From Bite to Mind: TMD—

A Personal and Literature Review Carl Molin, LDS, Odont Dt^

Purpose: The purpose oí this study was to present a personal view of the development ol
prevailingopinionsaboLit temporomandibuiar disorders (TMD) during the last half
ccnturv' from a mechanistic to a psychosomatic concept. It also presents some hypotheses
concerning: (Hthe role of stress in the etiology of human oral parafunaions and its
relationship to oral stereotypies in domestic animals; and (2) the pathogenetic
mechanisms of masticator\' muscle pain. Materials and Methods: The basis tor this article
was a review of personal experiences derived from clinical and research work with TMD
patients. Studies of both older and more recent literature on TMD and related disorders—
especiaily in the fields of stress research, psychosocial medicine, occupational medicine,
and etiology—were also used. Results: A clear line is iound in the development ot the
ideas on etiology, pathogenesis, and therapy of TMD, trom the mechanistic attitude of
Costen syndrome through the introduction of psychologic and psychophysical theories by
the Columbia and Chicago schools to the now increasingly accepted biopsychosocial
concept and the view of refractory TMD as a chronic pain condition. Conclusion: The
formerly dominant bite-centered therapies—including intraorai appliances, the effects of
which still are unexplained—appear to be increasingly banished to the domain of
placebo. Hence, to an ever-increasing extent occlusal treatments are replaced by
physiotherapy and cognitive behavior therapy. The presented hypotheses may have
implications for the understanding of the origin of oral parafunction and masticatory'
muscle pain, int i Prostbodont 1999; 12:279-288.

The aim of this article was to depict, as personally

F or more than half a century one of the most con-
troversial fields in dentistry has been the syndrome
that generally is known as temporomandibuiar dis-
experienced, the development of the concepts of
TMD from a mechanistic to a psychosomatic view.
order ITMD).' At times the debate has been so heated In addition, some hypotheses are presented about the
that it can be well illustrated by the English philoso- role of stress in the etiology of human oral parafunc-
pher Augustus De Morgan's comment: "I don't quite tions as compared to oral stereot\'pies in domestic an-
hear what you say, but I beg to differ entirely with imals, as well as the pathogenetic mechanisms of
you" (cited in McNeill).' masticatory muscle pain.

ASurvey of TMD
'Professor Emeritus, Department of Orai and law Diseases,
Karolinslca Hospitai, Stockholm, Sweden.
Symptoms and Nomenclature
Reprint requests: Dr Carl Molin, Ludvigsbergsgatan I2.S-IIS23
Stockholm. Sweden, Fax: í 46 10)8 669 49 09. e-maii:
carl.molin&stockholm.mail.teha.com The cardinal symptom of TMD is pain. Common
signs are clicking noises in the joint, limited opening
This article is based on a paper that was presented at the XVIth capacity, and deviations in the movement patterns of
Conference of the Nordic Society ot the History of Medicine,
the mandible."* In addition to local symptoms TMD
28-31 May 1997.

