Temporomandibuhr articulation

The symptmnelegy of tumpumma&Jar

joint disturbance

H. T. Perry, Jr., D.D.S., Ph.D.* Northwestern University Dental School, Chicago, Ill.

T he theme to be developed in this article deals with an area of diagnosis which is on the nebulous border between dentistry and medicine.

The mandible moves in speech, deglutition, mastication, and certain emotional

situations at the dictates of the nervous system, by the grace of the musculature. In a patient with a healthy dentition, even though a malocclusion may exist, the

maximum occlusal position is attained with a bilateral contraction of the man- dibular elevators. The mandibular condyles arc in a stable and not a strained posi- tion in their fossae. However, should there occur an imbalance in the occlusion which could effect an asymmetrical contraction of the elevators and a strained

condyle-fossa relation in maximum occlusion, the balance of the system is in danger. In the movement of the mandible to its maximal contact with the maxillary teeth there develops, through neural paths, a protective mandibular shift- -protective in the sense that the offending tooth or teeth are not traumatized by “premature”

(deflective or interceptive) occlusal contact. * In due course, the imbalance may

be reflected in the muscles, the joints, or even the teeth.? What are the principal symptoms of temporomandibular joint disturbances?

How are these symptoms initiated? How can we differentiate between these symp- toms and other common oral-facial problems ? Can we initiate conservative treat-

ment procedures to resolutely effect a cure ?

SYMPTOMS OF TEMPOROMANMBULAR JOINT DlSTUftBAWES

Costen:’ is recognized as one of the first to observe and report a group of symptoms which he associated with “over-closures” of the mandible. These symp- toms were later grouped and termed Costen’s syndrome.

Read before the Australian Society of Orthodontists, Queensland, Australia, and the American Equilibration Society in Chicago, 111.

This investigation was supported by Public Health Service Research Grant No. DE-0983 from the National Institute of Dental Research.

*Professor and Chairman, Department of Orthodontics.

288

Volumr l!) Numtxr 3

Temporomandibular joint disturbance 289

There are many symptoms which may be associated with temporomandibular joint disturbances, that, when taken individually, are closely allied with other bodily afIlictions.

It is thus very important that the many symptoms found in temporomandibular joint patients be taken as separate and individual features. A gross pattern of

symptoms should not prompt an abrupt diagnosis; rather, WC should take each symptom in turn, determine in which direction each will lead, and only then estab-

lish the final pattern. It is often wise to begin with the simple question, “Will you describe your

principal complaint. 2” Then, as the patient talks, watch his expressions, the move-

ment of the mandible, and the relation of the maxillary midline to the mandibular midline. Watch closely for any irregular or “jumping” movements of the mandible.

Is there audible evidence of joint dysfunction? Attempt to learn from the patient when the first symptoms were noted. What,

in his mind, was the causative factor ? Is there anything he does which will in- crease or decrease the pain? Does either heat or cold alter the painful sensation?

Does aspirin or any other specific drug eliminate the pain? Is pain and/or im- mobility greater at the beginning of the day or at the end of the day? All of these questions should be asked in such a way as to give the patient considerable latitude

in his answer. Diagnostic casts are made of the patient’s teeth, these are trimmed with a was

wafer, and an interocclusal record is made with the teeth in occlusion. Intraoral

photographs and a panographic radiograph are made, the former to be used for reference, the latter to rule out the possibility of local dental problems reflexly

referring pain to the facial structures as described by Wolff and Wolf4 The symptoms of a typical temporomandibular joint dysfunction patient may

be generally classified and described under three headings. It is proposed to discuss

these patients in the light of the following semeiologic triad: ( 1) pain and its sequelae, (2) clicking and crepitus, and (3) irregularities of mandibular movement.

PAIN

Historically and physiologically, one of the most common of all cranial dis- turbances is pain. The pain pattern of the majority of our temporomandibular joint patients will closely resemble that seen in other disturbances.

