The Etiology of Temporomandibular Disorders: Implications for Treatment

This article begins by reviewing the history of etiologic thinking in the field of temporomandibular disorders (TMD). I conclude from this review that not only are the old mechanistic etiologic concepts incorrect, but also that 2 of the most popular current concepts (biopsychosocial and multifactorial) are seriously flawed. Therefore, what we really have at the individual TMD patient level is nearly always an idiopathic situation—we simply do not know enough, or cannot measure enough, or cannot precisely determine why each patient has a TMD. In addition, we do not understand the host resistance factors that ultimately determine why one person gets sick while another does not. The issue of “why” (etiology) must be differentiated from the issue of “how” (pathophysiology), both semantically and intellectually, to discuss all of this properly. However, our current inability to precisely identify etiologies in TMD patients does not prevent us from providing sensible (and often successful) treatment for most of these patients. Many health conditions currently are treated by physicians and dentists with either incomplete or flawed understanding of their etiology, but the availability of empirical data about treatment outcomes permits some level of appropriate care to be given. Fortunately, a large number of comparative studies have been done in the field of TMD therapy, providing us with a basis for selecting initial therapies as well as for dealing with treatment failures. Even in the absence of a perfect understanding of etiology, we still can provide good conservative care, and we should avoid aggressive and irreversible treatments, especially when they are based on flawed concepts of etiology. The article concludes by discussing current basic science research activities in the field of TMD and orofacial pain. I propose that these ongoing studies of the molecular and cellular mechanisms of joint disease, muscle pain, and chronic pain are the most likely avenues to future progress in this field, as specific countermeasures are developed to become the basis for more precisely targeted therapies.

temporomandibular disorders; etiology; pathophysiology; treatments

1. Greene CS. Myofascial pain-dysfunction syndrome: The evolution of concepts. In: Sarnat BG, Laskin DM (eds). The Temporomandibular Joint, ed 3. Springfield, IL: Charles C. Thomas, 1980:277–288.

2. Greene CS. Temporomandibular disorders: The evolution of concepts. In: Sarnat BG, Laskin DM (eds). The Temporomandibular Joint: A Biologic Basis for Clinical Practice, ed 4. Philadelphia: Saunders, 1992:298–315.

3. Wright WH. Deafness as influenced by malposition of the jaws. J Natl Dent Assoc 1920;7:979–992.

4. Monson GS. Occlusion as applied to crown and bridge work. J Natl Dent Assoc 1920;7:399–413.

5. Decker JC. Traumatic deafness as a result of retrusion of condyles of mandible. Ann Otol Rhinol Laryngol 1925;34:519–527.

6. Costen JB. A syndrome of ear and sinus symptoms depen-dent upon disturbed function of the temporomandibular joint. Ann Otol Rhinol Laryngol 1934;43:1–15.

7. Sicher H. Temporomandibular articulation in mandibular overclosure. J Am Dent Assoc 1948;36:131–139.

8. Zimmerman AA. Evaluation of Costen’s syndrome from an anatomic point of view. In: Sarnat BG (ed). The Temporomandibular Joint, ed 1. Springfield, IL: Charles

C. Thomas, 1951:82–110.

9. Block LS. Diagnosis and treatment of disturbances of the temporomandibular joint, especially in relation to vertical dimension. J Am Dent Assoc 1947;34:253–260.

10. Weinberg LA. Role of condylar position in TMJ dysfunc-tion-pain syndrome. J Prosthet Dent 1979;41:636–643.

11. Thompson JR. Temporomandibular disorders: Diagnosis and treatment. In: Sarnat BG (ed). The Temporo-mandibular Joint, ed 2. Springfield, IL: Charles C. Thomas, 1964:146–184.

