Medical Hypotheses 74 (2010) 710–718

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Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy

Stomatognathic adaptive motor syndrome is the correct diagnosis

for temporomandibular disorders
Carlos Roberto Douglas, José Luiz Villaça Avoglio *, Heloisa de Oliveira
Rua João Zappa 215, 12516 300 Guaratinguetá, SP, Brazil

a r t i c l e i n f o s u m m a r y

Article history: Temporomandibular disorder is a generic and inadequate conception to be used as a diagnosis. It fails to
Received 9 October 2009 express the etiology or the pathophysiology and it is mainly associated with the anatomical site. More-
Accepted 14 October 2009 over, the clinical condition presents a mandibular motor problem and not a joint problem. The hypothesis
presents the new diagnosis stomatognathic motor adaptive syndrome, which comprehend a motor
response and the adaptive processes it induces. Inadequate occlusal contacts cause the mandible to shift
in order to reach an ideal intercuspal position. The condylar displacements are proportional to such
movements. Temporomandibular joint (TMJ) receptors respond to the capsular mechanical stress and
the information reaches the trigeminal sensory nuclei. The mandibular modified position seems to be rel-
evant information and may interfere with catecholaminergic neurotransmission in basal ganglia. The
main motor responses comprise increased jaw muscle tone, decreased velocity of movements and inco-
ordination. The overload of muscle function will produce adaptive responses on many stomatognathic
structures. The muscle adaptive responses are hypertonia, pain, fatigue and weakness. Temporomandib-
ular joint presents tissue modification, disc alteration and cracking noise. Periodontium show increased
periodontal membrane, bone height loss and gingival recession. Teeth manifest increased wear facets,
abfraction and non-accidental fractures. The periodontal and teeth adaptive processes are usually iden-
tified as occlusal trauma. The altered stomatognathic functions will show loss of velocity during masti-
cation and speech. Fatigue, weakness in jaw muscle and difficulties to chew hard food are related to
hypertonia. Incoordination between stomatognathic muscles groups is found, causing involuntary ton-
gue/cheek biting and lateral jaw movements on speech. Otologic complaints, as aural fullness and tinni-
tus, are related to the tensor tympani muscle, innervated by the trigeminal nerve.
Ó 2009 Elsevier Ltd. All rights reserved.

Introduction have been used incorrectly as internal derangement, like osteoar-

thritis of the temporomandibular joint. The etiology were subject
‘‘Temporomandibular disorders (TMD) refer to a collection of of many consideration, but at moment may be considered as un-
medical and dental conditions affecting the temporomandibular known or not established. Consequently, there is a fully agreement
joint and/or the muscles of mastication, as well as contiguous tis- that just conservative and reversible therapies are recommended.
sue components” [1]. Under this concept various conditions, that The concept in such diagnosis is based mainly on the anatomi-
have no common etiology, are joined in the same diagnosis. Joint cal site and not on the etiology or the pathophysiology. In this
diseases, facial or joint or muscle pain, headache, joint sounds, den- sense, the belief that the etiology of TMD is multifactorial is not
tal wear, hearing disturbance and others are examples of condi- applicable [2]. Various diseases are multifactorial, as lung cancer,
tions aggregated on the same diagnosis. pneumonia and emphysema. Indeed, should Lung Disorders be
The conflict of the prevailing concept is the admission of func- adopted as the diagnosis, there would be no way to prove that a
tional, degenerative, autoimmune and inflammatory problems as treatment was effective to all manifestations. It would not be pos-
one pathology. In addition, there is a general acceptance of a joint sible to prove that chemotherapy, or antibiotic are effective treat-
disease with subtypes. Many subtypes were suggested, and ranges ments. The diagnosis ‘‘temporomandibular disorder” jeopardizes
from myofascial pain, arthralgia, disc displacement to internal the comparison of clinical studies because the sample could not
derangements. Many of the diseases classified as subtype have be always homogeneous.
their own code on the International Classification of Diseases and The stomatognathic system performs many physiologic func-
tions. They embrace mastication, speech mechanics, suction,
* Corresponding author. Tel.: +55 012 3125 1767. deglutition, spitting, blowing and vomiting, among others. In all
E-mail address: [email protected] (J.L.V. Avoglio). those functions there are mandibular motor request and, at the