Pain is an experience which is entirely individual; it is subjective. The extent, intensity, duration, and nature of the pain are solely for the patient to experience

and describe. Pain perception or awareness is dependent upon neural pathways and proper

peripheral initiation. The reaction to pain varies greatly from one individual to the

next. The emotional status of the individual as well as the individual’s previous experience with pain can alter his reaction to pain.

Most often, in a given temporomandibular joint patient, the pain is unilateral. It may be bilateral in some, but if bilateral, it need not be symmetrical.

The quality or character of the pain reported by the patient most often will fall into three gross categories. In an attempt to be objective, the patients are asked which one best describes the pain they experience. Most patients experience more

290 Perry J. lhs. Dent. March, 1968

Fig. 1. Diagrammatic distribution of subjectively noted pain types.

Fig. 2. Principal areas of pain of 467 temporomandibulat joint patients.

than one type of pain, but the localization of the types appears uniform for the patients as a group.

The three gross qualities most often experienced in these patients are: ( 1) a dull-aching pain, (2) a sharp-shooting pain (burning), and (3) a tight-drawing sensation (Figs. 1 and 2).

Dutl-aching pain. According to Wolff and Wolf,” dull-aching pain is charac- teristic of deep pain. It differs from superficial pain in that deep pain is often

poorly localized and includes skeletal muscle spasm.

Temporomandibular joint disturbance 291

Most of our patients have been examined electromyographically. In those

;)atients experiencing dull-aching pain, surface electrodes revealed “spasm-like” discharge at “rest.“G This is not characteristic of healthy, resting skeletal muscle and is related to emotional stress or to reflex contraction of muscle about fractures

or painful joints. It occurs in subjects with severe malocclusions. In those patients for whom successful treatment measures were instituted,

follow-up electromyography i%dicated that the electrical discharge at rest had

ceased with the disappearance of the dull-aching sensation. It is proposed that this dull-aching pain, when noted in true temporoman-

dibular joint problems, is due to muscle pain. Its surface distribution closely follows the anatomic area of the muscles in question. Dull-aching pain is usually found

over the masseters, temporals, and suprahyoids, and the lateral and postcemical muscles. The topography of this pain composite closely parallels the areas from which the electromyograph registers activity in postural positions of the head and Inandihle.

In separate studies, electromyographic evidence has been presented of muscle

discharge in patients whose dentures were deliberately misconstructed and in situa- tions of psychic stress. 7, ’ The former precipitated a pain pattern by stretching the

r~~uscles of mastication and the latter was thought to be produced by a Karoli OI

bruxism effect engendered through the reticular forrnation of the brainstem.

Sharp-shooting pain. A second type of pain that these patients perceive is that of a sharp-shooting or burning pain. This pain is well defined and localized. It is rnost often noted in the dermal triangle immediately over the condyle. Those who

expericmce this type state that it “shoots up” to the top (vertex) of the head 01 anteriorly along the zygomatic arch. Often in conjunction with this, there is a complaint of a burning sensation in the anterior half of the entire external ear.

Many of the patients describing this pain stated that the pain was intermittent and sNmcd to accompany movement of the jaw, as in eating or yawning.

‘I‘hc third highest frequency of pain reported in our sample (after that of the muscle areas and that of the dcrmal sqmr:nt over thcx condyle) is a painful tongue.

This usually was dcscribcd as h&g at the side of the tongue with the pain “burning or shooting” in nature.

Many patients who experienced this pain thought they had bitten the tongue itI eating, or had done so repeatedly in their sleep. Some complained that the tongue scerned to get in the way when they were chewing. This has been noted

previously in a serial electromyographic study of patients with severe malocclusions. In patients with malocclusion, the tongue is not active in rolling a food bolus from one side to the other in chewing, but in some the tongue seemed to bc a definite hindrance to mastication. The patient with normal occlusion uses the tongue ac-

tively in mastication and swallowing, as ~41 as in rolling a bolus to the oppo- sitcx side of the arch.” The tongue, of the patient with normal occlusion is well coordinated with the masticatory muscles, but apparently this is not trur whr~: tllcre is severe malocclusion or temporomandibular joint dysfunction.

