Carlsson GE.

JPPA 2013; 01(02): 81-86

Occlusion and Temporomandibular Disorders: Past and

Present Opinions on Management*
Gunnar E Carlsson, LDS, Odont Dr/PhD, Dr Odont hc, Dr Dent hc, FDSRCS (Eng)
Department of Prosthetic Dentistry/Dental Materials Science, Institute of Odontology, The
Sahlgrenska Academy, University of Gothenburg, Box 450, SE 405 30 Gteborg, Sweden.

Correspondence: Gunnar E Carlsson. E-mail: g.carlsson@odontologi.gu.se

* Footnote: This article is a revised and updated version of a presentation given by the author at
the Conference of the International College of Prosthodontists 1821 September 2013 in Turin, Italy.

ABSTRACT
The role of occlusal factors in temporomandibular disorders (TMDs) has been a much-discussed topic
for long, and it still is. This article will briefly present the development of opinions on the relationship
between occlusion and TMDs and how this has affected the management. The early belief that
deviations from an ideal occlusion would imply a risk of creating TMDs has gradually been abandoned.
Today most TMD experts de-emphasize the importance of occlusion in the aetiology of TMD. Available
evidence-based knowledge has suggested that occlusal interventions are not justified for treatment of
TMDs since occlusion is in general not at all or only weakly associated with TMDs. Instead counselling
and simple reversible methods should be the first choice in management of TMD patients. Oral
appliances / splints are frequently used and can often effectively reduce signs and symptoms in TMD
patients. However, they are not always necessary and a low-cost, non-splint self-care treatment should
be the first choice in management of the majority of primary TMD patients.
Conclusion. TMDs will often improve with simple treatment that can be performed in general dental
practice, without occlusal interventions. Educating patients about their disorder is an important part of
the management. Only few TMD patients need more extensive treatment and / or referral to orofacial
or medical specialists.
Key words: Concepts of Occlusion, Differential Diagnosis, Oral Appliances, Orofacial Pain, TMJ
Disorders.
How to cite this article: Carlsson GE. Occlusion and Temporomandibular Disorders: Past and Present
Opinions on Management. J Pak Prosthodont Assoc 2013; 01(02): 81 86.

Introduction will be used in the following text. TMD was earlier

Dental occlusion has been a much-discussed topic for
long, and it still is. According to the Glossary of
Prosthodontic Terms, occlusion is defined as the
static relationship between the incising or masticating
surfaces of the maxillary or mandibular teeth or tooth
analogues, whereas the dynamic contact
relationship between the occlusal surfaces of the
teeth during function is called articulation. These
definitions may seem straightforward but the clinical
and practical interpretation of them has caused much
1
confusion and many controversies in dentistry. The
most persistent controversy has been related to the
role of occlusal factors in temporomandibular
disorders (TMDs). A great number of names have
been used over the years for pain and functional
disturbances of the masticatory system; TMD / TMDs
considered a single entity, characterised by pain, joint
sounds, and irregular or limited jaw function. Today
TMDs is a collective term embracing a broad
spectrum of clinical joint and muscle problems in the
orofacial area with a number of possible aetiologies.
During the last few decades the interest has focused
more on the pain than on the dysfunction aspect of
TMDs. Orofacial pain is increasingly used in parallel
with TMD and one of the most respected journals in
the field is named Journal of Orofacial Pain.
This article will present a brief description of the
development of opinions on the relationship between
occlusion and TMDs and how this has affected the
management of TMDs.
81
Carlsson GE.
Some Notes on Development of Concepts of
Occlusion
th
In the 19 century the interest in occlusion increased
by the development and improvement of articulators
used to facilitate the construction of complete
dentures; specific criteria of occlusion were
considered necessary for well-functioning prostheses.
