- Email: [email protected]
Clinical evaluation of two hundred patients with temporomandibular joint syndrome
TEMPOROMANDIBULAR SECTION
JOINT
l
OCCLUSION
EDITOR
GEORGE A. ZARB
Clinical evaluation of two hundred patients with temporomandibular joint syndrome Harold
Gelb, D.M.D.,
and Ira Bernstein,
D.M.D.
New York, N.Y.
T
he population in this study consisted of 200 patients referred to a temporomandibular joint (TM J) specialty practice by dentists, physicians, and other health professionals. The referrals were based on diagnoses of craniomandibular disorders with a variety of chief complaints, including headache, facial pain, tinnitus, vertigo, and clicking or popping joint noises. This article describes how muscle disorders related to craniomandibular dysfunction can have effects throughout the body. Dentists must therefore embrace a much broader view of their patients since the consequences of their treatment, or its omission, can have ramifications far greater than traditional concepts of dental practice have previously realized. CURRENT
CONCEPTS
The last several years have seen a great increase in TM J-related textbooks, continuing education courses, professional journal articles, and public media attention. This has resulted in a significant increase in professional and lay awareness of TMJ disorders. However, it has also produced some confusion as different authors and lecturers have placed varying degrees of emphasis on different etiologic factors. Consequently, terminology and treatment procedures have varied according to the clinician’s concept of etiology. Theories
of etiologic
concepts
De Boever’ organizes these etiologic concepts into the following five basic theories. Mechanical displacement theory. This theory includes the TMJ theories of Costen and others,3a4 who felt that the distal displacement of the condyles after loss of posterior teeth caused impingement on various structures in the region with resultant symptoms. Sicher’ and others later showed that the anatomic basis of Costen’s syndrome was not valid. However, mandibular overclosure (reduced vertical relation of occlusion) as an etiologic factor has remained prevalent in many current concepts. The position of the condyle is dictated by the
234
FEBRUARY
1983
VOLUME
49
NUMBER
2
occlusion. When occlusal problems result from missing teeth or prematurities (deflective occlusal contacts), or insufficient eruption of the posterior teeth cause a deviation of the condyles from their normal centric position, the muscles then become involved, creating dysfunction and pain. The mechanical displacement group relies heavily on the use of radiographs and diagnostic casts for diagnosis and the determination of proper mandibular position. Muscle theory. Muscle tension increases and results in pain and spasm as a manifestation of Selye’s General Adaptation syndrome when the stressesof everyday life do not have an adequate outlet or release. Muscles are primarily involved as part of a generalized rather than localized reaction. Psychologic theory. This group has several diverse thoughts with published studies by various authors producing conflicting results. However, it is generally agreed that emotional and behavioral factors play some role in TM J disorders, either as modifying or initiating factors. Some authors, such as Moulton” and Lupton,’ feel that psychologic factors are capable of initiating TM J pain-dysfunction. The patient is psychologically predisposed or pain prone with occlusal changes or trauma merely serving as trigger factors. Others, such as Mozak,” feel that psychologic factors found in TMJ patients are a result of the patients’ living with long-term, constant pain resulting from occlusal disharmonies and/or jaw imbalance. Obviously, treatment varies depending on whether the clinician subscribes to the concept of eliminating the psychologic factors first or initially treating the occlusion. Neuromuscular theory. The proponents of this theory consider the occlusion as the major influence on the functional remodeling and development of arthrosis in the joint. It is responsible for causing parafunctional habits such as grinding or clenching, providing that a background of psychic tension, stress, or anxiety is present. Laskin9 believes that the reverse is true. He
0022-3913/83/020234
+ 10$01.00/00
1983 The C. V. Mosby Co.
TMJ SYNDROME
believes that emotional disturbances trigger the parafunctional habits, which then lead to emotional interferences. In either instance emotional factors account prominently as etiologic factors. Psychophysiologic theory. In this theory masticatory muscle spasm is considered the main etiologic factor in causing pain and dysfunction. Overextension, overcontraction, or muscle fatigue may initiate the spasm and result in occlusal disharmonies and pathologic joint changes. This group stresses that occlusal changes occur in response to or as a result of muscle spasm.
from one person to another.“” General health, emotional status and other predisposing factors must be considered in their influence on this adaptive capacity. This accounts for severe malocclusions in some persons not causing symptoms, while the slightest deviation in others results in extreme discomfort. Because of the multicausal etiology, symptoms are understandably varied. Clinically, this becomes more obvious when one seesthe potential of many different muscles throughout the body become involved in the myospasm-pain-spasm cycle. DIAGNOSIS
ETIOLOGY In its recent position article, the American Academy of Craniomandibular Disorders emphasized the multicausal etiology of TMJ disorders.‘O The etiologic factors were divided into predisposing, precipitating, and perpetuating groups. Predisposingfactors include structural discrepancies, psychologic disorders, metabolic disorders, and pathologic or behavioral factors. Precipitating (triggering) factors include trauma, an adverse stress response, iatrogenic problems, infection, and idiopathic factors. Perpetuating (sustaining) factors are usually manifested by the myospasm-pain-spasm cycle and can be related to any one or a combination of the predisposing or precipitating factors. Gelb and Arnold” previously stated that the pain associated with TMJ disturbances has been attributed mainly to the masticatory muscles. The pain and limited activity are associated with “trigger areas” within the muscles. These are small areas in the myofascial structures which are hypersensitive to stretch and give rise to muscle spasm with referred pain. “it has been stated that excessive opening of the mouth, as occurs in a yawn or during prolonged dental visits, sudden pain in the teeth, or severe pain in the area of the mouth, can evoke a compensating extended contraction similar to the action of a stretch reflex of other skeletal muscles. This would result in a prolonged tonic spasm of the jaw muscle, such as found in bruxism. Since there is no relaxation, the resulting dysfunction of the TM J produces more pain, leading to a vicious cycle. “We must always bear in mind that malposition of the .jaw does not necessarily result in pain or other disturbances.” This is a predisposing factor. “Whether or not such conditions occur depends not only on the presence of abnormal stressesor strains, but also on the adaptive capacity of the person. This quality varies
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Before diagnosing a TMJ disorder, a prior medical consultation to rule out other causes of orofaeial pain is necessary. Cardiovascular; neurologic; arthritic or systemic disease; hormonal imbalance; drug side-effects; and local ear, nose, throat, sinus. or cervical spine pathology should be considered. A thorough history is imperative. Patients will often give a diagnosis and indicate the proper approach to treatment. A clinician who listens closely will gain insight not only into diagnosis and treatment but the prognosis as well as the patients’ emotional needs and expectations in relation to their illness are often manifested. It also gives the clinician an opportunity to develop a personal rapport with the patient. A good listener imparts a sense of faith and hope to patients. APPROACH TO DIAGNOSIS CRANIOCERVICAL-MANDIBULAR SYNDROME”
OF THE
I. Preliminary examination A. Chief complaint 1. Pain: date of onset, location unilateral or bilateral, frequency, duration, quality, tr lgger devices, and factors alleviating pain 2. Nonpain: date of onset, location, unilateral or bilateral, frequency, duration, and quality B. Medical history: ruling out etiologic factors previous1y mentioned and evaluating medical consultation data (otolaryngologic, ophthalmic, neurologic, orthopedic, psychiatric, and endocrinologic) C. Dental history 1, Evaluation of previous dental experiences 2. Previous TMJ treatment 3. Pain in specific teeth 4. Oral symptoms other than pain: bruxism,
235
GELB AND
muscle fatigue, gingival bleeding and swelling, and facial swelling D. Personal history and psychologic evaluation: marital status (past and present), children, in-laws, parents, sickness in the family, working habits and environment, commuting to and from work, sleeping habits, and gastrointestinal history-duodenal ulcers, colitis, nervous stomach (Our philosophy is “LSMFT”listening sympathetically makes fine therapy.) E. Radiographic examination 1. Intraoral: minimum of 14 periapical radiographs and four bite-wings 2. Extraoral a. Right and left lateral temporomandibular radiographs: closed, rest position, and wide open b. Right and left anteroposterior temporomandibular radiographs, if required c. Cephalometric radiographs, if required d. Tomograms, if required II. Clinical examination A. Facial symmetry B. Relation of midlines: open and closed showing mandibular deviation (generally open to affected side) C. Intraoral examination: charting of mouth for caries, various types of prostheses and restorations, missing teeth, extruded teeth, lingually and buccally displaced teeth D. Deviate swallowing habits 1. Incisal thrust 2. Full fan thrust: molar to molar 3. Bimaxillary protrusion thrust 4. Class III thrust a. Pseudo b. Skeletal 5. Open-bite thrust 6. Closed-bite thrust 7. Posterior unilateral thrust 8. Posterior bilateral thrust E. Three-dimensional analysis of diagnostic casts 1. Midsagittal 2. Coronal 3. Horizontal F. Intraoral functional occlusal analysis: centric occlusion, centric relation, vertical dimension, working and balancing side interferences, protrusive interferences
