Open Access Review

Article DOI: 10.7759/cureus.61108

Exploring Temporomandibular Disorders (TMDs)

and Occlusion Debate in Dentistry: Biting Into
Received 11/02/2023
Controversy
Review began 02/24/2024
Review ended 05/25/2024 Kumari Monika 1, Amit Reche 1, Shweta Tagore 1
Published 05/26/2024

© Copyright 2024 1. Public Health Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Higher Education and
Monika et al. This is an open access article Research, Wardha, IND
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
Corresponding author: Kumari Monika, [email protected]
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.

Abstract
Some conditions known as temporomandibular disorders (TMDs) affect surrounding muscles and jaw joints.
In dentistry, there has been discussion and research on the connection between TMDs and occlusion, which
is how the upper and lower teeth meet. Although some dental experts have proposed a direct link between
TMDs and occlusion, the specifics of this relationship are still unclear and have many facets. More
particularly, the research facets of "occlusion" remain one of the most contentious subjects in TMDs. This
abstract aims to provide an overview of TMDs and occlusion, summarizing the key points from the literature.
The etiological factors contributing to the TMDs, including occlusal, psychological, and hormonal factors,
are also analyzed. The second part of the article includes the concept of malocclusion, emphasizing its
significance in masticatory function and overall health. Anterior open and posterior open bites and the
potential influence of occlusal factors on TMDs are elucidated.

Categories: Public Health, Dentistry

Keywords: orthodontics, malocclusion, occlusion, aetiology, tmds

Introduction And Background

Temporomandibular disorders (TMDs) have cumbersome, heterogeneous causes. There are numerous
potential causes of a TMD [1]. The importance of occlusion as an etiological component in the emergence of
TMDs has been a heated dispute among dentists for ages. Because most arguments for causation are based
on anecdotal evidence rather than scientific data, the function of occlusion in the development of TMD
remains debatable. Since the "occlusal question" has not been answered, the occlusion-TMD topic is still
frequently the subject of conjecture [2].

Surgical, periodontic, prosthodontic, and orthodontic patients frequently exhibit occlusal change [3].
Occlusal changes can be caused by missing teeth, correcting malocclusions, or extracting teeth, which
dentists often do. However, after occlusal modification, what will happen? According to clinical evidence,
occlusion-altering procedures may cause immediate discomfort in patients. After a few days, this discomfort
may go away or get worse, resulting in complaints of ongoing pain in the functional complex of tissues and
organs housed within the oral and craniofacial cavities, as well as the development of TMDs, which are a
body of persistent pain state affecting the masticatory muscles, the temporomandibular joint (TMJ) and
other tissues, and structures [4]. Ages 20 to 40 are the most common ranges for temporomandibular
dysfunction in people [5]. Biomechanical, neuromuscular, biopsychosocial, and neurobiological may be the
components of TMDs [6]. These components are divided into three categories to highlight their roles in the
development of TMD: aggravating (parafunctional, hormonal, or psychosocial factors), initiating (trauma or
repetitive adverse loading of the masticatory system), and predisposing (structural, metabolic, and
psychological conditions) [7]. Some studies show that occlusion plays a very central role in the etiology of
TMD [8]. However, many TMD specialists hold contradictory opinions [9], and a variety of dental procedures,
including joint orthodontic therapy, have been implicated as TMD triggers [10]. However, in the most recent
investigations, no differences were found between patients with malocclusion and those with normal
occlusion [11], as well as between those who had undergone orthodontic treatment and those who had not
[12]. Bruxism, exogenous estrogen, orthodontic instability, occlusal abnormalities, joint laxity, and micro
and macro trauma are among the conditions' causes. TMD symptoms include TMJ pain that can radiate or
refer to nearby or distant structures; otalgia, tinnitus, or both in the absence of the aural disease; and
clicking, popping, or crepitus of the TMJ on any movements in which the joint is locked [13]. Durham et al.
stated that some patients present primarily due to reported painless clicking (disc displacement with
reduction). Others describe a failure to open the mouth widely (disc displacement with reduction with
intermittent, limited opening), a prolonged closed lock (disc displacement without reduction with limited
opening), or repeated dislocation of the TMJ. Recurrent painful (closed) locking is also described.