Early in the 20th century gnathological concepts
appeared stating that ideal occlusion was necessary
2
for the health of the whole masticatory system. This
led to the belief of an occlusal aetiology of TMD. Both
Monson and Decker in the 1920s and Costen 10 years
later maintained that temporomandibular joint (TMJ)
symptoms as well as deafness and other ear problems
might be caused by distal condylar displacement and
3
overclosure of the mandible. These ideas resulted in
recommendations for reconstructive dentistry using
bite raising to treat both TMJ and ear problems.
However, these ideas also caused both confusion and
controversy between anatomists, maxillofacial
surgeons and dentists: should the disorder be treated
with TMJ surgery or occlusal therapy? Even if the
professionals soon agreed that Costens explanation
was not anatomically acceptable, the concept
survived long, at any rate in the name Costens
syndrome that was used for TMD in many texts up to
th
the end of the 20 century.
4
The textbook Occlusion by Ramfjord and Ash
emphasised occlusal disturbances in the aetiology of
TMDs, or Functional disturbances of the masticatory
system as it was called in the book. According to the
book occlusal adjustment was also the treatment of
choice for treatment of TMDs. This book had an
enormous impact on the thinking in the field of pain
and functional disturbances of the masticatory
system. The book appeared in 4 editions during three
decades, the last came in 1995.
Parallel with this great interest in occlusion,
masticatory muscles were found to be the source of
much of the pain in TMDs, and the term myofascial-
pain-dysfunction syndrome (MPD) was coined.
Treatment directed to the painful muscles, e.g. jaw
exercises were shown to be as effective as occlusal
adjustment in managing TMDs. However, confusion
persisted in the TMD field and the literature gave
little help to solve the controversies as the
interpretation of available studies was difficult, as
JPPA 2013; 01(02): 81-86
they did not use comparable diagnoses and
methodological criteria. The launching of the research
diagnostic criteria for temporomandibular disorders
(RDC / TMD) in 1992 aimed at improving the quality
5
of research in the field. Even if it was far from ideal it
became dominant in clinical TMD research worldwide
and helped to specify diagnoses. The system included
6
however evident shortcomings and it was criticized.
New versions of RDC / TMD have recently been
7
published. It is still too early to say if the new
versions will increase the applicability and utility of
the system.
The interest in the field of Orofacial Pain / TMDs is
reflected in the rapid increase of research articles
over the last few decades. Advanced education
programs have been developed in several centres to
further the specialization in the field. TMD / Orofacial
Pain has been accepted as a dental specialty in a few
countries, and in others attempts are continuing to
achieve a specialty status.
The Future
What will happen with the TMD / Orofacial Pain field
in the coming years? To make a prognosis for the
future is difficult because we dont know what will
happen(Unknown thinker). Nevertheless I list a few
points, perhaps more hopes than realistic prognoses:
The relative importance of TMDs increases
in parallel with decreasing prevalence of
caries and periodontal disease and / or
increasing prevalence of TMDs?
Improved undergraduate education makes
general dentists capable of diagnosing and
managing most TMD patients?
Specialist training and special clinics are
necessary and will hopefully be developed
for complicated patients, unusual TMDs /
Orofacial Pain, and chronic pain syndromes
Research in the field is expanding and
hopefully more of it will be directed to
transferring the results to clinically useful
treatment methods.
In contrast to these fairly optimistic, or at any rate
8
hopeful, predictions, Trp presented in a recent
review, forecasting the development up to 2020, a
pessimistic view on the future educational level of the
general practitioners, which he prophesised to
remain poor. He concluded however that compared
82
Carlsson GE.
to today, some clinically relevant changes may be
expected, and in the years ahead the field of orofacial
pain will continue its journey of emancipation away
from traditional dentistry, heading towards pain
medicine.
Diagnosis
A thorough history and a careful clinical examination
and evaluation are the most important steps. A mm
ruler and observations of jaw movements are enough
to notice restriction and irregularity in mouth
opening. Instrumental and electronic devices, e.g.
surface EMG and jaw tracking systems, or occlusal
analysis in an articulator, do not improve diagnostic
accuracy. For differential diagnosis of some TMJ
disorders imaging techniques may be desirable, but
9-11
not always necessary. For the most common TMJ
disorders a clinical evaluation by a trained clinician
has shown acceptable agreement with diagnoses
12, 13
gained by TMJ imaging. A radiographic
examination of teeth and jaws should be performed
to be able to differentiate odontogenic pain from
TMD symptoms.