236
BERNSTEIN
G. Palpation: painful joints; coronoid processes; tenderness in muscles of mastication, head, neck, shoulders, and back; anterior wall tenderness (by placing small fingers into external auditory meatuses and pressing forward) H. Auscultation: crepitation, rubbing, sagittal opening click, sagittal closing click I. Pulp test for vitality or percussion testing of various teeth J. Applied kinesiology (testing procedures) K. Nutritional workup 1. Hair analysis 2. Urinalysis 3. Blood analysis
TREATMENT The initial step in treatment is positive assurance that the patient can be helped. Many patients have been in chronic pain for some time. Some are cancerphobic. Most have visited several physicians to find help for their condition. A brief explanation of the mechanism involved in the cause of their symptoms may in itself produce some relief, as some of the fear and resultant stress (an etiologic factor) are diminished. This may indeed be the most important step toward a successful result.‘3p’4 Actual therapy begins with an attempt to alleviate some of the pain. Initially, moist heat, soft diet, ultrasonic therapy, electrogalvanic stimulation, vapocoolant spray with movement, and vinyl resin night guard prostheses are used to palliate the patient. The next step in therapy is to reposition the mandibular condyles in their respective glenoid fossae so that optimal neuromuscular balance is obtained. A mandibular acrylic resin prosthesis that covers the occlusal surfaces of the posterior teeth is selectively adjusted over a period of time as the muscles accommodate to the new mandibular position. Where sufficient interocclusal distance is present to properly position the condyles in their fossae, selective occlusal equilibration of the natural dentition may be indicated. This is an irreversible procedure and should only be considered by clincians experienced in proper mandibular positioning and equilibration techniques. If not done with extreme care, this procedure may iatrogenically cause a malposition of the condyles and can result in an exacerbation of existing symptoms or the initiation of symptoms where none existed previously. Palpable trigger areas are injected with lidocaine without vasoconstrictors. Where indicated, patients are
FEBRUARY
1983
VOLUME
49
NUMBER
2
fMI
SYNDROME
Table I. Age groupings
of symptoms
-----__-.__-Age
group --
--_~
--I___--.------.~.
10-20
21-30
31-40
41-50
Men Women
3 15
20 34
14 37
Muscles in spasm Internal pterygoids External pterygoids Masseters ~Tcmporal Sternocletdomastoid Posterior cervicals Mylohyoids Trape’rius Others
15 17 16 15 16 15 12 16 17
41 44 50 44 46 45 34 44 52
41 46 44 42 45 43 35 45 50
28 31 28 25 29 27 27 29 33
3 2
15 9
24 19
IO 5
6 16
30 54
36 51
23 33
-, / 21
8 13
9
29
35
19
I:!
10
14 13 10 12
19 9 9 29
9 6 9 17
‘2 ‘7 5 9
h 2 5 5
13 20 43
30 28 43
12 17 22
11 13 14
6 6 5
Ear symptoms rinnitus Heartng Loss Temporomandibular Clicknrg Pain
Head pain Facial Occipital Cervical ‘Temporal Vertigo Stuffiness Popping or whoosing noise on opening or closing
3 6 10
_--_.-.
61-70
6
8
28
16
1 I2
lb
11
19 22
12 11 10 10 IO 9
lb
18 17 lb lb
OF PROSTHETIC
DENTISTRY
71-80
Total
10 12
21
9
~--
given specific exercises and treated with physical therapy modalities. Biofeedback, hypnosis, acupuncture, nutritional counseling, and myofunctional therapy are some of the adjunctive therapies commonly used. Because of its multifactorial etiology, other disciplines such as cranial osteopathy, chiropractic kinesiology, endocrinology, orthopedics, physiatrics, and psychiatry may be called on to play an active role in the treatment of the TMJ patient. Dnce the patient has had several months relatively free from symptoms, the final stage of treatment may begin. The jaw position is stabilized by reproducing the occlusion created by the prosthesis. This is done by allowing eruption of the teeth into the same position using functional orthodontics, removable partial den-
THE JOURNAL
51-60
joint
Bruxism
~~..~- _
b 5
-.--...
...-
tures that overlay the teeth, fixed restorations, or combinations of these procedures. COMMENTS
ON FINDINGS
This study is based on the findings at the initial examination of 200 patients in a TMJ specialty practice. All patients were examined by the same clinician, Dr. Harold Gelb. The patients were divided into seven age groups, each spanning 10 years (Table I). Almost 70% (69.5) of the patients were between 21 and 50 years of age. The ratio of women to men in this group was 2.7:1. Weinberg and Lager” had the same proportion of the sexes in a recent study of a similar but smaller private practice population. Although many patients described more than one
237
GELB AND
DIAGNOSTIC
BERNSTEIN
FINDINGS
CHIEF COMPLAINTS pain No % A 57 28.5
Headache No % A 83 41.5
TMJ
Facial pain No. % 18 9
Neck pain No % A 22 11
Ear pain No % A 9 4.5
Click No. 6 3
‘I’irmitus No. 21
Other No % L3 1.5
REFERRALS Dentist No % 123
Physician No % A 24 12
Other health professionals No % A 16 8
Other patients % LNo 28 14
Media No. 9 4.5
ILIAC CREST PAIN/TENDERNESS Right only 12
Left only 123
GASTROCNEMIUS
Roth -iii
MUSCLE PAIN
PREVIOUS TMJ THERAPY Drugs 106
Surgery 12
Equilibration 14
Appliance 38
Restorations or prosthesis 18
Chiropractor 12
Other 38
Combination 69
CHRONIC ILLNESS Hysterectomy 1
Thyroid 38
Surgery 126
Psychologic 69
chief complaint, only their most severe single complaint was recorded for purposes of this study. The chart above shows that 70% of the patients had a chief complaint of either headache (41.5%) or TM J pain (28.5%). Neck pain (11%) and facial pain (9%) were the next most common chief complaints. The remaining patients had chief complaints of ear pain (4.5%), clicking (3%), and tinnitus (1%). Back pain, an uncosmetic facial appearance, and facial tic were also cited as chief complaints. The great majority of the referrals came from dentists (61.5%). Patients who had been previously treated for TM J disorders referred 14% of the patients. Apparently this patient group had become “TMJ missionaries” diagnosing friends and relatives and accounting for more referrals than physicians (12%) and other health professionals (8%). This reinforces the importance of educating patients under treatment as they become a significant source of new patients. The media, including radio, television, newspapers, and magazines, were cited by 4.5% of the patients as their chief source of information in seeking treatment. Some form of previous therapy was the chief com-
238
ENT Ti-
Orthopedist 105
Combination 134
plaint of 129 patients (64.5%). Thirty-four and five tenths percent had attempted two or more different modes of therapy. Drug therapy, including aspirin, narcotic analgesics, tranquilizers, mood elevators, muscle relaxants, and vitamins, was used by 53% of the patients. Nineteen percent of the patients had been treated with some type of intraoral prosthesis. Nine percent had either new dentures or other prostheses fabricated or had undergone fixed partial denture rehabilitation in attempts to alleviate their symptoms. Equilibration had been performed unsuccessfully in 7% of the patients. For some patients this last procedure actually brought on additional symptoms or exacerbated existing symptoms. Six percent of the patients had some form of surgery. This included third molar and “infected” tooth extractions, TM J surgery, and “jaw” surgery; and one patient underwent removal of a cervical lymph node. Another 6% had been treated by chiropractors. Other forms of treatment included root canal therapy, physical therapy, injections into the TMJ, muscle trigger point injections, allergy treatments, psychiatric counseling, acupuncture, biofeedback, hypnosis, nutritional counseling, myofunctional
FEBRUARY
1983
VOLUME
49
NUMBER
2
therapy, t ranscutaneous electrical nerve stimulation, and the use of a cervical collar. One patient even had intermaxillary fixation to keep her from opening her mouth for 6 weeks. The broad range of treatment modalities indicated the need for interdisciplinary education and communication as patiems apparently seek a variety of health professionals for treatment. Rocabado’!’ stated that degenerative changes as a result of traumatic in,juries (such as whiplash) to the skeletal system may not become apparent until at least 6 to 8 months after the injury. Hughes” reported that traumatic injuries, no matter how long standing, may play some contributing role in producing symptoms. In the 5-year period preceding this examination, 46 patients had some type of traumatic injury to the skeletal system, including whiplash, blows to the head or face, and broken bones. Ninety-nine patients had a history of trauma more than 5 years previously. The pauents in this study were divided into five groups based on their medical histories: 180 patients (90%) had a history of either prior surgical procedures (63%); orthopedic treatment (52.5%) ear, nose, and throat (ENT) treatment (40.5%); psychiatric counseling (34.5%); or clinical signs or symptoms of thyroid dysfunction (19Yo). One patient had had a hysterectomy. Sixty-seven percent had indicated a positive history in two or more of the five groups. Are these patients suffering from TMJ syndrome because they are predisposed to illness? Or is the reverse a possibility? Does TMJ syndrome make an individual prone to illness? In an article on chronic illness profiles Smith’” states that “there seems to be a direct relationship between the health of the patients and their occlusion.” He stated that when the malocclusion and jaw position are corrected, the patient’s general health improves. Fonder’” reported that TM J malposition results in a “dental distress syndrome” that manifests itself in pathology in other parts of the body. He stated: “Through the myofascial trigger mechanism, referred pain may occur in many areas of the head and neck, as well as in more distant parts of the body. All these factors are sources of stress in the patient, capable of initiating the General Adaptation Syndrome. If they persist, or if they are compounded by further stress factors, they can produce diseases of adaptation anywhere in the body.” The muscles most frequently in spasm on palpation were the masseter (88%), external pterygoid (87%), and sternocleidomastoid muscles (84%). Almost all patients examined (95.5’70) had some involvement of