12. Posselt U. The temporomandibular joint and occlusion. J Prosthet Dent 1971;25:432–438.

13. Jankelson B. Neuromuscular aspects of occlusion. Dent Clin North Am 1979;23:157–168.

14. Greene CS. Orthodontics and the temporomandibular joint. Angle Orthod 1982;55:166-172.

15. Greene CS. Orthodontics and temporomandibular disor-ders. Dent Clin North Am 1988;32:529–538.

16. Roth RH. Temporomandibular pain-dysfunction and occlusal relationships. Angle Orthod 1973;43:136–153.

17. Crawford SD. Condylar position, as determined by the occlusion and measured by the CPI instrument, and signs and symptoms of temporomandibular dysfunction. Angle Orthod 1999;69:103–116.

18. Greene CS. Comment on Crawford SD, Condylar posi-tion, as determined by the occlusion and measured by the CPI instrument, and signs and symptoms of temporoman-dibular dysfunction [letter]. Angle Orthod 1999;69:391–392.

19. Mohl ND, McCall WD, Lund JP, Plesh O. Devices for the diagnosis and treatment of temporomandibular disorders. Part I: Introduction, scientific evidence, and jaw tracking. J Prosthet Dent 1990;63:198–201.

20. Mohl ND, Lund JP, Widmer CG, McCall WD. Devices for the diagnosis and treatment of temporomandibular disorders. Part II: Electromyography and sonography. J Prosthet Dent 1990;63:332–336.

21. Mohl ND, Ohrbach RK, Crow HC, Gross AJ. Devices for the diagnosis and treatment of temporomandibular disor-ders. Part III: Thermography, ultrasound, electrical stimu-lation, and electromyographic biofeedback. J Prosthet Dent 1990;63:472–477.

22. Lund JP, Widmer CG, Feine JS. Validity of diagnostic and monitoring tests used for temporomandibular disorders. J Dent Res 1995;74:1133–1143.

23. Rocabado M, Tapia V. Radiographic study of the cranio-cervical relation in patients under orthodontic treatment and the incidence of related symptoms. Cranio 1987;5:36–42.

24. Mannheimer JS, Rosenthal RM. Acute and chronic postu-ral abnormalities as related to craniofacial pain and tem-poromandibular disorders. Dent Clin North Am 1991;35:185–208.

25. Hackney J, Bade D, Clawson A. Relationship between for-ward head posture and diagnosed internal derangement of the temporomandibular joint. J Orofac Pain 1993;7:386–390.

26. Darlow LA, Pesco J, Greenberg MS. The relationship of posture to myofasacial pain dysfunction syndrome. J Am Dent Assoc 1987;114:73–75.

27. Seligman DA, Pullinger AG. The role of functional occlusal relationships in temporomandibular disorders: A review. J Craniomandib Disord Facial Oral Pain 1991;5:265–279.

28. Carlsson GE, Droukas B. Dental occlusion and the health of the masticatory system: A literature review. J Craniomandib Pract 1984;2:142–147.

29. Pullinger AG, Seligman DA. Trauma history in diagnostic subgroups of temporomandibular disorders. Oral Surg Oral Med Oral Pathol 1991;71:529–534.

30. Schwartz L. Conclusions of the TMJ Clinic at Columbia. J Periodontol 1958;29:210–212.

31. Marbach JJ, Lipton JA. Aspects of illness behavior in patients with facial pain. J Am Dent Assoc 1978;96:630–638.

32. Moulton RE. Emotional factors in non-organic temporo-mandibular joint pain. Dent Clin North Am 1966; Nov:609–620.

33. Laskin DM. Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 1969;79:147–153.

34. Laskin DM, Greene CS. Influence of the doctor-patient relationship on placebo therapy for patients with myofas-cial pain-dysfunction (MPD) syndrome. J Am Dent Assoc 1972;85:892–894.

35. Lupton DE. Psychological aspects of temporomandibular joint dysfunction. J Am Dent Assoc 1969;79:131–136.

36. Schwartz RA, Greene CS, Laskin DM. Personality charac-teristics of patients with myofascial pain-dysfunction (MPD) syndrome unresponsive to conventional therapy. J Dent Res 1979;58:1435–1439.