Review
Search methodology

How to cite this article

Monika K, Reche A, Tagore S (May 26, 2024) Exploring Temporomandibular Disorders (TMDs) and Occlusion Debate in Dentistry: Biting Into
Controversy. Cureus 16(5): e61108. DOI 10.7759/cureus.61108
 We conducted a review through PubMed and Google scholar using a combination of keywords, such as
"temporomandibular disorder," "TMD," "occlusal factors," "psychological factor," "hormonal factor,"
"secondary occlusal changes," "anterior open bite," "unilateral posterior open bite," ((( "temporomandibular
disorder" [Title/Abstract]) OR ("temporomandibular disorder" [MeSH Terms]), (("TMD" [Title/Abstract]) OR
("TMD" [MeSH Terms]), ("Occlusal factor" [Title/Abstract]) OR ("Occlusal factor" [MeSH Terms],
("Psychological factor" [Title/Abstract]) or ("Hormonal factor" [Title/Abstract]) OR ("Hormonal factor" [MeSH
Terms], ("Secondary occlusal changes" [Title/Abstract]) OR ("Secondary occlusal changes" [MeSH Terms],
("Anterior open bite" [Title/Abstract]) OR ("Anterior open bite" [MeSH Terms],("Unilateral posterior open
bite" [Title/Abstract]) OR ("Unilateral posterior open bite" [MeSH Terms]. For inclusion, studies in both
published reports in English were considered. We excluded research published in other languages because of
the lack of resources and the reviewer's inability to acquire full-text articles. Figure 1 represents the search
study of the articles included in the review.

FIGURE 1: PRISMA flow diagram of the included study.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( pubmed.ncbi.nlm.nih.gov;
https://scholar.google.com/)

Search Results

A bibliographic search of PubMed and Google Scholar databases identified 70 relevant articles, of which 50
were duplicates. A manual search was done on Google Scholar, where the first 10 pages were considered. The
first stage of screening resulted in excluding six articles based on title and abstract screening. After title and
abstract screening, 44 articles remained and were read in full. Articles were eliminated based on the
inclusion and exclusion criteria; the reasons for exclusion are included in the PRISMA flowchart (Figure 1).

TMDs
TMJ dysfunction and associated pain are collectively referred to as TMDs. Regional facial and preauricular
pain, restrictions in jaw mobility, and TMJ noises during jaw movement are among its most prevalent
symptoms [14]. Costen was the initial one to identify the warning mark of TMDs in 1934 [15]. The earliest
description of TMD was made in 1887 by a British surgeon who wrote about the surgical treatment of disc
displacements in the TMJ. In a groundbreaking article, Costen noted that dental malocclusions contributed
to ear and TMJ pain and other ear symptoms, such as ringing in the ear, auditory perception loss, and
vertigo. In the following years, no evidence supported the sole-factor theories of TMD, such as the TMJ,
muscles, or tooth occlusion.

Etiology of TMDs
TMDs are thought to have a complicated, multifaceted cause. Poorly understood and often misunderstood is

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 the etiology of TMD. No single "cause" exists because there are starting, predisposing, and perpetuating
variables [16]. The causes of the condition include joint laxity, exogenous estrogen, bruxism, orthodontic
instability, occlusal abnormalities, and micro and macro trauma [17]. Below is a structured version of the
information provided, organized in a table format to clearly delineate the predisposing factor, initiating
factor, and perpetuating factor (Table 1).

Category Description

Predisposing factor Raise the possibility of developing temporomandibular dysfunction. Pathophysiological, psychological, and structural processes that alter the masticatory system.

Initiating factor It is what causes an illness to start. It is more likely connected to the paradoxical loading and trauma of the musculoskeletal system.

Perpetuating factor Impede the recovery process or accelerate the development of temporomandibular disorders. Behavioral cause, social cause, emotional cause, and cognitive cause.

TABLE 1: Etiological factors of temporomandibular disorders (TMDs)

Occlusal Factor

The most primary and contentious for the TMDs is occlusion. Clinically speaking, "occlusion" refers to all of
the stomatognathic system's components, including the teeth and their supporting tissues, the
neuromuscular system, bones, and the TMJ, as well as the dynamic morpho-physiological interactions
between them [18]. Occlusion may contribute to susceptibility and the onset or progression of TMD.
Nowadays, it is one of the factors that most researchers consider when analyzing TMDs [19]. Below is a
structured table summarizing the studies and findings on TMDs as provided (Table 2).