0306-9877/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.mehy.2009.10.028
 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718 711

same time, movements of the tongue, hyoid, soft palate, lips and incorrect restoration among others, generically denominated as
other structures. All functions are motor events involving several inadequate occlusal contact in this paper.
muscle groups that reach the neck, and maybe more. All these When inadequate contact appears, the mandible is forced to
tasks happen under the command of the central nervous system make minimal movements to obtain better intercuspal position,
and undergo the influence of peripheral inputs, allowing the har- because teeth and condyles have a fixed relation in the same bone
monious execution of all those events. (Fig. 1). The TMJ capsular mechanoreceptors will fire impulses sig-
The mandible distinguishes in the system as the only movable naling the altered mandibular position, with reflex response on
bone and by its role as support for the movement of other muscles mandibular muscles.
groups, in addition to its own muscles. Moreover, the mandible is Reflex muscular response is the first stomatognathic system
involved in the stabilization of the head and in the maintenance of adaptive mechanism. Probably mediated by the basal ganglia,
the postural equilibrium, because mandibular and hyoid muscles there will be decreased mandibular movements, higher levels of
are antagonist of the cervical musculature [3]. muscle tone and incoordination of mandibular movement and
On the mandibular motor action, many demands of movements other stomatognathic structures. It could be found involuntary
and postural muscle tone occur simultaneously. During speech, for movements also.
example, mandibular movements are executed by isotonic contrac- Along the time, the overload of muscle response will activate
tion of the muscles, but with instantaneous increase of tone, when other stomatognathic adaptive mechanisms and cause modifica-
the tongue is elevated and moved. These movements are the execu- tions in other structures due to the over-solicitation. Such adaptive
tion of central commands that continuously evaluate peripheral in- changes will occur on TMJ tissues, periodontium, teeth and mus-
puts in order to obtain the correct function performance. cles (Fig. 2). These dynamic processes can be named allostasis
Teeth have an effect on mandibular actions. The intercuspal po- and the organic reaction can be effective enough to sustain normal
sition of maxillary and mandibular teeth is determinant to the jaw clinical conditions or reach a situation of insufficiency.
movement envelope, especially while chewing. This primary man- In temporomandibular structures changes will happen in artic-
dibular action can influence all other tasks, because the occlusal ular tissues, disc and cracking noises will appear. The periodon-
anatomy is closely related with the mandibular function. Noting tium will show remodeling changes with or without tooth
the mandible and teeth crowns evolution through the phylogene- hypermobility, bone loss and gingival recession. Teeth will reveal
sis, such correlation is always preserved. wear facets, abfraction, and non-accidental crown or restoration
When some perturbation intervenes on the motor procedures of fractures. Muscle will evidence hypertonia, pain on palpation and
the stomatognathic system, the organism uses various adaptive increased volume. Functional alterations will include incoordina-
processes to maintain the efficient execution of the different func- tion, as intraoral involuntary biting while chewing (tongue and/
tions. In case of depletion or insufficiency of such adaptive capac-
ity, the system will produce a failure in some point, which will be
manifested as a sign or a symptom, interpreted as a disease or as a
dysfunction. The aim of this paper is to propose a new hypothesis,
attempting to demonstrate that the problems nowadays diagnosed
as temporomandibular disorder are not a joint problem, but a mo-
tor problem. Such motor alterations involve all stomatognathic
system and its functions, and the signs and symptoms found in
these cases will be analyzed, explaining the pathophysiology re-
lated to those processes.

The hypothesis

Mandibular movements are governed by the central nervous

system. Several encephalic structures are involved in the control
of movements during the execution of varied functions, as can be
observed following electrical stimulation. Among them, the basal
ganglia seem to have an important role on selecting a determinate Fig. 1. Inadequate contacts force the mandible to make minimal movements to
obtain better intercuspal position, because teeth and condyles have a fixed relation
motor program and on the coordination of simultaneous activities
in the same bone.
carried out by several muscle groups. This control modulates the
magnitude of movements and tone, while executing the appropri-
ate motor program. The basal ganglia assess the relevance of
peripheral impulses and give an output to brainstem motoneurons
controlling mandibular movements and postural tone.
The intercuspal relation of the teeth has a relevant role on man-
dibular movements and postural tone. There is considerable con-
troversy about mandibular positions, but it is generally accepted
that there is a mandibular position independent of tooth contact
that represents the position of the condyle-disc complex in the gle-
noid fossa, denominated centric relation (CR). Another is the cen-
tric occlusion (CO), an intercuspal position independent of the
condylar position. These positions are not always ideally coinci-
dent, but constantly the receptors from periodontium and TMJ cap-
sule will fire to inform those positions.
Several dental conditions can cause those positions to show
anterioposterior difference, like caries, tooth loss, malocclusion, Fig. 2. Flowchart of the stomatognathic motor adaptive syndrome.
712 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718