7’ight-drawing sewation. The third general category of pain symptom was not

pprccivrd as truly painful. hut rnc~ly mildly nosious and uncomfortable. ‘I’his oftcltl was descrihcd as tight and drawing. “I’he principal arrxa for this sensation was at

292 Perry

the occipital and frontal regions of the head. It closely follows the topography of the occipitalis and frontalis muscles. These areas were primarily sore and tender to touch.

Over forty of the patients surveyrcl were aware of pain or discomfort in swal- lowing or speaking. If asked to pinpoint the area, many were unable to do so. ‘I’hcy stated that it was a i‘fullncss~’ in the cars? the throat: and side of the neck or back of the tongue, but very rarely could they designate a specific location.

There seemed to be a great overlapping of the dull-aching and sharp-shooting pain patterns in the region of the condyle, just antrrior to the csternal auditoq mcatus.

CLICKING AND CREWTUS (JOINT SOUNDS)

The second of the triad of general symptoms associated with tcmporomandibu- lar joint dysfunction is that of joint sounds (Fig. 3).

Often, when temporomandibular joint patients arc being treated, clicking and/or crepitus will return to a joint. To many of the patients this is alarming. but they should be reassured that normal mobility is returning and that a limita- tion of movement had previously prevented the clicking.

The elimination of pain and mandibular deviation with proper thcraljy will often relieve the annoying symptom of clicking. The actual cause of the clicking and crepitus is still open to yuestiort. There is, of course, no specific means of getting into the joint capsule to set what clicks, and postmortem specimens do not seem to exhibit it. A sound explanation on a teleologic basis was offered by Keel;‘” in his article on the temporomandibular joint.

Rees noted that the disk of the temporomandibular joint was formed by fom clearly dctincd transvcrsc ellipsoidal zones which he termed: ! 1) the anterior band. : 2: the intermediate band. 1 3! the posterior band, and c-1 ) the bilaminar zone. The first three are composed of densely plaited white fibrous tissue. In most nlovca- merits of the mandiblr, Rees frlt that these disk components were interposed br- twcen condylc and fossa or condylc ant1 cminencc. However! in cxtrernc opening.

467 TOtal

Sample

37 Absent

the condyle may slip past the anterior band with a jump and in some people pro-

duce a “clicking” sound. This, he stated, occurred when the meniscus was brought forward to its full extent permitted by the elastic attachment posteriorly, but the

translation of the condyle continues over the anterior fibrous band producing the audible “click.” A “click” also may occur upon closing. This very well could be the repositioning “jump” of the condyle back over the anterior band to its propel

condyle-meniscus relation. This repositioning need not occur at the wide open position, but may occur as the condyle is translated back into the fossa along the articular eminence.

Sicher” believes it is also possible for a click to occur as the result of an in- coordination of the sphenomeniscus head of the lateral pterygoid, and the elastic component at the posterior border of the meniscus. A contracture or shortening of

the lateral pterygoid may hold the mandible in a slight protrusion while the pos- tcxrior elastic component attempts to retract the capsule and meniscus. Thus, the usual meniscus-condyle relation is altered and movement of the condyle precipitates

;I click as the parts move at incoordinated rates.

MANDIBULAR DEVIATION

Mandibular deviation is a third characteristic often evident in temporoman- dibular joint patients. Mandibular deviation, in this instance, refers not only to

that observed in maximal opening, but also that noted in closure from an evaluated “rest” position to full (maximum) occlusal tooth contact (Fig. 4).

The displacement occurring from “rest” to occlusion most probably originates from tooth contacts, and the deviation from “rest” to wide open is a result of joint malfunction and muscle pain.

‘I‘he muscles which act in areas of painful joints are often in a state of partial contraction that is clinically termed “splinting.” This is the result of an effort by thr neuromuscular system to limit painful movement of the affected joint. This

type of muscle shortening in certain forms of degenerative arthritis rnay produce contracture, but in most of our temporomandibular joint patients we observe myo-

spasms. This is a result of repetitive firing in the motor nerve, which in turn is

self-pclrpetuating, as the result of proprioreceptive, tactile, or pain stimuli.