Intemalional loumal of Proidiodonlic

Number 3, 1999 279
 TMD—PersoiiLi! and Lileralure Review Malin

patients often report more mental distress, sleep dys- History

functions, and psychosomatic disorders than non-
TMD controls.''-^ The fact that interest in TMD has been so pronounced
The disparity in opinions regarding etiology is re- during the last half century should not deceive us into
flected in the many different terms applied to this dis- believing that we are dealing with an ailment that has
order.'^ Previously, for pathogenetic reasons, the recently escaped from Pandora's box. We know from
phrase "temporomandibular joint" (TMJ) almost al- 5,000-year-old papyri that describe the technique of
ways was included. Nowadays, the more neutral and repositioning a dislocated TMJ that TMD existed in an-
American Dental Association-approved term "tem- cient Egypt, Dislocation of the TMJ may certainly be re-
poromandibular disorder" is used most frequently. It garded as the most advanced feature of the syndrome
is, however, evident that TMD is not a single entity of muscle tension and disturbed coordination that
but comprises several diseases ofvarying etioiogy and constitutes the most common t/pe of TMD. Besides, the
pathology,^ ancient Greeks knew the repositioning technique that
The present article, however, will consider only dis- is exactly the same as the one still used.'^
turbances affecting the musculature, ie, masticatory For more than 2 millennia, very little happened in
muscle pain (MMP), according to a recent classifi- this field. At the end of the last century dentistry
cation of TMD.^ The articular diseases or disorders of passed through a period of dynamic progress, espe-
the TMJ, eg, rheumatoid arthritis or internal de- cially in the United States. New materials had be-
rangements, are beyond the scope of this article, come available for prosthetic purposes, and to make
which mainly deals with conditions without demon- the best use of them it was necessary to increase
strable physical pathology. While conditions with knowledge of mandibular movements and occlu-
organic pathology are classified as diseases, the neu- sion. This new awareness called into question
romuscular disorders that generally lack such signs whether disturbances in this field might have reper-
belongto the category called illness.'°'^^ Sufferers of cussions for the TMJ.
illness seem, in contrast to diseased patients, to be
more severely psychologically distressed and more at Etiology
risk of developing chronic pain conditions.^^
Costen Syndrome
Prevalence
In 1918 the American anatomist Prentiss, with the den-
Temporomandibular disorder is not an uncommon tist Summa, published a study ofthe dental conditions
condition. At a 1996 conference arranged by the US ofhumancadavers. Their study reported lesions in the
National institutes of Health (NIH) in 1996 it was es- TMj, which they proposed were caused by defective
timated that more than 10 mi I lion Americans were af- bites that had caused excessive load on the joints,'^
fected.'•'The syndrome, however, afflicts individuals Far more attention was attracted by the 1934 arti-
selectively. It is more frequent among those who are cle, "A syndrome of ear and sinus symptoms depen-
better educated and more affluent. Women constitute dent upon disturbed function of the temporo-
about'Í of those who seek treatment, and the major- mandibular joint," written by the American otologist
ity of them are in their reproductive years—between James B. Costen.^' HereGosten brought together no
20 and 40 years of age. less than 14 different symptoms, the most important
Thus, the sociologie aspects of the syndrome are of which were pain in and around the ears, clicking
intriguing. The first to study this problem was Arnold in the joints, limited jaw opening, and other move-
Franks.''' In Stockholm he once surprised his audi- ment disturbances. Even impaired hearing, dizzi-
ence by open ing his lecture on TMD by projecting a ness, and headaches were included in the syndrome
map of the Pacific. Pointing to the island of Guam, based on experience of 11 patients. Focusing on oc-
he declared that the US Armed Forces had set up a clusion as the most important factor, Costen's paper
medical center there that included a TM| clinic. Since had immense impact, and its consequences were far
the natives ofthe island were privy to its medical ser- reaching for both patients and dentists.
vices, an additional motive was the opportunity to
study TMD in a population unaffected by V\/estern Costen's Concept
civilization. This project, however, proved to be a
complete failure; nota single native appeared at the Gosten's pathogenetic concept—one may be tempted
TMD clinic. Instead, the majority of the patients were to call it a pathogenic theory—was that in the absence
officers' wives! (Franks AST, personal communica- of molar support the powerful elevating muscles of
tion, 1968.) the mandible could press the condyles upward and