37. Rugh JD, Solberg WK. Psychological implications in tem-poromandibular pain and dysfunction. In: Zarb GA, Carlsson GE (eds). Temporomandibular Joint Function and Dysfunction. Copenhagen: Munksgaard, 1979:239–268.

38. Malow RM, Olson RE, Greene CS. Myofascial pain-dys-function syndrome: A psychophysiological disorder. In: Golden C, Alcaparras S, Strider F, Graber B (eds). Applied Techniques in Behavioral Medicine and Medical Psychology. New York: Grune & Stratton, 1981:101–133.

39. Mercuri LG, Olson RE, Laskin DM. The specificity of response to experimental stress in patients with myofascial pain-dysfunction syndrome. J Dent Res 1979;58: 1866–1871.

40. Malow RM, Grimm L, Olson RE. Differences in pain per-ception between myofascial pain dysfunction patients and normal subjects: A signal detection analysis. J Psychosom Res 1980;24:303–309.

41. Curran SL, Carlson CR, Okeson JP. Emotional and physiologic responses to laboratory challenges: Patients with temporomandibular disorders versus matched control subjects. J Orofac Pain 1996;10:141–150.

42. Fillingim RB, Maixner W, Kincaid S, Sigurdsson A, Harris MB. Pain sensitivity in patients with temporomandibular disorders:Relationship to clinical and psychosocial factors. Clin J Pain 1996;12:260–269.

43. Flor H, Birbaumer N, Schulte W, Roos R. Stress-related electromyographic responses in patients with chronic temporomandibular pain. Pain 1991;46:145–152.

44. Kapel L, Glaros AG, McGlynn FD. Psychophysiological responses to stress in patients with myofascial pain-dysfunction syndrome. J Behav Med 1989;12:397–406.

45. Katz JO, Rugh JD, Hatch JP, Langlais RP, Terezhalmy GT, Borcherding SH. Effect of experimental stress on masseter and temporalis muscle activity in human subjects with temporomandibular disorders. Arch Oral Biol 1989;34:393–398.

46. Maixner W, Fillingim R, Booker D, Sigurdsson A. Sensitivity of patients with painful temporomandibular disorders to experimentally evoked pain. Pain 1995;63:341–351.

47. Greene CS, Olson RE, Laskin DM. Psychological factors in the etiology, progression, and treatment of MPD syndrome. J Am Dent Assoc 1982;105:443–448.

48. Rugh JD, Davis SE. Temporomandibular disorders: Psychological and behavioral aspects. In: Sarnat BG, Laskin DM (eds). The Temporomandibular Joint: A Biologic Basis for Clinical Practice, ed 4. Philadelphia: Saunders, 1992:329–345.

49. Greene CS. A critique of nonconventional treatment concepts and procedures for temporomandibular disorders. In: LaskinDM, et al (eds). President’s Conference on Examination, Diagnosis, and Management of Temporomandibular Disorders. Chicago: American Dental Association, 1983:177–181.

50. Greene CS. An evaluation of unconventional methods of diagnosing and treating temporomandibular disorders. Oral Maxillofac Surg Clin North Am 1995;7:167–173.

51. Gelb H (ed). Clinical Management of Head, Neck, and TMJ Pain and Dysfunction. Philadelphia: Saunders, 1977.

52. Goodheart GJ. Kinesiology and dentistry. J Am Soc Prev Dent 1976;6:16–18.

53. Ramfjord SP. Dysfunctional temporomandibular joint and muscle pain. J Prosthet Dent 1961;11:353–374.

54. Ramfjord SP, Ash MM. Occlusion, ed 3. Philadelphia: Saunders, 1983.

55. Dworkin SF, Burgess JA. Orofacial pain of psychogenic origin: Current concepts and classification. J Am Dent Assoc 1987;115:565–571.

