From Bite to Mind: TMD—

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

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

The aim of this article was to depict, as personally

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

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

Intemalional loumal of Proidiodonlic

Number 3, 1999 279
 TMD—PersoiiLi! and Lileralure Review
patients often report more mental distress, sleep dys-
functions, and psychosomatic disorders than non-
TMD controls.''-^
The disparity in opinions regarding etiology is re-
flected in the many different terms applied to this dis-
order.'^ Previously, for pathogenetic reasons, the
phrase "temporomandibular joint" (TMJ) almost al-
ways was included. Nowadays, the more neutral and
American Dental Association-approved term "tem-
poromandibular 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 dis-
turbances affecting the musculature, ie, masticatory
muscle pain (MMP), according to a recent classifi-
cation of TMD.^ The articular diseases or disorders of
the TMJ, eg, rheumatoid arthritis or internal de-
rangements, are beyond the scope of this article,
which mainly deals with conditions without demon-
strable physical pathology. While conditions with
organic pathology are classified as diseases, the neu-
romuscular 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.^^
Prevalence
Temporomandibular disorder is not an uncommon
condition. At a 1996 conference arranged by the US
National institutes of Health (NIH) in 1996 it was es-
timated that more than 10 mi I lion Americans were af-
fected.'•'The syndrome, however, afflicts individuals
selectively. It is more frequent among those who are
better educated and more affluent. Women constitute
about'Í of those who seek treatment, and the major-
ity of them are in their reproductive years—between
20 and 40 years of age.
Thus, the sociologie aspects of the syndrome are
intriguing. The first to study this problem was Arnold
Franks.''' In Stockholm he once surprised his audi-
ence by open ing his lecture on TMD by projecting a
map of the Pacific. Pointing to the island of Guam,
he declared that the US Armed Forces had set up a
medical center there that included a TM| clinic. Since
the natives ofthe island were privy to its medical ser-
vices, an additional motive was the opportunity to
study TMD in a population unaffected by V\/estern
civilization. This project, however, proved to be a
complete failure; nota single native appeared at the
TMD clinic. Instead, the majority of the patients were
officers' wives! (Franks AST, personal communica-
tion, 1968.)
The International Journal QfPiDsthocJortics
Malin
History
The fact that interest in TMD has been so pronounced
during the last half century should not deceive us into
believing that we are dealing with an ailment that has
recently escaped from Pandora's box. We know from
5,000-year-old papyri that describe the technique of
repositioning a dislocated TMJ that TMD existed in an-
cient Egypt, Dislocation of the TMJ may certainly be re-
garded as the most advanced feature of the syndrome
of muscle tension and disturbed coordination that
constitutes the most common t/pe of TMD. Besides, the
ancient Greeks knew the repositioning technique that
is exactly the same as the one still used.'^
For more than 2 millennia, very little happened in
this field. At the end of the last century dentistry
passed through a period of dynamic progress, espe-
cially in the United States. New materials had be-
come available for prosthetic purposes, and to make
the best use of them it was necessary to increase
knowledge of mandibular movements and occlu-
sion. This new awareness called into question
whether disturbances in this field might have reper-
cussions for the TMJ.
Etiology
Costen Syndrome
In 1918 the American anatomist Prentiss, with the den-
tist 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 arti-
cle, "A syndrome of ear and sinus symptoms depen-
dent upon disturbed function of the temporo-
mandibular 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 move-
ment disturbances. Even impaired hearing, dizzi-
ness, and headaches were included in the syndrome
based on experience of 11 patients. Focusing on oc-
clusion 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 concept—one may be tempted
to call it a pathogenic theory—was that in the absence
of molar support the powerful elevating muscles of
the mandible could press the condyles upward and
280 Volume 12, NjmL= . „ ^ i i ™

