REVIEW

Occlusion, temporomandibular disorders, and orofacial pain:

An evidence-based overview and update with
recommendations
Michael J. Racich, DMD

Orofacial pain has been ABSTRACT

defined as “pain localized to This paper presents an overview of dental disciplines involved in the treatment of orofacial pain,
the region above the neck, in temporomandibular disorders (TMD), and occlusion and provides an evidence-based contemporary
front of the ears and below update of their interrelationships. English language peer-reviewed articles were identified using
the orbitomeatal line, as well PubMed. Key words bruxism, implants, occlusion, orofacial pain, orthodontics, prosthodontics,
as pain within the oral cavity, restorative dentistry, and TMD were used. (J Prosthet Dent 2018;-:---)
including pain of dental origin
and TMD (temporomandibular disorders).”1 TMD has by most dental practitioners, with conditions such as
been defined in the Glossary of Prosthodontic Terms as aphthous ulcers and irreversible pulpitis, whereas chronic
“conditions producing abnormal, incomplete, or orofacial pain, which tends to be refractory, is often
impaired function of the temporomandibular joint(s) confounding. Somatic (soft or hard tissue body) orofacial
[TMJs] and/or the muscles of mastication” (Table 1), pain is described as dull, achy, throbby, and thermally
whereas occlusion is defined as “the static relationship responsive. Neuropathic pain (frequently a result of
between the incising or masticating surfaces of the nerve damage) is described as burning or stabbing.
maxillary or mandibular teeth or tooth analogues.”2-20 Psychogenic pain (especially somatoform) commonly
Since the beginning of the current millennium, lacks organic origins, with emotional, mood, and cogni-
evidence-based dental reports have evolved and grown tive belief comorbidity findings. Often, patients present
in each of the respective fields of orofacial pain, TMD, with orofacial concerns representative of 2 or 3 of these
and occlusion. This paper presents an overview of these 3 main pain categories.27-41 Placebo effects too can account
dental disciplines and explores contemporary diagnostic for up to 50% of patient symptom improvement, with
and clinical interrelationships. Diagnostic and treatment nocebo effects that are antithetical (patient symptom
recommendations for interdisciplinary (within the dental non-improvement or decline).42-46
profession) and multidisciplinary (among health care Afferent facial sensory information reaches the central
professions) care are discussed. nervous system through the fifth (trigeminal) cranial nerve,
synapsing mainly in the spinal tract subnucleus caudalis
(Fig. 1).47 This afferent information can be thermal, me-
OVERVIEW
chanical, mechanoceptive, or nociceptive in nature. Also
Acute and chronic orofacial pain are divided into 3 main synapsing or converging in the subnucleus caudalis is
categories: somatic, neurogenic, and psychogenic.21-26 primary-order afferent information from the facial (VII),
Acute orofacial pain is readily handled and understood glossopharyngeal (IX), vagus (X), hypoglossal (XI), and

Presented at the 78th annual meeting of the Pacific Coast Society of Prosthodontics annual meeting, Anchorage, Alaska, June 2013, and the 23rd annual meeting of the
Canadian Academy of Restorative Dentistry and Prosthodontics, Toronto, Ontario, October 2015.
Private practice, West Vancouver, British Columbia, Canada.

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Table 1. TMD diagnostic and treatment considerations

Clinical Implications Findings Pain
Common Pain not aggravated by
Orofacial pain, temporomandibular disorder and Altered sensation Facial expressions
occlusal therapeutic management are integral parts Mechanical compromise Physical exertion
of contemporary interdisciplinary (orthodontic, Pain with function Speaking
prosthodontic, restorative) dental care, often Common examination Confounders
requiring a multidisciplinary team approach for the Alterations in motion Limited jaw opening (giant cell
benefit of all stakeholders. arteritis)
Occlusal discrepancies Occlusal discrepancies
Muscle hypertrophy Muscle hypertrophy
Palpation pain Palpation pain
first 3 cervical nerves (C1 to C3). This convergence of
48
TMJ noises TMJ noises
multiple cranial and cervical nerves is one of the expla- Worn dentition Worn dentition
nations for referred pain, where the pain site and source Treatment failure etiologic
differ (Table 2). As second-order neurons relay afferent possibilities
information to the thalamus and finally tertiary neurons, Complicating comorbid factors
transfer to the cortex is complete. Once nociceptive in- Irreversible tissue injury