Table 1 muscle activity were was noticed after capsule anesthesia even
Structure and the signs and symptoms related to stomatognathic motor adaptive with the mandible having being fixed [7].
syndrome.
Wyke [8] observed that capsule receptors are able to detect the
TMJ Tissues modification static and dynamic position of the condyle, as well as acceleration
Disc alteration and deceleration of movements and extreme posterior displace-
Cracking noise
ment. Those receptors are essential in the perception of TMJ struc-
Periodontium Increased periodontal membrane tures posture and motion and are the major contributors in the
Bone height loss
Gingival recession
reflex regulation of muscle tone, presumably operating through
the fusimotor system. He remarked that incidental observation
Teeth Increased wear facets
Abfraction
suggests that the articular receptors reflexes operate along poly-
Non-accidental fractures synaptic pathways and project to gamma system rather than only
Muscle Pain
to alphamotoneurons.
Hypertonia The mechanoreceptors from TMJ capsule are responsible for the
Fatigue proprioception of mandibular static position and dynamic move-
Weakness ment and act through reflex muscle tone. Experiments, where
Function Loss of velocity Mastication destruction or anesthesia of those receptors was performed,
Speech showed abnormalities on movements and reflex posture. Type I
Tone Fatigue
mechanoreceptors (see Wyke’s classification) continuously con-
Weakness
Difficulty to chew hard food tribute to isotonic and isometric changes in jaw muscles, while
Incoordination Involuntary tongue/cheek biting type II bring tone increase on acceleration and deceleration condy-
Lateral jaw movement on speech lar movements. The type III mechanoreceptors act as brake to limit
Otologic Aural fullness excessive posterior displacement of the condyles, causing inhibi-
complaints Tinnitus tion of musculature [8].
Experiments with TMJ mechanoreceptors performed by Clark
and Wyke reveal that generalized increase on motor activities of
or cheek), lateral movement and decreased speed on speech, fati- all mandibular muscles were found after anesthetic infiltration in
gue and difficulty while chewing hard food. Otologic complaints the posterior region of the capsule [6]. Electrocoagulation of the
maybe related to tonic changes in the tensor tympani and/or the TMJ anterior region expressed a significative reduction of the dy-
tensor veli palatini, since both receive trigeminal motor innerva- namic reflex activities in response to the passive opening, in all
tion (Table 1). muscles. Combined electrocoagulation of both anterior and poster-
It does not seem to have distinction between men and women ior regions of TMJ virtually abolished the dynamic reflex activities
about the pathophysiology described, but can be noted that wo- in both directions. The results of such experiments are evidence
men manifest more symptoms, especially muscle pain, while that capsular mechanoreceptors have crucial contribution to the
men show more dental signs. Another aspect of the problem is reflex control of motor activities of jaw muscles.
the emotional/behavioral condition interrelation with the motor Rapidly adapting responses were found in certain places of the
response. medulla and spinal trigeminal sensory nuclei obtained by opening
This hypothesis makes a pathophysiological model, where all and closing movements of the condyle, with corresponding activi-
signs and symptoms, nowadays diagnosed as temporomandibular ties on the homolateral trigeminal motor nucleus. This indicates
disorders, can be connected. The appropriate diagnosis should be that not only the muscle proprioception but also the inputs from
stomatognathic adaptive motor syndrome. TMJ participate on the control of muscle activities of the jaw [9].
The inadequate intercuspal relation of the teeth may result in
minimal mandibular positional changes and, in consequence, mod-
Physiology of the mandibular motor control ification on condylar position, causing alteration on capsular stress
pattern. This will cause changes on firing rate of the TMJ capsule
Mandibular movements and postural tone are performed by the mechanoreceptors [6]. Similar preparation suggested that TMJ
trigeminal motor nucleus that represents the lower motoneuron. mechanoreceptors operate through multisynaptic pathway, in con-
The operation of the lower motoneuron is controlled by upper trast with the monosynaptic nature of the miotatic masticatory re-
motoneurons, distributed throughout the central nervous system. flex [5].
Those neurons are found in motor cortex, basal ganglia, limbic sys-
tem, cerebellum and reticular formation. Mandibular movements Periodontal receptors
represent the action of central motor programs, but influenced
by many other variables, like head position, peripheral impulses Periodontal mechanoreceptors also influence the reflex control
and emotional/behavioral conditions. The relevancy of receptor of jaw muscles and participate on the regulation of the force ap-
information may affect muscle response in a wide range, from a plied over the occlusal surface by jaw muscles. Evidence of this
hypokinetic–hypertonic to a hyperkinetic–hypotonic pattern. observation is the improvement on brain control of mandibular
movements in patients that used conventional complete dentures,
TMJ capsular receptors but without melioration on occlusal force following rehabilitation
with dental implants [10,11]. Studies demonstrated that bite force
Temporomandibular capsular receptors are involved in reflex dramatically decreases with local anesthesia of the teeth. It can be
control of mandibular muscles. When there is a displacement of concluded that periodontal mechanoreceptors add an extra excita-
the condyle, the muscles contract in response. Studies with tion of the closing muscles and provide the essential information to
anesthesia of TMJ capsule showed great variation on amplitude avoid periodontal damage [12]. Those receptors could have lesser
and direction of mandibular movements following uni- or bilateral influence on movements, acting on the occlusal phase of the mas-
TMJ capsule anesthesia [4–6]. Mandibular rest position is under ticatory cycle. Nevertheless, in altered motor response this mecha-
control of neuromuscular reflex and determined by the tone of nism is connected with longstanding tightened occlusal contacts
supra and infra mandibular muscles, because an increase on mentioned in dental literature as occlusal trauma.
 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718 713