backward, causing damage to vessels and nerves, in-
cluding 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 diag-
nosed 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 im-
portance of a somatic diagnosis for legitimizing an ill-
ness is ver\' powerful, and may explain the willing-
ness 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 ef-
fect, 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 hear-
ing (Ramfjord S, personal communication, 1968). As
mentioned, "impaired hearing" was among the symp-
toms included in Gosten syndrome.'' Soon after the
last procedure the apices of the mandibular incisors
could be palpated under his chin! iRamfjord S, per-
sonal communication, 1968.}
Other Etiologic and Pathogenetic Tbeories
Since Costen put forth his concept an enormous body
of literature has been published about these disorders,
Costen's theory' of overclosure assumed major defects
in the bite; later the tendency was to consider even
very minute occlusal disturbances to be dangerous.
In a way, smaller disturbances were thought to be
even more pathogenic by disturbing the intricate pro-
prioception and coordination, thus causing effects
even on the central nervous system.-°-'
As late as the 1970s this belief in the ability of oc-
clusal disturbances to cause irritation was generally
embraced. One leading Scandinavian textbook at
this time stated:
The anxiety that many patients with muscular hyperac-
tivity in the masticatory apparatus demonstrate may there-
fora, 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 ac-
cordingly a secondary phenomenon. Clinically, this is not
an uncommon experience.^' (Italics in original.)
. .-i.mber3,l999
TMD—Personal and Literature Review
Laszio Scbwartz: Pioneer for a Scientific Approacb
Gosten's theories were soon questioned, and finally
disproved by anatomists." Laszio L. Schwartz, a gen-
eral dental practitioner, adopted a new approach
and founded the first academic research center at
Golumbia University, with a multidisciplinary col-
laboration on what he called the "temporomandibu-
lar joint pain dysfunction syndrome."-^ Despite the
chosen term, Schwartz considered the disorders to be
localized in the masticatory muscles rather than in the
joint. Themental constitution of the patient was con-
sidered to be more important than occlusal distur-
bances, which play but a contributing role. The ef-
fects of stress and anxiety in increasing tension in the
masticator\' muscles were considered to be the basis
ofthe disorder. Alarming diagnoses or physiologically
or psychologically traumatic treatment can aggra-
vate the disorder.-"* In the team of medical and den-
tal specialists that Schwartz assembled at Golumbia-
Presbyterian Medical Genter, psychiatrist Ruth
Moulton played an important role in furthering the
understanding of the significance of emotional
factors.'"-"
More than any other author in the field of TMD,
Laszio Schwartz broke new ground for understand-
ing the many problems in this area. Under his guid-
ance the work at the Columbia TMj clinic brought
about a paradigm shift in understanding what causes
TMD. The acceptance of Schwartz's ideas, however,
was very slow. To understand Laszio Schwartz's
achievements it is necessary- to mention his devotion
to the humanities, especially to the history of medi-
cine and dentistr\'. He was a founder ofthe Academy
ofthe FHistory of Dentistry, and he managed to add a
course on this subject to the curricula at Golumbia
Dental School .^^
The Psychophysiologic School
After Schwartz's death in 1966, the center of research
activity moved to Chicago. At the University of
Illinois, surgeon Daniel M- Laskin, with orthodontist
ChariesS. Greene, founded theTemporomandibular
Research Center with a focus on psychophysiologic
factors.-" As with other psychophysiologic condi-
tions (eg, hypertensionl, TMD was considered to be
caused by an interaction between a physiologic pre-
disposition and psychologic and physical stress. The
effect on the individual depended on his or her abil-
ity to adapt to stress. This adaptation is referred to as
"coping" and has come to the forefront of research
activity on stress and chronic pain.^^ -^ To emphasize