Sr
Authors Study Finding
No.

Pullinger and Comparison of occlusal features between patients with and without Some occlusal traits may be symptoms rather than causes, and malocclusion may contribute to the development of
1.
Selignen [20] temporomandibular disorders symptoms temporomandibular disorder. Occlusal variables account for 10-20% of temporomandibular disorders etiological factors.

Rammelsberg Summary of the etiopathogenic theory for temporomandibular disorder

2. Occlusal instability increases the risk of severe wear and poor therapeutic outcomes in posterior teeth.
et al. [21] emergence

Le Bell et al. Subjective responses to artificial interferences in individuals with and without a Artificial interferences do not cause dysfunctional symptoms in healthy individuals but exacerbate clinical symptoms in those
3.
[22] history of temporomandibular disorder with a history of temporomandibular disorder.

Padala et al. The connection between temporomandibular disorder signs and symptoms and Individuals with temporomandibular disorder may exhibit significant dental inter-arch discrepancies and notable condylar
4.
[23] condylar position and centric occlusion-centric connection discrepancy. displacements, which can be identified by measuring centric relation-centric occlusion discrepancy.

TABLE 2: Results of the previous studies conducted in this field.

Psychological

Research in psychology reveals that individuals suffering from TMD share the same psychological makeup
and maladjustment as those with other chronic musculoskeletal conditions like arthritic or tension-type
back pain [24]. The study conducted by Kindler et al. (“Depressive & Anxiety Symptoms as Risk Factors for
Temporomandibular Joint Pain: A Prospective Cohort Study in the General Population") shows that
depression and anxiety act as the risk factors. The study found that depressive symptoms had a stronger
correlation with joint pain than muscle pain, but anxiety symptoms had a stronger correlation with muscle
pain. There are at least two reasons why there might be a connection between depressive or anxious
symptoms and a higher chance of experiencing joint or muscle pain. Anxiety and depression may initially
manifest as hyperactivity in the muscles, which can subsequently result in anomalies in the muscles and
changes in their mechanics, all of which can lead to pain in the muscles [25]. Inflammation of the joints, as
well as biomechanical changes, may result from them. In addition, abnormal pain processing in the
trigeminal system brought on by imbalances in common neurotransmitters like serotonin and
catecholamines may be linked to TMD [26]. Table 3 shows the relationship between psychological factors
with TMD.

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 Psychological factor Relationship with TMD

Stress Increase in the stress can cause an increase in the somatic reaction, leading to linear increase in TMD [27].

Anxiety It can intensify the chewing muscle hyperactivity linked to TMJ disorders, which can lead to joint overload. It is frequently associated with TMJ disorder [28].

Depression It is connected to how severe the pain from the TMD is [29].

TABLE 3: Psychological factors and their relationship with TMD

TMD: temporomandibular disorder, TMJ: temporomandibular joint

Hormones and TMJ

Women are more prone to have TMDs than men. TMDs primarily affect women, which supports the idea that
estrogens may play a role in their pathomechanism, peaking at 20 to 45 years of age [30]. Patients with TMD
experience painful sensations during the menstrual cycle and during pregnancy due to hormonal changes
[31]. Although women of childbearing age are more susceptible to periodontitis and gingiva hyperplasia due
to high levels of estrogen during pregnancy, myofascial pain may worsen due to variations in estrogen levels.
Conversely, low estradiol levels during menopause are linked to osteoporosis, alveolar bone resorption, and
TMJ degeneration [32]. Women with TMD feel less discomfort during pregnancy when there is an increase in
progesterone, estrogens, and relaxin hormones that have a significant influence on TMJ degeneration. The
only hormone produced during pregnancy, relaxin, increases the flexibility and laxity of the TMJ muscles,
tendons, and ligaments [33]. Uncertainty surrounds the path mechanism by which female reproductive
hormones affect the masticatory organ. Because it boosts the production of matrix metalloproteinase (MMP9
and MMP13) in the fibrocartilage of the TMJ, which leads to cartilage degradation, 17-estradiol (E2) in
women of reproductive age plays a crucial role in the pathogenesis of lesions of the masticatory organs [34].
The mechanisms behind the harmful effects of E2 are, regrettably, poorly understood [35].