Periodontal receptors have their cellular bodies on trigeminal allowing some motor solicitation and inhibiting others. The basal
mesencephalic nucleus (Vmes) and on trigeminal ganglion ganglia operate essentially inhibiting the several motor solicita-
[13,14]. Most of periodontal receptors which somas are located tions and, apparently, liberate the solicitation with most significant
in the mesencephalic nucleus are distributed in apical region and priority. It is argued that in Parkinson’s disease there is incapability
tend to have slowly adaptation, while the more coronal receptors to remove this inhibitory motor control and difficulties on the
are innervated by neurons from trigeminal ganglion. selection mechanism. Other conditions may be related with failure
Trigeminal ganglion neurons show fast adaptation and burst in the mechanism that suppresses the activities of other motor
with tooth displacement [15]. Studies showed that those projec- solicitation, not having the mechanism that interrupts the motor
tions reach the supratrigeminal region, the interstitial system of execution, like in Huntington’s chorea.
the spinal trigeminal tract, parvocellular reticular formation, as The lower motoneurons in brainstem are maintained under ba-
well as the upper cervical spinal cord and cerebellum. This indi- sal ganglia tonic inhibition output through GABAergic projections
cates that those receptors collaborate on the control of jaw posture from Globus Pallidus and Substantia Nigra. When a demand exists
by the forces generated on teeth intercuspal position. for a motor action that inhibition is suppressed [17]. The selection
Neurons from Vmes are related with mandibular reflexes and operates in memory-guided behavior, sequential procedures and
are active on occlusal phase of masticatory cycle, since an increase reward oriented behavior [18].
on the firing rate of these neurons are proportional to the mastica- The neurons from striatum receive the basal ganglia incoming
tory force. inputs from different cortex regions [17]. In addition, the striatum
For this reason it is possible to suppose that inadequate occlusal receive inputs form various thalamic nuclei. Spiny output neurons
contacts will produce motor responses that change the mandibular from striatum are high threshold inhibitory (GABAergic) and re-
position in relation to maxilla. This change is detected by the TMJ spond only to intense excitatory input. They tend to remain stabi-
mechanoreceptors with compensatory muscle repercussion. This lized, in hyperpolarized status (down state). However, in the
supposition explains the probable action of varied interocclusal presence of dopamine (via D1 receptors) they reach an up state,
splints, which promote the elimination of teeth contacts allowing close to firing threshold. Most of these neurons project to output
the normalization of the condylar position. neurons of basal ganglia (substantia nigra pars reticulata, globus
pallidus pars interna and ventral pallidum). When the striatum
Integration of peripheral inputs and motor response neurons are activated, they will inhibit these output neurons and
then suppress the inhibition over brainstem motor centers, activat-
Mastication and other functional jaw motions seem to be ing motor programs. Therefore, the motor control of basal ganglia
sequential procedures activating motor areas, which may generi- depends on cortical and thalamic excitatory impulses and the
cally be called motor programs. There is a pattern of movements dopaminergic system. The brain controls through the dopaminer-
with activation and inhibition of antagonist muscles and coordina- gic system the voluntary movements by tone decreasing and
tion with different muscle groups. Such movements take place in increasing contractility of skeletal muscles [19].
all stomatognathic functions and are related with motor, emotional Electrical stimulation of the substantia nigra influences the con-
and behavioral aspects. trol on movements and tone. The stimulation of the ventral portion