that the muscles, not the joint, are the most important
component, the group adopted the term "myofascial
281 The ln.ema.ior,allo.rnalof Prosthodontta
 TMD—Personal and Literature Review
Fig 1 The oonoept of dynamic equilibrium may be illustrated
by considering the manner in which jets of water can balance a
ball alotl in a fountain; tlie position of the ball is not static although
tlie ball appears to be virtually fixed in place. Teeth maintain their
positions in a bite in a similar way.
pain dysfunction (MPD) syndrome,"^" which had
been introduced in medicine for similar disorders by
Janet Travell et al.^^
In conformity with Ruth Moulton, parafunctions
were seen as subconscious attempts to work off psy-
chic tension. The fatigue and pain spasms produced
in the masticatory muscles by such efforts, especially
bruxism, were thought to bring about, maintain, and
even aggravate the symptoms.^° Thus, the group
shared Travell et al's opinion that muscular overex-
ertion produces a vicious circle." This theory has
proven to be erroneous'^; the disorders seldom get
worse if they are not fixated by improper treatment.
Moulton's view of the relationship between symp-
toms and psychic tension, however, holds true and
will be considered later in this article.
Regarding occlusai factors, the opinion of the
Chicago group was at least as negative as Schwartz's.
One example is the farcical, but also to some extent
seriously intended "American Non-Equilibration
Society" that Daniel Laskin founded in 1977. (Itwas
a great honor to have been appointed one of its 12
fellows.) The barb was aimed at the "American
Equilibration Society," which by that time was very
mechanistic.
Occlusion and Bruxism ¡n the Etiology of TMD
Costen posited that the cause of the syndrome was
in the bite, and consequentiy the treatment ought to
be directed against it.'-' Bruxism or other parafunc-
tions, however, were not mentioned in his article. As
already mentioned, both Schwartz and Laskin re-
garded occiusal factors as fairly unimportant. What
the patient does with his or her bite was considered
more important than how it looks.
Among dentists, however, resistance to this notion
was considerable. Occiusal treatment, equilibration,
and orthodontic and/or prosthetic reconstruction be-
came the fashion. The ideal occlusion and articula-
tion of a complete denture became the object, even
for "prophylaxis."" The American Equilibration
Stjciety set the tone, and among occlusion-fixated
propagandists, Drs Peter Dawson and Nathan Shore
may be mentioned.^"'^^ Finally, this policy became
so widely accepted that it brings to mind Mark
Twain's statement: "Ifyour only tool isa hammer, you
may treat everything as nails."
How Do Occiusal Disturbances Arise?
It has been proposed that the noniatrogenic occlusai
disturbances often observed and subjected to treat-
ment are not tbe cause oí, hut are instead caused by,
parafunctional activity,^°'^^The positions of the teeth
in the occlusion are not stable; they are determined
by the dynamic activity of the oral environment.
The requirement for keeping the teeth in unchanged
positions is that the sum total of all forces acting
upon them is constant. These forces may include the
occiusal and articulating ones as well as the pressure
from surrounding tissues, ie, the lips, cheeks, and
tongue (Fig 1 ). When such an equilibrium exists, no
perceptible movements take place, and, conse-
quently, the teeth rnaintain their positions for long
periods of time. If equilibrium does not exist, the
teeth are driven by the acting forces into new posi-
tions, where they often constitute what is called oc-
ciusal disturbances. It is then futile to treat the oc-
clusion without taking the causes of the patient's
behavior into consideration.^'' The common expe-
rience of the nonlasting effects of equilibration sup-
ports this opinion. The disturbances that are elimi-
nated often recur or new ones arise.^''•^^
EMG Studies
In 1961 Sigurd Ramfjord published a study that prob-
ably has been more influential than any other
to strengthen the doctrine of the importance of
occlusion.^^ Studying conscious experimental sub-
 TMD—Personal and Literature Review

