Oral Surgery ISSN 1752-2471

INVITED REVIEW

Temporomandibular disorders (TMD): an overview

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

Key words: Abstract

review, temporomandibular disorders,
temporomandibular joint This article discusses the aetiology, signs and symptoms, diagnosis, psycho-
logical factors and management of temporomandibular disorders (TMD).
Correspondence to: It highlights the difficulty of evidence-based practice with respect to TMD.
Dr J Durham
School of Dental Sciences
Newcastle University
Framlington Place
NE2 4BW
UK
Tel.: +44 191 222 6000
Fax: +44 191 222 8191
email: [email protected]

Accepted: 28 April 2008

doi:10.1111/j.1752-248X.2008.00020.x

debated within the literature and therefore this article

Introduction
will continue to use the term, as defined by the AAOP,
Signs and symptoms of temporomandibular disorders for the interim.
(TMD) were first recognised by Costen in 19341 and This article will discuss the aetiology, signs and
since then a plethora of terms have been used, some- symptoms, diagnosis, psychological factors and man-
what interchangeably, to describe TMD. These include agement of TMD. The article will highlight areas where
Costen’s syndrome, temporomandibular joint dys- there is a need for more research and illustrate why
function syndrome2, pain dysfunction syndrome3 and evidence-based management of TMD is difficult.
facial arthromyalgia4. TMD5, defined by the American
Association of Orofacial Pain (AAOP) as:
Aetiology
A collective term embracing a number of clinical
The aetiology of TMD is poorly understood and can
problems that involve the masticatory
easily be misrepresented. There are initiating factors,
musculature, the Temporomandibular joint and
predisposing factors and perpetuating factors and
associated structures, or both6.
consequently no single ‘cause’8. Okeson9 identifies five
The incorrect use of TMD as a catch-all term factors associated with TMD: occlusal factors, trauma,
has recently been highlighted7. Laskin suggests that emotional stress, deep pain input and parafunctional
researchers have tended to use it as a singular noun and activities, but these have been the subject of much
by doing so have made their findings difficult to inter- debate and enthusiastic treatment10–21.
pret in relation to the differing origins of the complaint.
His editorial suggests that TMD should be removed
Signs and symptoms
from the diagnostic vocabulary and instead individual
terms should be used that describe the origin of the Signs and symptoms of TMD have a higher incidence in
complaint. This very recent suggestion has yet to be the general population (20–75%) than the proportion

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Durham Temporomandibular disorders

of the population who present for treatment (2–4%). aids. Only thermography has yet to be fully investi-
The age range of presentation varies from the second to gated; the others have been rejected as unreliable in all
the fourth decade3. Gender differences in symptoms are potential functions as diagnostic aids42–46.
not observed (1:1) but the ratio presenting for treat- The final option available for diagnosing TMD is
ment is substantially different, with females outnum- the clinical diagnostic index. There have been a
bering males, 7:13,22–25. Suggestions that this is due to number of attempts over the years to construct a
differences in gender behaviour are not scientifically definitive index5,6,47–51 and the National Institute of
supported23. Dental Research in the U.S.A. supported research into
There is a great deal of inter-individual variability in producing clinically applicable research criteria for
the signs and symptoms of TMD but they can be divided TMD. The result of this sponsorship was the RDC51,
into six broad groups3,8,26,27: a dual-axis approach to the diagnosis of TMD.
Axis 1 of the RDC concentrates on the clinical
● Joint noises – clicking, creptius (grinding);
examination and Axis 2 focuses on the psychosocial
● Locking – open (inability to close fully) closed
effects of the condition. Axis 1 has a standardised pro-
(inability to open fully);
tocol for the clinical examination, has well defined
● Pain – in head, neck and shoulders;
inclusion and exclusion criteria, and permits multiple
● Muscular tenderness – in face, neck and shoulders;
diagnoses. Axis 1 is, however, extremely long which
● Ear complaints – otalgia, tinnitus;
may make it inapplicable to routine clinical use in all
● Psychosocial effects.
but its simplest classification. Its three groups of TMD
The variability in the signs and symptoms of TMD are: Group I – myofascial pain disorder; and Group II –
can make diagnosis, and therefore, the standardisation disc displacement disorder; Group III – degenerative
of inclusion criteria for trials difficult unless specific disease disorder.
criteria are followed. Axis 2 of the RDC consists of a self-administered
questionnaire that the patient completes. The clinician
can use this questionnaire, with the scoring system
Diagnosis
provided, to assess the level of the patient’s: chronic
Diagnosis of TMD has been attempted via epidemio- jaw pain; disability caused by their jaw complaint;
logical indices, radiography, electronic tests and clinical depression and non-specific symptoms. The question-
diagnostic indices. naire can also be used as a basis for discussion when
Epidemiological indices have been created to screen eliciting the patient’s complaint.
populations for global signs and symptoms of TMD28–34. The RDC has shown fair to good reliability in diag-
These indices are applicable for large population nosing into its three distinct Axis 1 subgroups52,53 and is
surveys but perhaps less applicable to individual clini- reliable enough to be the only descriptive diagnostic
cal situations as they do not subclassify the patient in system in wide spread use for TMD research. Further
any way or discriminate between the differing origins details and videos of how to complete both axes
of the complaint. are available on the RDC web site (http://www.
Simple plain radiography, despite much debate, has rdc-tmdinternational.org).
not been found to be particularly useful in the diagnosis
or monitoring of TMD as defined by the Research
Diagnostic Criteria (RDC) 35–37. It is, however, useful for
Psychological and psychosocial factors
demonstrating, or excluding, other pathology of the
in TMD
temporomandibular joint, e.g. rheumatoid arthritis.
Computed tomography tends to be limited to the same TMD is now recognised as a group of biopsychosocial
use. Magnetic resonance imaging has been accepted as illnesses; a trio of physical, psychological and psycho-
the current gold standard for imaging of the joint and social factors27. The physical, psychological and psy-
its associated structures when the history and clinical chosocial factors of TMD have measurable impacts on
exam indicate38 although it is not without problems oral health related quality of life54 but the relationship
such as false positives9,39 and misinterpretation40. Other between these impacts and the effects on the patient
newer imaging techniques, such as ultrasound41, have is best described as indirect and complex55. There is still
yet to undergo thorough evaluation. no real evidence to equate any aspect of psychology
Over the years, electronic tests such as jaw tracking, as an aetiological factor, or as a consequence of TMD.
vibratography, sonography, electromyography and Irrespective of this, the influence of psychological
thermography have all been suggested as diagnostic factors on TMD is of therapeutic importance27.