In summary, the diagnosis of TMDs should mainly be
based on the history and clinical evaluation, whereas
imaging of the TMJs can be reserved to a minority of
TMD patients.
Treatment
A great number of treatment methods for TMDs, such
as dental, physical, psychological, pharmacological,
surgical and other, have been advocated and tried
10
over the years. In spite of the fundamental
differences between these treatment modalities,
many of them have shown good therapeutic
effectiveness and control of signs and symptoms in
the majority (75% to 90%) of TMD patients. One
explanation to this may be that TMD was for long
looked upon as a single disease entity, i.e. differential
diagnoses of TMDs were not included in study
designs, and many of the studies presented were of
11
poor methodological quality.
The previously predominant role of occlusal therapy /
adjustment has been seriously questioned, and most
so-called TMD experts de-emphasize today the
importance of occlusion in the etiology of TMD.
Several systematic reviews have concluded that
occlusal adjustment cannot be recommended for the
JPPA 2013; 01(02): 81-86
14-16
management or prevention of TMDs. However,
many practitioners still adhere to a concept focusing
on occlusal factors in TMD diagnosis and treatment.
The main reasons for that are that many dentists
continue to rely on their early professional training
and experiences, they are reluctant to accept that
TMDs are mainly non-dentally related disorders, and /
or they believe in schools of thought sponsored by
charismatic gurus. They are also unfamiliar with
current literature and continuing education in the
11, 17
field.
Available evidence-based knowledge has thus
suggested that occlusal interventions are not justified
for treatment of TMDs since occlusion is in general
not at all or only weakly associated with TMDs. It is
therefore unethical to continue providing irreversible
18
changes to occlusion as treatment for TMDs.
Counselling and simple reversible methods should be
the first choice in management of TMD patients.
Management of TMDs
The precise etiology of most TMDs is not well known,
but successful management is still possible!
TMDs will often improve with simple
treatment.
Educating patients about their disorder is
an important part of the management.
Combining counselling, analgesics for pain
relief, and simple jaw exercises should be
used initially in most TMD patients.
This simple treatment can be performed in general
dental practice and will be successful for most
primary TMD patients. However, there are other
types of patients, e.g. those who are psychosocially
compromised, do not respond to simple treatment,
and / or have persistent or chronic pain. Such patient
groups will require additional clinical attention and
19
multidisciplinary treatment planning.
Oral Appliances
Splints, also called inter-occlusal or oral appliances,
night guards, etc., are common in treatment of TMDs.
The most common are stabilization splints (Figure 1).
They are thought to be effective by means of occlusal
stabilization. However, there are other possible
mechanisms of efficacy (Table 1). An anterior bite
plate (relaxation plate, Hawley plate, etc.) uses a
quite different mechanism but has been found to be
83
Carlsson GE.
20
as effective as the stabilization splint. Several
studies during the last few years have demonstrated
that a so-called placebo splint, which only covers the
palate without any influence on the occlusion, also is
effective in reducing TMD symptoms. It is therefore
probable that the mechanism is not at all or only
marginally related to occlusal factors, but can be
explained as effects of, for example, placebo, the
21
time factor, and the fluctuation of the complaints.
Table 1: Proposed mechanisms discussed in the
literature to explain the treatment effect of intraoral
appliances.
Proposed mechanisms
Occlusal disengagement.
Stabilization of occlusion.
Neurophysiologic effects on the masticatory
system.
Change of vertical dimension.
Change of caput-fossa relation.
Cognitive awareness of harmful behaviour (e.g.
parafunctions).
Stress absorber / reduced load on masticatory
system components.
Placebo effect.
Figure 1. Stabilization splint. Top: Occlusal view. The blue
marks indicate a wide distribution ofocclusal contacts.
