TMJ Overview and Jaw Dysfunctions … S women than men. significant, long-term symptoms. that you...

TMJ Overview and Jaw Dysfunctions Associated with the Cervical Spine

1

TMJ DISORDERS

Temporomandibular joint and muscle disorders commonly called ldquoTMJrdquo are a group of conditions that cause pain and dysfunction in the jaw joint and the muscles that control jaw movement We donrsquot know for certain how many people have TMJ disorders but some estimates suggest that over 10 million Americans are affected The condition appears to be more common in women than men

For most people pain in the area of the jaw joint or muscles does not signal a serious problem Generally discomfort from these conditions is occasional and temporary often occurring in cycles The pain eventually goes away with little or no treatment Some people however develop significant long-term symptoms

If you have questions about TMJ disorders you are not alone Researchers too are looking for answers to what causes these conditions and what the best treatments are Until we have scientific evidence for safe and effective treatments itrsquos important to avoid when possible procedures that can cause permanent changes in your bite or jaw This booklet provides information you should know if you have been told by a dentist or physician that you have a TMJ disorder

2

WHAT IS THE TEMPOROMANDIBULAR JOINT

The temporomandibular joint connects the lower jaw called the mandible to the bone at the side of the headmdashthe temporal bone If you place your fingers just in front of your ears and open your mouth you can feel the joints Because these joints are flexible the jaw can move smoothly up and down and side to side enabling us to talk chew and yawn Muscles attached to and surrounding the jaw joint control its position and movement

When we open our mouths the rounded ends of the lower jaw called condyles glide along the joint socket of the temporal bone The condyles slide back to their original position when we close our mouths To keep this motion smooth a soft disc lies between the condyle and the temporal bone This disc absorbs shocks to the jaw joint from chewing and other movements

The temporomandibular joint is different from the bodyrsquos other joints The combination of hinge and sliding motions makes this joint among the most complicated in the body Also the tissues that make up the temporomandibular joint differ from other load-bearing joints like the knee or hip Because of its complex movement and unique makeup the jaw joint and its controlling muscles can pose a tremendous challenge to both patients and health care providers when problems arise

3

OPEN

Temporal muscle covering

temporal bone

Disc

Condyle

Masseter muscleMandible

CLOSED

4

WHAT ARE TMJ DISORDERS

Disorders of the jaw joint and chewing musclesmdashand how people respond to themmdashvary widely Researchers generally agree that the conditions fall into three main categories

1 Myofascial pain involves discomfort or pain in the muscles that control jaw function

2 Internal derangement of the joint involves a displaced disc dislocated jaw or injury to the condyle

3 Arthritis refers to a group of degenerativeinflammatory joint disorders that can affect the temporomandibular joint

A person may have one or more of these conditions at the same time Some people have other health problems that co-exist with TMJ disorders such as chronic fatigue syndrome sleep disturbances or fibromyalgia a painful condition that affects muscles and other soft tissues throughout the body These disorders share some common symptoms which suggests that they may share similar underlying mechanisms of disease However it is not known whether they have a common cause

5

Rheumatic disease such as arthritis may also affect the temporomandibular joint as a secondary condition Rheumatic diseases refer to a large group of disorders that cause pain inflammation and stiffness in the joints muscles and bone Arthritis and some TMJ disorders involve inflammation of the tissues that line the joints The exact relationship between these conditions is not known

How jaw joint and muscle disorders progress is not clear Symptoms worsen and ease over time but what causes these changes is not known Most people have relatively mild forms of the disorder Their symptoms improve significantly or disappear spontaneously within weeks or months For others the condition causes long-term persistent and debilitating pain

TMJ

6

WHAT CAUSES TMJ DISORDERS

Trauma to the jaw or temoromandibular joint plays a role in some TMJ disorders But for most jaw joint and muscle problems scientists donrsquot know the causes Because the condition is more common in women than in men scientists are exploring a possible link between female hormones and TMJ disorders

For many people symptoms seem to start without obvious reason Research disputes the popular belief that a bad bite or orthodontic braces can trigger TMJ disorders

There is no scientific proof that soundsmdashsuch as clickingmdashin the jaw joint lead to serious problems In fact jaw sounds are common in the general population Jaw noises alone without pain or limited jaw movement do not indicate a TMJ disorder and do not warrant treatment

7

WHAT ARE THE SIGNS AND SYMPTOMS

A variety of symptoms may be linked to TMJ disorders Pain particularly in the chewing muscles andor jaw joint is the most common symptom Other likely symptoms include

n radiating pain in the face jaw or neck

n jaw muscle stiffness

n limited movement or locking of the jaw

n painful clicking popping or grating in the jaw joint when opening or closing the mouth

n a change in the way the upper and lower teeth fit together

TMJ

8

HOW ARE TMJ DISORDERS DIAGNOSED

There is no widely accepted standard test now available to correctly diagnose TMJ disorders Because the exact causes and symptoms are not clear identifying these disorders can be difficult and confusing Currently health care providers note the patientrsquos description of symptoms take a detailed medical and dental history and examine problem areas including the head neck face and jaw Imaging studies may also be recommended

You may want to consult your doctor to rule out other known causes of pain Facial pain can be a symptom of many conditions such as sinus or ear infections various types of headaches and facial neuralgias (nerve-related facial pain) Ruling out these problems first helps in identifying TMJ disorders

9

HOW ARE TMJ DISORDERS TREATED

Because more studies are needed on the safety and effectiveness of most treatments for jaw joint and muscle disorders experts strongly recommend using the most conservative reversible treatments possible Conservative treatments do not invade the tissues of the face jaw or joint or involve surgery Reversible treatments do not cause permanent changes in the structure or position of the jaw or teeth Even when TMJ disorders have become persistent most patients still do not need aggressive types of treatment

Conservative Treatments

Because the most common jaw joint and muscle problems are temporary and do not get worse simple treatment may be all that is necessary to relieve discomfort

Self-Care Practices

There are steps you can take that may be helpful in easing symptoms such as

n eating soft foods

n applying ice packs

n avoiding extreme jaw movements (such as wide yawning loud singing and gum chewing)

n learning techniques for relaxing and reducing stress

TMJ

10

n practicing gentle jaw stretching and relaxing exercises that may help increase jaw movement Your health care provider or a physical therapist can recommend exercises if appropriate for your particular condition

Pain Medications

For many people with TMJ disorders short-term use of over-the-counter pain medicines or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may provide temporary relief from jaw discomfort When necessary your dentist or physician can prescribe stronger pain or anti-inflammatory medications muscle relaxants or anti-depressants to help ease symptoms

Stabilization Splints

Your physician or dentist may recommend an oral appliance also called a stabilization splint or bite guard which is a plastic guard that fits over the upper or lower teeth Stabilization splints are the most widely used treatments for TMJ disorders Studies of their effectiveness in providing pain relief however have been inconclusive If a stabilization splint is recommended it should be used only for a short time and should not cause permanent changes in the bite If a splint causes or increases pain or affects your bite stop using it and see your health care provider

11

The conservative reversible treatments described are useful for temporary relief of pain ndash they are not cures for TMJ disorders If symptoms continue over time come back often or worsen tell your doctor

Botox

Botoxreg (botulinum toxin type A) is a drug made from the same bacterium that causes food poisoning Used in small doses Botox injections can actually help alleviate some health problems and have been approved by the Food and Drug Administration (FDA) for certain disorders However Botox is currently not approved by the FDA for use in TMJ disorders

Results from recent clinical studies are inconclusive regarding the effectiveness of Botox for treatment of chronic TMJ disorders Additional research is under way to learn how Botox specifically affects jaw muscles and their nerves The findings will help deter-mine if this drug may be useful in treating TMJ disorders

TMJ

12

Irreversible Treatments

Irreversible treatments that have not been proven to be effective ndash and may make the problem worse ndash include orthodontics to change the bite crown and bridge work to balance the bite grinding down teeth to bring the bite into balance called ldquoocclusal adjustmentrdquo and repositioning splints also called orthotics which permanently alter the bite

Surgery

Other types of treatments such as surgical procedures invade the tissues Surgical treatments are controversial often irreversible and should be avoided where possible There have been no long-term clinical trials to study the safety and effectiveness of surgical treatments for TMJ disorders Nor are there standards to identify people who would most likely benefit from surgery Failure to respond to conservative treatments for example does not automatically mean that surgery is necessary If surgery is recommended be sure to have the doctor explain to you in words you can understand the reason for the treatment the risks involved and other types of treatment that may be available

13

Implants

Surgical replacement of jaw joints with artificial implants may cause severe pain and permanent jaw damage Some of these devices may fail to function properly or may break apart in the jaw over time If you have already had temporomandibular joint surgery be very cautious about considering additional operations Persons undergoing multiple surgeries on the jaw joint generally have a poor outlook for normal pain-free joint function Before undergoing any surgery on the jaw joint it is extremely important to get other independent opinions and to fully understand the risks