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Table II. Condition
of dentition No. of patients
Full complement of teeth With fixed partial (dentures Partially edentulous with no replacement With some fixed restorations Complete maxillary and complete mandl bular dentures
Removable partial dentures Complete maxillary and removable mandibular partial denture
nonmasticatory muscles listed under the grouping “other.” These included deltoid; upper, middle, and lower back; and pectoral and gastrocnemius muscles (Table I). Although the muscles just mentioned were most commonly involved, the temporal, trapezius, posterior cervical, and internal pterygoid muscles each exhibited spasm in a large number of the patients. Ear symptoms were common complamts. Ninetyfive patients were aware of a sensation of stuffiness in one or both ears. Hearing loss was mentioned by 49 patients, tinnitus, by 71 patients, and vertigo by 79 patients. In discussing the otomandibular syndrome Arlen”’ blames spasm of the tensor veli palatini and tensor tympani muscles for producing the above symptoms. He feels that this spasm occurs as an extension of the chronic strain and resultant spasm of the various masticatory muscles involved in TMJ dysfunction as they share anatomic and functional proximity and nerve innervation. Popping or whooshing noises on opening or closing the jaws were reported by 142 patients. One hundred seven patients exhibited some type of joint click. Forty-nine patients exhibited reciprocal opening and closing clicks on the same side. Twenty patients had single-sided opening clicks only, and 28 had singlesided closing clicks only. Three patients had bilateral opening clicks, and seven had bilateral closing clicks. Pain in the TMJ on preauricular palpation was elicited in 194 patients. Palpation through the external auditory meatus elicited pain in 152 patients. Of this number 114 ha.d unilateral anterior wall tenderness, and 38 had bilateral pain. According to Laskin’s’ criteria for differentiating TM J arthritis from myofascial pain-dysfunction, this factor (anterior wall tender-
239
GELB AND
Table III. Postural patterns and other findings No. of
patients Deviant
swallowing
144
pattern
Clicks Click on opening and closing Unilateral click on opening Unilateral click on closing Bilateral opening click Bilateral closing click
49 20 28 2 7
Anterior wall tenderness Both ears Right ear Left ear One side only
38 82 108 114
High eye and low hip on same side Right side Left side
147 3
Previous orthodontic therapy Orthodontics with extractions
43 15
(premolar)
Previous history of trauma Within past 5 years
46 99 24
Five years or longer Had both Midline deviation on same side as high eye Closed-right and left Open-right and left
65 82
High eye and anterior same side Yes No
86 62
wall tenderness
on
BERNSTEIN
swallowing pattern may also be a causative factor,” and 144 patients had some form of this pattern. Pressure from the tongue, cheeks, or lips can exert forces that inhibit vertical growth of the alveolus and suppress or modify tooth eruption and position. In this study a mandibular opening of 40 mm or more was considered normal. Seventy-three percent of the patients had an opening of 40 mm or greater. The average opening of all 200 patients was 49.5 mm. Most of the patients exhibited some facial asymmetries. When these findings were correlated with some of the other data, some interesting observations were made. One hundred sixty-nine patients had a right eye that was higher than the left eye. Of this number 147 had one hip lower than the other, also on the right side. Only three patients had this same-sided high eye-low lip correlation on the left side. The high number of patients with this right-sided correlation appears to be significant and merits further study from a postural standpoint. One hundred fifty-four patients had tenderness on palpation of the iliac crests. In the great majority (123) pain was elicited in the left iliac crest only. Ninteen patients had pain in both right and left iliac crests. Significant tenderness to palpation was even found in the gastrocnemius muscles, where 102 patients had tenderness on the right side and 16 on the left side. Sixteen patients had tenderness on both sides. It appears that there is a significant postural pattern in many of the patients we examined. A high right eye, lower (but less tender) right hip, and tender right calf appeared in a significant number of this population (Table III).
DISCUSSION ness) alonewould place 76% of the patients in the other categories. Historically, TMJ problems have been associated with a loss of posterior occlusal support or “collapsed bite” resulting from missing teeth. Yet, 110 of the patients had a full complement of natural teeth. An additional 38 had a full complement as a result of fixed partial denture replacements. Although the problem may be an insufficient vertical dimension of occlusion, it is more likely to be a result of unrealized vertical dimension rather than lost vertical dimension (Table 11). Among the factors partially responsible in preventing the alveolar process and teeth from reaching their full growth and eruption potentials are bruxism and clenching. 21 One hundred sixteen patients had an awareness of bruxing or clenching habits. A deviant
240
It is rare to find but a single muscle in spasm, as another muscle will in some way have to compensate for the resultant change in skeletal equilibrium. If one muscle group becomes tense, then adjacent muscles are in tension. In effect a chain or sequence with the involvement of many muscles is created. A ripplelike effect on muscles throughout the entire body takes place. Our results indicated that no one muscle of mastication greatly outnumbers the others in degree of involvement. Many of the muscles of mastication were found to be tender and in spasm in a large percent of the patients. The fact that almost all patients had involvement of other muscles throughout the body can also be explained by this chain or sequence theory as described by Kraus.23 This ripple effect appears to be greater in patients with endocrine disorders or nutritional defi-
FEBRUARY
1983
VOLUME
49
NUMBER
2
TMJ SYNDROME
ciencies as these conditions increase the susceptibility of muscles to spasm and its propagation. Endocrine imbalance may predispose the patient to the production of trigger points, and even borderline hypothyroidism or estrogen deficiencies can be significant contributing factors in muscle problems. 23However, the mechanism for the cause of pain and spasm due to hormonal deficiency is not fully understood.24 Bone will yield to muscle, and form will follow function; therefore, prolonged spasm of a chain of muscles may cause generalized postural abnormalities and asymmetries. The patients examined commonly had the right eyebrow higher than the left, the right eye higher and larger, the lips turned up to the right side, the right ear tending to be higher, and the midline of the incisors frequently off to one side. The facial high side often corresponded with a greater deficiency in the vertical dimension of occlusion on that side as corroborated by palpation through the external auditory meatus, TM J radiographs, and phonetics. If one were to stand in front of the patient and view the planes of occlusion of the posterior quadrants, the mandibular left side would generally be higher than the right. The shoulder is generally lower on the right side than on the left side, as well as the level of the breasts and hips. It will usually be found that the leg is slightly shorter on this side as well. The midline almost always shifts into the quadrant with the greatest deficiency of vertical height. The condyle on that side is now more pronounced when palpated through the external auditory meatus, and it may even exhibit a click on closing. Regarding the problem of postural maintenance, consider the shoulder girdle, clavicula, sternum, and scapula as constituting a fixed base of operations. The head may be said to virtually teeter on the atlantooccipital joint. Because the center of gravity of the head lies in front of the occipital condyles, it naturally follows that definite force must be applied to hold the head erect, a force that is provided by the large muscles of the neck. Several groups of muscles are attached directly or indirectly to the anterior part of the head; their functions tend to add to the force of gravity and thus to the load on the posterior cervical muscles, thereby requiring greater bulk and strength on their part. The most important of these anterior cranial muscles are the masticatory and supra- and infrahyoid groups. They constitute a chain with the mandible and hyoid bone to which they are attached. They join the cranium to the shoulder girdle. In ideal posture a plumb line should pass (on
THE JOURNAL
OF PROSTHETIC
DENTISTRY
1
2
Fig. 1. 1, Power balancing power through opposed muscle centers (m.c.). Muscle centers coordinate crossline of gravity in movement when bones are balanced. 2, Bones opposing bones. When bones are unbalanced, weight opposes weight across line of gravity, thus throwing muscle centers under tension. (From Gelb, H.: Clinical Management of Head, Neck, and TMJ Pain and Dysfunction. Philadelphia, 1977, W. 8. Saunders Co.)