Bottom: Schematic drawing showing the splint providing
occlusal contacts over the whole arch.
84
JPPA 2013; 01(02): 81-86
Splints are often useful but we do not really know
why. A statement referring to the enigma of
treatment success from Bill Solberg, UCLA (personal
communication) deserves to be quoted: Did the
patient improve because of the appliance, in spite of
the appliance, or did the appliance have nothing to do
with anything? Another thought provoking citation
could also be added: Tincture of time may cure many
things. Often the patient improves and we had
nothing to do with their improvement, but take the
credit anyway.
Since oral appliances in many studies have shown to
effectively reduce signs and symptoms in TMD
patients they can be recommended and are
16, 22
frequently used. However, splints may not be
necessary for a successful management of TMD
patients. A well-controlled study found that TMD
patients who received a dentist-guided home self-
treatment without splint had after 12 months
improved as much as those who had been treated
23
with splints. The conclusion was that a low-cost,
non-splint self-care treatment should be the first
choice in management of the majority of primary
TMD patients.
Occlusal adjustment
As discussed above, the current opinion among TMD
specialists is that occlusal therapy, in general, seldom
is indicated in TMD patients! However, occlusion is of
course important in many other clinical situations, as
in restorative and prosthetic dentistry, although
opinions vary much how occlusion should be
1
organized.
There are several clinical situations when occlusal
adjustment may be considered
Gross occlusal interferences.
Occlusal trauma with tooth hypermobility.
Occlusal instability.
Before and after restorative procedures.
For aesthetic improvement.
As an example of a situation when occlusal
adjustment can be used is an open bite, which can
often be improved by selective grinding of the
posterior teeth (Figure 2).
Carlsson GE.
Figure 2. Occlusal adjustment in a patient with open bite.
Top: Occlusal contacts only on the most posterior teeth.
Bottom: Occlusion after selective grinding, mainly on the
most posterior teeth.
New paradigm in understanding occlusion
New research has shown a remarkable adaptability of
the sensorimotor central control system
neuroplasticity in response to changes in the
orofacial region. Central neuroplasticity supports
adaptation to dental treatment, including changes in
occlusal design and occlusal status. This new
knowledge can enhance our understanding of
patients adaptation to different types of
prosthodontic work and variations in occlusal design
and morphology.
1, 24
The possible impact of this new
knowledge on the diagnosis and management of
TMDs is not yet known. It can be expected that new
methods in pain research, such as brain neuro-
imaging for visualizing pain-related brain activity, will
be used also in the TMD /orofacial pain field. It is not
likely however that such methods will lead to
revolutionary changes in patient management in the
near future.
8 10. Carlsson GE, Magnusson T. Management of
Conclusions
In diagnosing patients with a possible TMD it is
necessary to acknowledge the great variety of
causes of orofacial pain and dysfunction.
Initial TMD therapy includes explanation of the
problem, management of pain, instruction for
home self-care, and possibly a splint.
JPPA 2013; 01(02): 81-86
This simple treatment can be performed in
general dental practice and will be successful for
most primary TMD patients.
Only few TMD patients need more extensive
treatment and / or referral to orofacial or
medical specialists.
References
1. Carlsson GE. Some aspects on dental occlusion
and its importance in clinical dentistry. J Pak
Prosthodont Assoc 2013:1:311.
2. Mohl ND, Davidson RM. Concepts of occlusion.
In: Mohl ND, Zarb GA, Carlsson GE, Rugh JD (Eds)
A Textbook of Occlusion. Chicago: Quintessence,
1988:16175.
3. Zarb GA, Mohl ND. Occlusion and
temporomandibular disorders: A prologue. In:
Mohl ND, Zarb GA, Carlsson GE, Rugh JD (Eds) A
Textbook of Occlusion. Chicago: Quintessence,
1988:37783.
4. Ramfjord SP, Ash MM. Occlusion. Philadelphia:
WB Saunders, 1966.