The US Food and Drug Administration (FDA) monitors the safety and effectiveness of medical devices implanted in the body including artificial jaw joint implants Patients and their health care providers can report serious problems with TMJ implants to the FDA through MedWatch at httpwwwfdagovmedwatch or telephone toll-free at 1-800-332-1088

TMJ

14

IF YOU THINK YOU HAVE A TMJ DISORDER

Remember that for most people discomfort from TMJ disorders will eventually go away on its own Simple self-care practices are often effective in easing symptoms If treatment is needed it should be based on a reasonable diagnosis be conservative and reversible and be customized to your special needs Avoid treatments that can cause permanent changes in the bite or jaw If irreversible treatments are recommended be sure to get a reliable independent second opinion

Because there is no certified specialty for TMJ disorders in either dentistry or medicine finding the right care can be difficult Look for a health care provider who understands musculoskeletal disorders (affecting muscle bone and joints) and who is trained in treating pain conditions Pain clinics in hospitals and universities are often a good source of advice particularly when pain continues over time and interferes with daily life Complex cases often marked by prolonged persistent and severe pain jaw dysfunction co-existing conditions and diminished quality of life likely require a team of experts from various fields such as neurology rheumatology pain management and others to diagnose and treat this condition

15

RESEARCH

The National Institute of Dental and Craniofacial Research (NIDCR) one of the National Institutes of Health (NIH) leads the federal research effort on temporomandibular joint and muscle disorders In a landmark study NIDCR is tracking healthy people over time to identify risk factors that contribute to the development of these conditions Preliminary results from this study have identified a series of clinical psychological sensory genetic and nervous system factors that may increase the risk of having chronic TMJ disorders These new findings expand our scientific understanding of the onset and natural course of TMJ disorders and may lead to new diagnostic and treatment approaches

Additionally researchers are using data from a TMJ implant registry and repository that collected health information from patients who received implants and from those who had implants removed Recent studies using the data have helped researchers plan for new pain medication trials and other research projects

Pain Studies

Because pain is the major symptom of these conditions NIH scientists are conducting a wide range of studies to better understand the pain process including

n understanding the nature of facial pain in TMJ disorders and what it may hold in common with other pain conditions such as headache and widespread muscle pain

TMJ

16

n exploring differences between men and women in how they respond to pain and to pain medications

n pinpointing factors that lead to chronic or persistent jaw joint and muscle pain

n examining the effects of stressors such as noise cold and physical stress on pain symptoms in patients with TMJ disorders to learn how lifestyle adjustments can decrease pain

n identifying medications or combinations of medications and conservative treatments that will provide effective chronic pain relief

n investigating possible links between osteoarthritis and a history of orofacial pain

Replacement Parts

Research is also under way to grow human tissue in the laboratory to replace damaged cartilage in the jaw joint Other studies are aimed at developing safer more life-like materials to be used for repairing or replacing diseased temporomandibular joints discs and chewing muscles

HOPE FOR THE FUTURE

The challenges posed by TMJ disorders span the research spectrum from causes to diagnosis through treatment and prevention Researchers throughout the health sciences are working together not only to gain a better understanding of the temporomandibular joint and muscle disease process but also to improve quality of life for people affected by these disorders

TMJ DISORDERS is produced and distributed by the National Institute of Dental and Craniofacial Research in partnership with the Office of Research on Womenrsquos Health components of the National Institutes of Health (NIH) in Bethesda Maryland

For additional copies of this pamphlet contact

National Institute of Dental and Craniofacial ResearchNational Oral Health Information Clearinghouse1 NOHIC WayBethesda MD 20892-3500 1ndash866ndash232ndash4528httpwwwnidcrnihgov

This publication is not copyrighted Make as many photocopies as you need

NIH Publication No 13-3487 August 2013

NIHhellipTurning Discovery Into Health reg

Research ArticleCorrelation between TMD and Cervical Spine Pain and MobilityIs the Whole Body Balance TMJ Related

Karolina WalczyNska-Dragon1 Stefan Baron1

Aleksandra Nitecka-Buchta1 and Ewaryst Tkacz2

1 Department of Temporomandibular Joint Dysfunction and Orthodontics Medical University of Silesia Pl Traugutta 241-800 Zabrze Poland

2 Institute of Theoretical and Applied Informatics Polish Academy of Sciences 5 Batycka Street 44-100 Gliwice Poland

Correspondence should be addressed to Karolina Walczynska-Dragon karolinadragonwppl

Received 15 March 2014 Accepted 23 May 2014 Published 19 June 2014

Academic Editor Mieszko Wieckiewicz

Copyright copy 2014 Karolina Walczynska-Dragon et al This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Temporomandibular dysfunction (TMD) is considered to be associated with imbalance of the whole body This study aimed toevaluate the influence of TMD therapy on cervical spine range of movement (ROM) and reduction of spinal pain The study groupconsisted of 60 patients with TMD cervical spine pain and limited cervical spine range of movements Subjects were interviewedby a questionnaire about symptoms of TMD and neck pain and had also masticatory motor system physically examined (accordingto RDC-TMD) and analysed by JMA ultrasound device The cervical spine motion was analysed using an MCS device Subjectswere randomly admitted to two groups treated and control Patients from the treated group were treated with an occlusal splintPatients from control group were ordered to self-control parafunctional habits Subsequent examinations were planned in bothgroups 3 weeks and 3months after treatment was introducedThe results of tests performed 3months after the beginning of occlusalsplint therapy showed a significant improvement in TMJ function (119875 gt 005) cervical spine ROM and a reduction of spinal painThe conclusion is that there is a significant association between TMD treatment and reduction of cervical spine pain as far asimprovement of cervical spine mobility

1 Introduction

Recent years have seen a significant increase in the numberof patients suffering from temporomandibular disorders(TMD) [1] According to various sources 8 out of 10 patientscoming to the dentist are found to have bruxism or TMD[2]

The issue of relationships between temporomandibulardisorders and body posture is still a source of speculationsThe knowledge about connections between distant body dis-tricts has to be proven by appropriate diagnostic proceduresand instruments

TMD are musculoskeletal disorders needing a multi-disciplinary effort to manage with other professionals (egneurologist laryngologist and psychiatrist) [3]

Because of the variety of TMD symptoms many patientshad a history of multiple treatments and medications and

were treated previously by laryngologists neurologists orphysiotherapist but the therapy did not bring the expectedlong lasting results According to currently prevailing the-ories temporomandibular dysfunction is considered to beassociated with imbalance of the whole body [4]

In addition the body as a whole operates on the principleof compensation when it comes to disturbances in the upperquarter such as increased muscle tension this will leadto compensatory changes within the muscle tension in thespinal region so as to force the correct positionpostureTheseadaptive changes occur at all levels within tolerance of thebody [5 6]

When the body capacity to compensate for the patholog-ical changes progressing in given areas is exceeded howeverimbalance sets in and pathological symptoms will appearEach individual obviously has a unique compensation limitbeyond which such symptoms are triggered off

Hindawi Publishing CorporationBioMed Research InternationalVolume 2014 Article ID 582414 7 pageshttpdxdoiorg1011552014582414

2 BioMed Research International

It was pointed out by many authors that pain in the upperquarter and masticatory motor system may be caused by cer-vical spine disorders (generally by dysfunction of muscularorigin) and vice versa [7ndash9]

It could be explained by specific functional and mor-phological connections between the cervical and temporo-mandibular regions

2 Materials and Methods

The sample was comprised of 60 individual (30 female 30male age 18ndash40) and was divided into two groups with ran-domization Study and control groups both consisted of 30people with TMD cervical spine pain and limited cervicalspine range of movements (ROM) Subjects were directedfrom Cooperating Orthopaedic Service

Groups were not different regarding age and genderPatients from both groups met the criteria for inclusion

and exclusion of studies (Table 1)Patients from both groups were recruited from cooperat-

ing clinics and previously diagnosed by an orthopaedist whoexcludedmorphological and degenerative changes of cervicalspine Cervical spine pain was diagnosed by an orthopaedistaccording to theNeckPainTask Force recommendations [10]

Each patient had to have had cervical spine pain for atleast 12 months in multiple episodes at a frequency of at leastonce aweek Patientswere included in the study if having painin the area between occiput and C7

Subjects gave written consent to participate in the studyThe study was approved by the Ethics Committee of theMed-ical University of Silesia (number KNW0022KB16I10from 16032010)

Each patientwas examined three times At the 3-week and3-month evaluations symptoms of TMD and cervical spinepain and mobility were studied

The examination included the following

(1) medical history and physical examination based on asurvey card (according to RDCTMD)