formation is received by the cortex, the individual experi- Multiple diagnoses

Ongoing allostatic load
ences pain. Many opportunities exist within the central
Secondary gains
nervous system for nociceptive information to be modu-
Wrong diagnosis
lated, both while ascending (reticular formation) and
TMD, temporomandibular disorder; TMJ, temporomandibular joint.
descending (periaqueductal gray, raphe magnus nu-
cleus).49-55 Gate control and neuromatrix theories seek to
describe the complex multidimensional interactive expe-
rience within the central nervous system and the various
neurotransmitters thought to be involved (such as en-
dorphins, dopamine, serotonin), which ultimately lead to
resultant clinical symptoms.56-58
The human nervous system exhibits plasticity (neu-
roplasticity), the property of physiological modification,
depending on input.59-61 Neuroplasticity with primary-
order neurons, such as the trigeminal system, can lead
to sensitization or an upregulation of the central nervous
system (central sensitization). Central sensitization can
alter or initiate second-order nociceptive input to higher
centers and can also expand receptive nociceptive fields
by such vehicles as glial cell activation.62-68 Tooth pulp
nociceptive input (cracked tooth syndrome, odontoblast
excitation, pulp pathology) is an example of the creation Figure 1. Afferent noxious sensory input through first-order neuron
of central neuroplastic changes, with concomitant phys- synapses in brain stem subnucleus caudalis with second-order neurons
reaching thalamus before tertiary neurons relay input to cortex for
iologic and clinical sequelae.69-89 Central sensitization
sensory (pain) discrimination. Efferent signaling and inflammatory
can also stimulate efferent discharge of neuro-
mediator release also can occur through primary neurons (sterile or
inflammatory mediators (such as calcitonin gene-related centrally mediated myositis in temporomandibular disorders). Nerves
peptide), thus being the cause of common disorders involved include trigeminal ophthalmic division (V1), trigeminal maxillary
like migraine and secondary hyperalgesia (post-whiplash division (V2), trigeminal mandibular division (V3), facial (VII), glosso-
facial central-mediated myositis) (Fig. 1).90-95 Central pharyngeal (IX), vagus (X), hypoglossal (XI), and first 3 cervical nerves (C1
sensitization is thought to be the common pathophysi- to C3). Nuclei include raphe magnus (RM), subnucleus caudalis (NC), and
ological mechanism for many chronic pain states, such as spinal tract (ST). PAG, periaqueductal gray; RF: reticular formation.
TMD, atypical odontalgia, chronic fatigue syndrome,
complex regional pain syndrome, dysmenorrhea, fibro-
myalgia, irritable bowel syndrome, persistent idiopathic and neck nociceptive input, it is not surprising that
facial pain, restless leg syndrome, and tension-type misinterpretations and misdiagnoses occur. Furthermore,
headache.96-103 epigenetic phenotypic expression makes some in-
With such an array of causative and diagnostic pos- dividuals not only more susceptible to different orofacial
sibilities within the central nervous system from head pain states but also acts to orchestrate differing orofacial

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Table 2. Possible sources of toothache