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Temporomandibular disorders Durham

It is known that psychological disorders are prevalent ment modality for TMD once organic pathology is
in patients suffering from TMD56,57, that they increase excluded76. They define conservative therapy as
the risk of progressing to long-term TMD, which is dif- including: supportive patient education, physical
ficult to manage58, and that their role varies depending therapy (physiotherapy), pharmacological pain control,
on gender59. Specifically, the presence of psychological intraoral appliances and simple occlusal therapy.
disorders is more frequent in females, in the form of The other, irreversible, therapies purported for
depression59. TMD are complex occlusal interventions (such as full
Psychological disorders are present both in acute and rehabilitation) and surgical approaches76. There are, of
in chronic TMD patients but more so in the latter. It is course, other ‘medical’ therapies available for TMD
thought that they may have an influence on the pro- including transcutaneous electrical nerve stimulation,
gression towards chronic TMD56. It is known that the soft laser, radiofrequency surgical cauterisation and
myofascial subgroup of TMD (Group I in RDC Axis I) chiropractic care. None of these, according to Greene,
have a predisposition to experiencing more psycho- has any scientific foundation to be recommended as a
logical distress than the other subgroups60. treatment modality in TMD77.
Two of the more common psychological disorders in Before considering the literature behind the man-
chronic TMD are somatisation (55% of patients)56,61,62 agement of TMD in detail it is important to bear in mind
and depression (39% of patients)62,63; this is in keeping Greene and Laskin’s statement, ‘with TMD patients
with chronic pain generally64. Both somatisation and it is often not what is done for them, but how it is done,
depression are felt to affect treatment adversely, with that is important.’ This statement is based on their
patients being less able to cope and placing greater research which that elicited a 35–60% placebo
demands on health care62,65,66,58. It is reasonable, response rate70,78–82 with TMD patients.
however, to question whether this is a ‘chicken and
egg’ situation and therefore TMD sufferers should not
Conservative therapy
be stigmatised.
A number of approaches have been used within
conservative therapy: cognitive behavioural therapy,
Management of TMD
physical therapy, pharmacological therapy and intra-
The literature surrounding the management of TMD is oral appliances. Although cognitive behavioural
vast, often confusing, idiosyncratic, and can be scien- therapy has been used with varying success in TMD
tifically unsubstantiated. This is in the main due to: patients83, it is suggested that all patients might experi-
methodological flaws, the multitude of outcome mea- ence some benefit from it84. It aims to increase patients’
sures employed9, the lack of a reliable standardised knowledge about factors that influence TMD symp-
outcome measure so that meta-analysis of randomised toms; increase functional and physical activities; and
controlled trials can occur67,68 and until recently (1992), train individuals to use relaxation, hypnosis and other
the lack of a clear diagnostic classification of TMD for techniques to modify the perception of pain and related
research purposes. sensations85. At the most basic level some of this can be
There is now a consensus that reversible conser- provided by simple reassurance from the clinician that
vative therapy, because of its efficacy in relieving TMD usually follows benign self-limiting course when
symptoms, should be the first-line management for managed conservatively86–88 and is a chronic illness89.
TMD8,69–71. It should be instituted once organic pathol- Physical therapy (physiotherapy) seems an intuitive
ogy such as systemic disease, hereditary conditions, or choice for an individual who may have pain in their
neoplasia is excluded as a possible diagnosis. Such musculature. Its aim is to restore normal joint function,
organic pathology is rare, recent figures for incidentally decrease loading and pain and facilitate rehabilitation
found tumours of the temporomandibular joint show to normal everyday activities90. Although physical
their incidence to be less than 1% of cases72, but cases of therapy produces short-term relief of signs and symp-
fibrosarcoma, nasopharyngeal carcinoma and lateral toms, there is little evidence suggesting that it produces
pharyngeal space infections have been reported in a long-term reduction in signs and symptoms of
the literature as mimicking the signs and symptoms TMD91–95. It will, however, perform a useful role in
of TMD73–75. Practitioners should therefore ensure helping the sufferer re-establish a degree of control in
they have undertaken a thorough examination of the an acute phase of TMD.
patient and should investigate patients appropriately. Pharmacological therapy for TMD has included such
The National Institute of Health in the U.S.A. suggests classes of drugs as non-steroidal anti-inflammatories,
reversible conservative therapy as the primary treat- opiates, antidepressants, anxiolytics and cortico-