Electrical stimulation of motor cortex, amygdala, hypothala- induced rhythmical activities on orofacial muscles. There are evi-
mus, basal ganglia, and reticular formation evoke rhythmic jaw dences that mandibular movements are also mediated by the con-
movements. These movements are under the influence of periphe- nection from substantia nigra to superior colliculus [20].
ral impulses that help the execution of the function. Experiments Hikosaka suggests that basal ganglia control the movements
of cortically induced mastication in anesthetized animals showed through projections to the brainstem motor areas and thalamus.
that after inserting objects between teeth, the masticatory cycle Particular patterns of movement like saccadic, chewing, vocaliza-
becomes significantly longer with mandibular deviation toward tion and swallowing are generated on brainstem, and the basal
the contralateral side during the occlusal phase. Similar prepara- ganglia involvement on these movements could be related with
tion showed increased muscle activity proportional to the thick- the achievement of automatic control of these processes that fol-
ness of plastic strips inserted between the teeth. The removal of low the voluntary movements [20]. The author emphasizes the sig-
periodontal impulses by anesthesia or sectioning virtually abol- nificance of the GABAergic projections to the mesopontine
ished these effects [13]. tegmentum on tone and movements control. Therefore, the basal
However, it there appears to be a difference in the action of the ganglia control mandibular motor actions through the inhibition/
peripheral impulse when related to the evaluation of food hardness disinhibition of muscle tone and movement systems. These sys-
and when related to inadequate intercuspal relation. The former tems can be individually controlled because the lateral part of sub-
could be associated with periodontal receptors and the latter with stantia nigra controls postural tone and the medial part controls
capsular receptors. The capsular receptors suggest a long lasting locomotion.
action, with the condition being added to the jaw motor program. The striatum is involved on several mandibular motor aspects,
In another words, the inadequate intercuspal condition is merged like rhythmical movements and muscle tone. Neurochemical
with the motor program while performing the mandibular changes in this region were associated with occlusal interferences
functions. in rats. Not only dopaminergic but also noradrenergic. Evidences
Evidences of that supposition will be discussed below, but it is suggest that inadequacy on occlusal relation induces sensory stim-
observable that alterations occur on speech movements even with- uli to the central nervous system, through trigeminal path, which
out dental contacts on this function. Another is the involuntary may change the neurotransmission of dopamine in various regions.
tongue/cheek biting while chewing. These functions also show de- Experiments with occlusal disharmonies in rats showed accu-
creased velocity of movements and increased tone. mulation of DOPA on the striatum that returned to control levels
The basal ganglia are supposed to participate on the selection of after 14 days, except in the left striatum causing an imbalance be-
the motor pattern and on the integration with other stomato- tween hemispheres. This study gave evidences of a central modu-
gnathic structures movements (e.g. tongue). Lesions of basal gan- lation of catecholaminergic neurotransmission induced by
glia are associated with alterations on planning, initiation and inadequate occlusal contacts. Moreover, the results appear to be
execution of motor actions. Some authors accept the hypothesis related to the nature of the occlusal alteration and the duration
that basal ganglia act as a centralized selection mechanism [16], of the problem. Long lasting inadequate occlusal contacts can
714 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718