profile) through the tragus of the ear, the tip of the shoulder, the hip joint, posterior to the patelia of the knee joint, and anterior to the ankle bone (Fig. l).‘” However, in most TM J patients the head is forward of this plumb line. The head is in hyperextension in response to contracted masseter and sternomastoid muscles to keep the bipupil line horizontal with the ground. The body will shift so that it can maintain
the
pupils in a horizontal plane.lh The position of the head in space therefore materially affects the posture of the body. Whenever mandibular-neuromuscular tension is
241
GELB AND
present, the mandible’s abnormal position affects the normal physiologic posture of the cervical vertebrae, resulting in abnormal strains on the muscles of the upper torso, which affect the posture of the head, neck, and shoulder girdle. Kraus26 has stated that “muscle tension is probably the most frequent single or central cause of muscular. derangement of the TMJ. This is equally true of a history of non-traumatic or post traumatic orthopedic difficulties. Muscle tension is unfortunately built into our civilized and mechanized way of life. It does not necessarily have to be produced by emotional problems or even associated with them. It is the result of a consistently repeated normal response to the unreleased fight and flight stimulus.” He continues: “Among the endocrine and other organic reactions caused by emotional irritation, the tensing of skeletal muscles probably ranks first in frequency. It may be reinforced by endocrine imbalance, produced by the same stresses and by conditional reflexes to which we are exposed when identical irritation occurs with identical warning signs (such as ringing of the telephone), and can be further aggravated by emotional difficulties, situational problems, and postural peculiarities.” CONCLUSION Observations have been made of 200 private practice TMJ patients. The findings suggest that we are dealing primarily with a neuromuscular problem that has definite postural overtones. There are varied approaches to diagnosis and treatment of TMJ disorders, which have a multifactorial etiology that requires a multidisciplinary approach. Therefore, dentists have an obligation to expand their vision beyond that of the teeth and mouth and broaden their traditional view of the patient. It is not enough to rule out histories of drug allergy, rheumatic fever, or diabetes and only examine the patient’s mouth. The dentist should be aware of the impact that such factors as nutritional and hormonal imbalances, history of trauma to other parts of the body, and behavioral factors can have on the entire skeletal system, of which the stomatognathic system is a part. The dentist should recognize the effect that treatment of the mouth and jaws will have on the rest of the body. The dentist should learn to develop and use the sensesin examination and diagnosis. HEAR what the patient is saying. Take a meticulous history, and listen for that hint that will provide the insight necessary for successful treatment. LOOK at the patient. Observe facial expressions, body language, gait, complexion, posture, and asymmetries. 242
BERNSTEIN
TOUCH the patient. Routinely palpating muscles can elicit information of trigger points, referred pain, etc. This can be done as a simple extension of the oral cancer and soft tissue examinations. SPEAK to the patient. Talk to the patients at their level. Give reassurances, and explain the nature of their symptoms and what steps will be necessary in treatment. If necessary be prepared to work with and educate allied health professionals such as the otolaryngologist, neurologist, endocrinologist, physical therapist, and chiropractor, who are often unaware of TM J pathology and its ramifications and the role of the dentist in treating seemingly nondental complaints. Headaches, ear symptoms, neck aches, and the other symptoms discussed are not symptoms that have traditionally lent themselves to the consultation of a dentist in differential diagnosis. In this study patients have undergone numerous medical consultations, experienced complicated and expensive medical tests and hospitalization, had unnecessary surgical and dental procedures, become addicted to various medications, and suffered the destructive effects of long-term, chronic pain or personality traits. Treating patients with craniomandibular disorders is not necessarily an obligation for every dentist. However, the dental profession has an obligation to visualize, listen attentively, and palpate in the identification of these patients. They do exist and are present in every dentist’s practice. REFERENCES I.
2.
3. 4. 5. 6.
De Boever, J. A.: Functional disturbances of the temporomandibular joint. In Zarb, G. A., and Carlsson, G. E., editors: Temporomandibular Joint Function and Dysfunction. St. Louis, 1979, The C. V. Mosby Co. Costen, J. G.: Syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhino1 Laryngol 43:1, 1934. Prentiss, H. J.: Preliminary report upon the temporomandibular articulation in the human. Dent Cosmos 60:505, 1918. Monson, G. G.: Occlusion as applied to crown and bridge work. Nat1 Dent Assoc J 7:399, 1921. Sicher, H.: Temporomandibular articulation in mandibular overclosure. J Am Dent Assoc 36:131, 1948. Moulton, R. E.: Psychiatric considerations in maxillofacial pain. J Am Dent Assoc .51:408, 1955. Lupton, E. E.: Psychological aspects of the temporomandibular joint dysfunction. J Am Dent Assoc 79:131, 1969. Mosak, H.: Does a “TMJ personality” exist? In Gelb, H., editor: Clinical Management of Head, Neck, and TMJ Pain and Dysfunction. Philadelphia, 1977, W. B. Saunders Co., p 198. Laskin, D. M.: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969.
FEBRUARY
1983
VOLUME
49
NUMBER
2
TMJ SYNDROME
10.
11. 12.
13. 14.
15.
16.
17.
18. 19. 20.
LlcNeill. C., Danzig, W. M., Farrar, W. B., Gelb, H., Lerman, M. D.. MofPett, B. C., Pertes, R., Solberg, W. K., and Wemberg, 1.. h.. Craniomandibular (TMJ) disorders-The SI.UCof the an J Ptwsrwx DINT 44:434, 1980. (&lb. I-l., and Arnold, G.: Syndromes of the head and neck of dent
THE JOURNAL
OF PROSTHETIC
DENTISTRY
21. 22. 23.
24.
25.
26.
Clinical Management ot Head, Neck. and T.?iJ Pain 2nd ( :(I.. Dysfunction. Philadelphia, 1077, W 13. i:iunrlrrs p 186. Christiansen, R.: Some biologic considerations 1:: orthodontic research. Am J Orthod 60~338, 197 1. Weinstein, S: Minimal forces In loo!h mtw mcnt .\m J Orthod 53:881, 1967. Kraus, H.: Muscular aspects of oral dysfunction In Gelh. f-l.. editor: Clinical Management of Head, Neck. ;IIUI ‘I’MJ Pain and Dysfunction. Philadelphia, 1977. Lv. B :\aundrr>. (:o.. p 123. Sonkm. L.: Endlxrine disordera. locomotrrr and :en~porornandibular iomt dvifunc&n. In Gelb, H., editor- ( Xnwal Management of Head. Neck, and 7‘n/lJ Patin and D&unct~on. Philadelphia, 1977. W. B. Saunders (:o., p I’? Lieb, hf.: Oral orthopedics. Irl Gelb. H.. eil~tor: Clinical hIanagemen1 of Head, Neck, and TM,J Pain n.?tl Dvsfunction. Philadelphia, 1977. W. B. Saunders Co., p 3~. Kraus, H.: &fusxdar aspects of oral dysfuncrror~ In Gelb, H., editor: Clinical Management of Head. Neck, alld T~ZJ Pain and Dysfunction. Philadelphia. 197’. \.2i K Saunders (:o,, p 80.