56. Okeson JP. Bell’s Orofacial Pains, ed 5. Chicago: Quintessence, 1995:475–479.

57. American Academy of Orofacial Pain, Okeson JP (ed). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Chicago: Quintessence, 1996:119–127.

58. Fricton JR, Kroening RJ, Hathaway KM (eds). Temporomandibular Disorders and Craniofacial Pain: Diagnosis and Management. St Louis: Ishiaku Euro America, 1988.

59. Woda A, Pionchon P. Focus article: A unified concept of idiopathic orofacial pain: Clinical features. J Orofac Pain 1999;13:172–184.

60. Fricton JR. Critical commentary 1: A unified concept of idiopathic orofacial pain: Clinical features. J Orofac Pain 1999;13:185–189.

61. Okeson JP. Critical commentary 2: A unified concept of idiopathic orofacial pain: Clinical features. J Orofac Pain 1999;13:189–191.

62. Van der Waal I. Critical commentary 3: A unified concept of idiopathic orofacial pain: Clinical features. J Orofac Pain 1999;13:192–194.

63. Harris M. Idiopathic orofacial pain: Idiopathic facial pain. In: Campbell JN (ed). Pain: An Updated Review. Seattle: IASP Press, 1996:403–412.

64. Zarb GA, Thompson GW. Assessment of clinical treatment of patients with temporomandibular joint dysfunction. J Prosthet Dent 1970;24:542–554.

65. Greene CS, Laskin DM. Long-term evaluation of conservative treatment for myofascial pain-dysfunction syndrome. J Am Dent Assoc 1974;89:1365–1368.

66. Greene CS, Markovic M. Response to nonsurgical treatment of patients with positive radiographic findings in the temporomandibular joints. J Oral Surg 1976;34:692–697.

67. Cohen SR. Follow-up evaluation of 105 patients with myofascial pain-dysfunction syndrome. J Am Dent Assoc 1978;97:825–828.

68. De Leeuw R, Boering G, Stegenga B, de Bont LG. Symptoms of temporomandibular joint osteoarthrosis and internal derangement 30 years after non-surgical treatment. Cranio 1995;13:81–88.

69. Mjersjo C, Carlsson GE. Long-term results of treatment for temporomandibular joint pain-dysfunction. J Prosthet Dent 1983;49:809–815.

70. Greene CS, Laskin DM. Long-term evaluation of treatment for myofascial pain-dysfunction syndrome: A comparative analysis. J Am Dent Assoc 1983;107:235–238.

71. Mjersjo C, Carlsson GE. Analysis of factors influencing the long-term effects of treatment of TMJ pain-dysfunction. J Oral Rehabil 1984;11:289–297.

72. Okeson JP, Hayes DK. Long-term results of treatment for temporomandibular disorders: An evaluation by patients. J Am Dent Assoc 1986;112:473–478.

73. Greene CS, Laskin DM. Long-term status of clicking in patients with myofascial pain and dysfunction. J Am Dent Assoc 1988;117:461–465.

74. Garafis P, Grigoriadu E, Zarafi A, Koidis PT. Effectiveness of conservative treatment for craniomandibular disorders: A 2-year longitudinal study. J Orofac Pain 1994;8:309–314.

75. Stohler CS, Zarb GA. On the management of temporomandibular disorders: A plea for a low-tech, high-prudence therapeutic approach. J Orofac Pain 1999; 13:255–261.

76. De Bont LG, Dijkgraaf LC, Stegenga B. Epidemiology and natural progression of articular temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:72–76.

77. Clark GT, Seligman DA, Solberg WK, Pullinger AG. Guidelines for the examination and diagnosis of temporomandibular disorders. J Craniomandib Disord Facial Oral Pain 1989;3:7–14.

