
cluding bones, joints, muscles, fascia, liga¬ concerned with diseases of the ear, larynx,
ments, and cartilage. upper respiratory tract, and other head and
orthopedic appliance See orthotic. neck structures.
orthostatic Relating to an erect or upright otologic Pertaining to the ear.
position. overbite Vertical overlap of anterior teeth.
orthotic Mechanical appliance or splint for overjet Horizontal overlap of anterior teeth.
orthopedic use to support or improve the
function of part of the body.
osseous Bony. P
ossification Development of bone..
Paget’s disease Disorder of unknown etiol¬
osteoarthritis A chronic disease resulting in ogy with inflammation of one or many bones,
joint deformity caused by disintegration and resulting in thickening and softening of bones
abrasion of articular cartilage. In late stage is with unorganized bone repair.
accompanied by proliferation of new skeletal
pain Unpleasant sensory and emotional expe¬
tissue at the margins of the joint surface, known
rience triggered by noxious stimulation of sen¬
as marginal osteophytes, lipping, or spurs.
sory nerve endings, usually from tissue damage.
Not a disorder of cartilage, but the conse¬
quences of repetitive microfractures sustained pain mediator factors Neurovascular sub¬
by bone during high-impact loading. The car¬ stances activated by noxious stimuli that trig¬
tilage fibrillation and breakdown is not an ger or sustain pain. Include leukotriene B4
inflammatory process, but the breakdown is [LTB4], prostaglandin E2 [PCE2], platelet¬
accompanied by inflammation. activating Factor[PAF], and substance P.

osteoarthrosis Noninflammatory joint dis¬ palliative Mitigating, reducing the severity

order characterized by progressive deteri¬ of, or denoting the elimination of symptoms
oration and loss of articular cartilage and without curing the underlying disease.
subchondral bone, may be accompanied by palpation Examination by feeling with the
proliferation of new bone and soft tissue. hands; perceiving by the sense of touch.
osteoblast Bone-forming cell derived from palsy Paralysis, often connoting paresis.
mesenchyme. panic disorder [syn: anxiety disorder] Vio¬
osteoblastoma Benign, vascularized tumor lent and unreasoning anxiety and fear, with the
of poorly formed bone and fibrous tissue that person unable to organize any defense or cop¬
causes resorption of native bone, ing skills.
osteoclast Multinucleated cell that causes panoramic radiograph Circular tomography
absorption and removal of bone. that images the jaws and related structures.
osteoma A benign slow-growing mass of pantograph Dental device that incorporates
mature bone, usually arising from the skull or a pair of facebows fixed to the jaws, used for
mandible. recording mandibular movement patterns and
osteomyelitis Inflammation of bone, espe¬ centric jaw relationships.
cially of the marrow, caused by pathogenic parafunction Nonfunctional activity includ¬
organisms. ing clenching and grinding (bruxism) or rhyth¬
osteophyte Marginal adaptation of joint mic chewing-like empty mouth movements.
formed by new skeletal tissue. paralysis Palsy, loss of power or voluntary
osteosarcoma A malignant bone tumor movement in muscle through injury or disease
comprised of anaplastic cells derived from of its nerve supply.
mesenchyme. paravertebral Alongside or near the ver¬
osteotomy Incision or cutting through a bone. tebral column.

133
Glossary

paresis Partial or incomplete paralysis. physical therapy [syn: physiotherapy] Treat¬

paresthesia Altered sensation, such as burn¬ ment with physical and mechanical means such
ing, prickling, tickling, or tingling. as massage, manipulation, exercise, heat, cold,
ultrasound, and electricity.
parotid gland Paired salivary gland located
superficial to the masseter and extending from Pierre Robin syndrome Unusual smallness
in front of the ear to down below the angle of of the jaw combined with cleft palate, down¬
the mandible. ward displacement of the tongue, and an ab¬
sent gag reflex, characterized by respiratory
paroxysmal Sudden onset of a symptom or
obstruction in infants.
disease, with recurrent manifestations. A sharp
jabbing pain, spasm, or convulsion. pinna [syn: auricle] External ear.