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Durham Temporomandibular disorders

steroids. As Dionne96 points out, in his review of phar- and therefore they continue to be used, most com-
macological interventions for TMD, most of those monly for myogenous and arthogenous TMD112.
pharmacological agents used to manage TMD have not
completed any standardised assessment of efficacy. They
Irreversible therapy
therefore, as with most TMD treatment, require careful
evaluation through appropriately constructed ran- The two main forms of irreversible therapy for TMD are
domised controlled trials to demonstrate their efficacy. occlusal therapy and surgery and over the years their
The final approach to conservative management is popularity has waxed and waned.
the use of intra-oral appliances. Many designs of intra- The inception of occlusal therapy was probably with
oral appliances have been purported as efficacious in Costen’s original theory1 where he questioned the
the management of TMD; this review will discuss the ‘bite’ of individuals presenting with signs and symp-
two most common splints, the soft splint and the sta- toms of TMD and suggested that treatment ought to be
bilisation splint97,98. The soft splint is usually a flexible directed towards correcting it. In particular, correcting
polyvinyl, 2 mm thick, full coverage ‘mouth guard’ overclosure because of loss of teeth or worn dentures.
type lower jaw appliance99. It is not adjusted to the Subsequently, the ideal occlusion of teeth became
occlusion but it will provide approximate bilateral somewhat of a mantra and prophylactic measures to
occlusal contact. correct it became briefly acceptable113. The theory
The mechanism of action of splints is poorly under- underlying the correction of occlusion was that it, to a
stood and disputed, with physiological and behavioural large extent, controlled the forces applied to the TMJ
mechanisms the main theories mooted13. Splints’ and muscles of mastication and therefore if the occlu-
effectiveness is also a matter for debate because of: sion was optimised there would be no TMD.
variation in outcome measures, variability in follow-up The process of equally distributing contacting forces
and explanation of treatment outcomes100. across the teeth and ‘correcting’ the occlusion is known
Soft splints have little evidence to support their effi- as equilibration and it is done through a complex
cacy. In myogenous TMD they appear to significantly process of a diagnostic stabilisation splint, sometimes
improve symptoms in comparison to no intervention101 mounted study model trials (a mock equilibration) and
and perform as well as stabilisation appliances102. As eventual grinding of the teeth in the mouth (the
with stabilisation splints there are, however, counter occlusal equilibration).
claims that they are ineffective103,104 and some say that Occlusal therapy has been shown to be effective
they can cause increases in symptomatology in a small in some cases37,114–116 but evidence for its widespread
number of sufferers99. These claims and counter-claims use as prophylaxis or treatment has found to be
are all somewhat flawed because of the methods used lacking68,109,117 and this includes the replacement of
in the studies investigating. In light of the poor evi- posterior teeth21.
dence base for most TMD treatment and as soft splints The best summation of the indications for occlusal
are reversible, inexpensive, easy to construct, well tol- therapy is by De Boever et al.20, ‘Occlusal therapy and
erated by most patients and possibly efficacious, they occlusal adjustment as the only treatment modality is
seem a reasonable choice for the initial management of rarely defendable; however, in combination with other
TMD sufferers. forms of therapy, occlusal adjustment can contribute to
The stabilisation splint can be provided in either jaw a positive treatment outcome in selected cases’.
but often is provided in the upper jaw (maxillary). It is Temporomandibular joint surgery has taken many
usually constructed from hard acrylic or from softer forms over the years, ranging from open joint proce-
polyvinyl, or a combination, although these are less dures to minimally invasive arthroscopy. Indications
common approaches105,106. It is accurately adjusted to for surgery have been suggested to be either absolute
the patient’s occlusion and provides an optimal occlu- or relative118,119. Absolute indications are associated
sion for the individual which places their condyles in with trauma, ankylosis, congenital anomalies or
their most ‘musculoskeletally stable position’9. organic pathology that requires excision. Relative
Stabilisation splints have their proponents107–109 and indications, it is suggested, are subjectively deter-
opponents110,111. Their efficacy, as with so many TMD mined by the surgeon and should not blindly include
treatments, may also be questionable as there is some failure of conservative therapy as this may be based
evidence to show the placebo effect is similar to their on inaccurate diagnosis and treatment. Psychological
own112. A systematic review of stabilisation splints and cultural background should also play a large part
usage67 recently concluded that there was insufficient in helping the surgeon determine whether or not
evidence to argue for or against their widespread usage surgery is an option. In the main the philosophy that

Oral Surgery 1 (2008) 60–68. © 2008 The Author 63

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Temporomandibular disorders Durham

surgery ‘should avoid further harm to the joint’