Keprmc requ'~'lJ lo. DR. HAROLD GELB 635 M,UUSOI\: AVE. NEW YORK, NY 100.!2
243
JOINT
l
OCCLUSION
EDITOR
GEORGE A. ZARB
Clinical evaluation of two hundred patients with temporomandibular joint syndrome Harold
Gelb, D.M.D.,
and Ira Bernstein,
D.M.D.
New York, N.Y.
T
he population in this study consisted of 200 patients referred to a temporomandibular joint (TM J) specialty practice by dentists, physicians, and other health professionals. The referrals were based on diagnoses of craniomandibular disorders with a variety of chief complaints, including headache, facial pain, tinnitus, vertigo, and clicking or popping joint noises. This article describes how muscle disorders related to craniomandibular dysfunction can have effects throughout the body. Dentists must therefore embrace a much broader view of their patients since the consequences of their treatment, or its omission, can have ramifications far greater than traditional concepts of dental practice have previously realized. CURRENT
CONCEPTS
The last several years have seen a great increase in TM J-related textbooks, continuing education courses, professional journal articles, and public media attention. This has resulted in a significant increase in professional and lay awareness of TMJ disorders. However, it has also produced some confusion as different authors and lecturers have placed varying degrees of emphasis on different etiologic factors. Consequently, terminology and treatment procedures have varied according to the clinician’s concept of etiology. Theories
of etiologic
concepts
De Boever’ organizes these etiologic concepts into the following five basic theories. Mechanical displacement theory. This theory includes the TMJ theories of Costen and others,3a4 who felt that the distal displacement of the condyles after loss of posterior teeth caused impingement on various structures in the region with resultant symptoms. Sicher’ and others later showed that the anatomic basis of Costen’s syndrome was not valid. However, mandibular overclosure (reduced vertical relation of occlusion) as an etiologic factor has remained prevalent in many current concepts. The position of the condyle is dictated by the
234
FEBRUARY
1983
VOLUME
49
NUMBER
2
occlusion. When occlusal problems result from missing teeth or prematurities (deflective occlusal contacts), or insufficient eruption of the posterior teeth cause a deviation of the condyles from their normal centric position, the muscles then become involved, creating dysfunction and pain. The mechanical displacement group relies heavily on the use of radiographs and diagnostic casts for diagnosis and the determination of proper mandibular position. Muscle theory. Muscle tension increases and results in pain and spasm as a manifestation of Selye’s General Adaptation syndrome when the stressesof everyday life do not have an adequate outlet or release. Muscles are primarily involved as part of a generalized rather than localized reaction. Psychologic theory. This group has several diverse thoughts with published studies by various authors producing conflicting results. However, it is generally agreed that emotional and behavioral factors play some role in TM J disorders, either as modifying or initiating factors. Some authors, such as Moulton” and Lupton,’ feel that psychologic factors are capable of initiating TM J pain-dysfunction. The patient is psychologically predisposed or pain prone with occlusal changes or trauma merely serving as trigger factors. Others, such as Mozak,” feel that psychologic factors found in TMJ patients are a result of the patients’ living with long-term, constant pain resulting from occlusal disharmonies and/or jaw imbalance. Obviously, treatment varies depending on whether the clinician subscribes to the concept of eliminating the psychologic factors first or initially treating the occlusion. Neuromuscular theory. The proponents of this theory consider the occlusion as the major influence on the functional remodeling and development of arthrosis in the joint. It is responsible for causing parafunctional habits such as grinding or clenching, providing that a background of psychic tension, stress, or anxiety is present. Laskin9 believes that the reverse is true. He
0022-3913/83/020234
+ 10$01.00/00
1983 The C. V. Mosby Co.
TMJ SYNDROME
believes that emotional disturbances trigger the parafunctional habits, which then lead to emotional interferences. In either instance emotional factors account prominently as etiologic factors. Psychophysiologic theory. In this theory masticatory muscle spasm is considered the main etiologic factor in causing pain and dysfunction. Overextension, overcontraction, or muscle fatigue may initiate the spasm and result in occlusal disharmonies and pathologic joint changes. This group stresses that occlusal changes occur in response to or as a result of muscle spasm.
from one person to another.“” General health, emotional status and other predisposing factors must be considered in their influence on this adaptive capacity. This accounts for severe malocclusions in some persons not causing symptoms, while the slightest deviation in others results in extreme discomfort. Because of the multicausal etiology, symptoms are understandably varied. Clinically, this becomes more obvious when one seesthe potential of many different muscles throughout the body become involved in the myospasm-pain-spasm cycle. DIAGNOSIS
ETIOLOGY In its recent position article, the American Academy of Craniomandibular Disorders emphasized the multicausal etiology of TMJ disorders.‘O The etiologic factors were divided into predisposing, precipitating, and perpetuating groups. Predisposingfactors include structural discrepancies, psychologic disorders, metabolic disorders, and pathologic or behavioral factors. Precipitating (triggering) factors include trauma, an adverse stress response, iatrogenic problems, infection, and idiopathic factors. Perpetuating (sustaining) factors are usually manifested by the myospasm-pain-spasm cycle and can be related to any one or a combination of the predisposing or precipitating factors. Gelb and Arnold” previously stated that the pain associated with TMJ disturbances has been attributed mainly to the masticatory muscles. The pain and limited activity are associated with “trigger areas” within the muscles. These are small areas in the myofascial structures which are hypersensitive to stretch and give rise to muscle spasm with referred pain. “it has been stated that excessive opening of the mouth, as occurs in a yawn or during prolonged dental visits, sudden pain in the teeth, or severe pain in the area of the mouth, can evoke a compensating extended contraction similar to the action of a stretch reflex of other skeletal muscles. This would result in a prolonged tonic spasm of the jaw muscle, such as found in bruxism. Since there is no relaxation, the resulting dysfunction of the TM J produces more pain, leading to a vicious cycle. “We must always bear in mind that malposition of the .jaw does not necessarily result in pain or other disturbances.” This is a predisposing factor. “Whether or not such conditions occur depends not only on the presence of abnormal stressesor strains, but also on the adaptive capacity of the person. This quality varies
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Before diagnosing a TMJ disorder, a prior medical consultation to rule out other causes of orofaeial pain is necessary. Cardiovascular; neurologic; arthritic or systemic disease; hormonal imbalance; drug side-effects; and local ear, nose, throat, sinus. or cervical spine pathology should be considered. A thorough history is imperative. Patients will often give a diagnosis and indicate the proper approach to treatment. A clinician who listens closely will gain insight not only into diagnosis and treatment but the prognosis as well as the patients’ emotional needs and expectations in relation to their illness are often manifested. It also gives the clinician an opportunity to develop a personal rapport with the patient. A good listener imparts a sense of faith and hope to patients. APPROACH TO DIAGNOSIS CRANIOCERVICAL-MANDIBULAR SYNDROME”
OF THE
I. Preliminary examination A. Chief complaint 1. Pain: date of onset, location unilateral or bilateral, frequency, duration, quality, tr lgger devices, and factors alleviating pain 2. Nonpain: date of onset, location, unilateral or bilateral, frequency, duration, and quality B. Medical history: ruling out etiologic factors previous1y mentioned and evaluating medical consultation data (otolaryngologic, ophthalmic, neurologic, orthopedic, psychiatric, and endocrinologic) C. Dental history 1, Evaluation of previous dental experiences 2. Previous TMJ treatment 3. Pain in specific teeth 4. Oral symptoms other than pain: bruxism,
235
GELB AND
muscle fatigue, gingival bleeding and swelling, and facial swelling D. Personal history and psychologic evaluation: marital status (past and present), children, in-laws, parents, sickness in the family, working habits and environment, commuting to and from work, sleeping habits, and gastrointestinal history-duodenal ulcers, colitis, nervous stomach (Our philosophy is “LSMFT”listening sympathetically makes fine therapy.) E. Radiographic examination 1. Intraoral: minimum of 14 periapical radiographs and four bite-wings 2. Extraoral a. Right and left lateral temporomandibular radiographs: closed, rest position, and wide open b. Right and left anteroposterior temporomandibular radiographs, if required c. Cephalometric radiographs, if required d. Tomograms, if required II. Clinical examination A. Facial symmetry B. Relation of midlines: open and closed showing mandibular deviation (generally open to affected side) C. Intraoral examination: charting of mouth for caries, various types of prostheses and restorations, missing teeth, extruded teeth, lingually and buccally displaced teeth D. Deviate swallowing habits 1. Incisal thrust 2. Full fan thrust: molar to molar 3. Bimaxillary protrusion thrust 4. Class III thrust a. Pseudo b. Skeletal 5. Open-bite thrust 6. Closed-bite thrust 7. Posterior unilateral thrust 8. Posterior bilateral thrust E. Three-dimensional analysis of diagnostic casts 1. Midsagittal 2. Coronal 3. Horizontal F. Intraoral functional occlusal analysis: centric occlusion, centric relation, vertical dimension, working and balancing side interferences, protrusive interferences