passive range of motion Motion imparted placebo effect Physical or emotional change
to an articulation, an associated capsule, liga¬ occurring after a substance is taken or a treat¬
ments, and muscles by another individual, ma¬ ment is provided, with the change not directly
chine, or outside force. attributable to any specific property of the
substance or effect of the therapeutic agent.
passive resistive stretch Activity designed
to increase muscle strength by activating the planar scintigraphy Imaging process in
muscle against an opposing force. which area of interest is scanned with a gamma
camera 2 to 4 hours after the administration of
pathognomonic Special characteristic or
a radioactive material.
symptom of a disease.
platelet aggravating factor [PAF] Produced
pathophysiologic derangement of function
by reaction of antigen on IgE-sensitized baso-
Alteration of function seen in disease as dis¬
philes, which aggregates platelets and is a fac¬
tinguished from structural alteration.
tor in producing inflammation.
pathologic Diseased, morbid, causing dis¬
plication The stitching of folds or tucks in a
ease or pathosis.
tissue to reduce its size, as in the retrodiscal
pathosis Diseased state or condition, tissue of the temporomandibular joint, in an
periarticular Surrounding a joint. attempt to reposition a displaced articular disc.
pericranium Fibrous membrane surround¬ polyarthritis Inflammation of more than
ing the cranium, periosteum of the skull. one joint.
periodontium The connective tissue between polymyalgia rheumadca Pain and stiffness
a tooth and the alveolar bone. of the proximal limbs that evolves insidiously
over weeks or months or acute onset with
peripheral nervous system The motor and
myalgia and fever. Onset may be unilateral but
sensory nerves and ganglia outside the brain
invariably becomes bilateral. Successive in¬
and spinal cord, consisting of 12 pairs of crani¬
volvement of muscle groups with morning
al nerves, 31 pairs of spinal nerves, and their
stiffness. Muscle strength is unimpaired and
various branches in body organs.
electromyographic findings and serum enzyme
perpetuating factors Factors that interfere levels are normal.
with resolution of or enhance the progression
polysynaptic reflex Neural conduction
of a disease or disorder.
pathway formed by a chain of many synap-
pharmacotherapy Treatment of disease or tically connected nerve cells.
disorder by means of drugs.
posterior ligament [unfavorable term] See ret¬
pharynx Passageway for air from the nasal rodiscal tissue.
cavity to the larynx.
postherpetic neuralgia Neuralgia caused by
phonophobia Abnormal sensitiveness to persistent varicella zoster virus that remains
sound. latent in nerve ganglia until the host’s immu¬
photophobia Abnormal sensitiveness to light, nity has waned.
especially of the eyes. postsurgical neuralgia [syn: anesthesia do-