References
should be adopted120 and there should be objective
signs that it is indicated. Given the limitations of 1. Costen JB. A syndrome of ear and sinus symptoms
imaging techniques already mentioned, it is important based on disturbed function of the tempromandibular
to use these as supportive evidence rather than as an joint. Ann Otol Rhinol Laryngol 1934;43:1–15.
absolute indication for surgery119. 2. Shore NA. Occlusal Equilibration and
Arthroscopy and arthrocentesis have been reported Temporomandibular Joint Dysfunction. Philadelphia,
as minimally invasive and efficacious in the manage- PA: JB Lippincott, 1959.
ment of a range of TMD including disc displacement, 3. Gray RJ, Davies SJ, Quayle AA. A clinical approach to
arthogenous TMD, and TMD that is refractory to con- temporomandibular disorders. 1. Classification and
servative treatment121–123. Unfortunately the numerous functional anatomy. Br Dent J 1994;176:429–35.
4. Madland G, Feinmann C, Newman S. Factors
studies of arthroscopy and arthrocentesis suffer from
associated with anxiety and depression in facial
the same flaws as other trials of TMD management. A
arthromyalgia. Pain 2000;84:225–32.
recent meta-analysis of surgical treatments highlighted
5. Bell WE. Clinical Management of Temporomandibular
this, specifically mentioning the lack of randomised
Disorders. Chicago, IL: Year Book Medical Publishers,
controlled trials124.
1982.
Reston and Turkelson in their meta-analysis124 did, 6. McNeill C. Temporomandibular Disorders. Guidelines
however, use a method to minimise the possibility of for Classification, Assessment and Management.
spontaneous improvement in a parallel control group. Chicago, IL: Quintessence, 1990.
Using this method they found that arthrocentesis 7. Laskin DM. Temporomandibular disorders: a term past
and arthroscopy were effective for disc displacement its time? J Am Dent Assoc 2008;139:124–8.
without reduction. Interestingly, they also found no 8. McNeill C. Management of temporomandibular
significant difference in outcome between arthroscopy disorders: concepts and controversies. J Prosthet Dent
and arthrocentesis. These results must, however, be 1997;77:510–22.
interpreted with caution as Reston and Turkelson rec- 9. Okeson JP. Management of Temporomandibular
ognise the ‘low quality’ TMD literature their review is Disorders and Occlusion. St. Louis, MO: Mosby, 2003.
based on and call for better designed trials of surgical 10. Lobbezoo F, Lavigne GJ. Do bruxism and
therapy for TMD, as do other reviews of surgical temporomandibular disorders have a cause-and-effect
therapy125,126. A recent randomised effectiveness study relationship? J Orofac Pain 1997;11:15–23.
has demonstrated that, as a primary treatment modal- 11. Ciancaglini R, Gherlone EF, Radaelli G. The
ity for closed lock, arthroscopy provides no significant relationship of bruxism with craniofacial pain and
benefit over medical management127. These discrepan- symptoms from the masticatory system in the adult
cies in the literature mean that definitive answers on population. J Oral Rehabil 2001;28:842–8.
the place of arthrocentesis and arthroscopy in the 12. Auerbach SM, Laskin DM, Frantsve LM, Orr T.
Depression, pain, exposure to stressful life events, and
management of TMD are still lacking.
long-term outcomes in temporomandibular disorder
patients. J Oral Maxillofac Surg 2001;59:628–33;
Conclusions discussion 634.
13. Dao TT, Lavigne GJ. Oral splints: the crutches for
TMD are a group of complex biopsychosocial chronic
temporomandibular disorders and bruxism? Crit Rev
illnesses, which may exhibit high placebo response
Oral Biol Med 1998;9:345–61.
rates to therapy. This along with the lack of a standar-
14. Macfarlane TV, Gray RJM, Kincey J, Worthington HV.
dised reproducible patient-based outcome measure
Factors associated with the temporomandibular
makes the evidence for TMD management difficult to
disorder, pain dysfunction syndrome (PDS):
interpret. Reversible therapies are currently considered Manchester case-control study. Oral Dis
to be the first-line management of TMD. There may be 2001;7:321–30.
specific indications for when irreversible therapies 15. Kirveskari P, Alanen P. Occlusal variables are only
might be efficacious in the management of TMD but moderately useful in the diagnosis of
these are yet to be substantiated by high-quality evi- temporomandibular disorder. J Prosthet Dent
dence. There is a need for an accepted standardised 2000;84:114–5.
reproducible outcome measure for TMD so that large- 16. Mongini F, Ciccone G, Ibertis F, Negro C. Personality
scale meta-analyses of management modalities can be characteristics and accompanying symptoms in
carried out. Only then will truly evidence-based man- temporomandibular joint dysfunction, headache, and
agement of TMD be possible. facial pain. J Orofac Pain 2000;14:52–8.

64 Oral Surgery 1 (2008) 60–68. © 2008 The Author

Journal compilation © 2008 Blackwell Munksgaard
Durham Temporomandibular disorders