236
BERNSTEIN
G. Palpation: painful joints; coronoid processes; tenderness in muscles of mastication, head, neck, shoulders, and back; anterior wall tenderness (by placing small fingers into external auditory meatuses and pressing forward) H. Auscultation: crepitation, rubbing, sagittal opening click, sagittal closing click I. Pulp test for vitality or percussion testing of various teeth J. Applied kinesiology (testing procedures) K. Nutritional workup 1. Hair analysis 2. Urinalysis 3. Blood analysis
TREATMENT The initial step in treatment is positive assurance that the patient can be helped. Many patients have been in chronic pain for some time. Some are cancerphobic. Most have visited several physicians to find help for their condition. A brief explanation of the mechanism involved in the cause of their symptoms may in itself produce some relief, as some of the fear and resultant stress (an etiologic factor) are diminished. This may indeed be the most important step toward a successful result.‘3p’4 Actual therapy begins with an attempt to alleviate some of the pain. Initially, moist heat, soft diet, ultrasonic therapy, electrogalvanic stimulation, vapocoolant spray with movement, and vinyl resin night guard prostheses are used to palliate the patient. The next step in therapy is to reposition the mandibular condyles in their respective glenoid fossae so that optimal neuromuscular balance is obtained. A mandibular acrylic resin prosthesis that covers the occlusal surfaces of the posterior teeth is selectively adjusted over a period of time as the muscles accommodate to the new mandibular position. Where sufficient interocclusal distance is present to properly position the condyles in their fossae, selective occlusal equilibration of the natural dentition may be indicated. This is an irreversible procedure and should only be considered by clincians experienced in proper mandibular positioning and equilibration techniques. If not done with extreme care, this procedure may iatrogenically cause a malposition of the condyles and can result in an exacerbation of existing symptoms or the initiation of symptoms where none existed previously. Palpable trigger areas are injected with lidocaine without vasoconstrictors. Where indicated, patients are
FEBRUARY
1983
VOLUME
49
NUMBER
2
fMI
SYNDROME
Table I. Age groupings
of symptoms
-----__-.__-Age
group --
--_~
--I___--.------.~.
10-20
21-30
31-40
41-50
Men Women
3 15
20 34
14 37
Muscles in spasm Internal pterygoids External pterygoids Masseters ~Tcmporal Sternocletdomastoid Posterior cervicals Mylohyoids Trape’rius Others
15 17 16 15 16 15 12 16 17
41 44 50 44 46 45 34 44 52
41 46 44 42 45 43 35 45 50
28 31 28 25 29 27 27 29 33
3 2
15 9
24 19
IO 5
6 16
30 54
36 51
23 33
-, / 21
8 13
9
29
35
19
I:!
10
14 13 10 12
19 9 9 29
9 6 9 17
‘2 ‘7 5 9
h 2 5 5
13 20 43
30 28 43
12 17 22
11 13 14
6 6 5
Ear symptoms rinnitus Heartng Loss Temporomandibular Clicknrg Pain
Head pain Facial Occipital Cervical ‘Temporal Vertigo Stuffiness Popping or whoosing noise on opening or closing
3 6 10
_--_.-.
61-70
6
8
28
16
1 I2
lb
11
19 22
12 11 10 10 IO 9
lb
18 17 lb lb
OF PROSTHETIC
DENTISTRY
71-80
Total
10 12
21
9
~--
given specific exercises and treated with physical therapy modalities. Biofeedback, hypnosis, acupuncture, nutritional counseling, and myofunctional therapy are some of the adjunctive therapies commonly used. Because of its multifactorial etiology, other disciplines such as cranial osteopathy, chiropractic kinesiology, endocrinology, orthopedics, physiatrics, and psychiatry may be called on to play an active role in the treatment of the TMJ patient. Dnce the patient has had several months relatively free from symptoms, the final stage of treatment may begin. The jaw position is stabilized by reproducing the occlusion created by the prosthesis. This is done by allowing eruption of the teeth into the same position using functional orthodontics, removable partial den-
THE JOURNAL
51-60
joint
Bruxism
~~..~- _
b 5
-.--...
...-
tures that overlay the teeth, fixed restorations, or combinations of these procedures. COMMENTS
ON FINDINGS
This study is based on the findings at the initial examination of 200 patients in a TMJ specialty practice. All patients were examined by the same clinician, Dr. Harold Gelb. The patients were divided into seven age groups, each spanning 10 years (Table I). Almost 70% (69.5) of the patients were between 21 and 50 years of age. The ratio of women to men in this group was 2.7:1. Weinberg and Lager” had the same proportion of the sexes in a recent study of a similar but smaller private practice population. Although many patients described more than one
237
GELB AND
DIAGNOSTIC
BERNSTEIN
FINDINGS
CHIEF COMPLAINTS pain No % A 57 28.5
Headache No % A 83 41.5
TMJ
Facial pain No. % 18 9
Neck pain No % A 22 11
Ear pain No % A 9 4.5
Click No. 6 3
‘I’irmitus No. 21
Other No % L3 1.5
REFERRALS Dentist No % 123
Physician No % A 24 12
Other health professionals No % A 16 8
Other patients % LNo 28 14
Media No. 9 4.5
ILIAC CREST PAIN/TENDERNESS Right only 12
Left only 123
GASTROCNEMIUS
Roth -iii
MUSCLE PAIN
PREVIOUS TMJ THERAPY Drugs 106
Surgery 12
Equilibration 14
Appliance 38
Restorations or prosthesis 18
Chiropractor 12
Other 38
Combination 69
CHRONIC ILLNESS Hysterectomy 1
Thyroid 38
Surgery 126
Psychologic 69
chief complaint, only their most severe single complaint was recorded for purposes of this study. The chart above shows that 70% of the patients had a chief complaint of either headache (41.5%) or TM J pain (28.5%). Neck pain (11%) and facial pain (9%) were the next most common chief complaints. The remaining patients had chief complaints of ear pain (4.5%), clicking (3%), and tinnitus (1%). Back pain, an uncosmetic facial appearance, and facial tic were also cited as chief complaints. The great majority of the referrals came from dentists (61.5%). Patients who had been previously treated for TM J disorders referred 14% of the patients. Apparently this patient group had become “TMJ missionaries” diagnosing friends and relatives and accounting for more referrals than physicians (12%) and other health professionals (8%). This reinforces the importance of educating patients under treatment as they become a significant source of new patients. The media, including radio, television, newspapers, and magazines, were cited by 4.5% of the patients as their chief source of information in seeking treatment. Some form of previous therapy was the chief com-
238
ENT Ti-
Orthopedist 105
Combination 134
plaint of 129 patients (64.5%). Thirty-four and five tenths percent had attempted two or more different modes of therapy. Drug therapy, including aspirin, narcotic analgesics, tranquilizers, mood elevators, muscle relaxants, and vitamins, was used by 53% of the patients. Nineteen percent of the patients had been treated with some type of intraoral prosthesis. Nine percent had either new dentures or other prostheses fabricated or had undergone fixed partial denture rehabilitation in attempts to alleviate their symptoms. Equilibration had been performed unsuccessfully in 7% of the patients. For some patients this last procedure actually brought on additional symptoms or exacerbated existing symptoms. Six percent of the patients had some form of surgery. This included third molar and “infected” tooth extractions, TM J surgery, and “jaw” surgery; and one patient underwent removal of a cervical lymph node. Another 6% had been treated by chiropractors. Other forms of treatment included root canal therapy, physical therapy, injections into the TMJ, muscle trigger point injections, allergy treatments, psychiatric counseling, acupuncture, biofeedback, hypnosis, nutritional counseling, myofunctional
FEBRUARY
1983
VOLUME
49
NUMBER
2
therapy, t ranscutaneous electrical nerve stimulation, and the use of a cervical collar. One patient even had intermaxillary fixation to keep her from opening her mouth for 6 weeks. The broad range of treatment modalities indicated the need for interdisciplinary education and communication as patiems apparently seek a variety of health professionals for treatment. Rocabado’!’ stated that degenerative changes as a result of traumatic in,juries (such as whiplash) to the skeletal system may not become apparent until at least 6 to 8 months after the injury. Hughes” reported that traumatic injuries, no matter how long standing, may play some contributing role in producing symptoms. In the 5-year period preceding this examination, 46 patients had some type of traumatic injury to the skeletal system, including whiplash, blows to the head or face, and broken bones. Ninety-nine patients had a history of trauma more than 5 years previously. The pauents in this study were divided into five groups based on their medical histories: 180 patients (90%) had a history of either prior surgical procedures (63%); orthopedic treatment (52.5%) ear, nose, and throat (ENT) treatment (40.5%); psychiatric counseling (34.5%); or clinical signs or symptoms of thyroid dysfunction (19Yo). One patient had had a hysterectomy. Sixty-seven percent had indicated a positive history in two or more of the five groups. Are these patients suffering from TMJ syndrome because they are predisposed to illness? Or is the reverse a possibility? Does TMJ syndrome make an individual prone to illness? In an article on chronic illness profiles Smith’” states that “there seems to be a direct relationship between the health of the patients and their occlusion.” He stated that when the malocclusion and jaw position are corrected, the patient’s general health improves. Fonder’” reported that TM J malposition results in a “dental distress syndrome” that manifests itself in pathology in other parts of the body. He stated: “Through the myofascial trigger mechanism, referred pain may occur in many areas of the head and neck, as well as in more distant parts of the body. All these factors are sources of stress in the patient, capable of initiating the General Adaptation Syndrome. If they persist, or if they are compounded by further stress factors, they can produce diseases of adaptation anywhere in the body.” The muscles most frequently in spasm on palpation were the masseter (88%), external pterygoid (87%), and sternocleidomastoid muscles (84%). Almost all patients examined (95.5’70) had some involvement of