(2) analysis of pain using the visual analogue scale (VAS)and the cervical Oswestry scale for the cervical spine

(3) TMJ functional evaluation by JMA device(4) cervical spine motion evaluation with the MCS de-

vice

In order to describe individual TMD symptoms the entiresample filled out a questionnaire according to research diag-nostic criteria for TMD the translated Polish version (RDCTMD axis I)The questionnaire focuses on symptoms specifi-cally in the jaw-face neck shoulder girdle intensity of spinalpain and any other complaints of TMD and spinal originPresence of symptoms was marked according to durationfrequency and intensity The survey card was completed byeach patient 3 times during three consecutive examinationswhich enabled a comparison of symptoms between groupsaccording to treatment provided in treated group

On a questionnaire patients indicated the intensity ofspinal pain experienced at the time of examination on a100 mm visual analogue scale (VAS) Additionally subjects

Table 1 Inclusion and exclusion criteria of studies

Inclusion criteria Exclusion criteria(1) Spinal pain(2) Women men(3) Age between 18 and 40(4) Functional changes of thespine muscle-related(5) Temporomandibular jointdisorderbruxism(6) Patient agreement

(1) After spine surgery(2) Congenital or degenerativechanges of the spine confirmedradiologically(3) Neuropathy(4) Ongoing medication orphysiotherapy(5) TMJ internal derangement

described symptoms of pain and reducedmobility of cervicalspine by filling in the cervical Oswestry scale

Clinical examination was performed according to RDCTMD guidelines too

Previously trained examiner assessed face symmetrydentition and occlusion as far as ldquoupper quarterrdquo muscletenderness to palpation with an emphasis on the masticatorymuscles trapezius muscles suprahyoid muscles infrahyoidmuscles sternocleidomastoid muscles and neck muscles inthe region of the linea nuchae Each time the muscle tensionwas examined by the same examiner

Mandibular motion was recorded using jaw motionanalyzer (JMA) fromZebris (GmBbH) and the software pro-vided (WinJaw) [11]The device allows recording mandibularposition and movements

The subjects were provided with an explanation as to theobjective of the axiographic examination and its course aswell as what types of mandibular movements should bemadeand how For each examination it was necessary to make aparaocclusal clutch mounted on the vestibular surface of thelower teeth and fitted with an electronic sensor The tool wasmade of light-cured Multitray (Espe)

The study was based on the performance of patientsrsquomovements opening and closing of the mandible lateralmovements protrusion and retrusion To avoid bias all sub-jects performed each trials three times For each movementthe baseline position was the mandibular rest position Itseems that the rest position should be the starting point whenassessing the motor function of the stomatognathic systemusing instrumental techniques (Figure 1)

The advantages of this system are the ease of use anda positional accuracy of about 100 micrometers Softwareallowed creating data report which consists of graphic dia-grams of TMJ function (eg Condyle pathmaximal openingand Bennett angle)

Afterwards the MCS (Zebris GmbH) ultrasonic-baseddevice was used to collect external kinematic data of thecervical spine movements Patients with a neutral (comfort-ably seated) position performed maximal head movementsflexion extension rotation to the right and left side andlateral flexion movements Each movement was repeatedthree times in order to minimise measurement errors Thesystem was calibrated before each measurement Data weremonitored in a real time (Figure 2)

BioMed Research International 3

Figure 1 Patient during the mandibular movementsrsquo examination(JMA)

Figure 2 Patient during the cervical spine movementsrsquo examina-tion

Thanks to the repeatable measurements values werefound describing the cervical spine ROMs presented in theform of relevant graphs

After the subjectsrsquo examination data containing informa-tion about the quality and range of movement in both theTMJ and cervical spine were stored on a personal computer

After the first examination each patient selected for thetreated (experimental) group was supplied with an occlusalsplint Every patient suffered from TMD of muscular origin(RDCTMD axis I) therefore subjects were supplied withan occlusal splint SVED (Sagittal Vertical Extrusion Device)SVED is a removable flat-plane appliance which makescontact only with the anterior teeth in the opposing arch [12]It disengages the posterior teeth and thus eliminates theirinfluence in the function of the masticatory system by chang-ing the input signal from proprioceptive fibres contained inthe periodontal ligament of the posterior teeth (Figure 3)

The SVED appliance is used in case of hyperactivity ofmasticatory muscles without the occlusal reason of TMD[13] It is usually used to promote jaw muscle relaxation inpatients with stress related pain symptoms like headache orneck pain of muscular origin The splint also obliges thepatient to find a new mandibular position which results in amuscular balance Patients were ordered to wear the occlusalsplint during sleep but not more than 8ndash10 hours per day

Table 2 Characterization of the sample according to age andgender

Gender Group TotalTreated Controls

Female 16 14 30Male 14 16 30Mean age in years 3265 3487 3376

Figure 3 SVED appliance

According to many researchers there is no ideal wayto handle the problem of control treatment especially insplint studiesThe use of a placebo control group can balancethe nonspecific effects in the treatment group and allow forindependent assessment of the real treatment effect [14] Inour study control subjects were instructed to self-controlclenching and other parafunctional habits

The statistical analysis of the results was performed usingthe statistical package STATISTICA 90 (StatSoft) The testprobability of 119875 lt 005 was assumed to be significant whilethe test probability of 119875 lt 00001 was highly significant

3 Results

60 subjects were examined 30 belonged to the treated groupand 30 to the control group Patients were randomly admittedto groups The characteristics of age and gender for bothgroups are shown in Table 2

All patients were simultaneously assessed by the sameexaminer

31 RDCTMD Diagnoses Referring to TMD research diag-nostic criteria in patients from both treated and controlgroups myofascial pain (I) or disc displacement with reduc-tion (DDR IIa) was diagnosed

After a three-month therapy with an occlusal splintconsiderable improvements of TMJ function were found inthe experimental group with 78 of the subjects reportingno DDR symptoms or acoustic phenomena like clicks duringmandible movements the abduction path of the mandiblewas symmetrical and there was no pain during the move-ments (Table 3)

Most interestingly however there were changes on thecondyle path in the TMJ during the measurements made


Table 3 Symptoms of DDR and myofascial pain during 3 examinations

Myofascial pain(treatedcontrol)

Disc displacement with reductionLeft side

(treatedcontrol)

Disc displacement with reductionRight side

(treatedcontrol)Examination 1 27 29 13 11 15 12Examination 2 19 26 8 11 10 12Examination 3 4 25 3 10 6 12

with a JMA Deviations within the condylar path which hadbeen noticeable in the first examination (such as lack ofsymmetry between the length of the path in the right andleft TMJ) became reduced in 28 subjects as a result of thetreatment and during the third measurement the graphs ofthe condylar paths were asymmetrical on both sides in asfew as four subjects In 24 subjects there were considerableimprovements which also improved the TMJ function

In the control group no changes in theTMJ functionwereobserved in the clinical examination or instrumental checkwith a JMA in successive examinations

Muscle tension was examined by palpation by the sameexaminer In all subjects upper quarter muscle tenderness(masticatory muscles semispinalis muscles trapezius mus-cles sternocleidomastoideus muscles suprahyoid musclesand neck muscles in the region of the linea nuchae) wasdiagnosed during three consecutive examinations The pres-ence of muscle pain and tenderness during palpation wasregistered in both experimental and control groups

During the third examination the muscle tension of thesubjects in the experimental group lowered considerably andthey reported lack of pain in the examination by palpationOut of the 27 subjects in whom intensified tension of theexamined muscles had been found 22 reported no com-plaints during the third examination No significant changeswere found in the control group

32 Spinal Pain The whole group showed cervical spinepain Cervical spine pain according to VAS scale in a treatedgroup significantly improved during three-month therapy(Figure 4)

During treatment cervical spine pain diminished andafter 3 weeks it occurred in 39 of subjects and after 3monthspain was only in 8 subjects from treated group (2 subjects)

The difference between treated and control groups wasstatistically significant (119875 lt 00001)

33 Cervical Spine ROM During the first examination cervi-cal limited ROM at least during one of the tested movementswas reported in 60 subjects

For each measurement a relevant physiological standardwas established to which the cervical spine ROM resultswere referred [15] The norm assumed was dependent on thegender and age of the subject

Many authors claim that in the ROM examinations ofthe cervical spine it is not correct to treat an imposed andinflexible range of values within which the ROM shouldbe included as the only indicator As the resultant data are

0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl

Figure 4 The VAS scale score according to groups during threeexaminations

dependent on too many additional factors in the study weplaced special emphasis on the comparison between theresults from the first second and third examinations and onthe assessment whether they have been changed or improvednot merely whether they fell within the standard