421 403

1.ter.l Rest To

276 261 Rest To

179

Protrvrion

Fig. 4. Altrration of mandibular movrrncnt patterns

DIFFERENTIAL DIAGNOSIS

‘1’1~ pi,incipal symptom d the triad 101, terrlporoiilar~tlibular joint dysfunction,

as described hrrcin; is pain. It is: thercforc, essential that some howledge of othci problems causing similar cranial pain patterns bc recognized when obscrvcd in

the course of an examination. Ni.rtarr~i~~ic~ cc~phalalgin. Horton. .MacI,c~aii. and Craig” described a qroulr 01

symptoms as “cr~thromalalgia of the: head.” Horton later demonstrated that the

pain patterns could bc reproducrd by subcutaneous injections of histamine. He thrn rc~frrrcd to the syndrome as “histaminic cephalalgia. ” The distribution of thcsc symp-

toms is similar to that notccl in trmporomandibular joint pain, but the intcnsityv and quality of the pain are different. ‘l’he symptoms described by Horton last irom

a few minutes to hours, the affected side of the fact may flush and the eyelids swell. the pain occurs with clocklike re‘gularity usually at night. The pain is

sc’\~‘rc, usttally unilatc~ral j I Iorton noted only -1~ per cent of his patients had a

bilateral distribution of pain : . constant. burning, and located about the cyc. tcmplc. ant1 other parts of the head and neck.

Migrairze~. Wolff’,’ 11;ts presented considerable evidence that migraine is the

result of a dilatation of cranial arteries. The pain of mi,qraine is hemicranial, and it may be bilateral or shift from side to side between attacks. It is more frc~quently noted in women, and has a farnily history of occurrence. There is intense. throb-

bing pain which may produce nausea and vomiting. Partial blind spots may occur. and there may vvell br evitlencc of photophobia.

7’cmiorL lzcadaclr~. ‘l’hc tension type of headaches are usually the result of a

~rcncral vasodilation of the intercranial arteries. The pain is characteriztd as burst- > ing, throbbing. and mom intense when lying down.

Nu~crl .cC~zz~.( I~catlacl~c. l’his type of pain may oftc’n follow an infection of the

upper respiratory tract. ‘Ihcrc may br a nasal discharpc, congestion, or edema. ‘l’herc is often a tempcratnrc~ clcvation which is rarely noted in patients with temporomandibular joint disturbances. There is tenderness to pressure over the

invohed sinuses. The pain is dull, fairly ronstant. and ma)- he unilateral or bilateral in thr region of the invohecl sinuses,

‘l’+mlilral nc~wnlgia. ‘l‘hc principal symptorir of trigeminal neuralgia is p&l, its onset being sudden. The pain is knifelike, extremely sharp, and piercing. If the

pain is constant, and it may be, it is tlull and boring. There is very often a “trigger YOIIC” which, when contartctl or totrchecl. lvill precipitate an attack of pain. If on<’ is prcscnt, tha patient will usually guard the trigger zone very closely, and this is a Krcat aid in diagnosing this type of pain. The pain may radiate into the cervical ncrvcs and dowri into th arms. l‘hc pain always radiates along the branches of the trigeniinal nerve.

‘l‘hc first pain attack is usually unprecipitated, urrilatcral, sharp and fast. ‘rhe second attack may occur in a few minutes or iii several months, but each following attack is lortger in duration and more painful.’ i

7’cwrpo,-al artcritis. VPrml~oral arteritis is due to an inflammation of the tcm- poral artcry and was first reported iii 19% by Horton, Magath, and Brown.‘: It is thought to be a systemic disttirbancc with local symptoms.

Herr: we find symptoms very similar to those of our temporomandibular joint

Temporomandibular joint disturbance 295

patients. There is pain in chewing, severe pain localized in the temporal region or generalized at the lateral aspect of the head. There are enlarged and tender tem-

poral vessels. There also may be a sudden loss of vision due to occlusion of the central retinal vessels, and often there is an elevation of body temperature.