jects, he reported that occlusal adjuslment could re-

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

Parafunctions and Stereotypies

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

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

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

 TMD—Personal and Literature Review
Bruxism
In clinical studies the reported prevalence of bruxism
varies between 6.5% and 88%, while the figures in
epidemioiogic studies generally are lower.''^ The
validity ofthese assessments has been questioned by
Marbach andothers, who consider that patients have
been influenced by their dentist's attitude.^^'^"* As it
has been all butaxiomatic that bruxism is the crucial
factor in TMD, the dentists take for granted that the
patient is a bruxist. Consequently, they influence the
patient by their explanations and leading questions
to believe in and concede to such activity. Moreover,
there is no reliable method for determining whether
wear facets are caused by bruxism or by other
factors. "-5^
Other Parafunctional Activities
The concept that bruxism is the dominant factor for
causing TMD has had such impact that other para-
functional activities have been totally eclipsed.
Bruxism is just one—maybe not even the most dele-
terious—of the parafunctions in which the mastica-
tory system can be engaged. Examples of such prob-
lematic habits are tongue thrusting and sucking and
biting on the lips and cheeks.
In bruxing the working mode of the muscles is
dynamiclie, they alter their length), while in pressing
it is static, isometric, tivcn more deleterious is
antagonistic tension, that is, when groups of muscles
with different tasks counteract each other. The phys-
iologically most noxious effects, however, are caused
when muscles work eccentrically, that is, when they
are elongated during simultaneous contraction.^^•^'' In
this type of action the forces within the muscle may
exceed the strength ofthe connective tissue, resulting
in microruptures, edema, and pain.^^'^^ An illustration
is the well-known fact that climbing downhill causes
more stiffness and aching than climbing uphill.
The lateral pterygoid is especially vulnerable in this
respect. Besides being the prime mover of protrusion
and laterotrusion, it also acts as a stabilizer of both the
mandible and the meniscus.^''^^ During times of stress,
it probably is as common to tense the masticatory
muscles antagonistically as it is to bite together or to
brux. Certainly many of us have noticed how a patient
during history taking tenses the masticatory muscles
and moves the jaw to one side without biting together
when we happen to touch upon some emotionally del-
icate topic. The force that the lateral pterygoid can de-
velop in such isometric or negative contraction would
be sufficient to produce pain. Eurthermore, the upper
bellyofthe lateral pterygoid is exceptional because it
has no antagonistic muscle. It protracts the articular
Ttie Irternaüonal lourrai of Pro slti odontic s
disc, but the returning movement is carried out by the
elasticity ofthe connective tissue that joins the disc to
the dorsal part of the articular fossa. IHyperactivity
may be responsible for fatigue and disruption of this
connective tissue, which in turn can lead to anterior
dislocation ofthe meniscus.'^^
The Origin of Muscle Pain in TMD
No satisfactory explanation of the muscle pain in
TMD has so far been presented. The most promising
explanation so far was proposed by Widmer.''^ EHe
suggests that the cause of masticatory muscle pain is
similarto that of angina pectoris, ie, because of local
disturbances in microcirculation. This gives a credi-
ble explanation ofhow but not why pain develops in
a muscle when it is producing only a small portion
of its maximum voluntary force. Erom quantitative
EMCJ studies we know that the forces in such activi-
ties are rather moderate.''^'^'''^^ Also, in the related dis-
order of tension-type headache recorded EiVlG levels
are not very great.^^
By drawing experiences from another field, occu-
pational medicine, it may be proposed that TrMD has
so much in common with some vocational disor-
ders, for example shoulder-neck complaints, that it
may be justifiable to regard them as branches ofthe
same tree. Strong support for this view can be derived
from the fact that psychosocial conditions have been
shown to be mure important than physical strain in
producing symptoms,'''^'^^
At moderate loads, it is the length of time rather
than the level of muscle activity that is the most im-
portant factor in pain.^''™ The reason for this is that
the activation of individual motor units takes place in
such a fixed order that the same motor units are al-
ways recruited first.^^ '•'^ When the force is reduced,
the motor units are disengaged in reverse order. This
means that a few muscle fibers are heavily loaded for
a long time even if the entire muscle is only slightly
loaded. The appropriate name "Cinderella fibers"
has been suggested for these hard-working units.'''
The fact that muscles can be activated by psychic
conditions is an old experience that has had new ap-
plications in sports. When an athlete mentally pre-
pares for an activity by imagining the movement pat-
tern, the appropriate muscles increase their
performance to some extent.''^''^ An observation that
corroborates this effect is that no difference in EMG
activity was found between physical pain produced
by injecting the masseter muscle with hypertonic (.5%)
saline and "sham" pain, ie, pain evoked by imagin-
ing pain.^^ Moreover, studies of occupational work sit-
uations demonstrate that emotional and environ-
mental factors, ie, psychosocial conditions, are
284 Volume 12, Nu