After introducing the occlusal splint therapy cervicalspine mobility improved

The highest improvement was seen during the flexionmovement which on the 1st examination only in 22 ofpatients was within normative values During the 3rd exam-ination in 70 of patients from treated group flexion move-ment conformed the norm (Figure 5)

For the anteflexion movement the improvement of theresults was highly significant (119875 = 00006) that is there weremore subjects in the experimental group with the result con-forming to the norm

Likewise for the retroflexion movement the results wereimproved by a highly significant factor (119875 = 00082) that isthere were more subjects in the experimental group with theresult conforming to the norm

In the control group no significant (119875 gt 005) changeswere found that is there was no ROM improvement in thecervical spine towards the values in the norm


()

TreatedControl

IIIII

Lateral flexionright ROM

IIIIII

Lateral flexionleft ROM

IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80

Figure 5 Cervical spine mobility results

The results of improving the mobility and reduction ofcervical spine pain influenced the cervical Oswestry scalescore The average score on the first examination in a treatedgroup was 922 points and during therapy after 3 months theaverage score changed to 371

4 Discussion

The results obtained have confirmed a correlation betweenthe pathologies and the positive impact of treatment withinthe motor aspect of the stomatognathic system on the allevi-ation of spine pain even in subjects experiencing such painfor many years

It is important to understand the complex interrelationsbetween the stomatognathic system and pain and dysfunc-tions in other areas of the body in order to be able to treatpatients more efficiently and effectively at the initial stagewhen painful symptoms appear and when curing them ispossible as well as much swifter andmore efficient To be abletomake successful therapeutic interventions dental surgeonsshould cooperate in an interdisciplinary fashion with neurol-ogists orthopaedists or laryngologists They all should alsotake such interdependencies into account in their diagnosticwork with their own patients

Scientists often note the importance of a holistic approachto therapy There are many voices in favor of this approachthat symptoms of the disorder are usually not isolated andthe dysfunction of one region of the body also applies to otherregions [16ndash20]

Although the etiology of cervical spine pain very oftenremains unexplained medical specialists in many cases re-port the comorbidity of dysfunctions in the stomatognathicsystem and the pain syndrome in the cervical spine [4]Numerous scientific reports confirm that many researchershave embarked on the examination of the impact of disordersin the ldquoupper quarterrdquo on body posture and pain experiencedin various areas of the body [21] In studies conductedthus far however the focus has been mainly to prove thepresence or absence of dependence between dysfunction ofthe stomatognathic system and pain in the cervical spineThemost commonly applied methodology was questionnaireswith questions concerning cervical spine pain and complaintsof the motor aspect of the stomatognathic system [22] Onthat basis researchers would look for a link between thedysfunction in themotor aspect of the stomatognathic systemand the pain felt in the cervical spine Our study howeverincluded a therapy with an occlusal appliance with no otherinvasive treatment methods used By applying treatment


with an occlusal splint in the experimental group a vastmajority of the subjects reported improvements and the totaldisappearance or considerable alleviation of cervical spinepain and TMD symptoms while the mobility of the cervicalspine improved considerably as well

In case of TMD there are often large discrepanciesbetween therapists concerning type of occlusal splint mostappropriate to useMany types of splints can be distinguishedfor example stabilization splint repositioning splint relax-ation splint or splints only for protecting oral tissues SVEDsplint which is a typical relaxing appliance was used becauseof its influence on jaw muscles No studies about differenttypes of splints used in patients with both TMD and spinalpain were found [23]

5 Conclusions

Our studies as well as the clinical followup suggest that TMDis very frequently present along with pain in the cervicalspine The key aspect of the studies described here is theconsiderable ROM improvement in the cervical spine and theelimination of cervical spine pain felt there by the subjectsin the experimental group Taking into account the results ofour study it seems obvious that interdisciplinary cooperationbetween orthopedist laryngologist neurologist and dentistis necessary and essential

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

This paper has been supported by the ProgramProject UMO-201207BST601238 and the authors would like to expresstheir appreciation for that Bioethical Committee number ofSilesian Medical University is KNW0022KB16I10 fromMarch 16 2010

References

[1] C M B M de Resende A C D M Alves L T Coelho JC Alchieri A G Roncalli and G A S Barbosa ldquoQuality oflife and general health in patients with temporomandibulardisordersrdquo Brazilian Oral Research vol 27 no 2 pp 116ndash1212013

[2] L Pimenta e Silva Machado M B de Macedo Nery C deGois Nery and C R Leles ldquoProfiling the clinical presentationof diagnostic characteristics of a sample of symptomatic TMDpatientsrdquo BMC Oral Health vol 12 article 26 2012

[3] W S Wong P P Chen J Yap K H Mak B K H Tamand R Fielding ldquoChronic pain and psychiatric morbidity acomparison between patients attending specialist orthopedicsclinic and multidisciplinary pain clinicrdquo Pain Medicine vol 12no 2 pp 246ndash259 2011

[4] L G K Ries and F Berzin ldquoAnalysis of the postural sta-bility in individuals with or without signs and symptoms oftemporomandibular disorderrdquo Brazilian Oral Research vol 22no 4 pp 378ndash383 2008

[5] M Miernik M Wieckiewicz A Paradowska and WWieckiewicz ldquoMassage therapy in myofascial TMD pain man-agementrdquo Advances in Clinical and Experimental Medicine vol21 no 5 pp 681ndash685 2012

[6] L Germain ldquoDifferential diagnosis of toothache pain part 2nonodontogenic etiologiesrdquoDentistry Today vol 31 no 8 p 8486 88-89 2012

[7] G Perinetti ldquoCorrelations between the stomatognathic systemand body Posture biological or clinical implicationsrdquo Clinicsvol 64 no 2 pp 77ndash78 2009

[8] P Weber E C R Correa F D S Ferreira J C Soares G DP Bolzan and A M T da Silva ldquoCervical spine dysfunctionsigns and symptoms in individuals with temporomandibulardisorderrdquo Jornal da Sociedade Brasileira de Fonoaudiologia vol24 no 2 pp 134ndash139 2012

[9] B Wiesinger H Malker E Englund and A Wanman ldquoDoes adose-response relation exist between spinal pain and temporo-mandibular disordersrdquo BMCMusculoskeletal Disorders vol 10article 28 2009

[10] C Lippold G Danesh M Schilgen B Drerup and L Hacken-berg ldquoSagittal jaw position in relation to body posture in adulthumansmdasha rasterstereographic studyrdquo BMC MusculoskeletalDisorders vol 7 article 8 2006

[11] R Enciso A Memon D A Fidaleo U Neumann and JMah ldquoThe virtual craniofacial patient 3D jaw modeling andanimationrdquo Studies in health technology and informatics vol 94pp 65ndash71 2003

[12] P Villalon J F Arzola J Valdivia et al ldquoThe occlusal applianceeffect on myofascial painrdquo Cranio vol 31 no 2 pp 84ndash91 2013

[13] S Tecco S Caputi S Tete G Orsini and F Festa ldquoIntra-articular and muscle symptoms and subjective relief duringTMJ internal derangement treatment with maxillary anteriorrepositioning splint or SVED andMORA splints a comparisonwith untreated control subjectsrdquo Cranio vol 24 no 2 pp 119ndash129 2006

[14] S B Graff-Radford ldquoFacial pain cervical pain and headacherdquoCONTINUUM Lifelong Learning in Neurology vol 18 no 4 pp869ndash882 2012

[15] M Gzik The Biomechanics of Spine Silesian University ofTechnology Gliwice Poland 2007

[16] D Manfredini T Castroflorio G Perinetti and L Guarda-Nardini ldquoDental occlusion body posture and temporomandib-ular disorders where we are now andwhere we are heading forrdquoJournal of Oral Rehabilitation vol 39 no 6 pp 463ndash471 2012

[17] C S Mienna and A Wanman ldquoSelf-reported impact on dailylife activities related to temporomandibular disorders head-aches and neck-shoulder pain among women in a Sami pop-ulation living in Northern Swedenrdquo Journal of Orofacial Painvol 26 no 3 pp 215ndash224 2012

[18] M Wieckiewicz A Paradowska B Kawala and WWieckiewicz ldquoSAPHO syndrome as a possible cause of masti-catory system anomalies a review of the literaturerdquoAdvances inClinical and Experimental Medicine vol 20 no 4 pp 521ndash5252011

[19] J C Turp and H Schindler ldquoThe dental occlusion as a suspect-ed cause for TMDs epidemiological and etiological considera-tionsrdquo Journal of Oral Rehabilitation vol 39 no 7 pp 502ndash5122012

[20] WWieckiewiczMMiernikMWieckiewicz andTMorawiecldquoDoes propolis help to maintain oral healthrdquo Evidence-BasedComplementary and Alternative Medicine vol 2013 Article ID351062 8 pages 2013