5. Dworkin SF, LeResche L. Research diagnostic
criteria for temporomandibular disorders:
review, criteria, examinations and specifications,
critique. J Craniomandib Disord 1992;6:301-55.
6. Steenks MH, de Wijer A. Validity of the Research
Diagnostic Criteria for Temporomandibular
Disorders Axis I in clinical and research settings. J
Orofac Pain 2009;23:916; discussion 1727.
7. Anderson GC, Gonzalez YM, Ohrbach R et al.:
The research diagnostic criteria for
temporomandibular disorders. VI: Future
directions. J Orofac Pain 2010;24:7988.
8. Trp JC. Orofacial pain care in 2020: A
prediction. Dtsch Zahnrztl Z 2013;68:60015.
9. Zarb GA, Carlsson GE. Examination and
differential diagnosis of occlusal problems. In:
Mohl ND, Zarb GA, Carlsson GE, Rugh JD (Eds) A
Textbook of Occlusion. Chicago: Quintessence,
1988:185207.
temporomandibular disorders in the general
dental practice. Chicago: Quintessence, 1999.
11. Manfredini D, Bucci MB, Montagna F, Guarda-
Nardini L. Temporomandibular disorders
assessment: medicolegal considerations in the
evidence-based era. J Oral Rehabil 2011;38:101
19.
12. Yatani H, Suzuki K, Kuboki T, Matsuka Y,
85
Carlsson GE.
Maekawa K, Yamashita A. The validity of clinical
examination for diagnosing anterior disk
displacement without reduction. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod
1998;85:65460.
13. Petersson A. Imaging techniques. In: Manfredini
D (Ed) Current concepts on temporomandibular
disorders. Berlin: Quintessence 2010:20722.
14. De Boever JA, Carlsson GE, Klineberg IJ. Need for
occlusal therapy and prosthodontic treatment in
the management of temporomandibular
disorders. Part I. Occlusal interferences and
occlusal adjustment. J Oral Rehabil 2000;27:367
79.
15. Greene CS. Managing the care of patients with
temporomandibular disorders: a new guideline
for care. J Am Dent Assoc 2010;141:10868.
16. List T, Axelsson S. Management of TMD:
evidence from systematic reviews and meta-
analyses. J Oral Rehabil 2010;37:43051.
17. Mercuri L. A heuristic approach to the
management of muscle-related
temporomandibular disorders. Faculty Dent J
2013;4:1127.
18. Reid KI, Greene CS. Diagnosis and treatment of
temporomandibular disorders: an ethical
analysis of current practices. J Oral Rehabil
2013;40:54661.
JPPA 2013; 01(02): 81-86
19. Suvinen TI, Kemppainen P, Le Bell Y, Valjakka A,
Vahlberg T, Forssell H. Research Diagnostic
Criteria Axis II in Screening and as a Part of
Biopsychosocial Subtyping of Finnish Patients
with Temporomandibular Disorder Pain. J Orofac
Pain 2013;27:31424.
20. Carlsson GE. Some dogmas related to
prosthodontics, temporomandibular disorders
and occlusion. Acta Odontol Scand 2010;68:313
22.
21. Dao TT, Lavigne GJ. Oral splints: the crutches for
temporomandibular disorders and bruxism? Crit
Rev Oral Biol Med 1998;9:34561.
22. Klasser GD, Greene CS, Lavigne GJ. Oral
appliances and the management of sleep
bruxism in adults: a century of clinical
applications and search for mechanisms. Int J
Prosthodont 2010;23:45362.
23. Truelove E, Huggins KH, Mancl L, Dworkin SF.
The efficacy of traditional, low-cost and
nonsplint therapies for temporomandibular
disorder: a randomized controlled trial. J Am
Dent Assoc 2006;137:1099107.
24. Trulsson M, van der Bilt A, Carlsson GE,
Gotfredsen K, Larsson P, Mller F, Sessle BJ,
Svensson P. From brain to bridge: masticatory
function and dental implants. J Oral Rehabil
2012;39:85877.
86