Seminars in Orthodontics 30 (2024) 267−270

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Seminars in Orthodontics
journal homepage:

What and how? Workflow of the management of joint disorders in the

clinical practice
Per Alstergren *
Malm€
o University, Faculty of Odontology, Orofacial Pain Unit, 205 06 Malm€o, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: This narrative review isl describing the most common TMJ conditions and suggest a straightforward, clinically
Arthritis relevant and feasible treatment workflow for each of these. The suggestions for treatment will be based on the
Disk displacement Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), the Swedish National Board of Health and Wel-
Inflammation
fare National guidelines for general dentistry as well as the Swedish Academy for Temporomandibular Disorders’
Osteoarthritis
Temporomandibular joint
National guidelines for TMD screening, diagnosis and treatment with the target audience of general practitioners.
Pain

Introduction hydrodynamic function of the connective tissue and to lubricate the

joint. It is also an important part of the mediating immune system func-
The temporomandibular joint tions within the joint.1
The TMJ system is the only joint system that comprises two synovial
The temporomandibular joint (TMJ) is a complex and crucial struc- joints that are connected over the midline (the mandible). This means
ture that plays a vital role in our ability to speak, eat, and express emo- that activity in one TMJ per definition requires activity of the joint on
tions through facial movements (smiling, talking, kissing etc), thereby the other side. The TMJ performs complex movements, including both
contributing to overall well-being.1 The TMJ is at the same time the rotation and translation.1 The movement is imposed by associated jaw
most used joint in the body. When problems arise in this joint they can and neck muscles and limited by ligaments as well as the dentition.
lead to a range of painful conditions and functional problems, which These facts, in combination with the need for both very fine motor func-
sometimes can be debilitating for the patients.1 tions and the ability to deliver powerful forces, causes a high demand on
The TMJ functions as a hinge joint but allows for both a rotational the sensorimotor control of the jaw.1
and a translational movement.1 These movements are essential for
speaking, chewing, and various facial expressions. When the TMJ func- Temporomandibular joint pathology
tions properly, these activities is performed without pain or discomfort.
The TMJ is a synovial joint and, as such, it can be subjected to a vari- A common clinical sign of TMJ pathology is pain from the joint and
ety of pathological conditions. These conditions span from local micro- surrounding tissues. There may be resting pain, pain on movement or
trauma to systemic arthritides and neoplasms. As all synovial joints, the loading, tenderness of the surrounding tissues as well as referred pain
TMJ has a joint capsule with an inner lining of a synovial membrane from the joint, mostly radiating towards the temporal muscle, masseter
except in intraarticular areas subjected to articulation and loading. muscle or the posterior dentition. Anatomically, the TMJ is located fairly
These areas are covered with fibrous cartilage in the TMJ, which differs deep under the skin surface. Indeed, there are at least 15 mm between
from most other synovial joints where these areas are lined with hyaline the skin surface and the lateral pole of the TMJ. This means that there is
cartilage. The synovial membrane produces synovial fluid that is a substantial volume of non-articular tissues overlying the joint proper,
released into the joint compartments. The synovial fluid is a blood tissues that very well may cause pain by themselves and thereby make it
plasma ultrafiltrate with the addition of for example nutrients, hyalur- more difficult determine if the pain is from the TMJ or not. In temporo-
onic acid, lubricine and immunocompetent cells. The synovial fluid is mandibular disorders (TMD), about 80% of the patients fulfill the Diag-
therefore crucial for the homeostasis of the cartilage, maintaining the nostic Criteria for Temporomandibular Disorders (DC/TMD)2 criteria

Abbreviations: 3Q/TMD, The three screening questions for temporomandibular disorders; CBCT, Cone-Beam Computerized Tomography; DC/TMD, Diagnostic Criteria
for Temporomandibular Disorders; MRI, Magnetic resonance imaging; OA, Osteoarthritis; SFB, Swedish Academy for Temporomandibular Disorders; TMD, Temporo-
mandibular Disorders; TMJ, Temporomandibular joint
* Corresponding author.
E-mail address: [email protected]

https://doi.org/10.1053/j.sodo.2023.11.005

1073-8746/© 2023 The Author. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
P. Alstergren Seminars in Orthodontics 30 (2024) 267−270