capable of producing increased unconscious muscle
activity.''''
In the facial muscles, those of facial expression as
well as those of mastication, psychic and especially
emotional conditions are particularly prone to man-
ifest themselves.' "• '^ The face is our facade, which we
unconsciously try to keep unaffected by tensing the
muscles ofthe face and ¡aw. In antagonistic tension,
as mentioned above, some motor units may remain
active for such a long time that pain is evoked.
The time of recovery between periods of activity is
important. When a muscle works, metabolites accu-
mulate and the balance of Na+, K*, and Ga"^ is dis-
turbed. IntracellularK* decreases, while extraceliularly
it increases. This may act on free nerve endings and
cause pain."" Impaired microcirculation in the muscle
fibers and/or in the vessels that supply the nerve may
contribute. To elucidate the problem, however, more
research is needed, especially on the conditions in sep-
arate muscle fibers. Research involving the separate
fibers is possible using ultrathin needle electrodes.^^
Why Does the Belief in Occiusai Etiology Survive?
The main reason for the continued confusion about
the etiology of TMD is the fact that in most individ-
uals, it is possible to identify some "bite disturbance"
and often also some kind of dysfunction, even when
theydonot have any complaints, A comparison with
other bodily conditions may be worthwhile; how
many individuals have a perfect gait^ Analogously,
should those who do not have a perfect gait be
equipped with arch supports?
In a discerning article Nigel G. Clarke once made
the critical comment that
the masticatory system mus! either be unique in the
body's evoluiionary development in its failure to fulfill
its function profierly or else our comprehension of the
system has mistakenly led us to describe as abnormal-
ities conditions tbat in fact may be normal and play no
role in bruxism and
Apparently Clarke is alluding to those epidemioiogic
studies that overrate the occurrence of occiusai dis-
turbances and symptoms: these studies were also se-
verely criticized by Greene and Marbach.^^ In recent
years, however, it is obvious that a more realistic at-
titude has emerged.^^-^^ Especially important is that
this more matter-of-fact assessment also includes the
Treatment
Given the high prevalence of symptoms and signs
of TMD in epidemioiogic studies and the considerably
2. Number 3,1999
TMD—Personal and Literalure Review
lower rate of treatment seekers, it may be concluded
that most of those affected by TMD recover
spontaneously. 5tudies of treatment outcome show
that between 70% and 90% improve or get well irre-
spective of the treatment method, and no particular
procedure has proven to be superior to any other or
even to placebo.'^•^^-^' Thus, every dortor can assert
without risk that it is just his or her method of treatment
that works—at least in their hands. After all, the most
important consideration is that irreversible aaions be
avoided.^^ Such measures may increase the risk that
the patient's bite will become fixated—or even expe-
rience what Marbach calls a "phantom bite" and thus
become a chronic pain case.^-
However, as in other psycho physic a I disorders, there
is a considerable minority of patients who fail to re-
spond to the conventional physically aimed therapy
and continue to suffer from persistent or recurring pain
and disability.^^'^"* Gmcial factors behind a negative out-
come seem to he psychosocial faaors such as depres-
sion, hypochondria, an extemal locus of health control,
abnormal illness behavior, and lack of emotional sup-
port resulting in impaired coping capability.^^^^^ Thus,
for these patients treatment ought to aim more at psy-
chosocial factors than at physical ones.^^"* This ap-
proach is corroborated by the fact that successful treat-
ments are more effective against symptoms, eg, pain,
than against clinical signs ofthe disorder.^^'^^
At a 1996 treatment conference arranged by the
NIH, a recommendation was given that disorders
such as tension-type headache and TMD be treated
with tension-relieving actions, including relaxation
and counseling with information about the disorder
and its background.'^ The importance of reassur-
ance cannot be overestimated. "The Doaor is the
most potent drug," as the Hungarian-British psycho-
analyst Michael Balint expressed it.'°' These meas-
ures may suffice to decrease stress and anxiety and
alleviate the symptoms.'^ Very important, however,
is that this strategy is applied as early as possible,
preferably by the first care provider.
For patients who nevertheless develop chronic dis-
order, the general rules for treatment of chronic pain
should be applied. For developing such strategies, the
late Dr lohn Bonica at the University of Washington
in Seattle probably has contributed more than anyone
else. His deep devotion was based on experience with
patients during and after the war in the Pacific.'"' He
was also a founder ofthe International Association for
the Study of Pain. Nowadays, treatment at special pain
centers is organized in the form of pain schools with
a multidisciplinar/ approach.'«»^ Gognitive behavioral
therapy plays an important role in increasing the pa-
tienf s awareness of his or her personal mode of reac-
tion and its underlying causes.'°'*'"^5 Even if treatment
285 The International Journal of Proithodohtics
 TMD—Personal and LiLerature Review
cannot fully remove the pain, it may help the patient
to cope and therefore alleviate suffering.'^^
It is logical that one ofthe most active TMD research
groups is connected with the University of Washington
in Seattle. Under the leadership of Dr Samuel F, Dwor-
kin its activity has principally been devoted to psycho-
social problems in connection with TMD and other
chronic pain conditions. A further area of focus has
been the development of standardized diagnostic cri-
teria, primarily for research purposes on TMD.^ The
classification system (Research Diagnostic Criteria for
TMD, RDC/TMD) contains 2 axes: one consisting of
physical TMD conditions and one concerning pain-re-
lated disability and psychologic status. A recent study
indicates the capacity ofthe RDC/TMD to predict which
patients are at risk of developing chronic disorders.^^
Looking back, the mechanistic etiologic ideas that
transferred the treatment of TMD from medicine to
dentistry seem very far away. Looking ahead, it is ev-
ident that dental training must be directed toward a
more comprehensive medical knowledge, especially
including a more phychosomatic view that will help
dentists understand the etiology and natural history of
TMD; this will allow them to treat sufferers of these dis-
orders. Put simply, the focus must be shifted from the
bite to the mind.
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Literature Afistract-

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

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

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

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

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