Source
 Cardiac  Neuritic (multiple types)
 Central  Neurovascular
 Glandular  Periodontal
 Muscular  Psychogenic
 Mucosal  Pulpal

pain states, induced by central sensitization (migraine

and TMD), to act in concert.104-106 Hence, oral health
care practitioners must be aware of orofacial pain path-
ophysiology, TMD inclusive, and the overloading of the
craniofacial complex during dental treatment to prevent
occurrence of comorbidity. A “go-low, go-slow” Figure 2. Complete coverage by mandibular hard acrylic resin dental
approach to oral health care (comprehensive or not) is orthotic for patients with temporomandibular disorders during sleep.
the most prudent manner of action. While awake, protection is obtained by patients keeping their teeth
apart.
The usual discussion of dental occlusion, as exempli-
fied by the Glossary of Prosthodontic Terms definition,
generally assumes a static relationship of the occluding
surfaces of the jaw, whether it is tooth (natural or pros-
thetic/restored), implant, or nonimplant-supported.20
Research has shown that dental occlusion is not static or
in a perpetual state of contact but rather diurnally dy-
namic.107 Therefore, it is essential to educate and remind
patients to keep their teeth apart while awake.108-112
While patients are sleeping, their aggressive and abusive
tooth contact through clenching and/or bruxing can occur
for lengthy periods, with tooth and prosthodontic/
restorative protection provided by hard acrylic resin, flat
plane style orthotics (mandibular hard acrylic resin, flat
plane orthotics are preferred for patients with TMD to
minimize sleep apnea and bruxism orthotic effects)
(Fig. 2).113-124 Figure 3. Anatomic, physiologic occlusion. Premolar, natural dentition;
For patients who undergo orthodontic, prosthodontic, first molar, ceramic onlay; second molar, gold onlay.
or restorative comprehensive oral care, practitioners should
optimally provide mutually protective occlusal schemes (in
is encouraged for masticatory efficiency (Figs. 3, 4).150-152
maximum intercuspation and for excursive movements),
Implant-supported prostheses are fabricated according to
taking advantage of class III lever principles (although
these guidelines but may also incorporate implant-protected
group function and balanced occlusal schemes can be
occlusions (8-mm shim stock relief in light jaw contact for
entertained as well).20,125-130 These rehabilitative occlusal
partial implant-supported prostheses), cantilever minimiza-
schemes are performed at an acceptable vertical dimension
tion, occlusal table narrowing, or the use of splinting con-
in a consistently reproducible (CR) position of the
cepts.153-158 Consideration of shortened dental arches for
mandibular condyles in the glenoid fossa centric relation,
those patients who are partially dentate and not interested in
with subjective operator preference of CR and its accuracy
implant surgery or removable prostheses should be part of
at the time of definitive records being paramount.131-141
the recommended treatment options.159,160
Posterior dentition CR tooth contact (oftentimes only 1
per tooth or analog and in a buccalized fashion) is tactically
DISCUSSION
and visually symmetrical to the operator while being
perceptually balanced for patients.20,142-145 Anteriorly, the Most dental care worldwide is carried out in the habitual
envelope of function is respected, with fremitus thereby jaw relationship position or maximum intercuspation.161-166
minimized.20,146,147 When possible, the dentition (artifi- When comprehensive care (orthodontic, prosthodontic,
cial or natural) is arranged sagittally and coronally to restorative) is planned, dental practitioners should create
embrace the physiological advantages of the neutral zone definitive, mutually protective occlusal schemes in
concept.20,148,149 Sharp, crisp, functional tooth anatomy consistently reproducible (CR) jaw positions at acceptable

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Figure 4. Anatomic, physiologic occlusion with implant-supported metal-ceramic fixed partial denture. A, Clinical view. B, Periapical radiograph.