Changes in occlusion secondary to TMDs

Anterior Open Bite

According to multiple reports, the most typical malocclusion among TMD patients is an open bite
[36]. According to an epidemiological study, the most prevalent bite pattern among TMD patients is anterior
open bite [37]. According to a case study report about the ‘’acute anterior open bite,’’ the anterior open bite
occurs due to the internal derangement of the TMJ. One more case study conducted by Alzabeg et al. found
that after using a soft night guard to treat TMD symptoms, a sudden acute open bite with an undetermined
cause occurred.

Association With Unilateral Posterior Bite

Table 4 shows that there has been research on a connection between posterior bite and TMDs. Based on
publications chosen by predetermined criteria, the current updated review concurs with past thoughts in
finding both a positive and a negative correlation between TMD and posterior cross-bite.

Sr No. Author Year Finding

1. De boer and stinks et al. [38] 1997 The findings of this small study suggest that temporomandibular dysfunction cannot be prevented with FUPC treatment.

2. Egermark I et al. [39] 2003 Other malocclusions have a weak relationship with TMDs except for lateral force between RCP and ICP, unilateral crossbite.

3. Demir et al. [40] 2005 They found statically that all occlusal factors are related to muscle tenderness except for the posterior crossbite and functional shift.

4. Farella et al. [41] 2007 A young adolescent's TMJ disk displacement is not associated with unilateral crossbite.

TABLE 4: Results of the previous studies conducted on TMDs and crossbite

TMJ: temporomandibular joint, TMDs, temporomandibular disorders; FUPC: functional unilateral posterior crossbite, RCP: retruded contact position, ICP:
intercuspal contact position

Interestingly, while crossbite type was disregarded, there was general interest in the various TMD variables.
This can be seen in subcategories of TMDs, such as fractures, joint discomfort, articular disorder (disc

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 disorders such as acute anterior disc displacement without reduction), joint stiffness (synovial
chondromatosis), and masticatory muscle disorder subcategories [42]. Disorders of the muscles of
mastication (MMDs) include myalgia or spasms. In sensitive spots within taut muscle bands, these points
may signal myofascial pain. Two mild occlusal abnormalities that can cause trigger areas in the inferior
lateral pterygoid are disoccluded ipsilateral posterior teeth and premature anterior teeth contact (Table 5).

Subcategories of

temporomandibular Definition Clinical examination

disorders

Range of motion and palpation of the lateral aspect of the TMJ may replicate the patient's pain complaints.
According to the expanded taxonomy of DC-TMD, the condition is defined as TMJ ‘’pain that is
Inflammatory symptoms like redness, swelling, or elevated temperature in the TMJ region may accompany this.
Joint pain not linked to any systemic illness and is accompanied by clinical signs of localized inflammation
One-sided or bilateral posterior open bites with deep anterior tooth contacts may result from intraarticular
or infection.’’
swelling and effusion of inflammatory exudate, depending on the condition's severity.

A disc condyle complex-related intracapsular biomechanical disorder is known as disc

In acute anterior DDW/OR, the disc becomes anteriorly dislodged, and the condyle immediately presses firmly
displacement without reduction with limited opening (DDW/OR). Acute disc displacement
Disc disorder against the methodical tissue. On the affected side, this could result in slightly altered occlusal contact or mild
without reduction with limited opening cases typically results in anterior and medial articular disc
occlusion changes. The retrodiscal tissue may then become irritated, potentially leading to a posterior open bite.
displacement, with posterior and lateral displacement occurring less frequently.

Synovial
Benign lesion with multiple calcifications in the joint as a result of cartilaginous metaplasia in the
chondromatosis Preauricular swelling and the patient's pain complaints reproducing with TMJ palpation are possible [43].
synovium.

The bony parts of the joint may be affected by a displaced or non-displaced fracture, which may
Fractures Preauricular swelling and the patient's pain complaints reproducing with TMJ palpation are possible.
result in occlusal abnormalities like a contralateral posterior open bite.