The International Journal QfPiDsthocJortics 280 Volume 12, NjmL= . „ ^ i i ™

 TMD—Personal and Literature Review

backward, causing damage to vessels and nerves, in- Laszio Scbwartz: Pioneer for a Scientific Approacb
cluding the corda tympani.'~ The logical treatment,
ofcourse, was to restore the vertical dimension ofthe Gosten's theories were soon questioned, and finally
bite. If molars were lacking, partial prostheses were disproved by anatomists." Laszio L. Schwartz, a gen-
fitted: in dentate cases where overclosure was diag- eral dental practitioner, adopted a new approach
nosed the bite was raised. This mode of treatment and founded the first academic research center at
spread rapidly throughout the United States and then Golumbia University, with a multidisciplinary col-
the world. The success of the concept was a result of laboration on what he called the "temporomandibu-
the advantages it offered both patients and dentists. lar joint pain dysfunction syndrome."-^ Despite the
The patients found a simple, somatic explanation for chosen term, Schwartz considered the disorders to be
their mysterious symptoms, hience, they willingly localized in the masticatory muscles rather than in the
accepted even extensive occlusal treatment. The im- joint. Themental constitution of the patient was con-
portance of a somatic diagnosis for legitimizing an ill- sidered to be more important than occlusal distur-
bances, which play but a contributing role. The ef-
ness is ver\' powerful, and may explain the willing-
fects of stress and anxiety in increasing tension in the
ness of patients with psychogenic disorders to
masticator\' muscles were considered to be the basis
undergo drastic treatment.'^ ''' For dentists, Gosten's
ofthe disorder. Alarming diagnoses or physiologically
concept was a stroke of fortune because it provided
or psychologically traumatic treatment can aggra-
them with an expanded field of activity. vate the disorder.-"* In the team of medical and den-
If treatment of the bite did not give the desired ef- tal specialists that Schwartz assembled at Golumbia-
fect, it was interpreted as not having been radical Presbyterian Medical Genter, psychiatrist Ruth
enough. In a lecture (Stockholm 1965), the late Prof Moulton played an important role in furthering the
Sigurd Ramfjord of Ann Arbor-—of whom, certainly, understanding of the significance of emotional
no undervaluingofthe importance of occlusion may factors.'"-"
be suspected^told of an American colleague who
had had his bite raised 3 times to improve his hear- More than any other author in the field of TMD,
ing (Ramfjord S, personal communication, 1968). As Laszio Schwartz broke new ground for understand-
mentioned, "impaired hearing" was among the symp- ing the many problems in this area. Under his guid-
toms included in Gosten syndrome.'' Soon after the ance the work at the Columbia TMj clinic brought
last procedure the apices of the mandibular incisors about a paradigm shift in understanding what causes
could be palpated under his chin! iRamfjord S, per- TMD. The acceptance of Schwartz's ideas, however,
sonal communication, 1968.} was very slow. To understand Laszio Schwartz's
achievements it is necessary- to mention his devotion
to the humanities, especially to the history of medi-
Other Etiologic and Pathogenetic Tbeories
cine and dentistr\'. He was a founder ofthe Academy
ofthe FHistory of Dentistry, and he managed to add a
Since Costen put forth his concept an enormous body course on this subject to the curricula at Golumbia
of literature has been published about these disorders, Dental School .^^
Costen's theory' of overclosure assumed major defects
in the bite; later the tendency was to consider even
very minute occlusal disturbances to be dangerous. The Psychophysiologic School
In a way, smaller disturbances were thought to be
even more pathogenic by disturbing the intricate pro- After Schwartz's death in 1966, the center of research
prioception and coordination, thus causing effects activity moved to Chicago. At the University of
even on the central nervous system.-°-' Illinois, surgeon Daniel M- Laskin, with orthodontist
ChariesS. Greene, founded theTemporomandibular
As late as the 1970s this belief in the ability of oc-
Research Center with a focus on psychophysiologic
clusal disturbances to cause irritation was generally
factors.-" As with other psychophysiologic condi-
embraced. One leading Scandinavian textbook at
tions (eg, hypertensionl, TMD was considered to be
this time stated:
caused by an interaction between a physiologic pre-
The anxiety that many patients with muscular hyperac- disposition and psychologic and physical stress. The
tivity in the masticatory apparatus demonstrate may there- effect on the individual depended on his or her abil-
fora, thanks to the close co-operation between ihe reticular ity to adapt to stress. This adaptation is referred to as
system, the cortex and the limbic system, be a consequence
of disturbances or the interocclusal morphology and ac- "coping" and has come to the forefront of research
cordingly a secondary phenomenon. Clinically, this is not activity on stress and chronic pain.^^ -^ To emphasize
an uncommon experience.^' (Italics in original.) that the muscles, not the joint, are the most important
component, the group adopted the term "myofascial