17. John MT, Hirsch C, Drangsholt MT, Mancl LA, Setz the north of Finland. Proc Finn Dent Soc
JM. Overbite and overjet are not related to self-report 1974;70:37–49.
of temporomandibular disorder symptoms. J Dent Res 30. Helkimo M. Studies on function and dysfunction of
2002;81:164–9. the masticatory system. II. Index for anamnestic and
18. John MT, Miglioretti DL, LeResche L, Von Korff M, clinical dysfunction and occlusal state. Sven Tandlak
Critchlow CW. Widespread pain as a risk factor for Tidskr 1974;67:101–21.
dysfunctional temporomandibular disorder pain. Pain 31. Levitt SR, Lundeen TF. The TMJ scale: quantitative
2003;102:257–63. measurements of symptoms and treatment results.
19. Alanen P. Occlusion and temporomandibular TMJ Update 1987;5:77–80.
disorders (TMD): still unsolved question? J Dent Res 32. Levitt SR, McKinney MW, Lundeen TF. The TMJ scale:
2002;81:518–9. cross-validation and reliability studies. Cranio
20. De Boever JA, Carlsson GE, Klineberg IJ. Need for 1988;6:17–25.
occlusal therapy and prosthodontic treatment in the 33. Fricton JR, Schiffman EL. The craniomandibular
management of temporomandibular disorders. Part I: index: validity. J Prosthet Dent 1987;58:222–8.
occlusal interferences and occlusal adjustment. J Oral 34. Fricton JR, Schiffman EL. Reliability of a
Rehabil 2000;27:367–79. craniomandibular index. J Dent Res
21. De Boever JA, Carlsson GE, Klineberg IJ. Need for 1986;65:1359–64.
occlusal therapy and prosthodontic treatment in the 35. Crow HC, Parks E, Campbell JH, Stucki DS, Daggy J.
management of temporomandibular disorders. Part II: The utility of panoramic radiography in
tooth loss and prosthodontic treatment. J Oral Rehabil temporomandibular joint assessment.
2000;27:647–59. Dentomaxillofac Radiol 2005;34:91–5.
22. Von Korff M, Dworkin SF, Le Resche L, Kruger A. An 36. Epstein JB, Caldwell J, Black G. The utility of
epidemiologic comparison of pain complaints. Pain panoramic imaging of the temporomandibular joint in
1988;32:173–83. patients with temporomandibular disorders. Oral Surg
23. de Bont LG, Dijkgraaf LC, Stegenga B. Epidemiology Oral Med Oral Pathol Oral Radiol Endod
and natural progression of articular 2001;92:236–9.
temporomandibular disorders. Oral Surg Oral Med 37. Vallon D, Ekberg E, Nilner M, Kopp S. Occlusal
Oral Pathol Oral Radiol Endod 1997;83:72–6. adjustment in patients with craniomandibular
24. De Kanter RJ, Kayser AF, Battistuzzi PG, Truin GJ, disorders including headaches. A 3- and 6-month
Van ’t Hof MA. Demand and need for treatment of follow-up. Acta Odontol Scand 1995;53:55–9.
craniomandibular dysfunction in the Dutch adult 38. Laskin DM, Greene CS, Hylander WL
population. J Dent Res 1992;71:1607–12. Temporomandibular Disorders: An Evidence-Based
25. De Kanter RJ, Truin GJ, Burgersdijk RC, Van’t Hof MA, Approach to Diagnosis and Treatment. Chicago, IL:
Battistuzzi PE, Kalsbeek H et al. Prevalence in the Quintessence Pub., 2006:xii, 548.
Dutch adult population and a meta-analysis of signs 39. Ohnuki T, Fukuda M, Nakata A, Nagai H, Takahashi T,
and symptoms of temporomandibular disorder. J Dent Sasano T et al. Evaluation of the position, mobility, and
Res 1993;72:1509–18. morphology of the disc by MRI before and after four
26. Turk DC. Psychosocial and behavioral assessment of different treatments for temporomandibular joint
patients with temporomandibular disorders: disorders. Dentomaxillofac Radiol 2006;35:103–9.
diagnostic and treatment implications. Oral Surg 40. Widmalm SE, Brooks SL, Sano T, Upton LG, McKay
Oral Med Oral Pathol Oral Radiol Endod DC. Limitation of the diagnostic value of MR
1997;83:65–71. images for diagnosing temporomandibular joint
27. Suvinen TI, Reade PC, Kemppainen P, Kononen M, disorders. Dentomaxillofac Radiol 2006;
Dworkin SF. Review of aetiological concepts of 35:334–8.
temporomandibular pain disorders: towards a 41. Melis M, Secci S, Ceneviz C. Use of ultrasonography
biopsychosocial model for integration of physical for the diagnosis of temporomandibular joint
disorder factors with psychological and psychosocial disorders: a review. Am J Dent 2007;20:73–8.
illness impact factors. Eur J Pain 2005;9:613–33. 42. Lund JP, Widmer CG, Feine JS. Validity of diagnostic
28. Helkimo M. Studies on function and dysfunction of and monitoring tests used for temporomandibular
the masticatory system. 3. Analyses of anamnestic and disorders. J Dent Res 1995;74:1133–43.
clinical recordings of dysfunction with the aid of 43. Mohl ND, Lund JP, Widmer CG, McCall WD, Jr.
indices. Sven Tandlak Tidskr 1974;67:165–81. Devices for the diagnosis and treatment of
29. Helkimo M. Studies on function and dysfunction of temporomandibular disorders. Part II:
the masticatory system. I. An epidemiological electromyography and sonography. J Prosthet Dent
investigation of symptoms of dysfunction in Lapps in 1990;63:332–6.