134
 Glossary

lorosa] Loss of sensation of a part but with par¬ pseudogout Condition in which calcified
adoxical pain following surgical intervention. deposits in synovial fluid, articular cartilage,
posterior [ant: anterior] Relating to the back and adjacent soft tissues, free from urate and
or dorsal side of the human body. consisting of calcium hypophosphate crystals,
leads to gout-like attacks of pain and swelling
preauricular Located in front of the auricle
of the involved joints.
of the ear.
psoriatic arthritis Polyarticular, progressive
predisposing Indicating a tendency or sus¬
erosive joint inflammation with associated pso¬
ceptibility to develop a certain condition in
riatic skin lesions.
the presence of specific environmental stimuli.
psychic trauma Emotional shock, injury, or
predisposing factors Factors that increase
stressful situation that produces a lasting im¬
the risk of developing a disease or disorder.
pression, especially on the subconscious mind.
prevalence Number of cases of a disease or
psychogenic pain disorders Characterized
disorder at a given point in time, usually mea¬
by persistent and severe pain for which there is
sured as a ratio of the positive cases to the
no apparent physical cause. May be accom¬
number of people in the population of interest
panied by sensory or motor dysfunction.
at that point in time.
psychosocial Involving both psychological
prodrome Early or premonitory symptom
and social aspects of functioning in society.
indicative of an approaching event or disorder.
psychotic Affected by psychosis or mental
prognathic Having a forward projecting jaw
disorder causing gross distortion or disorga¬
or jaws relative to the craniofacial skeleton.
nization of a person’s mental capacity, affec¬
prostaglandins Fatty acids that are extremely tive response, and capacity to recognize real¬
active biologic substances with effects on the ity and to communicate with others. Difficulty
cardiovascular, gastrointestinal, respiratory, coping with the everyday demands of life.
and central nervous system.
psychotropic medications Drugs affecting
prosthetic Pertaining to the replacement of the mind, used to treat mental disorders.
a missing part or augmentation of a deficient
ptosis Prolapse or drooping of upper eyelid
part by an artificial substitute.
from altered third cranial nerve function or
protective splinting of muscle [syn: reflex cervical portion of the autonomic nervous
splinting] A reflexive contraction of adjacent system.
muscles to prevent movement or stabilize the
pulpitis Inflammation of the tooth pulp tis¬
tissue, resulting from noxious stimuli of a
sue.
sensory field of a joint, soft tissue, or other
structure.
proteoglycan Mucopolysaccharides bound R
to protein chains in covalent complexes occur¬
ring in the extracellular matrix of connective radionuclides Atoms that disintegrate by
tissue. emission of electromagnetic radiation, used in
protrusion State of being thrust forward or radiographic studies.
projected, moving the mandible forward of radiograph See roentgenogram.
centric position.
Ramsay Hunt’s syndrome [syn: nervous in-
provocation test Diagnostic method of in¬ termedius neuralgia, geniculate neuralgia]
ducing an episode or aggravating a symptom See geniculate neuralgia.
by provoking a tissue or system.
range of motion [ROM] The range, mea¬
proximal [ant: distal] Close to or toward the sured in degrees of a circle, through which a
origin. joint can be extended of flexed. Commonly
pseudoankylosis [syn: fibrous ankylosis] See reported in millimeters rather than in degrees
ankylosis. with reference to the TMJ.