. .-i.mber3,l999 281 The ln.ema.ior,allo.rnalof Prosthodontta

 TMD—Personal and Literature Review

Occlusion and Bruxism ¡n the Etiology of TMD

Costen posited that the cause of the syndrome was

in the bite, and consequentiy the treatment ought to
be directed against it.'-' Bruxism or other parafunc-
tions, however, were not mentioned in his article. As
already mentioned, both Schwartz and Laskin re-
garded occiusal factors as fairly unimportant. What
the patient does with his or her bite was considered
more important than how it looks.
Among dentists, however, resistance to this notion
was considerable. Occiusal treatment, equilibration,
and orthodontic and/or prosthetic reconstruction be-
came the fashion. The ideal occlusion and articula-
tion of a complete denture became the object, even
for "prophylaxis."" The American Equilibration
Stjciety set the tone, and among occlusion-fixated
propagandists, Drs Peter Dawson and Nathan Shore
may be mentioned.^"'^^ Finally, this policy became
so widely accepted that it brings to mind Mark
Twain's statement: "Ifyour only tool isa hammer, you
may treat everything as nails."
Fig 1 The oonoept of dynamic equilibrium may be illustrated
by considering the manner in which jets of water can balance a
ball alotl in a fountain; tlie position of the ball is not static although How Do Occiusal Disturbances Arise?
tlie ball appears to be virtually fixed in place. Teeth maintain their
positions in a bite in a similar way.
It has been proposed that the noniatrogenic occlusai
disturbances often observed and subjected to treat-
ment are not tbe cause oí, hut are instead caused by,
parafunctional activity,^°'^^The positions of the teeth
in the occlusion are not stable; they are determined
pain dysfunction (MPD) syndrome,"^" which had by the dynamic activity of the oral environment.
been introduced in medicine for similar disorders by The requirement for keeping the teeth in unchanged
Janet Travell et al.^^ positions is that the sum total of all forces acting
In conformity with Ruth Moulton, parafunctions upon them is constant. These forces may include the
were seen as subconscious attempts to work off psy- occiusal and articulating ones as well as the pressure
chic tension. The fatigue and pain spasms produced from surrounding tissues, ie, the lips, cheeks, and
in the masticatory muscles by such efforts, especially tongue (Fig 1 ). When such an equilibrium exists, no
bruxism, were thought to bring about, maintain, and perceptible movements take place, and, conse-
even aggravate the symptoms.^° Thus, the group quently, the teeth rnaintain their positions for long
shared Travell et al's opinion that muscular overex- periods of time. If equilibrium does not exist, the
ertion produces a vicious circle." This theory has teeth are driven by the acting forces into new posi-
proven to be erroneous'^; the disorders seldom get tions, where they often constitute what is called oc-
worse if they are not fixated by improper treatment. ciusal disturbances. It is then futile to treat the oc-
Moulton's view of the relationship between symp- clusion without taking the causes of the patient's
toms and psychic tension, however, holds true and behavior into consideration.^'' The common expe-
will be considered later in this article. rience of the nonlasting effects of equilibration sup-
Regarding occlusai factors, the opinion of the ports this opinion. The disturbances that are elimi-
Chicago group was at least as negative as Schwartz's. nated often recur or new ones arise.^''•^^
One example is the farcical, but also to some extent
seriously intended "American Non-Equilibration EMG Studies
Society" that Daniel Laskin founded in 1977. (Itwas
a great honor to have been appointed one of its 12 In 1961 Sigurd Ramfjord published a study that prob-
fellows.) The barb was aimed at the "American ably has been more influential than any other
Equilibration Society," which by that time was very to strengthen the doctrine of the importance of
mechanistic. occlusion.^^ Studying conscious experimental sub-
 TMD—Personal and Literature Review

jects, he reported that occlusal adjuslment could re-

duce eleciromyographic (EMC) activity. There was,
however, rno control group, eilher of an active (treated
with placebo) or passive (on a waiting list) nature.
In a sur\'ey, Clark and Adler**" state that there is
neither experimental nor epidemiologic evidence
ot the capability of premature contacts or other oc-
clusal disturbances to produce bruxism during sleep,
nor is there evidence for the cessation of such activity
if the interferences are removed. Moreover, recent
studies indicate that during rapid eye rTiovement
(REM), sleep receptors, eg, in the periodontium, are
not functioning."'^
The tendency in recent reviews of bruxism is to di-
minish the role of local factors and to emphasize a
central genesis.-'--'^ The results of Ramfjord's study
therefore are not without objeaions applicable to Fig 2 When undei stress animais can develop so-calied eral
sleeping subjects. Furthermore, when dealing with sterectypies, which correspond to human oral paratunctions.
Shown here is a heifer pertorming tongue rcliing' after being teth-
conscious subjects the effects of placebo or nocebo
ered after the end of the grazing season. (Repnnted by pennis-
factors are difficult to exclude.-'"' In addition, the sion ot Bedbo.''")
value of EMC investigations for clinical purposes
was called into question in a study demonstrating that
increased rest activity- does not necessarily mean that
the patient experiences muscle pain "'^