cause modifications on mandibular motor patterns by this mecha- Overload and adaptation
nism [21]. Nevertheless, the experiment refers to an acrylic cap on
both incisors of rats, which probably influenced the mandibular Adaptive processes are associated with the relation between
position, because the other groups of the study where the occlusal damage and defense. When a perturbation intervenes on a system,
alteration were just dental (incisal cut) the effects were not there will be an initial response to keep the functions running.
significant. Usually, the initial response promotes the activation of adaptive
Reflex modifications of jaw muscles pattern are also involved mechanisms in sites under overload. The composed response can
with the antigravitational muscles of the head. Equilibrium is an lead the situation to a balanced status even with higher level of en-
active process that keeps the extensor musculature under tonic ergy consumption. When the resources of a site are insufficient or
contraction, as consequence of the excitation of the gamma moto- ineffective, a failure will occur [34].
neuron, promoted by the vestibular complex. The vestibular nuclei The inadequate occlusal contact initially produces the altered
are excited by impulses from visual cortex, spindle from cervical mandibular position and the first response is muscular. Various
muscles, the vestibular sensory organs and cerebellar fibres [22]. sites of the stomatognathic system will be put under overloaded
Inadequate occlusal contacts caused immediate electromyographic solicitation and will respond with adaptive processes that can lead
changes in jaw muscles and sternocleidomastoid [23] and patients to a homeostatic situation and this maybe the reason because the
treated by occlusal adjustment reported significant improvement majority of individuals do not show any symptom. All these effects
on headache symptoms [24]. Electromyographic alterations were are considered allostasis, defined as achieving stability through
also found on jaw muscles when position of the head changed [25]. change [35]. In case of depletion or insufficiency of such adaptive
capacity, the allostatic overload is characterized. The motor reac-
tion of the stomatognathic system to the altered mandibular posi-
Centric relation and centric occlusion tion keeps running while the inadequate contact is maintained,
regardless of other adaptive processes.
There is an efficiency related situation between the intercuspal Studies where occlusal interferences were placed on animals
position and the condylar position into the glenoid fossa. When point to global organic reaction and not just on stomatognathic
TMJ capsular ligaments sustain the condyle-disc complex while system. Urinary cortisol excretion was significantly elevated in
displaced to posterior, the muscle solicitation to hold a mandibular monkeys that also presented increased teeth mobility [36]. Plasma
position is lesser. This observation is essentially valid to most syno- corticosterone and hypothalamic noradrenaline in the rat were af-
vial joints. fected by occlusal disharmony [37]. Study with accelerated senes-
This ideal condyle-disc complex position receives several cence mice found increased plasma corticosterone levels and
denominations. Centric relation is the most common, but it is also hippocampal neuron loss [38]. All those studies however attrib-
known as terminal hinge axis [26]. However, there is an agreement uted these effects to the occlusal inadequacy without a specific ref-
that centric relation is independent of tooth contact. It is a clini- erence to the capsular mechanoreceptor role.
cally reproducible position by manipulation or using interocclusal A motor phenomenon should not be examined without consid-
splints. It is also an anatomical position, because there is no poster- ering the psychological aspects involved. On the other hand, that
ior osseous limitation in TMJ. Ligaments restrict extreme displace- aspect must be examined under a physiological critical view,
ment to posterior and type III mechanoreceptors inhibit the jaw observing the emotional interrelation with motor activities. Con-
closer muscles when this position is reached [27–29]. siderations about the chronic emotional process, magnification
However, when the intercuspal position does not happen in and amplification are relevant. The involvement of the limbic sys-
centric relation and some tooth contacts occurs before the others, tem and the emotion against pain, as well as how such variables
there will be consequences on mandibular position. If an inade- modify the motor response are largely unknown. About this aspect,
quate contact (e.g. cusp incline) occurs, the mandible will slide to it is necessary to observe that different expressions may be found
get the ideal intercuspal position. This new position, which seems between men and women’s responses.
influenced by periodontal mechanoreceptors, is known as centric
occlusion. Therefore, when there is a difference between centric
relation and centric occlusion, there must be some degree of jaw Signs and symptoms
movement. This movement is always accompanied by muscle con-
traction [5]. On the other hand, this is a common event, found in Hypertonia and pain
many patients, and does not necessarily causes clinical symptoms
[30], but the muscle response will signalize to adaptive processes. The initial reactive motor response affects the coordination of
Centric relation is a terminal or a boundary position and there is movements and muscle tone. High level of tone may cause pain
still controversy if such position is utilized or not during the mas- symptoms. Evidence of such observation is the fact that patients
ticatory cycle. Although the reflex effects over jaw muscles are with hypertonic jaw muscles relate efficiency loss and fatigue,
undeniable when centric relation cannot be reached. Patients with becoming fatigued following chewing [39]. Comparative study on
considerable centric relation and centric occlusion discrepancy patients relating jaw muscle pain showed that muscle altered re-
showed longer muscle activity in chewing cycles [31]. sponse might be related to a central mechanism and not with a
Not only mandibular position changes from centric relation to peripheral nociceptive mechanism, because increased activities
centric occlusion are able to cause reflex muscle responses. Inade- on electromyography were found in rest condition [40].
quate contacts can also act during mandibular motion. They have Dawson [26] relates that the removal of occlusal interferences
been associated with pain and symptoms [32] and electromyo- causes immediate relief of pain. Another report stated that the
graphical alterations were observed in modifications of the occlu- insertion of orthodontic elastic separator caused the same effect
sal guidance [33]. [41]. These effects provide evidence for minimal intercuspal posi-
The main clinical characteristic of the altered muscle response tion changes affecting jaw muscles, due to changed condylar
in such situations is a decrease of movement speed. This is obser- position.
vable on the masticatory cycle and speech. The physiologic process Women commonly present more muscle pain symptoms. This
involved is the increased tone that appear to difficult the execution observation may be related to muscle fibres composition, lesser
of mandibular movements. resistant to tone solicitation than men, because testosterone
 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718 715