Table 3. Examination, evaluation, self-help considerations

Examination Tests Differential Diagnoses Self-help Therapies
Comprehensive hard and soft dental exam Sleep study Cervical pain disorders Diary(s) (pain, sleep, nutrition, and so on)
Cranial nerve TMJ Dental disorders General exercise (passive and active)
Head and neck Antinuclear antibody Musculoskeletal disorders Habit reconditioning
Cervical spine palpation Arthritis: IL-1B, IL-6, IL-Ra, glutamate, Neuropathic disorders Hypnosis
serotonin, TNF
Cranial palpation Bone scan Neurovascular disorders Judicious use OTC Rx
Muscle function tests C-reactive protein Psychologic disorders Nutrition
Muscle palpation Lyme disease Sleep disorders Posture
Temporal arteries Rheumatoid factor Vascular disorders Relaxation techniques (breathing, stress, muscle)
Posture Sleep hygiene
Vital signs

IL, interleukin; OTC Rx, over-the-counter medications; TMJ, temporomandibular joint; TNF, tumor necrosis factor.

occlusal vertical dimensions, especially allotting for and (antinuclear antibody, bone scans, C-reactive protein,
minimizing vertical overlap for bruxers and, hence, interleukin-6 [IL-6], lyme disease, rheumatoid factor) offer
excursive forces. Regardless of the ultimate endpoints of diagnostic and clinically relevant details. Sleep quality and
oral care, efforts should always be made by all practi- sleep apnea screening should be routinely done with ve-
tioners to minimize aberrant input, such as that from hicles such as Snoring, Tired, Observe, blood Pressure,
dental occlusion through occlusal equilibration, into the Body mass, Age, Neck size, Gender (STOP-BANG)
central nervous system, thereby mitigating any initiating questionaires.176 Muscles should be screened for local
or contributory effects to orofacial pain conditions, muscle soreness, myofascial trigger points and referral
including TMD.167,168 As indicated, interdisciplinary and patterns, and centrally mediated myositis, although tests
multidisciplinary care should be practiced. such as electromyography have marginal specificity.177
For patients who present with orofacial pain or TMD Dental hard and soft tissue examinations rule out patho-
concerns, thorough examinations, evaluations, assess- logic sources and use standard dental testing such as
ments, differential diagnoses, and prognoses are the anesthetic blocks, pulp vitality, and radiology.178
cornerstones of contemporary care.169-171 Patient history Management of orofacial pain and TMD is customized
information obtained from screening forms and in- for a multifaceted and initially conservative working
terviews are an indispensable starting point, with prac- diagnosis using the skill sets of both conventional and
titioner and team beliefs contributing significantly to alternative disciplines. These include acupuncture, ho-
outcomes.172 Clinical examination supports history find- meopathy, internal medicine, naturopathy, neurology,
ings, while medical and dental tests provide quantifica- osteopathy, physical and massage therapy, psychology,
tion (Table 3). Some temporomandibular joint (TMJ) tests rheumatology, and traditional Chinese medicine.13,179-184
such as cone beam computed tomography scanning, Patient belief systems and their cooperation with recom-
Doppler ultrasonography, joint vibration analysis, and mendations (self-help) account for a significant part of
magnetic resonance imaging, although they have favor- positive outcomes (“better”), with practitioners and teams
able sensitivity, lack specificity for long-term TMJ patho- beliefs being supportive (placebo versus nocebo effects)
genesis prognostication.173-175 Rather, other TMJ tests (Table 3).185 From a practical point of view, the role of

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Pain 1999;13:255-61. Dr Michael Racich
180. DeBar LL, Vuckovic N, Schneider J, Ritenbaugh C. Use of complementary 2322 Marine Dr
and alternative medicine for temporomandibular disorders. J Orofac Pain West Vancouver, British Columbia, V7V 1K8
2003;17:224-36. CANADA
181. Feinmann C, Newton-John T. Psychiatric and psychological management Email: [email protected]
considerations associated with nerve damage and neuropathic pain.
J Orofac Pain 2004;18:360-5. Acknowledgments
182. Craane B, Dijkstra PU, Stappaerts K, De Laat A. Randomized The author thanks Dorothy M. Racich for contributing the graphics.
controlled trial on physical therapy for TMJ closed lock. J Dent Res
2012;91:364-9. Copyright © 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.

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