Oral Surgery 1 (2008) 60–68. © 2008 The Author 65

Journal compilation © 2008 Blackwell Munksgaard
Temporomandibular disorders Durham

44. Mohl ND, McCall WD Jr., Lund JP, Plesh O. Devices between high-risk and low-risk patients with acute
for the diagnosis and treatment of temporomandibular TMD-related pain. J Am Dent Assoc 2004;
disorders. Part I: introduction, scientific evidence, and 135:474–83.
jaw tracking. J Prosthet Dent 1990;63:198–201. 59. Phillips JM, Gatchel RJ, Wesley AL, Ellis E, 3rd.
45. Mohl ND, Ohrbach RK, Crow HC, Gross AJ. Devices Clinical implications of sex in acute
for the diagnosis and treatment of temporomandibular temporomandibular disorders. J Am Dent Assoc
disorders. Part III: thermography, ultrasound, 2001;132:49–57.
electrical stimulation, and electromyographic 60. McCreary CP, Clark GT, Merril RL, Flack V, Oakley
biofeedback. J Prosthet Dent 1990;63:472–7. ME. Psychological distress and diagnostic subgroups of
46. Lund JP, Lavigne G, Feine JS, Goulet JP, Chaytor DV, temporomandibular disorder patients. Pain
Sessle BJ et al. The use of electronic devices in the 1991;44:29–34.
diagnosis and treatment of temporomandibular 61. Garofalo JP, Gatchel RJ, Wesley AL, Ellis E, 3rd.
disorders. J Can Dent Assoc 1989;55:749–50. Predicting chronicity in acute temporomandibular
47. Eversole LR, Machado L. Temporomandibular joint joint disorders using the research diagnostic criteria.
internal derangements and associated neuromuscular J Am Dent Assoc 1998;129:438–47.
disorders. J Am Dent Assoc 1985;110:69–79. 62. Yap AU, Tan KB, Chua EK, Tan HH. Depression and
48. Laskin DM, Block S. Diagnosis and treatment of somatization in patients with temporomandibular
myofacial pain-dysfunction (MPD) syndrome. disorders. J Prosthet Dent 2002;88:479–84.
J Prosthet Dent 1986;56:75–84. 63. Meldolesi G, Picardi A, Accivile E, Toraldo di Francia R,
49. Truelove EL, Sommers EE, LeResche L, Dworkin SF, Biondi M. Personality and psychopathology in
Von Korff M. Clinical diagnostic criteria for TMD. New patients with temporomandibular joint
classification permits multiple diagnoses. J Am Dent pain-dysfunction syndrome. A controlled
Assoc 1992;123:47–54. investigation. Psychother Psychosom 2000;69:322–8.
50. Farrar WB. Differentiation of temporomandibular 64. Birket-Smith M. Somatization and chronic pain. Acta
joint dysfunction to simplify treatment. J Prosthet Anaesthesiol Scand 2001;45:1114–20.
Dent 1972;28:629–36. 65. Fricton J, Dubner RB. Orofacial Pain and
51. Dworkin SF, LeResche L. Research diagnostic criteria Temporomandibular Disorders. New York: Raven
for temporomandibular disorders: review, criteria, Press, 1995.
examinations and specifications, critique. 66. Dworkin SF. Perspectives on the interaction of
J Craniomandib Disord 1992;6:301–55. biological, psychological and social factors in TMD.
52. Lausten LL, Glaros AG, Williams K. Inter-examiner J Am Dent Assoc 1994;125:856–63.
reliability of physical assessment methods for assessing 67. Al-Ani MZ, Davies SJ, Gray RJ, Sloan P, Glenny AM.
temporomandibular disorders. Gen Dent Stabilisation splint therapy for temporomandibular
2004;52:509–13. pain dysfunction syndrome. Cochrane Database Syst
53. John MT, Dworkin SF, Mancl LA. Reliability of clinical Rev 2004;CD002778.
temporomandibular disorder diagnoses. Pain 68. Koh H, Robinson PG. Occlusal adjustment for treating
2005;118:61–9. and preventing temporomandibular joint disorders.
54. Reissmann DR, John MT, Schierz O, Wassell RW. Cochrane Database Syst Rev 2003;CD003812.
Functional and psychosocial impact related to specific 69. Dimitroulis G. Temporomandibular disorders: a
temporomandibular disorder diagnoses. J Dent clinical update. BMJ 1998;317:190–4.
2007;35:643–50. 70. Greene CS, Laskin DM. Long-term evaluation of
55. Ohrbach R, Dworkin SF. Five-year outcomes in TMD: conservative treatment for myofascial
relationship of changes in pain to changes in physical pain-dysfunction syndrome. J Am Dent Assoc
and psychological variables. Pain 1998;74:315– 1974;89:1365–8.
26. 71. Greene CS, Laskin DM. Long-term evaluation of
56. Gatchel RJ, Garofalo JP, Ellis E, Holt C. Major treatment for myofascial pain-dysfunction syndrome:
psychological disorders in acute and chronic TMD: an a comparative analysis. J Am Dent Assoc
initial examination. J Am Dent Assoc 1983;107:235–8.
1996;127:1365–70, 1372, 1374. 72. Yanagi Y, Asaumi J, Maki Y, Murakami J, Hisatomi M,
57. Parker MW, Holmes EK, Terezhalmy GT. Personality Matsuzaki H et al. Incidentally found and unexpected
characteristics of patients with temporomandibular tumors discovered by MRI examination for
disorders: diagnostic and therapeutic implications. temporomandibular joint arthrosis. Eur J Radiol
J Orofac Pain 1993;7:337–44. 2003;47:6–9.
58. Wright AR, Gatchel RJ, Wildenstein L, Riggs R, 73. Brown RS, Johnson CD, Fay RM. The misdiagnosis of
Buschang P, Ellis E, 3rd. Biopsychosocial differences temporomandibular disorders in lateral pharyngeal