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Table II. Condition
of dentition No. of patients
Full complement of teeth With fixed partial (dentures Partially edentulous with no replacement With some fixed restorations Complete maxillary and complete mandl bular dentures
Removable partial dentures Complete maxillary and removable mandibular partial denture
nonmasticatory muscles listed under the grouping “other.” These included deltoid; upper, middle, and lower back; and pectoral and gastrocnemius muscles (Table I). Although the muscles just mentioned were most commonly involved, the temporal, trapezius, posterior cervical, and internal pterygoid muscles each exhibited spasm in a large number of the patients. Ear symptoms were common complamts. Ninetyfive patients were aware of a sensation of stuffiness in one or both ears. Hearing loss was mentioned by 49 patients, tinnitus, by 71 patients, and vertigo by 79 patients. In discussing the otomandibular syndrome Arlen”’ blames spasm of the tensor veli palatini and tensor tympani muscles for producing the above symptoms. He feels that this spasm occurs as an extension of the chronic strain and resultant spasm of the various masticatory muscles involved in TMJ dysfunction as they share anatomic and functional proximity and nerve innervation. Popping or whooshing noises on opening or closing the jaws were reported by 142 patients. One hundred seven patients exhibited some type of joint click. Forty-nine patients exhibited reciprocal opening and closing clicks on the same side. Twenty patients had single-sided opening clicks only, and 28 had singlesided closing clicks only. Three patients had bilateral opening clicks, and seven had bilateral closing clicks. Pain in the TMJ on preauricular palpation was elicited in 194 patients. Palpation through the external auditory meatus elicited pain in 152 patients. Of this number 114 ha.d unilateral anterior wall tenderness, and 38 had bilateral pain. According to Laskin’s’ criteria for differentiating TM J arthritis from myofascial pain-dysfunction, this factor (anterior wall tender-
239
GELB AND
Table III. Postural patterns and other findings No. of
patients Deviant
swallowing
144
pattern
Clicks Click on opening and closing Unilateral click on opening Unilateral click on closing Bilateral opening click Bilateral closing click
49 20 28 2 7
Anterior wall tenderness Both ears Right ear Left ear One side only
38 82 108 114
High eye and low hip on same side Right side Left side
147 3
Previous orthodontic therapy Orthodontics with extractions
43 15
(premolar)
Previous history of trauma Within past 5 years
46 99 24
Five years or longer Had both Midline deviation on same side as high eye Closed-right and left Open-right and left
65 82
High eye and anterior same side Yes No
86 62
wall tenderness
on
BERNSTEIN
swallowing pattern may also be a causative factor,” and 144 patients had some form of this pattern. Pressure from the tongue, cheeks, or lips can exert forces that inhibit vertical growth of the alveolus and suppress or modify tooth eruption and position. In this study a mandibular opening of 40 mm or more was considered normal. Seventy-three percent of the patients had an opening of 40 mm or greater. The average opening of all 200 patients was 49.5 mm. Most of the patients exhibited some facial asymmetries. When these findings were correlated with some of the other data, some interesting observations were made. One hundred sixty-nine patients had a right eye that was higher than the left eye. Of this number 147 had one hip lower than the other, also on the right side. Only three patients had this same-sided high eye-low lip correlation on the left side. The high number of patients with this right-sided correlation appears to be significant and merits further study from a postural standpoint. One hundred fifty-four patients had tenderness on palpation of the iliac crests. In the great majority (123) pain was elicited in the left iliac crest only. Ninteen patients had pain in both right and left iliac crests. Significant tenderness to palpation was even found in the gastrocnemius muscles, where 102 patients had tenderness on the right side and 16 on the left side. Sixteen patients had tenderness on both sides. It appears that there is a significant postural pattern in many of the patients we examined. A high right eye, lower (but less tender) right hip, and tender right calf appeared in a significant number of this population (Table III).
DISCUSSION ness) alonewould place 76% of the patients in the other categories. Historically, TMJ problems have been associated with a loss of posterior occlusal support or “collapsed bite” resulting from missing teeth. Yet, 110 of the patients had a full complement of natural teeth. An additional 38 had a full complement as a result of fixed partial denture replacements. Although the problem may be an insufficient vertical dimension of occlusion, it is more likely to be a result of unrealized vertical dimension rather than lost vertical dimension (Table 11). Among the factors partially responsible in preventing the alveolar process and teeth from reaching their full growth and eruption potentials are bruxism and clenching. 21 One hundred sixteen patients had an awareness of bruxing or clenching habits. A deviant
240
It is rare to find but a single muscle in spasm, as another muscle will in some way have to compensate for the resultant change in skeletal equilibrium. If one muscle group becomes tense, then adjacent muscles are in tension. In effect a chain or sequence with the involvement of many muscles is created. A ripplelike effect on muscles throughout the entire body takes place. Our results indicated that no one muscle of mastication greatly outnumbers the others in degree of involvement. Many of the muscles of mastication were found to be tender and in spasm in a large percent of the patients. The fact that almost all patients had involvement of other muscles throughout the body can also be explained by this chain or sequence theory as described by Kraus.23 This ripple effect appears to be greater in patients with endocrine disorders or nutritional defi-
FEBRUARY
1983
VOLUME
49
NUMBER
2
TMJ SYNDROME
ciencies as these conditions increase the susceptibility of muscles to spasm and its propagation. Endocrine imbalance may predispose the patient to the production of trigger points, and even borderline hypothyroidism or estrogen deficiencies can be significant contributing factors in muscle problems. 23However, the mechanism for the cause of pain and spasm due to hormonal deficiency is not fully understood.24 Bone will yield to muscle, and form will follow function; therefore, prolonged spasm of a chain of muscles may cause generalized postural abnormalities and asymmetries. The patients examined commonly had the right eyebrow higher than the left, the right eye higher and larger, the lips turned up to the right side, the right ear tending to be higher, and the midline of the incisors frequently off to one side. The facial high side often corresponded with a greater deficiency in the vertical dimension of occlusion on that side as corroborated by palpation through the external auditory meatus, TM J radiographs, and phonetics. If one were to stand in front of the patient and view the planes of occlusion of the posterior quadrants, the mandibular left side would generally be higher than the right. The shoulder is generally lower on the right side than on the left side, as well as the level of the breasts and hips. It will usually be found that the leg is slightly shorter on this side as well. The midline almost always shifts into the quadrant with the greatest deficiency of vertical height. The condyle on that side is now more pronounced when palpated through the external auditory meatus, and it may even exhibit a click on closing. Regarding the problem of postural maintenance, consider the shoulder girdle, clavicula, sternum, and scapula as constituting a fixed base of operations. The head may be said to virtually teeter on the atlantooccipital joint. Because the center of gravity of the head lies in front of the occipital condyles, it naturally follows that definite force must be applied to hold the head erect, a force that is provided by the large muscles of the neck. Several groups of muscles are attached directly or indirectly to the anterior part of the head; their functions tend to add to the force of gravity and thus to the load on the posterior cervical muscles, thereby requiring greater bulk and strength on their part. The most important of these anterior cranial muscles are the masticatory and supra- and infrahyoid groups. They constitute a chain with the mandible and hyoid bone to which they are attached. They join the cranium to the shoulder girdle. In ideal posture a plumb line should pass (on
THE JOURNAL
OF PROSTHETIC
DENTISTRY
1
2
Fig. 1. 1, Power balancing power through opposed muscle centers (m.c.). Muscle centers coordinate crossline of gravity in movement when bones are balanced. 2, Bones opposing bones. When bones are unbalanced, weight opposes weight across line of gravity, thus throwing muscle centers under tension. (From Gelb, H.: Clinical Management of Head, Neck, and TMJ Pain and Dysfunction. Philadelphia, 1977, W. 8. Saunders Co.)