causes great effect on jaw muscles myosin. Meanwhile, this may be sus is abolished when the bilateral anesthesia of the TMJ capsule is
just one aspect of the problem, because phenotypic characteristics performed [52].
may be involved in a magnified motor response, related to more These physiological phenomena are essential for mastication
pain relevance. and the intraoral biting just only occurs when there are alterations
Several theories have been proposed to explain muscle pain. on mandibular function. Such alterations may be related to rostral
Most of them try to point the cause and the effect inside the muscle areas and not to brainstem.
and do not consider the painful contraction as a reactive apparatus, The tongue motor control follows the extrapyramidal traject,
commanded by neurons and with origin in another structures like and there is not a monosynaptic connection between the cortex
joints. and the hypoglossal nucleus in primates [53]. Although can be ob-
Muscle pain related to mandibular reactive altered function is tained by cortical electrical stimulation, the tongue movements are
chronic, showing a regular behavior and sometimes is described accomplished by intermediate relay in various brain structures
as headache or ear pain. There is little variation on pain localiza- that includes the basal ganglia, cerebellum and reticular formation
tion, usually related with the trigeminal mandibular branch der- [54]. Apparently, the mandibular modified position, influenced by
matome. The type of pain is reported as tightened, not pulsatile inadequate occlusal contacts, can interfere on the execution of mo-
or sharp. The intensity of pain shows less individual variation. tor patterns controlled by the basal ganglia, as observed, inducing
The duration on the same individual does not demonstrate much an incoordination between mandible and tongue (and/or cheek)
variation. The most relevant characteristic is that there is not and causing such involuntary biting.
increase on muscle pain caused by movements. It seems that there
is not chronic pain by depletion or algogenic substances Speech mechanics
accumulation.
However, pain on palpation is easily observable and profusely Difficulty on speech mechanics, in patients with modified man-
related in dental literature. Such observations suggest that the pain dibular posture, is another motor alteration and rises with more
relates more to posture than to jaw movement and that there is the intensity as loss of velocity on mandibular movement. This is com-
involvement of the fusimotor system. Gentle muscle palpation has patible with muscle tone increase. In speech kinematics, the man-
been used to identify intrafusal afferents fibres in laboratory ani- dible moves to facilitate the generation of the phonemes and to
mal preparations [42,43]. Another interesting study showed that sustain tongue movements to produce the vowels [55]. According
there is an increase in discharge rate of fusimotor neurons during to the articulation place, the mandible executes varied movements
fatiguing contractions. When an arterial obstruction was produced, of rotation and/or translation. The tongue adopts various positions
the fusimotor discharge started early and was maintained until the to generate the vowels, moving on vertical and sagittal directions.
obstruction was removed [44]. Thus, there is instantaneous solicitation of jaw muscles tone to
It can be supposed that pain on palpation results from spindle support such tongue displacements.
stretching in hypertonic muscles. This may also explain the further In patients with altered mandibular motor patterns, the protru-
incidence of muscle pain in women, which usually show less resis- sive movements manifest more difficulty, especially on the /s/ pho-
tance to tone solicitation than men. On the other hand, women neme with the vowel [i:] (e.g. ‘‘SEEm”). In many patients, the sound
showed attenuated ATP reduction during repeated sprint exercise ‘‘[si:]” is generated with the approach of the canine teeth rather
[45,46]. than the incisors, so deviating the mandible from midline. This lat-
Botulinum A toxin has been used on patients with muscle alter- eral deviation is not a necessary movement on phonetics and,
ations involving the mandible. Initially the effects were credited to when excessive, constitutes a functional alteration. Another obser-
the termination of alpha motoneurons at the motor end plate. In- vable phenomenon is that the lesser protrusive run of the mandi-
deed, there are evidences that this substance also acts on gamma ble causes compensatory lip movement (e.g. phoneme/p/), and
motoneurons terminations, reducing thus the discharge to the al- lip wrinkle may be noted [56].
pha motoneurons. Evidences suggest that the results obtained
are related to not only motor paralysis, but also to reflex muscle Otologic symptoms
tone decrease, because there is improvement on pain, function,
mouth opening and sensibility to palpation [47,48]. The reaction Costen in 1934 related the correlation between otologic symp-
or adaptation to the increased muscle demand will cause more toms and the mandibular function [57]. The common related
than hypertonic and/or painful muscles. Various signs and symp- symptoms are ear pain, tinnitus and aural fullness. Many hypoth-
toms may appear jointly. eses were created to explain this correlation. In the context of this
paper, we will focus our attention on the innervation of the tensor
Involuntary intraoral biting (tongue and/or cheek) veli palatini and tensor tympani muscles, both from the trigeminal
nerve. The former is the main responsible for the opening of audi-
Involuntary biting of the tongue or cheek while chewing is a tory tube. The latter inserts on the malleus acting on the tympanic
common symptom in patients with altered mandibular functions. membrane movement.
It is also a neglected sign in dental literature. It indicates a non- The presence of the tensor tympani inside the middle ear is ex-
physiologic event and an incoordination of stomatognathic plained by the evolution of the mandible in mammalians. In rep-
muscles. tiles, various bones compose the mandible and the joint is
There is a reciprocal inhibition between the trigeminal mesen- between the articular (mandible) and the quadrate (cranium). In
cephalic nucleus and the hypoglossal nucleus, in such a way that mammalians, just the dentary bone forms the mandible and the
when one is active the other is found inhibited. When the mandible bones quadrate and articular become the incus and the malleus,
closes, the tongue comes to a centered position into mouth [49]. respectively [58]. It is relevant to observe that on the evolutionary
There also is reflex control of the genioglossus muscle by temporo- process changes also happened on teeth crown anatomy, with
mandibular receptors and the muscle becomes active as soon as narrow correlation between the mastication type and occlusal
the mouth opens [50]. Lowe and Sessle demonstrated that the shape [59].
mouth opening increases the activity of the genioglossus (respon- There are evidences of a double system of muscle fibres in the
sible for tongue protrusion) and the activity is maintained insofar tensor tympani, with fast and slow fibres, filling the necessities
the mandible remains opened [51]. This response of the genioglos- of movement and tone [60,61]. The motoneurons that innervate
716 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718