66 Oral Surgery 1 (2008) 60–68. © 2008 The Author

Journal compilation © 2008 Blackwell Munksgaard
Durham Temporomandibular disorders

space infections – two case reports. Cranio temporomandibular disorders. Oral Surg Oral Med
1994;12:194–8. Oral Pathol Oral Radiol Endod 1997;83:77–81.
74. Orhan K, Orhan AI, Oz U, Pekiner FN, Delilbasi C. 88. Magnusson T, Egermark I, Carlsson GE. A longitudinal
Misdiagnosed fibrosarcoma of the mandible epidemiologic study of signs and symptoms of
mimicking temporomandibular disorder: a rare temporomandibular disorders from 15 to 35 years of
condition. Oral Surg Oral Med Oral Pathol Oral Radiol age. J Orofac Pain 2000;14:310–9.
Endod 2007;104:e26–9. 89. Dworkin SF, Massoth DL. Temporomandibular
75. Reiter S, Gavish A, Winocur E, Emodi-Perlman A, Eli I. disorders and chronic pain: disease or illness?
Nasopharyngeal carcinoma mimicking a J Prosthet Dent 1994;72:29–38.
temporomandibular disorder: a case report. J Orofac 90. Di Fabio RP. Physical therapy for patients with TMD: a
Pain 2006;20:74–81. descriptive study of treatment, disability, and health
76. Albino JEN. Management of temporomandibular status. J Orofac Pain 1998;12:124–35.
disorders. National institutes of health technology 91. Feine JS, Widmer CG, Lund JP. Physical therapy: a
assessment conference statement. J Am Dent Assoc critique. Oral Surg Oral Med Oral Pathol Oral Radiol
1996;127:1595–606. Endod 1997;83:123–7.
77. Greene CS. An evaluation of unconventional methods 92. Feine JS, Lund JP. An assessment of the efficacy of
of diagnosing and treating temporomandibular physical therapy and physical modalities for the
disorders. Oral Maxillofac Surg Clin North Am control of chronic musculoskeletal pain. Pain
1995;7:167–73. 1997;71:5–23.
78. Shipman WG, Greene CS, Laskin DM. Correlation of 93. Sturdivant J, Fricton JR. Physical therapy for
placebo responses and personality characteristics in temporomandibular disorders and orofacial pain. Curr
myofascial pain-dysfunction (MPD) patients. Opin Dent 1991;1:485–96.
J Psychosom Res 1974;18:475–83. 94. Chapman CE. Can the use of physical modalities
79. Greene CS, Laskin DM. Meprobamate therapy for the for pain control be rationalized by the research
myofascial pain-dysfunction (MPD) syndrome: evidence? Can J Physiol Pharmacol 1991;69:
a double-blind evaluation. J Am Dent Assoc 704–12.
1971;82:587–90. 95. Michelotti A, de Wijer A, Steenks M, Farella M.
80. Laskin DM, Greene CS. Influence of the doctor-patient Home-exercise regimes for the management of
relationship on placebo therapy for patients with non-specific temporomandibular disorders. J Oral
myofascial pain-dysfunction (MPD) syndrome. J Am Rehabil 2005;32:779–85.
Dent Assoc 1972;85:892–4. 96. Dionne RA. Pharmacologic treatments for
81. Greene CS, Laskin DM. Splint therapy for the temporomandibular disorders. Oral Surg Oral Med
myofascial pain – dysfunction (MPD) syndrome: a Oral Pathol Oral Radiol Endod 1997;83:134–42.
comparative study. J Am Dent Assoc 1972;84:624–8. 97. Lindfors E, Magnusson T, Tegelberg A. Interocclusal
82. Goodman P, Greene CS, Laskin DM. Response of appliances – indications and clinical routines in
patients with myofascial pain-dysfunction syndrome general dental practice in Sweden. Swed Dent J
to mock equilibration. J Am Dent Assoc 2006;30:123–34.
1976;92:755–8. 98. Pierce CJ, Weyant RJ, Block HM, Nemir DC. Dental
83. Dworkin SF. Behavioral and educational modalities. splint prescription patterns: a survey. J Am Dent Assoc
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;126:248–54.
1997;83:128–33. 99. Gray RJ, Davies SJ. Occlusal splints and
84. Turner JA, Holtzman S, Mancl L. Mediators, temporomandibular disorders: why, when, how?
moderators, and predictors of therapeutic change in Dent Update 2001;28:194–9.
cognitive-behavioral therapy for chronic pain. Pain 100. Major PW, Nebbe B. Use and effectiveness of splint
2007;127:276–86. appliance therapy: review of literature. Cranio
85. Dworkin SF, Turner JA, Wilson L, Massoth D, 1997;15:159–66.
Whitney C, Huggins KH et al. Brief group cognitive- 101. Wright E, Anderson G, Schulte J. A randomized
behavioral intervention for temporomandibular clinical trial of intraoral soft splints and palliative
disorders. Pain 1994;59:175–87. treatment for masticatory muscle pain. J Orofac Pain
86. de Leeuw R, Boering G, Stegenga B, de Bont LG. 1995;9:192–9.
Clinical signs of TMJ osteoarthrosis and internal 102. Pettengill CA, Growney MR Jr., Schoff R, Kenworthy
derangement 30 years after nonsurgical treatment. CR. A pilot study comparing the efficacy of hard and
J Orofac Pain 1994;8:18–24. soft stabilizing appliances in treating patients with
87. Stohler CS. Phenomenology, epidemiology, and temporomandibular disorders. J Prosthet Dent
natural progression of the muscular 1998;79:165–8.