Parafunctions and Stereotypies

Moulton's opinion of parafunctions as an outlet for in-

ternal tension and stress receives support from an un-
expected source—our domestic animals. Cattle ranch- Later, however, in pace with the developing knowl-
ers and veterinarians are well acquainted with the edge in the wide and complicated fields of stress and
phenomenon that animals under stress engage in para- chronic pain, Schwartz's concepts increasingly gained
functional activities, referred io in veterinary termi- credence, while the belief in the importance of oc-
nology as "stereotypies.""'^ Cows manifest these sterec- clusal faaors correspondingly has lessened.
typies by rolling of the tongue (Fig 2], horses by Even though Schwartz himself did not use the term
crib-biling, and tethered pigs by biting on the chain (in "biopsychosocial," all of his aaivitles were character-
some parts of the world tethering of pigs in barns is still ized by this view. Schwartz's research work has chiefly
allowed)."*' Particularly frequent is tongue rolling in been carried on by his pupil Joseph J.Marbach. In a cas-
heifers when they are tethered in a cow shed during cade of articles he has argued that psychosocial factors,
the autumn months. During the summer they graze for not the state of the occlusion, should be the guiding
8 to 10 hours a day and ruminate for nearly as long. principles for therapy. (For example, see Marbach.^'^)
Once confined, they receive their feed calculated and His severe criticism of the prevailing treatments, di-
portioned out by a computer, and devour the fodder rected at occlusal factors, has caused colleagues to con-
in barely 45 minutes. After ruminating rapidly, they sider him the most dangerous dentist In America—note
have nothing meaningful with which to occupy them- well—not for patients, but for dentists!
selves and therefore begin rolling their tongues. For obvious reasons this vexation is easily under-
In collaboration with the ethologist Dr Ingrid Redbo stood. Studies show that the great majority of cl inicians
at the Swedish Universityof Agricultural Sciences, an in the United States—and around the world—still
article comparing human parafunctions with stereo- consider bruxism caused by occlusal anomalies to be
typies in domestic animals is under preparation. the single most important factor in TMD.''^'^°
Pecuniarily, it would certainly not be a small change
Psychologic and Psychosocial Factors in TMD to modify this view. A 199S article in the journal of
the American Dental Association estimated ^h¡tt$^ bil-
During Schwartz's lifetime his pioneering clinical and lion was spent annually in the United States on pro-
theoretical achievements were not fully recognized. ducing 3.6 million splints.^'