Brain tumor headache. The final group of symptoms accompanying brain tumor headache, perhaps is the least noted, but most lethal. I have had one patient

with such pain that it was referred to as temporomandibular joint pain. The patient had a typical joint symptom, but did not respond favorably to occlusal adjustment with a diagnostic splint. A suggested neurologic examination revealed

a tumor of the cerebellopontine angle which had precipitated the pain pattern noted.

‘I’hcse patients usually will complain of severe headache, nausea, and vomiting,

forgetfulness, confusion, weakness of limbs, visual disturbances, aphasia, and cranial nerve involvements. There may be general disturbances in gait and coordination which will suggest possible kinesiologic changes in mandibular movement and masscter reflexes. Vertigo and balance impairments in walking or sitting may be

present. These are not all of the problems that can confuse or mislead a proper diag-

nosis of temporomandibular joint disturbance. It is, however, a r&urn6 of some

of the principal ones. It should be apparent that we have a difficult problem in differentiating the true cause of cranial pain. The presence of vomiting, nausea: throbbing pain and increased temperature should prompt us to look elsewhere for

the symptoms, or to refer the patient to an internist, or to the family physician. In the presence of a dull-aching pain, mandibular immobility and deviation, as well as a history of joint sounds, we should suspect the occlusion or the temporo-

mandibular joints.

CAUSATIVE FACTORS

The causative factor of temporomandibular joint dysfunction may be abrupt

in occurrence (rnacrotrauma) ; may be the result of a long-standing irritation I microtrauma) or may be occlusal, intracapsular, or emotional in nature.

Total

467 Total

Sample

Sample 3720

95 d

Fig. 5. Sex and age range of patients in this study.

Etiologic factors of an abrupt nature in the group studied included: whiplaslr injury from an auto accident: wrestling blow, trauma in falling, and unexpectedly biting into a hard object in food. Some complain of t.he pain immediately following a long dental appointment or the extraction of mandibular third molars.

The great predominance of women having this disorder in comparison to men is noted. Possehl” Lammie.” and others have pointed to as high as an 80 per cent female occurrence (Fig. 5).

The age group having the most involvement in this particular study was the forty to fifty year bracket.

TREATMENT PROCEDURES

‘The intention of this article has been to establish certain benchmarks which will aid the dentist in recognizing the symptoms of temporomandibular dysfunction problems that arc within his realm and province of treatment. ‘The rationale ancl procedure of treatment have been purposely avoided because of the variation of solutions possible and the variety of patients probable. It would be ludicrous to list a. system of steps to follow in the correction of all problems. Some patients may’ respond to local anesthetic injection, others to heat and massage, some to exercise. and still others to temporary occlusal splints or occlusal adjustment by judicious grinding. Our experience with these problems has shown us that conservative therapy will produce relief of the symptoms in a great majority of patients (Fig. 6). The time factor for symptom relief with a conservative approach is of interest fork

271 Temporary

Spl I”1

86 0ccl”ral

72

Ti5. 38 NO

Rclsef

Fig. 6. Relief of symptoms (467 pntients)

316 One Week

Fig. 7. 7’ime interval noted in attaining relief of pain (after first adjustmrntl

Tcmporomandibular joint disturbance 297

it points to the importance of a proper diagnosis and treatment plan (Fig. 7).

Some few of those unsuccessfully diagnosed as temporomandibular joint patients were satisfactorily treated after referral for other ailments undetected in our original diagnosis.

SUMMARY

Throughout a professional man’s academic exposure, he should have assimi-

lated a vast spectrum of knowledge. His clinical ability is tested with each new day and its patients. The d’ff 1 ercnce between mediocrity and perfection is an intangible quality in many instances residing within the patient, but the professional man’s

obligation is to strive for perfection in his every endeavor. This may only be achicvcd consistently in dentistry and medicine by a constant recall and review of

the importance of the health sciences in the total appraisal of each patient.

CONCLUSIONS

1. The great majority of temporomandibular joint disturbances are dental

prohlcms which will respond to conservative therapy. 2. ‘l’he principal symptoms of temporomandibular joint disturbances are pain,

joint sounds (which may be absent with severe pain), and immobility or irregularity of mandibular movement.