135
Glossary

rapid eye movement [REM] sleep Active lation of the mandible to the maxilla when the
stage of sleep, characterized by prominent patient is resting comfortably in an upright
increase in the variability of heart rate, respi¬ position, with the condyles in a neutral, un¬
ration, and blood pressure, all of which are strained position in the glenoid fossa and the
very regular and at low levels in non-REM mandibular musculature in a state of minimum
sleep. Phasic REM sleep includes periods of tonic contraction to maintain the posture.
rapid eye movements and muscle twitching. restorative Pertaining to the repair, recon¬
reciprocal clicking Clicking noise during struction, or replacement of the dentition.
mandibular opening and again during closing, retrodiscal tissue [syn: bilaminar zone] Loose
usually just before the teeth occlude. connective tissue rich in interstitial collagen
recruitment of muscle Greater or sustained fibers, adipose tissue, arteries, and a venous
muscle activity in response to prolonged or in¬ plexus. Attaches to the posterior band of the
creased stimulus to a given receptor or affer¬ articular disc, extending to the posterior cap¬
ent nerve causing increase in the number and sule of the TMJ, consisting of an elastic supe¬
size of active motor units of a given muscle. rior lamina and a ligamentous inferior lamina.
reducing disc [ant: nonreducing disc] Tem¬ retrognathia Facial disharmony in which
porary repositioning of the articular disc of one or both jaws, usually the mandible, are
the TMJ, approximating its normal functional posterior to normal in their craniofacial rela¬
relationship to the condyle during mandibular tionship.
movements.
retruded contact position [RCP] [syn-. cen¬
referred pain Heterotropic pain, felt in an tric relation, centric relation occlusion]
area other than the site of origin. Point of initial tooth contact when the mandi¬
reflex splinting of muscle [yyw: protective ble is guided into a hinged or retruded posi¬
splinting] Restricted or guarded joint move¬ tion on closure.
ment due to reflex rigidity of muscles as a review of systems [ROS] A system-by-sys-
means of avoiding pain caused by movement. tem review of body functions while complet¬
reflex sympathetic dystrophy [RSD] Spe¬ ing the health history and physical examina¬
cific group of painful disorders precipitated by tion.
an injury to peripheral tissues and sustained rheumatoid arthritis Chronic polyarticular
by neural mechanisms. Characterized by pro¬ erosive disease characterized by bilateral in¬
gressive autonomic dysfunction including volvement with proliferative synovitis, more
changes in cutaneous temperature, color, tex¬ common in women.
ture, and perspiration followed by trophic
changes in the skin, muscle, and bone. rheumatoid factor [RhF] Antigamma globu¬
lin antibodies found in the serum of most
Reiter’s syndrome Triad of arthritis, ure¬ patients with rheumatoid arthritis but also
thritis, and conjunctivitis that usually follows
occurs in a small percentage of apparently
nonspecific urethritis. Polyarticular and oc¬
normal individuals and with other collagen
curs predominately in men.
vascular diseases, chronic infections, and non-
relaxed position of mandible See rest posi¬ infectious diseases.
tion.
risk factor Factor that causes an individual or
remodeling Adaptive alteration of tissue form a group to be vulnerable to a disease or disor¬
secondary to functional demands through cel¬ der, increasing the incidence or severity of the
lular response of articular cartilage and sub¬ event.
chondral bone.
roentgenogram [syn: radiograph] Image pro¬
repositioning appliance Interocclusal appli¬ duced by x-rays striking a sensitized film after
ance that alters mandibular position. passing through a structure.
rest position of mandible [syn: relaxed posi¬ rostral [syn: superior, cephalic, ant: caudal]
tion, physiologic rest position] Postural re¬ Toward the head.

136
 Glossary

rotation To move about an axis. signs An objective clinical finding as per¬

rotation of condyle Part of mandibular open¬ ceived by an examiner.
ing path, starting at maximum intercuspation, single photon emission computed tomog¬
prior to translation or protrusive movement raphy [SPECT] Similar to a CT scan except
of the condyle. Can occur before, during, or that the radiation source is inside the area of
after condylar translation. Full mandibular interest rather than external.
ROM requires a combination of rotation and sinusitis Inflammation of the mucosa of the
translation. Rotation occurs primarily between paranasal sinuses.
condyle and the inferior surface of disc.
Sjogren’s syndrome Collagen disorder that
is characterized by atrophic changes of the
s lacrimal and salivary glands, resulting in dry¬
ness of the eyes and xerostomia, more com¬
mon in women and sometimes with associated
sagittal Anteroposterior direction.
rheumatoid arthritis.
sarcoidosis Chronic infectious disease of un¬
skeletal Pertaining to bone, cartilage, and
known cause marked by granulomatous le¬
supporting soft tissue.
sions in the skin, lymph nodes, salivary glands,
eyes, lungs, and bones. sleep apnea Breathing abnormality occur¬
ring during sleep, commonly related to upper
scintigraphy Process in which image is derived
airway obstruction but may be related to cen¬
from measuring a radioactive isotope, revealing
tral apnea, characterized by cessation of air¬
its concentration in a specific organ or tissue.
flow secondary to a lack of respiratory effort.
scintillation detector Device for measuring
soft tissue Skeletal tissue including muscles
radioactivity that relies on the emission of
and their fascial envelopes, tendons, tendon
light or ultraviolet radiation from a crystal
sheaths, ligaments, joint capsule, and bursae.
subjected to ionizing radiation.
somatic Pertaining to the body as distinct
scleroderma Skin disease in which thick¬
from the mind or psyche. Pertaining to the
ened, hard, rigid, and pigmented patches oc¬
structures of the body wall, eg, skeletal tissue
cur due to an increase in the connective tissue
in contrast to visceral structures.
of the corium and subcutaneous structures.
somatization Process of expressing a disturbed
scotoma Isolated area of varying size and
mental condition as a disturbed bodily func¬
shape, within the visual field, in which vision is
tion.
absent or depressed.
somatoform disorders Conditions in which
secondary gain Indirect benefit, usually ob¬ psychogenic symptoms resemble those of
tained through an illness or debility, that may physical disease. The physical symptoms sug¬
include monetary and disability benefits, per¬ gest the presence of a physical disorder but
sonal attentions, or escape from unpleasant there are no organic findings. The symptoms
situations and responsibilities, are not under voluntary control, unlike the
sedimentation rate See erythrocyte sedi¬ symptoms occurring in factitious disorders.
mentation rate. The DSM-IIIR recognizes five disorders in
sensory nerve Afferent fibers that conduct this group: body dvsmorphic disorder, con¬
sensory impulses from the periphery of the version disorder, hypochondriasis, somatiza¬
body to the brain or spinal cord. tion disorder, somatoform pain disorder.