. . 2 . Number 3,1999 283 nal of Prosthodonlics

 TMD—Personal and Literature Review

Bruxism disc, but the returning movement is carried out by the

elasticity ofthe connective tissue that joins the disc to
In clinical studies the reported prevalence of bruxism the dorsal part of the articular fossa. IHyperactivity
varies between 6.5% and 88%, while the figures in may be responsible for fatigue and disruption of this
epidemioiogic studies generally are lower.''^ The connective tissue, which in turn can lead to anterior
validity ofthese assessments has been questioned by dislocation ofthe meniscus.'^^
Marbach andothers, who consider that patients have
been influenced by their dentist's attitude.^^'^"* As it The Origin of Muscle Pain in TMD
has been all butaxiomatic that bruxism is the crucial
factor in TMD, the dentists take for granted that the No satisfactory explanation of the muscle pain in
patient is a bruxist. Consequently, they influence the TMD has so far been presented. The most promising
patient by their explanations and leading questions explanation so far was proposed by Widmer.''^ EHe
to believe in and concede to such activity. Moreover, suggests that the cause of masticatory muscle pain is
there is no reliable method for determining whether similarto that of angina pectoris, ie, because of local
wear facets are caused by bruxism or by other disturbances in microcirculation. This gives a credi-
factors. "-5^ ble explanation ofhow but not why pain develops in
a muscle when it is producing only a small portion
Other Parafunctional Activities of its maximum voluntary force. Erom quantitative
EMCJ studies we know that the forces in such activi-
The concept that bruxism is the dominant factor for ties are rather moderate.''^'^'''^^ Also, in the related dis-
causing TMD has had such impact that other para- order of tension-type headache recorded EiVlG levels
functional activities have been totally eclipsed. are not very great.^^
Bruxism is just one—maybe not even the most dele- By drawing experiences from another field, occu-
terious—of the parafunctions in which the mastica- pational medicine, it may be proposed that TrMD has
tory system can be engaged. Examples of such prob- so much in common with some vocational disor-
lematic habits are tongue thrusting and sucking and ders, for example shoulder-neck complaints, that it
biting on the lips and cheeks. may be justifiable to regard them as branches ofthe
In bruxing the working mode of the muscles is same tree. Strong support for this view can be derived
dynamiclie, they alter their length), while in pressing from the fact that psychosocial conditions have been
it is static, isometric, tivcn more deleterious is shown to be mure important than physical strain in
antagonistic tension, that is, when groups of muscles producing symptoms,'''^'^^
with different tasks counteract each other. The phys- At moderate loads, it is the length of time rather
iologically most noxious effects, however, are caused than the level of muscle activity that is the most im-
when muscles work eccentrically, that is, when they portant factor in pain.^''™ The reason for this is that
are elongated during simultaneous contraction.^^•^'' In the activation of individual motor units takes place in
this type of action the forces within the muscle may such a fixed order that the same motor units are al-
exceed the strength ofthe connective tissue, resulting ways recruited first.^^ '•'^ When the force is reduced,
in microruptures, edema, and pain.^^'^^ An illustration the motor units are disengaged in reverse order. This
is the well-known fact that climbing downhill causes means that a few muscle fibers are heavily loaded for
more stiffness and aching than climbing uphill. a long time even if the entire muscle is only slightly
The lateral pterygoid is especially vulnerable in this loaded. The appropriate name "Cinderella fibers"
respect. Besides being the prime mover of protrusion has been suggested for these hard-working units.'''
and laterotrusion, it also acts as a stabilizer of both the The fact that muscles can be activated by psychic
mandible and the meniscus.^''^^ During times of stress, conditions is an old experience that has had new ap-
it probably is as common to tense the masticatory plications in sports. When an athlete mentally pre-
muscles antagonistically as it is to bite together or to pares for an activity by imagining the movement pat-
brux. Certainly many of us have noticed how a patient tern, the appropriate muscles increase their
during history taking tenses the masticatory muscles performance to some extent.''^''^ An observation that
and moves the jaw to one side without biting together corroborates this effect is that no difference in EMG
when we happen to touch upon some emotionally del- activity was found between physical pain produced
icate topic. The force that the lateral pterygoid can de- by injecting the masseter muscle with hypertonic (.5%)
velop in such isometric or negative contraction would saline and "sham" pain, ie, pain evoked by imagin-
be sufficient to produce pain. Eurthermore, the upper ing pain.^^ Moreover, studies of occupational work sit-
bellyofthe lateral pterygoid is exceptional because it uations demonstrate that emotional and environ-
has no antagonistic muscle. It protracts the articular mental factors, ie, psychosocial conditions, are