the tensor tympani appear to receive divergent impulses, both dence painful but hypertonic muscles and more effects on teeth
auditory (upper olivary complex) and sensory (trigeminal) and lo- and periodontium, usually men. This observation explains why
cated separately from the trigeminal motor nucleus [62,63]. How women are thought to be more affecting when the diagnosis tem-
much such motoneurons are influenced by the motor alteration poromandibular disorders are is applied.
described here remains to be explored.
However, tinnitus appears to be a generic diagnosis, describing Temporomandibular joint tissues response
a symptom, but may represent a manifestation with different path-
ophysiology. In some situations, the tinnitus seems to be involved Adaptive processes runs continuously on TMJ articular tissues.
with jaw muscle problems and responds to occlusal treatment. It They relate to the main function of mandible: chewing. Governed
was observed that an increase in tinnitus occurs when the individ- by the intercuspal relation, the changes respond to tooth loss and
ual bite with strong force for more than a minute [64]. The occlusal food hardness [77]. The articular cartilage becomes, after growth,
treatment that corrected the mandibular position in a patient with an adaptive centre that responds to compressing forces and may
otologic symptoms caused the relief of symptoms [65]. degenerate under overload. Soft diet and loss of occlusal support
caused diminution of cartilage thickness [78]. The TMJ fibrocarti-
Periodontal and teeth reaction lage may degenerate by ageing or by external factors response [79].
The remarkable characteristic of the temporomandibular carti-
The hypertonic functional state of jaw muscle causes effects on lage is its capacity of adaptive remodeling in response to external
teeth and periodontium in some individuals [12]. The excessive stimulation during or after growth [80,81]. The functional adapta-
force on tooth contact – related as occlusal trauma – is in fact a tion activates chemical physiological processes that act on synovial
muscle action, commanded by the trigeminal motor nucleus. As membrane, articular cartilage and disc and may lead to degenera-
the other signs, it is possible to find slight manifestation or large tive conditions [82].
destruction of the tissues. Patients can show two types of reaction.
One is when the mandible execute rhythmical movements as seen
in bruxism and the characteristic situation is huge occlusal and Anterior disc displacement
incisal wear but with minimal repercussion on periodontal tissues.
The second is when the movements are fewer but a strong bite Anterior disc displacement has been studied more as a regular
force manifests. These dental signs are abrasion, wear facets, disc out of position than a disc with degenerative alteration [83–
abfraction, and non-accidental tooth or restoration fractures. The 86]. At this point it is necessary to register that the insertion of a
periodontium will show remodeling changes with or without tooth muscle inside a joint is unique in the body and the lateral pterygoid
hypermobility, non-inflammatory bone loss and gingival recession. may be also designated as a discal muscle.
These reactions may be considered as allostasis [66–70]. In patients with the motor response described herein, the lat-
Periodontium presents a dynamic remodeling ability to react to eral pterygoid shall present high level of contraction, because the
forces applied on tooth crown. Examples of this physiological abil- mandibular positional changes imply in disc–condyle complex
ity are the orthodontic movements and the tooth migration follow- movement. This muscle appears to have a modulator role of on
ing extraction. Not just the tooth movement can be found, but also the closer jaw muscle, since it works in opposition to the jaw clos-
hypermobility and widening of the periodontal ligament space ers resultant force.
[66]. This phenomenon shall occur by increasing pressure when An interesting study showed that destabilized and uncoordi-
excessive forces are delivered to periodontium [71]. The same nated movement of the disc-capsule complex relative to the con-
forces carried out cause decrease in marginal gingiva blood flow, dyle – presumably under action of the lateral pterygoid – might
due to the tooth displacement [67], presumably facilitating the result in degenerative disc changes. Such long lasting situations
incidence of gingival recession in a long lasting condition. were related to alterations on disc anterior band, enlargement of
Finite elements study with the application of eccentric occlusal blood vessels and connective tissues close to the lateral pterygoid
loads on filled tooth showed increased cervical stress, due to cusp fibres insertion and hypertrophy of the synovial membrane. Bun-
flexure, especially under lateral forces. This relates to the loss of dles of elastic fibres are seen in the anterior band going downward
dental hard tissue at the cementoenamel junction, known as beneath the lateral pterygoid muscle fibres. On an advanced stage
abfraction [68]. Excessive occlusal forces interact with chemical the bulbous shape deformation occurs, shortening of the disc, and
corrosive reactions to cause stress corrosion at tooth cervical re- with the anterior part becoming curled up and pulled downward
gion [72]. This study refers to piezoelectricity – electric charge gen- [87]. The altered mandibular function, in addition to disc deforma-
erated by deformation of loaded tooth – as a contributing factor to tion, seems to induce modifications on condyle and articular emi-
the dental substance loss. Dental restorative materials may gener- nence [88], by the same mechanism that alters those structures
ate piezoelectric charges and causes pain under mechanical action when ageing and/or teeth loss [78], that is, an adaptive process
of masticatory forces [73]. Hypothetically, the piezoelectric or allostasis.
charges may reach pulp and/or periodontal receptors leading to ac-
tion potentials and causing jaw muscle reflex to avoid these teeth Articular sounds
contact. If true, this event may be a powerful originator of condi-
tioned reflex but investigations on this matter are unknown. Clicking TMJ is commonly found in patients with altered man-
The occurrence of cusp and/or restoration fractures is another dibular motor function. Joint clicking is a physiological event re-
effect of occlusal excessive force caused by hypertonic jaw muscle lated to articular release of many body joints and is associated
condition. Studies report that non-accidental fractures are gener- with increased distance between articular surfaces and freedom
ally found with more incidences on lingual lower molars cusps of motion [89]. Many theories have tried to explain such occur-
and buccal upper molars. More fractures are found in molars than rences and different mechanisms may produce the various sounds
bicuspids and in teeth with restorations [74–76]. emanated from the TMJ [90]. However, there is not a completely
Such dental and periodontal adaptive processes appear to be re- developed methodology to examine those sounds.
lated to strong muscle force applied on teeth occlusion. Patients While the mandible moves, the relation between articular
who manifest muscle pain tend to have lesser effects on these tis- superficies changes, with different concentration of mechanical
sues. Individuals with robust musculature ordinarily do not evi- stress and dynamic variation of the intra-articular space [91].
 C.R. Douglas et al. / Medical Hypotheses 74 (2010) 710–718 717

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