profile) through the tragus of the ear, the tip of the shoulder, the hip joint, posterior to the patelia of the knee joint, and anterior to the ankle bone (Fig. l).‘” However, in most TM J patients the head is forward of this plumb line. The head is in hyperextension in response to contracted masseter and sternomastoid muscles to keep the bipupil line horizontal with the ground. The body will shift so that it can maintain
the
pupils in a horizontal plane.lh The position of the head in space therefore materially affects the posture of the body. Whenever mandibular-neuromuscular tension is
241
GELB AND
present, the mandible’s abnormal position affects the normal physiologic posture of the cervical vertebrae, resulting in abnormal strains on the muscles of the upper torso, which affect the posture of the head, neck, and shoulder girdle. Kraus26 has stated that “muscle tension is probably the most frequent single or central cause of muscular. derangement of the TMJ. This is equally true of a history of non-traumatic or post traumatic orthopedic difficulties. Muscle tension is unfortunately built into our civilized and mechanized way of life. It does not necessarily have to be produced by emotional problems or even associated with them. It is the result of a consistently repeated normal response to the unreleased fight and flight stimulus.” He continues: “Among the endocrine and other organic reactions caused by emotional irritation, the tensing of skeletal muscles probably ranks first in frequency. It may be reinforced by endocrine imbalance, produced by the same stresses and by conditional reflexes to which we are exposed when identical irritation occurs with identical warning signs (such as ringing of the telephone), and can be further aggravated by emotional difficulties, situational problems, and postural peculiarities.” CONCLUSION Observations have been made of 200 private practice TMJ patients. The findings suggest that we are dealing primarily with a neuromuscular problem that has definite postural overtones. There are varied approaches to diagnosis and treatment of TMJ disorders, which have a multifactorial etiology that requires a multidisciplinary approach. Therefore, dentists have an obligation to expand their vision beyond that of the teeth and mouth and broaden their traditional view of the patient. It is not enough to rule out histories of drug allergy, rheumatic fever, or diabetes and only examine the patient’s mouth. The dentist should be aware of the impact that such factors as nutritional and hormonal imbalances, history of trauma to other parts of the body, and behavioral factors can have on the entire skeletal system, of which the stomatognathic system is a part. The dentist should recognize the effect that treatment of the mouth and jaws will have on the rest of the body. The dentist should learn to develop and use the sensesin examination and diagnosis. HEAR what the patient is saying. Take a meticulous history, and listen for that hint that will provide the insight necessary for successful treatment. LOOK at the patient. Observe facial expressions, body language, gait, complexion, posture, and asymmetries. 242
BERNSTEIN
TOUCH the patient. Routinely palpating muscles can elicit information of trigger points, referred pain, etc. This can be done as a simple extension of the oral cancer and soft tissue examinations. SPEAK to the patient. Talk to the patients at their level. Give reassurances, and explain the nature of their symptoms and what steps will be necessary in treatment. If necessary be prepared to work with and educate allied health professionals such as the otolaryngologist, neurologist, endocrinologist, physical therapist, and chiropractor, who are often unaware of TM J pathology and its ramifications and the role of the dentist in treating seemingly nondental complaints. Headaches, ear symptoms, neck aches, and the other symptoms discussed are not symptoms that have traditionally lent themselves to the consultation of a dentist in differential diagnosis. In this study patients have undergone numerous medical consultations, experienced complicated and expensive medical tests and hospitalization, had unnecessary surgical and dental procedures, become addicted to various medications, and suffered the destructive effects of long-term, chronic pain or personality traits. Treating patients with craniomandibular disorders is not necessarily an obligation for every dentist. However, the dental profession has an obligation to visualize, listen attentively, and palpate in the identification of these patients. They do exist and are present in every dentist’s practice. REFERENCES I.
2.
3. 4. 5. 6.
De Boever, J. A.: Functional disturbances of the temporomandibular joint. In Zarb, G. A., and Carlsson, G. E., editors: Temporomandibular Joint Function and Dysfunction. St. Louis, 1979, The C. V. Mosby Co. Costen, J. G.: Syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhino1 Laryngol 43:1, 1934. Prentiss, H. J.: Preliminary report upon the temporomandibular articulation in the human. Dent Cosmos 60:505, 1918. Monson, G. G.: Occlusion as applied to crown and bridge work. Nat1 Dent Assoc J 7:399, 1921. Sicher, H.: Temporomandibular articulation in mandibular overclosure. J Am Dent Assoc 36:131, 1948. Moulton, R. E.: Psychiatric considerations in maxillofacial pain. J Am Dent Assoc .51:408, 1955. Lupton, E. E.: Psychological aspects of the temporomandibular joint dysfunction. J Am Dent Assoc 79:131, 1969. Mosak, H.: Does a “TMJ personality” exist? In Gelb, H., editor: Clinical Management of Head, Neck, and TMJ Pain and Dysfunction. Philadelphia, 1977, W. B. Saunders Co., p 198. Laskin, D. M.: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969.
FEBRUARY
1983
VOLUME
49
NUMBER
2
TMJ SYNDROME
10.
11. 12.
13. 14.
15.
16.
17.
18. 19. 20.
LlcNeill. C., Danzig, W. M., Farrar, W. B., Gelb, H., Lerman, M. D.. MofPett, B. C., Pertes, R., Solberg, W. K., and Wemberg, 1.. h.. Craniomandibular (TMJ) disorders-The SI.UCof the an J Ptwsrwx DINT 44:434, 1980. (&lb. I-l., and Arnold, G.: Syndromes of the head and neck of dent
THE JOURNAL
OF PROSTHETIC
DENTISTRY
21. 22. 23.
24.
25.
26.
Clinical Management ot Head, Neck. and T.?iJ Pain 2nd ( :(I.. Dysfunction. Philadelphia, 1077, W 13. i:iunrlrrs p 186. Christiansen, R.: Some biologic considerations 1:: orthodontic research. Am J Orthod 60~338, 197 1. Weinstein, S: Minimal forces In loo!h mtw mcnt .\m J Orthod 53:881, 1967. Kraus, H.: Muscular aspects of oral dysfunction In Gelh. f-l.. editor: Clinical Management of Head, Neck. ;IIUI ‘I’MJ Pain and Dysfunction. Philadelphia, 1977. Lv. B :\aundrr>. (:o.. p 123. Sonkm. L.: Endlxrine disordera. locomotrrr and :en~porornandibular iomt dvifunc&n. In Gelb, H., editor- ( Xnwal Management of Head. Neck, and 7‘n/lJ Patin and D&unct~on. Philadelphia, 1977. W. B. Saunders (:o., p I’? Lieb, hf.: Oral orthopedics. Irl Gelb. H.. eil~tor: Clinical hIanagemen1 of Head, Neck, and TM,J Pain n.?tl Dvsfunction. Philadelphia, 1977. W. B. Saunders Co., p 3~. Kraus, H.: &fusxdar aspects of oral dysfuncrror~ In Gelb, H., editor: Clinical Management of Head. Neck, alld T~ZJ Pain and Dysfunction. Philadelphia. 197’. \.2i K Saunders (:o,, p 80.
Keprmc requ'~'lJ lo. DR. HAROLD GELB 635 M,UUSOI\: AVE. NEW YORK, NY 100.!2
243