serology Study of blood serum or exudate, somatopsychic Pertaining to both body and
mind, denoting a physical disorder that pro¬
shingles [unfavorable term] See postherpetic
duces mental symptoms,
neuralgia.
sonography Recording of sound through the
sialography Radiographic technique in which
use of ultrasonography,
a salivary gland is filmed after an opaque
substance is injected into its duct. space occupying lesion Abnormal mass or

137
Glossary

tumor that distends adjacent tissue as it en¬ Still’s disease Seronegative arthritis, often
larges. accompanied by fever and rash, representing
spasm of muscle Involuntary, sudden move¬ 70% of cases of arthritis that begin before the
ment or convulsive muscle contraction. Spasm age of 16 years.
may be clonic (characterized by alternating stomatognathic Denoting the mouth and jaws
contraction and relaxation), tonic (sustained), collectively.
or tetanic (prolonged, sustained involuntary stress Sum of the biologic reactions to any
contraction without interruption). adverse stimulus—physical, mental, emotion¬
sphenoid bone Compound, unpaired wedge- al, internal, or external —that tend to disturb
shaped bone at the base of the cranium sep¬ the homeostasis of an organism. When the
arating the frontal and ethmoid bones and reactions are inappropriate, they may lead to
maxillas frontally from the temporal and oc¬ disease states.
cipital bones at the back. stressor Cause of stress, any factor that dis¬
spinal accessory cranial nerve [CN 11] turbs homeostasis.
Motor nerve comprised of cranial and spinal subcondylar osteotomy [syn-. condylotomy]
branches that supply the trapezius, sterno- Surgical section beneath or below the condy¬
mastoid muscles, and pharynx. lar head.
splint [syn: orthosis] Rigid or flexible ap¬ subluxation Partial or incomplete disloca¬
pliance or device to immobilize, support, pro¬ tion in which the joint surfaces remain in
tect, or correct injured, displaced, or deformed partial contact. Relaxation or stretching of the
structures. capsule and ligaments of the temporoman¬
splinting of muscle Reducing motion of the dibular joint that results in popping noise
painful part as protection against pain. during movement.
spondylarthropathy Disease of the joints of submandibular Situated below the mandible.
the spine or intervertebral articulations. superior [syn: rostral, ant: inferior] Situated
spontaneous remission Resolution of signs above or upward, nearer the vertex.
or symptoms of disease occurring unaided, superior laryngeal neuralgia Condition
without treatment. characterized by paroxysmal, unilateral sub¬
spray and stretch Physical therapy tech¬ mandibular pain that may radiate to the ear,
nique utilizing vapocoolant spray followed by eye or shoulder, a distribution indistinguish¬
passive muscle stretch. able from glossopharyngeal neuralgia. The
stabilization appliance Intraoral appliance superior laryngeal nerve is a branch of the
utilized to control joint or muscle symptoms vagus nerve [CN X] and innervates the cri¬
during period of time required for mandibular cothyroid muscle of the larynx.
position or a temporomandibular joint disor¬ symmetry Correspondence in size, shape, and
der to stabilize. relative position on opposite sides of the
body.
standard of care Established model or guide¬
lines that identify the process and anticipated sympathectomy [syn: neurolysis] Excision
outcome of care in a given community or or interruption of some portion of the sympa¬
setting. thetic nervous pathway.
stellate ganglion Star shaped ganglion lo¬ sympathetic nervous system Division of
cated between the transverse process of the the autonomic nervous system originating in
seventh cervical vertebra and the head of the the thoracic and first few lumbar spinal cord
first rib with postganglionic fibers running to segments. System prepares for “fight or flight”
the carotid, middle ear, salivary and lacrimal reaction to stress.
glands, and the ciliary ganglion via cranial symptoms Indication of a disease as per¬
nerves IX, X, and XI, and the upper three ceived by a patient. A subjective symptom is
cervical nerves. one perceptible only to the patient, such as