for both diagnosis arthralgia and myalgia, indicating the difficulties to inflammation causing tissue degradation and/or growth disturbance
determine true TMJ pain. may also be pain-free for substantial periods. At a given time point, the
TMJ pain can severely affect a person’s well-being and jaw function clinical presentation may be anywhere on a continuum from no sign or
but there seems to be a difference between the TMJ pain entities.3 TMJ symptom whatsoever to any combination of pain, swelling/exudate, tis-
pain can be divided into pain at rest, pain on movement of the joint, sue degradation or growth disturbance. In addition, there is temporal
TMJ pain on loading and TMJ pain on external mechanical stimulation variation in the inflammatory activity which also may cause a fluctua-
(e.g. palpation). In general, pain on movement and loading usually tion in symptoms and signs in the chronic condition.7, 9
points to a pain that is related to the musculoskeletal system. Pain at rest For diagnosis of TMJ arthritis, clinical criteria have been lacking but
is perhaps less clearly related to the musculoskeletal system but is still such preliminary criteria were published in 2018 as a basis for clinical
common in TMD patients.4 Ahmed et al.3 investigated the influence of diagnosis and future research.7 In rheumatology, a swollen joint or a
TMJ pain of daily activities and quality of life in rheumatoid arthritis joint with palpation pain leads to a diagnosis of definite synovitis in that
(RA) patients. TMJ pain had a substantial impact on these aspects; the particular joint. However, TMJ swelling, redness or increased tempera-
median impact (numerical rating scale 0-10) was 3 but the 75th percen- ture occur very rarely,9 which severely limits the possibilities to identify
tile was 5 for both daily activities and quality of life. This means that TMJ arthritis based on the cardinal signs. In fact, ongoing chronic TMJ
25% of these patients rated the impact to be 5 or higher out of 10. This inflammation, i.e. arthritis, may not show any of the cardinal signs
must be considered as a major impact for this subgroup of patients. although there is ongoing disease progression. The TMJ also differs, to
Regarding the types of TMJ pain, pain on movement was most strongly some extent, from most other synovial joints since the mechanical pain
related to impairment of daily activities and reduced quality of life, sensitivity over the TMJ seems to be only weakly, if at all, related to an
where higher pain intensities resulted in substantial decreases in daily inflammatory intraarticular milieu.4 This means that TMJ arthritis is
activities and quality of life.3 In another study, RA patients were asked poorly indicated by TMJ palpation pain. There may be several explana-
to report which daily activities that the TMJ pain affected the most.5 tions to this fact. The TMJ is located quite deep under the skin surface,
The highest impact, 6 out of 10, was found to be on physical activities. there are at least 15 mm between the skin surface and the lateral pole of
The second and third activities (both 5 out of 10) were on social interac- the condyle in adults.4 Indeed, this means that there are other tissues
tion and on opening mouth wide.5 Taken together, this points to a sub- than the joint proper that are affected by jaw movements and palpation
stantial impact by TMJ pain on important aspects of a normal life like over the joint that very well may be sensitizied. And, as already men-
social interactions and physical activity, limiting well-being, quality of tioned, pain from the TMJ is very often associated with pain from the
life and important normal daily activities. masticatory muscles that often makes determination of actual TMJ pain
Pain from the TMJ area can occur due to several factors. There may difficult.6
be nociceptive pain from for example overstretch or transient overload. In the study that presented clinical criteria for TMJ arthritis based on
There may also be inflammatory pain related to arthritic conditions synovial fluid content of inflammatory mediators, about 17% of the
(trauma, osteoarthritis, rheumatic diseases etc), pain as a part of noci- TMJs that were classified as arthritic did not present any clinical pain
plastic pain (disturbed central pain modulation) and referred pain from findings. Chronic arthritis may thus very well be present without pain,
other locations like neck, masticatory muscles or the dentition. Neuro- although pain is common.7, 9 On the other hand, 78% of the TMJs with-
pathic pain from the TMJ itself is very rare but neuropathic pain in the out arthritis showed pain at rest or on provocation by movement or pal-
trigeminal system can project to the TMJ as part of the total pain pation. This pain is most probably due to sensitization, peripheral or
experience.6 central or a combination, of the articular or adjacent tissues of a non-
inflammatory nature or an overlap with masticatory muscle pain. It may
Arthritis, local and systemic also be due to pain related to internal derangements without an appar-
It is very important to emphasize that TMJ pain and TMJ arthritis are ent inflammatory component.7, 9
not the same condition. There is an overlap in signs and symptoms TMJ pain on mandibular movements (opening, laterotrusive and pro-
between TMJ pain and TMJ arthritis and pain may be present without trusive movements) have been found to be strongly related to an inflam-
arthritis and arthritis may exist without pain.7 matory intraarticular milieu,4 at least in rheumatic diseases. TMJ pain
Arthritis, i.e. articular tissue inflammation, in the TMJ is a disorder on jaw movement thus seems to be of relevance as a clinical sign of TMJ
due to either local or systemic factors.7 Examples of local factors are arthritis. If a TMJ fulfills the clinical diagnostic criteria for arthritis as
micro- or microtrauma, disc displacement or degenerative joint disease suggested by Alstergren et al.7, presence of TMJ pain on three or four
and infection. Systemic factors may be systemic inflammatory disorders mandibular movements indicates a higher inflammatory activity. This
such as RA, psoriatic arthritis or reactive arthritis. Clinically, TMJ arthri- may be of importance for clinical diagnosis and subsequently for choice
tis may present with articular pain and pain in adjacent structures and of therapy and for monitoring therapy effectivity.
reduced jaw mobility.7 Cartilage and bone tissue destruction due to the Arthritis may also cause functional limitations like impaired jaw
inflammatory activity within the joint may result in occlusal changes movement capacity. On the one hand via the pain, especially on move-
(loss of anterior contacts between the upper and lower jaw) with ments. On the other hand, via increased intraarticular swelling or contri-
impaired chewing (function).7 In addition, if present in children and bution to disk displacement or fibrous adhesions.
adolescents, arthritis can result in mandibular growth inhibition that Most rheumatic disorders, including osteoarthritis, may cause TMJ
may lead to micrognathia.8 arthritis. Usually, this manifests as a chronic inflammation of the TMJ,
Inflammation is a complex, rapid, first-line and highly unspecific which in turn may cause pain, tissue degradation, growth inhibition in
immune system response. This reaction has a clear and important bio- children and adolescents as well as promoting disk displacement and
logic purpose in the acute phase but may transfer into a chronic state functional limitations.
with very unclear, if any, biologic purpose).7
Since ancient times, inflammation has clinically been described and Osteoarthritis
diagnosed by the presence of five cardinal signs: swelling, redness, Osteoarthritis (OA) is nowadays defined as a disorder involving mov-
warmth, pain and impaired function. Today, this may still be adequate able joints characterized by cell stress and extracellular matrix degrada-
for certain inflammatory conditions like pericoronitis and sun-burned tion initiated by micro- and macro-injury that activates maladaptive
skin. However, for chronic inflammation, as well as for many acute repair responses including pro-inflammatory pathways of innate immu-
inflammatory states, these cardinal signs are neither sufficient nor ade- nity. The disease manifests first as a molecular derangement (abnormal
quate to describe, diagnose or monitor the inflammatory activity. In the joint tissue metabolism) followed by anatomic, and/or physiologic
case of TMJ arthritis, ongoing and progressive chronic TMJ derangements (characterized by cartilage degradation, bone