Zi. Three principal types of pain are present: a dull-aching pain which is from

the musculature and is poorly localized; a sharp-shooting or burning pain which is well localized and topically represents hyperalgesia; and a tight-drawing sensa- tion that is only slightly painful, but definitely irritating.

-1. Women make up the greatest number of patients in this study group, with the highest incidence of occurrence noted in the 40- to 50-year-olds.

5. ‘I’he majority of the patients were satisfactorily treated with conservative

therapy. 6. ‘l’hc similarity of temporomandibular and occlusal dysfunction pain with

that of other cranial disturbances necessitates a sound understanding of the health

sciences in rendering a correct diagnosis.

“Sature has perfections to show that she is God’s image and she has imperfrctions to show that she is only an imagr.” Pascal

References

1. Thompson, J. R.: Concepts Regarding Function of the Stomatognathic System, J. A. 1). A. 48: 626-637, 1954.

2. Perry. H. T.: The Physiology of Mandibular Displacement: Angle Orthodont. 30: !il-60, 1961).

.1. Costen; J, B.: A Syndrornc of Ear and Sinus Symptoms Dependent Upon Disturbed I:tmc.tion of the Temporomandibular Joint, Ann. Otol. Rhin. & I,aryng. 43: l-15, 1934.

I. Wolff. H. <:., and Wolf, S.: Pain, Springfield, 1951, Charles C Thomas: Publisher, 1’. 28.

5. Wolff. II. G., and Wolf, S.: Pain, Springfield, 1951: Charles C Thomas, Publisher, I’. ‘2.

6. PtLrry. I-I. T.: Facial. Crania1 and Cervical Pain Associated with Dysfunction of the: Occlusion and iirticulation of the Teeth, Angle Orthodont. 26: 121-128, 1956.

7. I,ammic, G. A., Perry, II. T., and Crumm, B. D.: Certain Observations on a Complex l)ent\lrc Patirnt. J. PKOS. DEST. 8: 786-795; 929-939, 1958; 9: 34-43, 1959.

298 Perry

8. Perry, H. T., Lammie, G. A., Main, J.. and ‘I‘euscher. (;. W.: Occlusion in a Strc.ss Situation, J. A. D. A. 60: 626-633, May, 1960.

9. Perry, H. T.: Kinesiology of the Temporal and Masseter ,Musrles in Chewin a lIom(~- geneous Bolus, Ph.D. Thesis, Chicago, Northwestern University Dental School, 1961.

IO. Rees, L. A.: The Structure and Function of the Mandibular Joint, Brit. 1). J. 96: 125-13:;. March 16, 195.1.

11. Sicher, H.: Oral Anatomy, St. Louis. 1952, ‘I’hr c:. v. Mosby (:onlparly, p. 17;.

12. IIorton, B. T., MacLean, A. R., and Craig, M’. WK.: A New Syndrome of Vascular Headache: Results of Treatment with Histamine: Preliminary Report, Proc. Staff Mecxt.

Mayo CIin. 14: 237: 260, 1939.

13. Wolff, II. G.: Headache and 0thcbr Head I’;~ins. csd. 2. Nvw !‘ork. 1963, Oxford l!nivvrsit) Press 11. “7’). ., . .

14. Stookey, B., and RansohofT, J,: Trigeruinnl Neuralgia. Springfield, 1959, Charles (: Thomas, Publisher, p. 90.

15. IIorton, B. T., Magath, T. B., and Browll. (;. E.: Arteritis of Temporal \‘essrls: a Pu,-

l-iously Endescribed Form, Arch. Int. Med. 53: ~100, March, 193-l.. 16. Posselt, U.: The Physiology of Occlusion and Rrhabilitation. Philaticlphia, 1962, I:. .Y

Davis Company, p. 89. 17. I,amlnie, (i. A.: Dent:11 Or!hop:rc&~s. Oxford. 1966, i\ldcn Prrss. p. 281

Elms TOWER BLW. Ems, ILI.. 60120