[21] K Okamoto A Tashiro Z Chang R Thompson and DA Bereiter ldquoTemporomandibular joint-evoked responses byspinomedullary neurons and masseter muscle are enhancedafter repeated psychophysical stressrdquo European Journal of Neu-roscience vol 36 no 1 pp 2025ndash2034 2012

[22] J Guzman S Haldeman L J Carroll et al ldquoClinical practiceimplications of the Bone and Joint Decade 2000ndash2010 TaskForce onNeck Pain and Its AssociatedDisorders from conceptsand findings to recommendationsrdquo Spine vol 33 supplement 4pp S199ndashS213 2008

[23] M Więckiewicz M Ziętek D Nowakowska and WWięckiewicz ldquoComparison of selected kinematic facebowsapplied to mandibular tracingrdquo BioMed Research Internationalvol 2014 Article ID 818694 5 pages 2014

Research ArticleJaw Dysfunction Is Associated with Neck Disability andMuscle Tenderness in Subjects with and without ChronicTemporomandibular Disorders

A Silveira1 I C Gadotti2 S Armijo-Olivo3 D A Biasotto-Gonzalez4 and D Magee3

1Alberta Health Services University of Alberta Hospital Edmonton AB Canada T6G 2B72Department of Physical Therapy Florida International University Miami FL 33199 USA3Faculty of Rehabilitation Medicine University of Alberta Edmonton AB Canada T6G 2G44Department of Physical Therapy and Postgraduate Program in Rehabilitation Sciences Nove de Julho University01504-001 Sao Paulo SP Brazil

Correspondence should be addressed to I C Gadotti igadottifiuedu

Received 22 August 2014 Revised 26 October 2014 Accepted 27 October 2014


Copyright copy 2015 A Silveira et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Purpose Tender points in the neck are common in patients with temporomandibular disorders (TMD) However the correlationamong neck disability jaw dysfunction and muscle tenderness in subjects with TMD still needs further investigation This studyinvestigated the correlation among neck disability jaw dysfunction and muscle tenderness in subjects with and without chronicTMD Participants Forty females between 19 and 49 years old were included in this study There were 20 healthy controls and 20subjects who had chronic TMD and neck disability Methods Subjects completed the neck disability index and the limitations ofdaily functions in TMD questionnaires Tenderness of the masticatory and cervical muscles was measured using an algometerResults The correlation between jaw disability and neck disability was significantly high (119903 = 0915 119875 lt 005) The correlationbetween level of muscle tenderness in the masticatory and cervical muscles with jaw dysfunction and neck disability showed fairto moderate correlations (119903 = 032ndash065) Conclusion High levels of muscle tenderness in upper trapezius and temporalis musclescorrelated with high levels of jaw and neck dysfunction Moreover high levels of neck disability correlated with high levels of jawdisabilityThese findings emphasize the importance of considering the neck and its structures when evaluating and treating patientswith TMD

1 Introduction

Temporomandibular disorders (TMD) are a musculoskeletaldisorder affecting the masticatory muscles the temporo-mandibular joint (TMJ) and associated structures Evidencesuggests that TMD are commonly associated with other con-ditions of the head and neck region including cervical spinedisorders and headache Presence of neck pain was shown tobe associatedwith TMD70of the time [1 2] Neuroanatom-ical and functional connections between masticatory andcervical regions are discussed as explanations for concomi-tant jaw and neck symptoms [3 4] The presence of pain inthe masticatory system especially related to myogenic TMDcould be caused by dysfunctions in the cervical column or

vice versa showing the intrinsic relationship between thedifferent structures [1 5]

Although the association of cervical spine disorders andTMD has been studied by different authors it is far frombeing exhaustively explained [6 7] Most of the studies agreethat symptoms from the cervical spine can be referred tothe stomatognathic region through the trigeminocervicalnucleus Several studies have examined the presence of signsand symptoms in the cervical region of patients sufferingwithTMD and that the presence of tender points in the cervicalarea of these patients is very common [8ndash13] de Laat et al[11] found that on palpation 23ndash67 of the patients withTMDhad neckmuscle tenderness in the sternocleidomastoidand upper trapezius as well as other cervical and shoulder



muscles which was only rarely present in the control groupRecently Greenspan et al [14] measured pressure pain thres-hold (PPT) in the center of the temporalis masseter andtrapezius muscles in subjects with and without TMD Theyshowed that patients with TMD were more sensitive to awide range of mechanical and thermal pain tests than controlsubjects including not only the orofacial area but also thetrapezius muscle

Muscle tenderness in the cervical spine and jaw wasshown to be associated with increased levels of jaw and neckdisability For example one study by our team revealed astrong relationship between neck disability and jaw disability(119903 = 082) A subject with a high level of TMD disability(grade IV) had an increase of about 19 points in theNDIwhencompared with a person without TMD disability [15] Dis-ability associated with jaw and neck pain interferes greatlywith daily activities and can affect the patientrsquos lifestyle whichdeclines the individualrsquos ability towork and interact in a socialenvironment [6 8]

Muscle tenderness is the most common sign [8 16ndash18]and muscle pain is the most common symptom [19] foundin patients with TMD and their evaluation is still one of themost important methods of establishing a clinical diagnosisof TMD [17 20] being of particular interest to clinicianstreating orofacial pain Treatment strategies such as exercisesmanual therapy stretching and education can be targeted topainful and sensitive muscles in order to reduce pain in theorofacial region [8 20ndash22]

Although several studies have evaluated neck tendernessin subjects with TMD none of these studies have evaluatedthe relationship between the level of tenderness and jawdysfunction Moreover most studies that investigatedmuscletenderness in subjects with TMD used palpation techniqueswhich are difficult to quantify and standardize [10 11]

There is a great interest on the knowledge for further rela-tionship between stomatognathic system and cervical spineIf further relationship is established new clinical strategiesthat target both regions should be considered and thereforethe need of amultidisciplinary approach should be reinforcedin the management of patients with alterations of the stom-atognathic system including TMD patients In order tofurther investigate this relationship the objective of this studywas to determine the correlation among neck disability jawdysfunction and muscle tenderness in subjects with chronicTMD We hypothesized that the higher the level of neck dis-ability the higher the level of jaw dysfunction and the higherthe level of muscle tenderness

2 Methods

21 Subjects A convenience sample of 20 female subjectsdiagnosedwith chronic TMD (at least 3-month duration) and20 healthy female subjects participated in this cross-sectionalstudy Subjects were recruited from the TMDOrofacial PainClinic at the University of Alberta and by using advertisingaround the university and on the local television news Sam-ple size calculation was based on bivariate correlation Basedon a moderated and conservative correlation (119903 = 04 effect

size) and using120572 = 005120573 = 020 and power = 80 approxi-mately 37 subjects were needed for this study [23]

Subjects with TMDwere classifiedwith eithermyogenousTMD (mainly muscle complaints) or mixed TMD (myoge-nous and arthrogenous) and presented concurrent neck dis-ability The subjects were excluded if they presented arthro-genic TMD only a medical history of neurological boneor systemic diseases cancer acute pain or dental problemsother than TMD or a history of trauma or surgery to theupper quarter within the last year or if they had taken anypain medication or muscle relaxants less than 4 hours beforethe diagnostic session

The healthy group included subjects with no pain or clin-ical pathology involving the masticatory system or cervicalspine for at least one year prior to the start of the studyExclusion criteria included previous surgery neurologicalproblems any acute or chronicmusculoskeletal injury or anysystemic diseases that could interfere with the procedure andtaking any medication such as pain relieving drugs musclerelaxants or anti-inflammatory drugs

After obtaining consent all subjects were examined clini-cally using the research diagnostic criteria for temporo-mandibular disorders (RDCTMD) [24] by a physical thera-pist specialized in TMD Neck disability was evaluated usingtheNeckDisability Index (NDI) [25]TheTMDgroup shouldscore more than 4 points on the NDI in order to be classifiedas presenting neck disability To measure their level of jawdisability all subjects completed the Limitations of DailyFunctions in the TMD Questionnaire (LDF-TMDQ) [26]The healthy group had to score less than 4 points on the NeckDisability Index in order to be considered as having no neckdysfunction

This studywas approved by the Ethics Review Board fromthe University of Alberta where the study was conducted

22 Questionnaires The ldquoLimitations of Daily Functions inTMDQuestionnairerdquo (LDF-TMDQ)was used tomeasure thejaw function of all the subjects in this studyThe LDF-TMDQis multidimensional and includes specific evaluations forTMD patients [26]The LDF-TMDQ consists of 10 items and3 factors and these factors are extracted by exploratory factoranalysis The first factor is named ldquolimitation in executing acertain taskrdquo and is composed of five items including severalproblems in daily physical and psychosocial activities thesecond factor is called ldquolimitation ofmouth openingrdquowhich iscomposed of three items and the third factor ldquolimitation ofsleepingrdquo is composed of two itemsThe internal consistencyof the questionnaire was calculated using Cronbachrsquos alphawhich was 078 for the 10 items 072 for ldquolimitation in execut-ing a certain taskrdquo 073 for ldquolimitation ofmouth openingrdquo and077 for ldquolimitation of sleepingrdquo indicating good consistencyThe LDF-TMDQ was tested for concurrent validity with thedental version of the McGill Pain Questionnaire and theauthors found correlations ranging between 049 and 054[26]