138
 Glossary

vertigo. An objective symptom is perceptible temporal Pertaining to the temples.

to patient and others.
temporal arteritis [unfavorable term] See gi¬
synapse Junction between the processes of ant cell arteritis, cranial arteritis.
two neurons or a neuron and an effector or¬
temporal bone Paired, large bone forming
gan.
the lower part of the cranium and consisting of
syndrome Grouping of symptoms or signs of four portions —the mastoid, the squama, the
disorder function relating to one another by petrous, and the tympanic.
means of some anatomic, physiologic, or bio¬ temporomandibular [TM] See temporo¬
chemical peculiarity. Combination of symp¬ mandibular joint.
toms resulting from a single cause.
temporomandibular disorder [TMD] Col¬
synostosis [syn: bony ankylosis] Normal or lective term embracing a number of clinical
abnormal fusion of adjacent bones by osseous problems that involve the masticatory mus¬
material. cles, the temporomandibular joint, or both.
synovial Containing a clear, thick lubricating Common patient complaints include jawache,
fluid in a joint, bursa, or tendon sheath se¬ headache, earache, and face pain and there
creted by the membrane lining the cavity or may be associated limited or asymmetric jaw
sheath. movement and joint sounds.
synovial chondromatosis Rare condition in temporomandibular joint [TMJ] Paired joint,
which cartilage nodules develop in the con¬ articulating the mandibular condyle, articular
nective tissue below the synovial membranes. disc, and squamous portion of the temporal
The cartilage foci on the surface of the syn¬ bone, capable of gliding and hinge move¬
ovium may detach and result in loose bodies ments.
within the joint. tendomyositis Inflammatory condition of a
synovial fluid Produced by the synovium to tendon and its associated muscle.
bathe the tendons, articular surfaces, and at¬ tendon Strong, flexible, and inelastic fibrous
tachment tissue to provide nutrition and re¬ band of tissue attaching muscle to bone.
duce friction.
tendinitis Inflammatory condition of a ten¬
synovial osteochondromatosis See synovial don, usually resulting from strain.
chondromatosis.
tension-type headache Head pain devoid of
synovitis Inflammation of the synovial lining migrainous characteristics. Usually bilateral
related to infection. Immunologic condition or and historically associated with muscle ten¬
secondary to cartilage degeneration or trauma. sion and occurring in relationship to emotion¬
synovium Synovial membrane. al conflict.
systemic disease Disease affecting the entire thermography Graphic representation of
organism as distinguished from any of its indi¬ the skin temperature variations between adja¬
vidual parts. cent tissues or between the same area on two
sides of the body.
systemic lupus erythematosus [SLE] Chron¬
ic inflammatory condition affecting many or¬ tic douloureux See trigeminal neuralgia.
gan systems, including lesions of the skin, vas¬ time-contingent basis Prescription of med¬
culitis, and renal and neurologic involvement. ication or other treatment on a regular, time-
related basis, rather than on the patient’s per¬
ceived need for medication or treatment be¬
T cause of pain severity.
tinnitus Subjective ringing, buzzing, or
tardive dyskinesia Involuntary, repetitious
roaring sound in the ear.
movements of the muscles of the face, the
limbs, and the trunk, most often related to the tomography Radiographic technique for
use of phenothiazine medications. representing a detailed cross section at a pre-