78. Clark GT, Seligman DA, Solberg WK, Pullinger AG. Guidelines for the treatment of temporomandibular disorders. J Craniomandib Disord Facial Oral Pain 1990;4:80–88.

79. Zarb GA, Carlsson GE, Sessle BJ, Mohl ND (eds). Temporomandibular Joint and Masticatory Muscle Disorders. Copenhagen: Munksgaard, 1994.

80. Cooper BC. The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;83:91–100.

81. Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems, ed 2. St Louis: Mosby, 1989.

82. Moloney F, Howard JA. Internal derangements of the temporomandibular joint, III. Anterior repositioning splint therapy. Aust Dent J 1986;31:30–39.

83. McCarty WL, Farrar WB. Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 1979;42:191–196.

84. Nickerson JW, Veaco NS. Condylotomy in surgery of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989;1:303-327.

85. Greene CS. Managing TMD patients: Initial therapy is the key. J Am Dent Assoc 1992;123:43–45.

86. Clark GT. A diagnosis and treatment algorithm for common TM disorders. J Jpn Prosthodont Soc 1996;40: 1029–1043.

87. Flor H, Turk DC. Etiologic theories and treatments for chronic back pain. I. Somatic models and interventions. Pain 1984;19:105–121.

88. Schwartz L. The pain-dysfunction syndrome. In: Schwartz L, Chayes CM (eds). Facial Pain and Mandibular Dysfunction. Philadelphia: Saunders, 1968:140–155.

89. Moulton R. Psychiatric considerations in maxillofacial pain. J Am Dent Assoc 1955;51:408–414.

90. Rugh JD, Solberg WK. Psychological implications in temporomandibular pain and dysfunction. Oral Sci Rev 1976;7:3–30.

91. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: Evaluating the efficacy of a tailored treatment protocol. J Consult Clin Psychol 1996;64:139–146.

92. Turk DC, Zaki HS, Rudy TE. Effects of intraoral appliances and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders. J Prosthet Dent 1993;70:158–164.

93. Dworkin SF. Behavioral and educational modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:128–133.

94. Wilson L, Dworkin SF, Whitney C, LeResche L. Somatization and pain dispersion in chronic temporomandibular disorder pain. Pain 1994;57:55–61.

95. Dworkin SF, Turner JA, Wilson L, et al. Brief group cognitive-behavioral intervention for temporomandibular disorders. Pain 1994;59:175–187.

96. Stohler CS. Occlusal therapy in the treatment of temporomandibular disorders. Oral Maxillofac Surg Clin North Am 1995;7:129–139.

97. Okeson JP. Long-term treatment of disk-interference disorders of the temporomandibular joint with anterior repositioning occlusal splints. J Prosthet Dent 1988;60: 611–616.

98. Clark GT. Interocclusal appliance therapy. In: Mohl ND, Zarb GA, Carlsson GE, Rugh JD (eds). A Textbook of Occlusion. Chicago: Quintessence, 1988:271–284.

99. Magnusson T, Carlsson GE. Treatment of patients with functional disorders in the masticatory system: A survey of 80 consecutive patients. Swed Dent J 1980;4:145–153.

100. Joondeph DR. Long-term stability of orthopedic repositioning. Angle Orthod 1999;69:201–209.

101. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, Criteria, Examination and Specifications, Critique. J Craniomandib Disord Facial Oral Pain 1992;6:301–355.

102. American Association of Dental Research: Scientific Information Statement on Temporomandibular Disorders. AADR Reports 1996;18(4).

103. Israel HA, Saed-Nejad F, Ratcliffe A. Correlation between arthroscopic diagnosis of osteoarthritis and synovitis of the human temporomandibular joint and keratan sulfate levels in the synovial fluid. J Oral Maxillofac Surg 1997;55:210–217.

104. Shafer DM, Assael L, White LB, Rossomando EF. Tumor necrosis factor-alpha as a biochemical marker of pain and outcome in temporomandibular joints with internal derangements. J Oral Maxillofac Surg 1994;52:786–791.