The NDI is a questionnaire designed to give informationabout how neck pain affects the ability of the subject tomanage her everyday life [25 27ndash30] The NDI includes 10itemsmdash7 items are associated with activities of daily living


2 are linked to pain and 1 is related to concentration [25 29]Each item is scored from 0 (no pain or disability) to 5 (severepain and disability) and the total score is expressed as apercentage (total possible score = 100) with higher scorescorresponding to greater disability [25 29] Depending onthe score the patient was classified as having neck disabilityor not (0ndash4 = no disability 5ndash14 = mild disability 15ndash24 =moderate disability 25ndash34 = severe disabilitygt35 = completedisability) [27] The NDI has proven to be valid and reliablein measuring neck disability allowing its use as a guide forclinical-decision making [28ndash30]

23 Pressure Pain Threshold (PPT) Measurements The man-ual pressure algometer (force dial) was used to measure themuscle tenderness in both groups by one investigator blindedto the subjectsrsquo group allocationMuscle tenderness wasmea-sured bilaterally in the following muscles masseter (ie deepmasseter anterior and inferior portions of the superficialmasseter) temporalis (ie anterior temporalis medial tem-poralis and posterior temporalis) sternocleidomastoid andupper trapezius (ie occipital region and half way betweenC7 and acromion) in a supine position for all muscles buttrapezius muscle which was evaluated in seating [17 31 32]These muscles were selected for investigation because pre-vious studies reported that patients with TMD tended todevelop tenderness in these muscles [31 32] Furthermorethese muscles were easy to evaluate because of their anatomicposition which avoided confusion with other anatomicstructures such as joints ligaments and other muscles

The pressure pain threshold (PPT) was defined in thisstudy as the point at which a sensation of pressure changedto pain At this moment the subject said ldquoyesrdquo the algometerwas immediately removed and the PPT was noted [33]Before the test was performed the procedure was demon-strated on the investigatorrsquos hand and a practice trial wasperformed on the subjectrsquos right hand [33] During the testthe algometer was held perpendicular to themasticatory (iemasseter and temporalis) and neck muscles (ie sternoclei-domastoid and upper trapezius) Figure 1 shows the sites inwhich the muscles were measured The measurements wererepeated 3 times at each site with 30-second intervals withpressure rate of 1 Kgsec for the neck muscles and 05 Kgsecfor the masticatory muscles [34 35] Since the first PPT of asession is usually higher than consecutive measurements thefirst PPT measurement was discarded and the mean of theother two PPT measurements was considered to be the finalpressure threshold of the sites tested [34]

Pressure rates were decided based on previously studiesthat showed the most reliable rates to use on cervical andfacial muscles [18 36ndash38]

24 Statistical Analysis Muscle tenderness data for all ana-lyzed muscles jaw and neck disability levels were analyzeddescriptively A paired 119905-test was performed to verify whetherthere were any differences between right and left sides ineach pair of muscles Spearmanrsquos rho was used to determine

Figure 1 PPT points evaluated (Q temporalis muscle ◼ massetermuscle 998771 sternocleidomastoid muscle and X upper trapeziusmuscle)

whether there was a correlation among neck disability jawdysfunction and muscle tenderness The criteria used tointerpret the correlation coefficient were as follows 000ndash025 little correlation 026ndash049 low correlation 050ndash069moderate correlation 070ndash089 high correlation and 090ndash100 very high correlation The correlation was consideredimportant when the correlation coefficient value was higherthan 070 The reference values to make this decision werebased on values reported by Munro [39]

Level of significance for all statistical analyses was set at120572 = 005 The SPSS (SPSS Inc Chicago) Statistical Programversion 180 (Statistical Package for the Social Sciences) wasused to perform the statistical analysis

3 Results

31 Subjects Demographics Mean age for TMD group was3105 (SD = 69) and for the healthy group was 323 (SD = 72)Thirteen subjects were classified as having mixed TMD and 7were classified as having myogenic TMD The range of neckdisability ranged from 0 to 31 (no to severe disability) and therange of jaw dysfunction ranged from 10 to 50 (no to severedisability) among all subjects included in this study

32 Correlation between Level of Muscle Tenderness and JawDysfunction and Neck Disability The correlations (Spear-manrsquos rho) between level of muscle tenderness and jawdysfunction (LDF-TMDQ) as well as between level of muscletenderness and neck disability (NDI) ranged from low tomoderate correlations Spearmanrsquos rho ranged from 0387 to0647 for muscle tenderness and jaw dysfunction and Spear-manrsquos rho ranged from 0319 to 0554 for muscle tendernessand neck disability (Table 1)

33 Correlation between Neck Disability and Jaw DysfunctionIt was found that the correlation (Spearmanrsquos rho) betweenjaw disability and neck disability was significantly high (119903 =0915 119875 lt 0001) The coefficient of variation was 082


Table 1 Correlation between muscle tenderness (PPTs) and neckdisability and jaw dysfunction

Spearmanrsquos rhoSide Muscle Jaw dysfunction Neck disability

Right

Temporalis minus0585 minus0517Masseter minus0512 minus0443Sternocleidomastoid minus0387 minus0319Upper trapezius minus0408 minus0352

Left


indicating that approximately 82 of the variance of jaw dis-ability is explained by the neck disability in this populationThus subjects who had no or low levels of jaw disability(evaluated through the JDI) also presented with no or lowlevels of neck disability (evaluated through the NDI)

4 Discussion

This study investigated the correlation among neck disabilityjaw dysfunction and muscle tenderness in subjects with andwithout chronic TMD

The main results of this study were that jaw dysfunctionand neck disability were strongly correlated showing thatchanges in jaw dysfunction might be explained by changesin neck disability and vice versa Also the results showed thatthe higher the level of muscle tenderness in upper trapeziusand temporalismuscles is the higher the level of jaw and neckdysfunction the subject will have These results add to thebody of knowledge in this area providing new informationregarding these associations Furthermore they corroboratedthe importance of looking at cervical spine and stomatog-nathic system as a functional entity when evaluating andtreating subjects with TMD neck pain and muscle tender-ness Another study that is corroborated to this associationwas the study byHerpich and colleagues [40] where head andneck posture was found to be different between patients withbruxism and controlsThey also found a relationship betweenposture alterations and the TMD severity

The discussion will focus on each of the results separatelyas well as highlighting the strengths and limitations of thisstudy

41 Correlation between Level of Muscle Tenderness of Masti-catory and Cervical Muscles and Jaw Dysfunction and NeckDisability Several studies examined the presence of signsand symptoms in the cervical area of patients suffering withTMD and they have been showing that the presence of tenderpoints in the cervical area of TMDrsquos patients is quite commonwhich is in line with the findings of this study [8ndash13] Bothupper trapezius and temporalis muscles had a moderate cor-relationwith jaw dysfunction and neck disabilityThis findingindicates that increased levels of tenderness in these twomus-cles were related to higher levels of dysfunction in patients

having TMD with concurrent neck disability Thereforeassessing temporalis and upper trapezius muscles in patientswith TMD and concurrent neck disability may allow physicaltherapists to have a better understanding of the level ofdysfunction of these patients and to consider the need ofmanaging these patients as a whole However although theseresults show a trend moderate correlations just indicateassociation between levels of dysfunction in patients havingTMD and concurrent neck disability with levels of muscletenderness in both upper trapezius and temporalis muscles[23]