TABLE 5: Summary of the subcategories of TMDs

TMDs: temporomandibular disorders, TMJ: temporomandibular joint, DC-TMD: Diagnostic Criteria for Temporomandibular Disorders

TMDs and occlusion

There has been debate about the function of occlusion in TMDs for many years. An early systematic review
published in 2004 examined the relationship between TMDs, malocclusion, and functional occlusion
parameters (such as nonworking-side occlusal contacts and occlusal interference). It was discovered that the
number of associations was relatively low [44]. The scientific evidence available until that point was
insufficient to draw firm conclusions about the relationship between TMD and particular untreated
malocclusion, according to a 2005 review conducted by the Swedish Council on Health Technology
Assessment [45]. Limited scientific evidence was also available to support the association between
orthodontic treatment and TMD. A review carried out in 2007 by Mohlin et al. confirmed these findings
[46]. It discovered no link between certain malocclusions or orthodontic procedures and the symptoms of
TMD. A limited number of studies found a correlation between anterior spatial relationships and attrition,
according to a review on decay, occlusion, and masticatory system dysfunction [47].

A study found that having fewer teeth could result in a higher tooth wear index, but no study found that
losing posterior teeth increased attrition; instead, it seemed to be associated with self-identified teeth
grinding. However, there was not enough information to make definite judgments about how TMD and wear
and tear related. In 2018, a different in-depth review of the positional and dimensional changes in the TMJ
after correcting children's posterior crossbites found insufficient data to draw a firm conclusion [48]. The
summarized version of the articles that were part of the review is displayed in Table 6.

Authors Year Findings

Gauer et al. [1] 2015 About the temporomandibular disorders

Manfredini et al. [2] 2017 There needs to be more evidence to support a more extensive theory that dental occlusion contributes to the pathophysiology of temporomandibular disorder.

Henrikson et al. [3] 1997 Normal occlusion has lower signs and symptoms than class 2 occlusion, which has increased signs and symptoms from the other groups.

McNeill et al. [4] 1990 Temporomandibular disorder diagnosis management and education and research.

Gesch et al. [5] 2004 Women showed higher signs and symptoms than men.

Suvinen et al. [6] 2005 Variations in the psychosocial variables determine how temporomandibular disorders manifest and are subtyped.

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 McNeill et al. [7] 1997 Temporomandibular disorder guidelines.

Visscher et al. [8] 2009 In order to verify a suspicion of temporal bone pain, positive dynamic/static tests are preferable. A negative RDC/TMD examination is a better indicator of the absence of TMD pain.

Glaros et al. [9] 1994 The etiology of temporomandibular disorders is commonly recognized by practicing dentists to involve mental health disorders and psychophysiological factors.

Luther et al. [10] 2007 There is insufficient data to support the theory that static occlusal factors cause TMD.

List et al. [11] 2010 Management of temporomandibular disorder.

Macfarlane et al. [12] 2009 TMD is neither caused nor prevented by orthodontic treatment. The only factors that could predict TMD in early adulthood were female sex and TMD during adolescence.

Schiffman et al. [13] 2012 Diagnostic criteria for headache secondary to temporomandibular disorders (TMDs).

LeResche et al. [14] 1997 Additionally, it appears that women experience the majority of the symptoms and indicators linked to specific temporomandibular disorders more frequently than men.

Costen et al. [15] 1934 The symptoms of ear and sinus disorders depend on the disturbed function of the temporomandibular disorder.

McNeill et al. [16] 1997 The majority of treatment for temporomandibular disorder would be non-invasive techniques that provide relief.

Gage et al. [17] 1985 Early identification of non-painful clicking in young adults TMJs may shield the condyle, disk, and temporal bone complex from long-term harm.

Türp et al. [18] 2008 Dental occlusion about the past, present, and future.

McNeill et al. [19] 1990 Craniomandibular guidelines.

Pullinger et al. [20] 2000 Though they might play a part, occlusal factors should be balanced in the identification of the TMD.

Chisnoiu et al. [21] 2015 Inadequate knowledge of temporomandibular disorders etiology.

Bell et al. [22] 2002 Patients with a history of temporomandibular disorder experience worsening clinical symptoms due to artificial interferences.

Padala et al. [23] 2012 Measuring and analyzing the centric relation centric occlusion discrepancy can reveal significant condylar displacements and dental inter-arch discrepancies in individuals with TMD.

Suvinen et al. [24] 1997 Typical forms of temporomandibular disorders.

Scrivani et al. [25] 2008 Common forms of temporomandibular disorders.

Bair et al. [26] 2003 In a pain sample, the prevalence of depression is higher than the prevalence rates when the conditions are looked at separately.

Pingitore et al. [27] 1991 This study shows that both physical and psychological factors are associated with bruxism.

Nguyen et al. [28] 2019 There was no correlation found between anxiety, depression, or reduced mandibular function and TMJ osseous changes.