Oral Surgery 1 (2008) 60–68. © 2008 The Author 67

Journal compilation © 2008 Blackwell Munksgaard
Temporomandibular disorders Durham

103. Nevarro E, Barghi N, Rey R. Clinical evaluation of 116. Vallon D, Ekberg EC, Nilner M, Kopp S. Short-term
maxillary hard and resilient occlusal splints. J Dent effect of occlusal adjustment on craniomandibular
Res 1985;64:313. disorders including headaches. Acta Odontol Scand
104. Okeson JP. The effects of hard and soft occlusal splints 1991;49:89–96.
on nocturnal bruxism. J Am Dent Assoc 117. Tsukiyama Y, Baba K, Clark GT. An evidence-based
1987;114:788–91. assessment of occlusal adjustment as a treatment for
105. Wright EF. Manual of Temporomandibular Disorders. temporomandibular disorders. J Prosthet Dent
Ames, IA: Blackwell Munksgaard, 2005:xvi, 338. 2001;86:57–66.
106. Moufti MA, Lilico JT, Wassell RW. How to make a 118. Dolwick MF, Dimitroulis G. Is there a role for
well-fitting stabilization splint. Dent Update 2007; temporomandibular joint surgery? Br J Oral
34:398–400, 402–4, 407–8. Maxillofac Surg 1994;32:307–13.
107. Magnusson T, Adiels AM, Nilsson HL, Helkimo M. 119. Dimitroulis G. The role of surgery in the management
Treatment effect on signs and symptoms of of disorders of the temporomandibular joint: a critical
temporomandibular disorders – comparison between review of the literature. Part 2. Int J Oral Maxillofac
stabilisation splint and a new type of splint (NTI). A Surg 2005;34:231–7.
pilot study. Swed Dent J 2004;28:11–20. 120. Dolwick MF. The role of temporomandibular joint
108. Davies SJ, Gray RJ. The pattern of splint usage in the surgery in the treatment of patients with internal
management of two common temporomandibular derangement. Oral Surg Oral Med Oral Pathol Oral
disorders. Part II: the stabilisation splint in the Radiol Endod 1997;83:150–5.
treatment of pain dysfunction syndrome. Br Dent J 121. Kunjur J, Anand R, Brennan PA, Ilankovan V. An
1997;183:247–51. audit of 405 temporomandibular joint arthrocentesis
109. Forssell H, Kalso E, Koskela P, Vehmanen R, Puukka P, with intra-articular morphine infusion. Br J Oral
Alanen P. Occlusal treatments in temporomandibular Maxillofac Surg 2003;41:29–31.
disorders: a qualitative systematic review of 122. Brennan PA, Ilankovan V. Arthrocentesis for
randomized controlled trials. Pain 1999;83:549–60. temporomandibular joint pain dysfunction syndrome.
110. Turp JC, Komine F, Hugger A. Efficacy of stabilization J Oral Maxillofac Surg 2006;64:949–51.
splints for the management of patients with 123. McCain JP, Sanders B, Koslin MG, Quinn JH, Peters
masticatory muscle pain: a qualitative systematic PB, Indresano AT. Temporomandibular joint
review. Clin Oral Investig 2004;8:179–95. arthroscopy: a 6-year multicenter retrospective study
111. Marbach JJ, Raphael KG. Future directions in the of 4831 joints. J Oral Maxillofac Surg 1992;50:926–30.
treatment of chronic musculoskeletal facial pain: the 124. Reston JT, Turkelson CM. Meta-analysis of surgical
role of evidence-based care. Oral Surg Oral Med Oral treatments for temporomandibular articular
Pathol Oral Radiol Endod 1997;83:170–6. disorders. J Oral Maxillofac Surg 2003;61:3–10;
112. Wassell RW, Adams N, Kelly PJ. Treatment of discussion 10–12.
temporomandibular disorders by stabilising splints in 125. Al-Belasy FA, Dolwick MF. Arthrocentesis for the
general dental practice: results after initial treatment. treatment of temporomandibular joint closed lock: a
Br Dent J 2004;197:35–41; discussion 31. review article. Int J Oral Maxillofac Surg
113. Molin C. From bite to mind: TMD – a personal and 2007;36:773–82.
literature review. Int J Prosthodont 1999;12:279–88. 126. Ethunandan M, Wilson AW. Temporomandibular
114. Forssell H, Kirveskari P, Kangasniemi P. Effect of joint arthrocentesis -more questions than answers?
occlusal adjustment on mandibular dysfunction. J Oral Maxillofac Surg 2006;64:952–5.
A double-blind study. Acta Odontol Scand 127. Schiffman EL, Look JO, Hodges JS, Swift JQ, Decker
1986;44:63–9. KL, Hathaway KM et al. Randomized effectiveness
115. Forssell H, Kirveskari P, Kangasniemi P. Response to study of four therapeutic strategies for TMJ closed
occlusal treatment in headache patients previously lock. J Dent Res 2007;86:58–63.
treated by mock occlusal adjustment. Acta Odontol
Scand 1987;45:77–80.

68 Oral Surgery 1 (2008) 60–68. © 2008 The Author

Journal compilation © 2008 Blackwell Munksgaard