Muscle tenderness is only one factor among multiplefactors that could contribute to maintaining or perpetuatinga level of dysfunction in people with TMD either in the jawor in the neck Usually jaw dysfunction and neck disabilityare both related to gender psychological factors and socialfactors For example studies have shown that the presence ofmuscle tenderness is more commonly found in women thanin men suffering with signs and symptoms of TMD [8 41ndash44] Femalesrsquo hormones seem to play a possible etiologic rolesince there is a higher prevalence of signs and symptoms ofTMD in women than in men as well as a lower prevalencefor women in the postmenopausal years [41] Increased ratesof occurrence of TMD have been shown during specificphases of the menstrual cycle and possible adverse effects oforal contraceptives have been cited in the literature [41 45]Sherman et al [45] showed significant differences in terms ofpressure pain threshold during different phases of a womanrsquosmenstrual cycle Women who have TMD and have not beenusing oral contraceptives showed lower pressure pain thresh-olds during menses and midluteal phases while womenwith TMD and using oral contraceptives had stable pressurepain threshold throughout menses ovulatory and midlutealphases with increased intensity at the late luteal phase [45]Fluctuations in estrogen levels during the menstrual cyclemay be related to the level of pressure pain in women [45]The authors speculated that TMD patients when exposed toexperimental pain stimuli might benefit from the use of oralcontraceptives since these patients did not experience thesame intensity of estrogen depletion levels throughout lateluteal and menses phases of the menstrual cycle nor the wideswings in estrogen levels during the ovulation [45]

ldquoPain is a complex phenomenon influenced by both bio-logic and psycologic [sic] factorsrdquo [46] (pp 236) Younger etal [47] found several limbic abnormalities in subjects suffer-ingwith TMD showing that these patients had alterations notonly in the sensory system but also within the limbic systemThe authors found alterations in the basal ganglia nucleiwhich contain neurons responsive to nociceptive input andserve the function of preparing behavioral responses tonoxious stimuli They also found alterations in the anteriorinsula of patients with TMD These alterations have beenreported to be responsible for the integration of emotionaland bodily states [47] According to the authors alterations inthe anterior insula region appear to be very important in theemotional awareness of internal states and the emotionalaspects of the pain experience and anticipation of sensationIt is important to note that pain is also perceived differently bydifferent people since factors such as fear anxiety attention


and expectations of pain can amplify the levels of painexperience [46] On the other hand self-confidence positiveemotional state relaxation and beliefs that pain is manage-able may decrease the sensation of pain [46] Studies haveshown that psychosocial factors are significantly associatedwith both jaw pain and neck pain [48ndash50] Vedolin et al [50]for example showed that the PPTs of jaw muscles of patientswith TMD were lower throughout a natural stressful event(ie academic examination) showing a relationship betweenstress and anxiety levels with level of muscle tendernessAnother study by Mongini et al [32] also showed a highrelationship between jaw and neck muscle tenderness withthe prevalence of anxiety and depression among patientssuffering from TMD Increased levels of stress anxietyand depression could enhance sympathetic activity and therelease of epinephrine at sympathetic terminals leading to anincrease in acetylcholine activity at the motor endplate Thiscould start a cascade of events causing a decreased pressurepain threshold in themuscles [50]The results of these studiessuggest that a more integrated treatment approach includingpsychosocial assessment is important when treating patientswith TMD Factors that might be related to the developmentof jaw dysfunction or neck disability were not evaluated inthis study so further conclusions regarding social emotionaland psychological factors are beyond the scope of this specificstudy

42 Correlation between Neck Disability and Jaw Dysfunc-tion The correlation (Spearmanrsquos rho = 0915) between jawdisability and neck disability was significantly high in thisstudy This means that the variance of jaw dysfunction ishighly dependent on the neck disability (approximately 82)Thus subjects who had high levels of jaw disability (evaluatedthrough the JDI) also presented with high levels of neck dis-ability (evaluated through the NDI) and vice versa Recentlythe study by Armijo-Olivo and colleagues [15] was the firstto show the relationship between jaw disability and neck dis-ability As in the present study a high correlation between jawdisability and neck disability was found Until now the asso-ciation between neck and jawwas always reported in terms ofsigns and symptoms but the authors showed the importanceof assessing the impact that the level of disability can have onpatients suffering with TMD

Disability is a complex concept since it involves morethan accounting for the individual signs and symptoms aloneIt also includes the perception of the patient about his orher condition as an important factor [15] The InternationalClassification of Functioning Disability and Health from theWorld Health Organization is helping health professionals tounderstand the importance of viewing chronic pain patientsfrom different perspectives such as body individual societaland environmental [51] The impact that the disability has onpatientrsquos body functions body structures activities and par-ticipation shows a more realistic vision of how the disease isimpacting an individualrsquos quality of life [15 51] TMDpatientsare a good example of how signs and symptoms can be per-ceived differently by different individuals Sometimes severeTMD signs and symptoms may only have a small impact onthe quality of life of a patient while mild signs and symptoms

may greatly interfere in other patientsrsquo livesTherefore assess-ing the level of disability of patients suffering with TMD isimportant to have a better view of how this condition is affect-ing these patients and which treatment approach is best foreach situation [15]

The fact that jaw disability and neck disability are stronglyrelated also shows that one has an effect on the other whichprovides further information about the importance of assess-ing and treating both regions when evaluating chronic TMDpatients Assessment of the neck structures such as joints andmuscles as well as the disability of patients with TMD coulddirect clinicians to include the cervical spine in their treat-ment approach In addition if patients with TMD have neckdisability in addition to jaw disability or vice versa physicaltherapists and dentists should work together to manage thesepatients

As strong correlation between jaw disability and neck dis-ability does not indicate a cause and effect relationship longi-tudinal studies where subjects with TMD are followed up todetermine the appearance of neck disability are still necessaryto determine any cause and effect connection

43 Clinical Relevance This study showed that the higher thelevel of muscle tenderness mainly in upper trapezius andtemporalis muscles the higher the level of jaw and neck dis-abilityTherefore when clinicians assess higher levels of mus-cle tenderness either in the jaw andor in the neck regionsthey should infer that this could be possibly related to higherlevels of jaw and neck disability This information will guidehealth professionals to consider new clinical strategies thatfocus on both masticatory and cervical regions to improvepatientsrsquo outcomes Jaw dysfunction and neck disability werestrongly correlated showing that changes in jaw dysfunctionmight be explained by changes in neck disability and viceversa This provides further information about the impor-tance of assessing and treating both the jaw and neck regionsas a complex system in TMD patients

44 Limitations The convenience sample used increasedthe potential subject self-selection bias It was difficult torecognizewhat characteristicswere present in thosewhoofferthemselves as subjects as compared with those who did notand it was unclear how these attributes might have affectedthe ability to generalize the outcomes [32] Although proba-bility samples would have been ideal for this type of studyhaving accessibility to the general population of TMDpatients was limited in this study Furthermore even withrandom selection not all of the TMD patients who couldhave been invited to participate in the study would give theirconsent

5 Conclusions

High levels of muscle tenderness were correlated with highlevels of jaw and neck disabilities Furthermore jaw dysfunc-tion and neck disability were strongly correlated showingthat changes in jaw dysfunction may be explained by changesin neck disability and vice versa in patients with TMD Thisstudy has highlighted the importance of assessing TMD


patients not only at the level of the jaw but also includingthe neck region Muscle tenderness however is only oneaspect of the TMD TMD is a complex problem and involvesmany factors such as gender levels of anxiety and stress andthe level of socialization of the patient Future studies inves-tigating the association between neck and jaw should alsoinclude factors other than muscle tenderness which are stillneeded



Acknowledgment

This study was supported by the Queen Elizabeth II Scholar-ship from the University of Alberta

References

[1] S Kraus ldquoTemporomandibular disorders head and orofacialpain cervical spine considerationsrdquo Dental Clinics of NorthAmerica vol 51 no 1 pp 161ndash193 2007

[2] M Padamsee N Mehta A Forgione and S Bansal ldquoIncidenceof cervical disorders in a TMD populationrdquo Journal of DentalRresearch vol 73 p 186 1994

[3] G Perinetti ldquoCorrelations between the stomatognathic systemand body posture biological or clinical implicationsrdquo Clinicsvol 64 no 2 pp 77ndash78 2009


[5] N M Oliveira-Campelo J Rubens-Rebelatto F J Martın-Vallejo F Alburquerque-Sendın and C Fernandez-De-Las-Penas ldquoThe immediate efects of atlanto-occipital joint manip-ulation and suboccipital muscle inhibition technique on activemouth opening andpressure pain sensitivity over latentmyofas-cial trigger points in the masticatory musclesrdquo Journal ofOrthopaedic and Sports PhysicalTherapy vol 40 no 5 pp 310ndash317 2010

[6] R Ciancaglini M Testa and G Radaelli ldquoAssociation of neckpain with symptoms of temporomandibular dysfunction in thegeneral adult populationrdquo Scandinavian Journal of Rehabilita-tion Medicine vol 31 no 1 pp 17ndash22 1999

[7] H V Piekartz and L Bryden Craniofacial Dysfunction amp PainManual Therapy Assessment and Management ButterworthHeinemann London UK 2001

[8] A Wanman ldquoThe relationship between muscle tenderness andcraniomandibular disorders a study of 35-year-olds from thegeneral populationrdquo Journal of orofacial pain vol 9 no 3 pp235ndash243 1995

[9] M Stiesch-Scholz M Fink and H Tschernitschek ldquoComor-bidity of internal derangement of the temporomandibular jointand silent dysfunction of the cervical spinerdquo Journal of OralRehabilitation vol 30 no 4 pp 386ndash391 2003