139
Glossary

determined depth and thickness of cut. Ac¬ trismus Limited mouth opening resulting
complished by moving the film and the x-ray from tonic contraction of the muscles of mas¬
source in opposite directions during the expo¬ tication that may occur with infection, en¬
sure, blurring the structures in front of and cephalitis, inflammation of salivary glands, or
behind the area of interest. tetanus.
Towne’s radiograph Fronto-occipital plain trophic Pertaining to nutrition or nourish¬
film projection of the skull. ment of a tissue.
transcranial radiograph Plain film projec¬ tubercle [syn: eminence] Small rounded ele¬
tion of the contralateral mandibular condyle vation on a bone.
from a superior angulation.
tumor See neoplasm.
transcutaneous electrical nerve stimulation
translation [TENS] Low voltage stimulation
used as therapy. u
translation of condyle [syn: gliding] Mandi¬
bular movement associated with protrusive or ultrasonography Delineation of structures
forward movement of the condyle. Can occur by measurement of the reflection or transmis¬
before, during, or after condylar rotation. Pro¬ sion of high frequency ultrasonic waves at
trusion or lateral excursion can consists of interfaces between adjacent structures.
pure translation with no rotation of mandible.
ultrasound Sound waves of frequency higher
In normal TMJ the movement occurs primar¬
than the range audible to the human ear or
ily between the superior aspect of the disc and
above 20,000 vibrations per second (Hz).
the articular tubercle.
traumatic arthritis Arthritis that is the di¬ unilateral [ant: bilateral] Occurring on one
side only.
rect result of an injury, affecting normal joints
or aggravating existing joint disease or de¬ urate crystals Salt of uric acid that may be
rangement. deposited in gouty joints.
Treacher-Collins syndrome Inherited dis¬
order characterized by mandibular and facial
dysostosis. V
trigeminal cranial nerve [CN V] Somato¬
vagus cranial nerve [CN X] Afferent and
sensory innervation for structures embryo-
efferent mixed nerve that exits via the jugular
logically derived from the first brachial arch
foramen and sends parasympathetic branches
including the oral cavity and the face. Innerva¬
to the viscera as well as the muscles of the
tion by three main branches —the opthalmic
pharynx and larynx.
(Vj), maxillary (V2), and mandibular (V3)
branches. The motor fibers of this mixed nerve vapocoolant spray Spray that acts as a coun¬
principally supply the muscles of mastication terirritant because of the extreme coldness of
as well as the mylohyoid, anterior belly of the the solution on evaporation when applied over
digastric, the tensor veli palatini, and the ten¬ the skin.
or tympani muscles.
vascular Pertaining to a blood vessel.
trigeminal neuralgia [syn: tic douloureux]
vasculitis Inflammatory condition of a blood
Disorder of the sensory divisions of the tri¬
vessel.
geminal nerve, characterized by recurrent par¬
oxysms of sharp, stabbing pains in the distribu¬ vertical dimension of occlusion [VDO] The
tion of one or more branches of the nerve. vertical height or position of the mandible
trigger point Irritable focus in a soft tissue with the teeth in occlusion as measured rela¬
structure, most commonly muscle, that when tive to the facial skeleton.
stimulated elicits referred pain. vertigo Sensation of irregular or whirling

140
 Glossary

motions, either of oneself or of external ob¬ X

jects, disturbance of equilibrium.
xerostomia Dryness of the mouth.

w
whiplash [unfavorable term] See flexion-
extension injury.
z
working occlusal contact Tooth contact on zygoma Area formed by the union of the
the ipsilateral side during guided lateral excur¬ zygomatic bone and the zygomatic process of
sive movement of the mandible. the temporal bone and the maxillary bone.

141
.
-