Ttie Irternaüonal lourrai of Pro slti odontic s 284 Volume 12, Nu

 TMD—Personal and Literalure Review

capable of producing increased unconscious muscle lower rate of treatment seekers, it may be concluded
activity.'''' that most of those affected by TMD recover
In the facial muscles, those of facial expression as spontaneously. 5tudies of treatment outcome show
well as those of mastication, psychic and especially that between 70% and 90% improve or get well irre-
emotional conditions are particularly prone to man- spective of the treatment method, and no particular
ifest themselves.' "• '^ The face is our facade, which we procedure has proven to be superior to any other or
unconsciously try to keep unaffected by tensing the even to placebo.'^•^^-^' Thus, every dortor can assert
muscles ofthe face and ¡aw. In antagonistic tension, without risk that it is just his or her method of treatment
as mentioned above, some motor units may remain that works—at least in their hands. After all, the most
active for such a long time that pain is evoked. important consideration is that irreversible aaions be
The time of recovery between periods of activity is avoided.^^ Such measures may increase the risk that
important. When a muscle works, metabolites accu- the patient's bite will become fixated—or even expe-
mulate and the balance of Na+, K*, and Ga"^ is dis- rience what Marbach calls a "phantom bite" and thus
turbed. IntracellularK* decreases, while extraceliularly become a chronic pain case.^-
it increases. This may act on free nerve endings and However, as in other psycho physic a I disorders, there
cause pain."" Impaired microcirculation in the muscle is a considerable minority of patients who fail to re-
fibers and/or in the vessels that supply the nerve may spond to the conventional physically aimed therapy
contribute. To elucidate the problem, however, more and continue to suffer from persistent or recurring pain
research is needed, especially on the conditions in sep- and disability.^^'^"* Gmcial factors behind a negative out-
arate muscle fibers. Research involving the separate come seem to he psychosocial faaors such as depres-
fibers is possible using ultrathin needle electrodes.^^ sion, hypochondria, an extemal locus of health control,
abnormal illness behavior, and lack of emotional sup-
Why Does the Belief in Occiusai Etiology Survive? port resulting in impaired coping capability.^^^^^ Thus,
for these patients treatment ought to aim more at psy-
The main reason for the continued confusion about chosocial factors than at physical ones.^^"* This ap-
the etiology of TMD is the fact that in most individ- proach is corroborated by the fact that successful treat-
uals, it is possible to identify some "bite disturbance" ments are more effective against symptoms, eg, pain,
and often also some kind of dysfunction, even when than against clinical signs ofthe disorder.^^'^^
theydonot have any complaints, A comparison with At a 1996 treatment conference arranged by the
other bodily conditions may be worthwhile; how NIH, a recommendation was given that disorders
many individuals have a perfect gait^ Analogously, such as tension-type headache and TMD be treated
should those who do not have a perfect gait be with tension-relieving actions, including relaxation
equipped with arch supports? and counseling with information about the disorder
In a discerning article Nigel G. Clarke once made and its background.'^ The importance of reassur-
the critical comment that ance cannot be overestimated. "The Doaor is the
most potent drug," as the Hungarian-British psycho-
the masticatory system mus! either be unique in the analyst Michael Balint expressed it.'°' These meas-
body's evoluiionary development in its failure to fulfill ures may suffice to decrease stress and anxiety and
its function profierly or else our comprehension of the
system has mistakenly led us to describe as abnormal-
alleviate the symptoms.'^ Very important, however,
ities conditions tbat in fact may be normal and play no is that this strategy is applied as early as possible,
role in bruxism and preferably by the first care provider.
For patients who nevertheless develop chronic dis-
Apparently Clarke is alluding to those epidemioiogic order, the general rules for treatment of chronic pain
studies that overrate the occurrence of occiusai dis- should be applied. For developing such strategies, the
turbances and symptoms: these studies were also se- late Dr lohn Bonica at the University of Washington
verely criticized by Greene and Marbach.^^ In recent in Seattle probably has contributed more than anyone
years, however, it is obvious that a more realistic at- else. His deep devotion was based on experience with
titude has emerged.^^-^^ Especially important is that patients during and after the war in the Pacific.'"' He
this more matter-of-fact assessment also includes the was also a founder ofthe International Association for
the Study of Pain. Nowadays, treatment at special pain
centers is organized in the form of pain schools with
Treatment a multidisciplinar/ approach.'«»^ Gognitive behavioral
therapy plays an important role in increasing the pa-
Given the high prevalence of symptoms and signs tienf s awareness of his or her personal mode of reac-
of TMD in epidemioiogic studies and the considerably tion and its underlying causes.'°'*'"^5 Even if treatment