[10] A de Wijer ldquoNeck pain and temporomandibular dysfunctionrdquoNederlands Tijdschrift voor Tandheelkunde vol 103 no 7 pp263ndash266 1996

[11] A de Laat HMeuleman A Stevens and G Verbeke ldquoCorrela-tion between cervical spine and temporomandibular disordersrdquoClinical Oral Investigations vol 2 no 2 pp 54ndash57 1998

[12] M Fink H Tschernitschek and M Stiesch-Scholz ldquoAsymp-tomatic cervical spine dysfunction (CSD) in patients with inter-nal derangement of the temporomandibular jointrdquo Cranio vol20 no 3 pp 192ndash197 2002

[13] E Inoue K Maekawa H Minakuchi et al ldquoThe relationshipbetween temporomandibular joint pathosis and muscle tender-ness in the orofacial and neckshoulder regionrdquo Oral SurgeryOral Medicine Oral Pathology Oral Radiology and Endodontol-ogy vol 109 no 1 pp 86ndash90 2010

[14] J D Greenspan G D Slade E Bair et al ldquoPain sensitivityrisk factors for chronic TMD descriptive data and empiricallyidentified domains from the OPPERA case control studyrdquo TheJournal of Pain vol 12 no 11 pp T61ndashT74 2011

[15] S Armijo-Olivo J Fuentes P W Major S Warren N M RThie and D J Magee ldquoThe association between neck disabilityand jaw disabilityrdquo Journal of Oral Rehabilitation vol 37 no 9pp 670ndash679 2010

[16] C M Visscher F Lobbezoo and M Naeije ldquoComparison ofalgometry and palpation in the recognition of temporoman-dibular disorder pain complaintsrdquo Journal of Orofacial Pain vol18 no 3 pp 214ndash219 2004

[17] M Farella A Michelotti M H Steenks R Romeo R Ciminoand F Bosman ldquoThe diagnostic value of pressure algometry inmyofascial pain of the jaw musclesrdquo Journal of Oral Rehabilita-tion vol 27 no 1 pp 9ndash14 2000

[18] R S S Silva P C Conti J R Lauris R O da Silva and L FPegoraro ldquoPressure pain threshold in the detection of masti-catory myofascial pain an algometer-based studyrdquo Journal ofOrofacial Pain vol 19 no 4 pp 318ndash324 2005

[19] J P Okeson Bellrsquos Orofacial Pains The Clinical Management ofOrofacial Pain vol 6th Quintessence Books Surrey Canada2005

[20] O Bernhardt E L Schiffman and J O Look ldquoReliability andvalidity of a new fingertip-shaped pressure algometer for assess-ing pressure pain thresholds in the temporomandibular jointand masticatory musclesrdquo Journal of Orofacial Pain vol 21 no1 pp 29ndash38 2007

[21] T List and S F Dworkin ldquoComparing TMD diagnoses andclinical findings at Swedish andUS TMD centers using researchdiagnostic criteria for temporomandibular disordersrdquo Journal ofOrofacial Pain vol 10 no 3 pp 240ndash252 1996

[22] H M Ueda M Kato M Saifuddin H Tabe K Yamaguchiand K Tanne ldquoDifferences in the fatigue of masticatory andneck muscles between male and femalerdquo Journal of OralRehabilitation vol 29 no 6 pp 575ndash582 2002

[23] L G Portney and M P Watkins Foundations of ClinicalResearch Applications to Practice PearsonPrentice Hall UpperSaddle River NJ USA 3rd edition 2009

[24] J O Look M T John F Tai et al ldquoThe research diagnosticcriteria for temporomandibular disorders II reliability of AxisI diagnoses and selected clinical measuresrdquo Journal of OrofacialPain vol 24 no 1 pp 25ndash34 2010

[25] J A Cleland J D Childs and J M Whitman ldquoPsychometricproperties of the neck disability index and numeric pain ratingscale in patients withmechanical neck painrdquoArchives of PhysicalMedicine and Rehabilitation vol 89 no 1 pp 69ndash74 2008

[26] M Sugisaki K Kino N Yoshida T Ishikawa T Amagasa andT Haketa ldquoDevelopment of a new questionnaire to assess pain-related limitations of daily functions in Japanese patients with

ldquoThis course was developed from the public domain document TMJ Disorders ndash

US Department of Health and Human Services National Institute of Health (NIH)rdquo

This course was edited and developed from the document Correlation between TMD and Cervical Spine

Pain and Mobility Is the Whole Body Balance TMJ Related ndash Karolina Walczynska BioMed Research International

(httpdxdoiorg1011552014582414) used under the Creative Commons Attribution Licenserdquo

This course was edited and developed from the document Jaw Dysfunction Is Associated with Neck Disability and Muscle

Tenderness in Subjects with and without Chronic Temporomandibular Disorders ndash A Silveira BioMed Research International


1

TMJ DISORDERS

Temporomandibular joint and muscle disorders commonly called ldquoTMJrdquo are a group of conditions that cause pain and dysfunction in the jaw joint and the muscles that control jaw movement We donrsquot know for certain how many people have TMJ disorders but some estimates suggest that over 10 million Americans are affected The condition appears to be more common in women than men

For most people pain in the area of the jaw joint or muscles does not signal a serious problem Generally discomfort from these conditions is occasional and temporary often occurring in cycles The pain eventually goes away with little or no treatment Some people however develop significant long-term symptoms

If you have questions about TMJ disorders you are not alone Researchers too are looking for answers to what causes these conditions and what the best treatments are Until we have scientific evidence for safe and effective treatments itrsquos important to avoid when possible procedures that can cause permanent changes in your bite or jaw This booklet provides information you should know if you have been told by a dentist or physician that you have a TMJ disorder

2

WHAT IS THE TEMPOROMANDIBULAR JOINT

The temporomandibular joint connects the lower jaw called the mandible to the bone at the side of the headmdashthe temporal bone If you place your fingers just in front of your ears and open your mouth you can feel the joints Because these joints are flexible the jaw can move smoothly up and down and side to side enabling us to talk chew and yawn Muscles attached to and surrounding the jaw joint control its position and movement

When we open our mouths the rounded ends of the lower jaw called condyles glide along the joint socket of the temporal bone The condyles slide back to their original position when we close our mouths To keep this motion smooth a soft disc lies between the condyle and the temporal bone This disc absorbs shocks to the jaw joint from chewing and other movements

The temporomandibular joint is different from the bodyrsquos other joints The combination of hinge and sliding motions makes this joint among the most complicated in the body Also the tissues that make up the temporomandibular joint differ from other load-bearing joints like the knee or hip Because of its complex movement and unique makeup the jaw joint and its controlling muscles can pose a tremendous challenge to both patients and health care providers when problems arise

3

OPEN


temporal bone

Disc

Condyle


CLOSED

4







5



TMJ

6





7








TMJ

8




9





Self-Care Practices


n eating soft foods




TMJ

10


Pain Medications




11


Botox



TMJ

12



Surgery


13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































3

OPEN


temporal bone

Disc

Condyle


CLOSED

4







5



TMJ

6





7








TMJ

8




9





Self-Care Practices


n eating soft foods




TMJ

10


Pain Medications




11


Botox



TMJ

12



Surgery


13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































5



TMJ

6





7








TMJ

8




9





Self-Care Practices


n eating soft foods




TMJ

10


Pain Medications




11


Botox



TMJ

12



Surgery


13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































7








TMJ

8




9





Self-Care Practices


n eating soft foods




TMJ

10


Pain Medications




11


Botox



TMJ

12



Surgery


13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































9





Self-Care Practices


n eating soft foods




TMJ

10


Pain Medications




11


Botox



TMJ

12



Surgery


13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































11


Botox



TMJ

12



Surgery


13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































13

Implants



TMJ

14




15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



































15

RESEARCH



Pain Studies



TMJ

16






Replacement Parts


HOPE FOR THE FUTURE


















1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References



















































1 Introduction
























vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References


















































vice



























3 Results










(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References







































(treatedcontrol)













0

1

2

3

4

5

6

7

8

9

10

IIIII

VAS scale

I

TreatedControl









()

TreatedControl

IIIII


IIIIII


IIIIII

Rotation rightROM

IIIIII

Rotation leftROM

IIIIII

Retroflexion

IIIIII

AnteflexionROM

I0

30

20

10

40

50

60

70

80



4 Discussion








5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References






































5 Conclusions




Acknowledgments


References

































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References











































1 Introduction











2 Methods


















3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References












































3 Results







Right


Left



4 Discussion

















5 Conclusions






Acknowledgment


References












































5 Conclusions






Acknowledgment


References











































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TMJ Overview and Jaw Dysfunctions … S women than men. significant, long-term symptoms. that you...

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