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Purpose: The purpose o 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 etiologywere 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 therapiesincluding intraorai appliances, the effects of
which still are unexplainedappear 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.
or more than half a century one of the most controversial fields in dentistry has been the syndrome
that generally is known as temporomandibuiar disorder ITMD).' At times the debate has been so heated
that it can be well illustrated by the English philosopher Augustus De Morgan's comment: "I don't quite
hear what you say, but I beg to differ entirely with
you" (cited in McNeill).'
ASurvey of TMD
Number 3, 1999
279
Symptoms and
Nomenclature
Malin
History
patients often report more mental distress, sleep dysfunctions, and psychosomatic disorders than nonTMD controls.''-^
The disparity in opinions regarding etiology is reflected in the many different terms applied to this disorder.'^ Previously, for pathogenetic reasons, the
phrase "temporomandibular joint" (TMJ) almost always was included. Nowadays, the more neutral and
American Dental Association-approved term "temporomandibular disorder" is used most frequently. It
is, however, evident that TMD is not a single entity
but comprises several diseases ofvarying etioiogy and
pathology,^
The present article, however, will consider only disturbances affecting the musculature, ie, masticatory
muscle pain (MMP), according to a recent classification of TMD.^ The articular diseases or disorders of
the TMJ, eg, rheumatoid arthritis or internal derangements, are beyond the scope of this article,
which mainly deals with conditions without demonstrable physical pathology. While conditions with
organic pathology are classified as diseases, the neuromuscular disorders that generally lack such signs
belongto the category called illness.''^^ Sufferers of
illness seem, in contrast to diseased patients, to be
more severely psychologically distressed and more at
risk of developing chronic pain conditions.^^
Etiology
Costen Syndrome
Prevalence
In 1918 the American anatomist Prentiss, with the dentist Summa, published a study ofthe dental conditions
ofhumancadavers. Their study reported lesions in the
TMj, which they proposed were caused by defective
bites that had caused excessive load on the joints,'^
Far more attention was attracted by the 1934 article, "A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint," written by the American otologist
James B. Costen.^' HereGosten brought together no
less than 14 different symptoms, the most important
of which were pain in and around the ears, clicking
in the joints, limited jaw opening, and other movement disturbances. Even impaired hearing, dizziness, and headaches were included in the syndrome
based on experience of 11 patients. Focusing on occlusion as the most important factor, Costen's paper
had immense impact, and its consequences were far
reaching for both patients and dentists.
Costen's Concept
Gosten's pathogenetic conceptone may be tempted
to call it a pathogenic theorywas that in the absence
of molar support the powerful elevating muscles of
the mandible could press the condyles upward and
280
backward, causing damage to vessels and nerves, including the corda tympani.'~ The logical treatment,
ofcourse, was to restore the vertical dimension ofthe
bite. If molars were lacking, partial prostheses were
fitted: in dentate cases where overclosure was diagnosed the bite was raised. This mode of treatment
spread rapidly throughout the United States and then
the world. The success of the concept was a result of
the advantages it offered both patients and dentists.
The patients found a simple, somatic explanation for
their mysterious symptoms, hience, they willingly
accepted even extensive occlusal treatment. The importance of a somatic diagnosis for legitimizing an illness is ver\' powerful, and may explain the willingness of patients with psychogenic disorders to
undergo drastic treatment.'^ ''' For dentists, Gosten's
concept was a stroke of fortune because it provided
them with an expanded field of activity.
If treatment of the bite did not give the desired effect, it was interpreted as not having been radical
enough. In a lecture (Stockholm 1965), the late Prof
Sigurd Ramfjord of Ann Arbor-of whom, certainly,
no undervaluingofthe importance of occlusion may
be suspected^told of an American colleague who
had had his bite raised 3 times to improve his hearing (Ramfjord S, personal communication, 1968). As
mentioned, "impaired hearing" was among the symptoms included in Gosten syndrome.'' Soon after the
last procedure the apices of the mandibular incisors
could be palpated under his chin! iRamfjord S, personal communication, 1968.}
The anxiety that many patients with muscular hyperactivity in the masticatory apparatus demonstrate may therefora, thanks to the close co-operation between ihe reticular
system, the cortex and the limbic system, be a consequence
of disturbances or the interocclusal morphology and accordingly a secondary phenomenon. Clinically, this is not
an uncommon experience.^' (Italics in original.)
. .-i.mber3,l999
Approacb
281
jects, he reported that occlusal adjuslment could reduce 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 occlusal 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 diminish the role of local factors and to emphasize a
central genesis.-'--'^ The results of Ramfjord's study
therefore are not without objeaions applicable to
sleeping subjects. Furthermore, when dealing with
conscious subjects the effects of placebo or nocebo
factors are difficult to exclude.-'"' In addition, the
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 "'^
. . 2 . Number 3,1999
283
Later, however, in pace with the developing knowledge in the wide and complicated fields of stress and
chronic pain, Schwartz's concepts increasingly gained
credence, while the belief in the importance of occlusal faaors correspondingly has lessened.
Even though Schwartz himself did not use the term
"biopsychosocial," all of his aaivitles were characterized by this view. Schwartz's research work has chiefly
been carried on by his pupil Joseph J.Marbach. In a cascade of articles he has argued that psychosocial factors,
not the state of the occlusion, should be the guiding
principles for therapy. (For example, see Marbach.^'^)
His severe criticism of the prevailing treatments, directed at occlusal factors, has caused colleagues to consider him the most dangerous dentist In Americanote
wellnot for patients, but for dentists!
For obvious reasons this vexation is easily understood. Studies show that the great majority of cl inicians
in the United Statesand around the worldstill
consider bruxism caused by occlusal anomalies to be
the single most important factor in TMD.''^'^
Pecuniarily, it would certainly not be a small change
to modify this view. A 199S article in the journal of
the American Dental Association estimated ^htt$^ billion was spent annually in the United States on producing 3.6 million splints.^'
nal of Prosthodonlics
Bruxism
284
Volume 12, Nu
Treatment
Given the high prevalence of symptoms and signs
of TMD in epidemioiogic studies and the considerably
2. Number 3,1999
285
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