Auerbach et al. [29] 2001 The conclusion that psychological factors are more prominent when pain is muscular is primarily supported by prior research showing a connection between emotional dysfunction and TMD.

Kim et al. [30] 2015 There may be physiological and pathological gender differences in TMD, and chronic illnesses and psychological factors play a significant role in chronic TMD.

Wang et al. [31] 2006 E2 upregulates MMP9 and MMP13 on fibrocartilage matrix turnover with a focus on the TMJ.

Robinson et al. [32] 2020 A summary of the TMJ homeostasis, alveolar bone remodeling, and pregnancy-related gingivitis signaling pathways in vitro and in vivo.

Holt et al. [33] 1994 Bacteriology.

Hashem et al. [34] 2006 Overly accelerated deterioration of collagen and GAGs by relaxin and β-estradiol may disturb the ECM's homeostasis in these joints and ultimately aggravate the target joint's degenerative condition.

Kapila et al. [35] 2009 Hormone-mediated induction of particular MMPs to target tissue turnover of the cartilage of specific joints.

Williamson et al. [36] 1977 Percentage of patients at risk for temporomandibular dysfunction who were diagnosed as teenagers before receiving orthodontic treatment.

Egermark et al. [37] 2000 Orthodontic treatment reduces the signs and symptoms of the temporomandibular disorder.

Mohlin et al. [38] 1997 The findings of this small study suggest that temporomandibular dysfunction cannot be prevented with FUPC treatment.

Egermark et al. [39] 2003 Other malocclusions have a weak relationship with TMDs except for lateral force between R.C.P. and I.C.P., unilateral crossbite.

Demir et al. [40] 2005 They found statically that all occlusal factors are related to muscle tenderness except for the posterior crossbite and functional shift.

Farella et al. [41] 2007 A young adolescent's TMJ disk displacement is not associated with unilateral crossbite.

Van't Spijker et al. [42] 2007 There is limited knowledge available about the relationship between TMD symptoms and attrition.

Padala et al. [43] 2012 The condyle position may significantly influence the etiopathogenesis of TMJ disorders.

M. De Boer et al. [44] 2008 FUPC should be treated early in order to achieve average growth and development rather than to prevent temporomandibular disorders.

Demir et al. [45] 2005 Female subjects had a higher prevalence of temporomandibular disorders, which their more incredible masticatory muscle tenderness may explain.

te Veldhuis AH et al.
2011 Synovial chondromatosis is one of the differential diagnoses of the temporomandibular disorder.

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 [46]

Gary et al. [47] 2022 Insufficient investigation into the temporomandibular joint and occlusion.

Thomas et al. [48] 2023 This is a modern interpretation of temporomandibular dysfunction.

TABLE 6: Summary of articles included in the review.

TMD: temporomandibular disorders, TMJ: temporomandibular joint, FUPC: functional unilateral posterior crossbite, RCP: retruded contact position, ICP:
intercuspal position

Conclusions
The correlation between occlusion and TMDs is multifaceted and intricate. It is crucial to understand that
TMD is a condition influenced by many factors, even though there is evidence suggesting that occlusion may
contribute to symptoms. These are some examples of occlusal disparities, tense muscles, stress, trauma, and
other unique factors. Occlusal discrepancies are not the only cause of TMD cases, as several different
variables, such as muscle tension, stress, trauma, and individual differences in anatomy and physiology, also
impact the disorder. Pain, anxiety, physical limitation, and limited mandibular movement are some of the
symptoms of TMDs, which can progressively worsen and decrease the level of comfort. There are few
alternatives to therapy available, and sometimes these are insufficient to meet the long-term needs of the
relatively young patient population. Because of this, it is crucial to identify potential etiologic factors as
soon as possible, along with how much they may be affecting the condition. Then and only then can the best
course of action to relieve the incapacitating TMD symptoms be determined.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Kumari Monika, Amit Reche, Shweta Tagore

Acquisition, analysis, or interpretation of data: Kumari Monika, Amit Reche, Shweta Tagore

Drafting of the manuscript: Kumari Monika, Amit Reche, Shweta Tagore

Critical review of the manuscript for important intellectual content: Kumari Monika, Amit Reche,
Shweta Tagore

Supervision: Kumari Monika, Amit Reche, Shweta Tagore

Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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