105. Ratcliffe A, Israel HA, Saed-Nejad F, Diamond BE. Proteoglycans in the synovial fluid of the temporomandibular joint as an indicator of changes in cartilage metabolism during primary and secondary osteoarthritis. J Oral Maxillofac Surg 1998;56:204–208.

106. Kubota E, Kubota T, Matsumoto J, Shibata T, Murakami KI. Synovial fluid cytokines and proteinases as markers of temporomandibular joint disease. J Oral Maxillofac Surg 1998;56:192–198.

107. Fang PK, Ma XC, Ma DL, Fu KY. Determination of interleukin-1 receptor antagonist, interleukin-10, and transforming growth factor beta-1 in synovial fluid aspirates of patients with temporomandibular disorders. J Oral Maxillofac Surg 1999;57:922–928.

108. Haskin CL, Milam SB, Cameron IL. Pathogenesis of degenerative joint disease in the human temporomandibular joint. Crit Rev Oral Biol Med 1995;6:248–277.

109. Alstergen P, Kopp S. Prostaglandin E2 in temporomandibular joint synovial fluid and its relation to pain and inflammatory disorders. J Oral Maxillofac Surg 2000;58:180–186.

110. Mense S. Nociception from skeletal muscle in relation to clinical muscle pain. Pain 1993;54:241–289.

111. Stohler CS. Muscle-related temporomandibular disorders. J Orofac Pain 1999;13:273–284.

112. Sessle BJ. The neural basis of temporomandibular joint and masticatory muscle pain. J Orofac Pain 1999;13:238–245.

113. Schafer M, Carter L, Stein C. Interleukin-1 beta and corticotropin-releasing factor inhibit pain by releasing opioids from immune cells in inflamed tissue. Proc Natl Acad Sci USA 1994;91:4219–4223.

114. Kinman E, Levine JD. Involvement of the sympathetic postganglionic neuron in capsaicin-induced secondary hyperalgesia in the rat. Neuroscience 1995;65:283–291.

115. Lewin GR, Rueff A, Mendell LM. Peripheral and central mechanisms of NGF-induced hyperalgesia. Eur J Neurosci 1994;6:1903–1912.

116. Sohrabi F, Miranda RC, Toran-Allerand CD. Estrogen differentially regulates estrogen and nerve growth factor receptors in RNA’s in adult sensory neurons. J Neurosci 1994;14:459–471.

117. Dubner R. Neuronal plasticity and pain following peripheral tissue inflammation or nerve injury. In: Bond MR, Charlton JE, Woolf CJ (eds). Proceedings of the Sixth World Congress on Pain. Amsterdam: Elsevier, 1991:264–276.

118. Sessle BJ. Acute and chronic craniofacial pain: Brain stem mechanisms of nociceptive transmission and neuroplasticity, andtheir clinical correlates. Crit Rev Oral Biol Med 2000;11:57–91.

119. Ren K, Dubner R. Focus article: Central nervous system plasticity and persistent pain. J Orofac Pain 1999;13:155–163.

120. Dionne RD. Critical commentary 1: Central nervous system plasticity and persistent pain. J Orofac Pain 1999;13:164–165.

121. Hu JW. Critical commentary 2: Central nervous system plasticity and persistent pain. J Orofac Pain 1999;13:166–167.

122. Widmer G. Critical commentary 3: Central nervous system plasticity and persistent pain. J Orofac Pain 1999;13:168–170.

123. Niv D, Devor M. Does the blockade of surgical pain preempt postoperative pain and prevent its transition to chronicity? IASP Newsletter 1993:2–7.

124. Ernberg M, Hedenberg-Magnusson B, Alstergen P, Lundeberg T, Kopp S. Pain, allodynia, and serum serotonin levels in orofacial pain of muscular origin. J Orofac Pain 1999;13:56–62.