2. Number 3,1999 285 The International Journal of Proithodohtics

 TMD—Personal and LiLerature Review

cannot fully remove the pain, it may help the patient 11. Dworkin S, Masoth D. Temporomandibular disorders and
to cope and therefore alleviate suffering.'^^ chronic pain:Diseaseorillnessf|Pi'osthel Dent 1994;72:29.-38.
12. Harness D, Donlon W, Eversole L. Comparison of clinical char-
It is logical that one ofthe most active TMD research
acteristics in myogenic, TMJ internal derangement and atypical
groups is connected with the University of Washington facial pain patients. Pain 1990:41:4-17.
in Seattle. Under the leadership of Dr Samuel F, Dwor- 13. National Institutes of Health Technology, Assessment conference
kin its activity has principally been devoted to psycho- statement: Management of temporamandibular disorders, 29
social problems in connection with TMD and other A p r i l - I May 1996. Oral Surg Oral Med Oral Pa(hol Oral Radiol
Endüd I997;83:I77-183.
chronic pain conditions. A further area of focus has
14. Franks A. The social character of temporomandibular ioint dys-
been the development of standardized diagnostic cri- function. Dent PracL 1964;15:94-100,
teria, primarily for research purposes on TMD.^ The 15. Schwartz LL. Disorders of the Temporomandibular Joint.
classification system (Research Diagnostic Criteria for Philadelphia: WB Saunders, 1959.
TMD, RDC/TMD) contains 2 axes: one consisting of 16. Prentiss H. A preliminary report upon the temporomandibular
articulation in the human type. Dent Cosmos 1918;60:505-512.
physical TMD conditions and one concerning pain-re-
1 7, Costen IB. A syndrome of ear and sinus symptoms dependent
lated disability and psychologic status. A recent study upon disturbed function ofthe temporomandibular joint. Ann
indicates the capacity ofthe RDC/TMD to predict which Otol I934;43:1-15.
patients are at risk of developing chronic disorders.^^ 18. Molir C. Oral galvanism in Sweden. J Am Dent Assoc 1990;
Looking back, the mechanistic etiologic ideas that 121:281-284.
19. Gothe C-J, Molin C, Nilsson CC. The environmental somatiza-
transferred the treatment of TMD from medicine to
11 on syndrome. Review article, Psychoso mat i cs 1 9 9 5 ; 3 6 : 1 - n ,
dentistry seem very far away. Looking ahead, it is ev- 20. Krogh-PoulsenWG, Olsson A. Occlusal disharmonies and dys-
ident that dental training must be directed toward a function of the stomatognathic system. Dent Clin North Am
more comprehensive medical knowledge, especially ]966;627-635.
including a more phychosomatic view that will help 3 1 . Ericsson S, Riise C. Musi<ulär hyperaktivitet. In: Krogh-Poiilsen
W , Cadsen O (eds). Bidfunktion Bettfysiologi. II. Patofunktion.
dentists understand the etiology and natural history of
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orders. Put simply, the focus must be shifted from the closure. J Am Dert Assoc1948;36:l 31-139.
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24. Schwartz LL. Pain associated with the temporomandibular joint,
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Literature Afistract-

A meta-analysis of EMG biofeedback treatment of temporomandibuiar disorders.

How efficient is electromyographio (EMG) bioteedback in treating temporomandibuiar disonJers

(TMD)? This study reviewed tbe available literature from the last 3 decades to eyaluate treat-
ment etficacy and estimate treatment etfect sizes. A iiterature search located 13 studies ot EMG
biofeedback treatment tor TMD patients. 6 controlied, 4 comparative treatment, and 3 uncon-
troiled triais. Patients had been screened tor or diagnosed with myofascial pain disorder. Three
types of outcome ot EMG bioteedback training were examined: giobai improvement, patient-
reported pain, and clinical examination findings. Meta-analytic methods were used to estimate
the magnitude ot EMG biofeedback treatment effeots tor these 3 types of outcome. Foliow-up
data were available tor 8 of the 12 bioteedback trials. Six of the triais oombined biofeedback
with stress-m an age ment training. Five ot six controlied studies with EMG biofeedback training
were superior to no treatment or psychologic placebo controls tor at least one ct the three types
of outcome. Data from 12 studies contributed to a meta-analysis of pretreatment to postlreat-
ment etfeot sizes tor EMG bioteedback treatments. Mean etfect sizes for both reported pain and
clinical examination outcome were larger for bioteedback treatments than tcr control conditions.
For example, 69% of patients who received biofeedback were rated as symptom free or signifi-
cantly improved, compared with 35% of patients treated with a variety of placebo interventions.
Foilow-up outcomes for EMG bioteedback treatments showed no deterioration from posttreat-
ment ieveis. The conciusions of this meta-anaiysis support the etiicacy of EMG biofeedback
treatments for TMD. However, the available data tcr analysis were limited in extent.

Crider AB, GlarosAG. JOfoiac Pain 1999;13.29-37. Relerences: 44. Reprints; Dr Ai an Gla ros, 650 East
251h Street, Kansas City, Missouri 64103. Fax: 816-235-2157. e-mail: [email protected]—AW

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