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P. Alstergren Seminars in Orthodontics 30 (2024) 267−270

remodeling, osteophyte formation, joint inflammation and loss of nor- Usually, these are treated by oral and maxillofacial surgeons or ear-
mal joint function), that can culminate in illness.10, 11 OA is also the dis- nose- and throat specialists.
ease that most commonly affects the TMJ.12 It is now generally accepted
that TMJ OA is a low-inflammatory “whole joint” disease and TMJ OA Workflow
can be of local or systemic nature.13-15
A common clinical sign and finding in OA is crepitus. It can range This article will describe the most common TMJ conditions and
from fine crepitus to very coarse, loud crepitus. Crepitus is a clinical sign suggest a straightforward, clinically relevant and feasible workflow
that is most probably related to injuries or damages on the cartilage sur- for each of these. The suggestions for treatment will be based on the
face but, in worse cases, it can be related to absence of cartilage in artic- The Swedish National Board of Health and Welfare National guide-
ulating areas with exposed bone tissue. Severe OA can cause occlusal lines for general dentistry19 as well as the Swedish Academy for Tem-
changes due to its ability to cause cartilage and bone tissue degradation. poromandibular Disorders’ (SFB) National guidelines for TMD
This is most likely a result from the low-grade chronic inflammation.13 screening, diagnosis and treatment with the target audience of gen-
eral practitioners.20
Disk displacement
Disk displacement can be of one of two variants: disk displacement Temporomandibular joint arthritis
with reduction or disk displacement without reduction. The difference is
that the disk displacement without reduction is permanently displaced, Diagnosis
usually to an anterio-medial direction from its initial location. Disk dis-
placement with reduction means that the disk sometimes, usually on 1) Base the clinical diagnosis on the suggestions in Alstergren et al.7 In
mouth opening, returns to its normal relationship to the condyle. This brief, “possible arthritis” is achieved if the patient has pain in the
usually causes a popping sound, a “click”. This condition is probably the TMJ on maximum mouth opening. “Probable arthritis” is achieved
most common in the TMJ: about 34% of the adult population experience if, in addition to TMJ pain on maximum mouth opening, the contra-
a popping sound in one or both TMJs.16, 17 lateral laterotrusive range is less than 8 mm. These criteria seem to
Why does disk displacement occur? It is unfortunately unknown but be valid for TMJs with pain.
some risk factors have been established: adolescent age, female sex, his- 2) For TMJs without pain, the following criteria indicates ongoing
tory of overloading, hypermobility, trauma including overextending the arthritis: TMJ crepitus detected by the operator and the contralateral
jaw, rheumatic disorders or chronic TMJ arthritis are perhaps the stron- laterotrusive range is less than 8 mm.
gest risk factors.17 3) If the criteria for the diagnosis arthritis are met, then the following
Disk displacement with reduction without locking or catching has a findings points to high inflammatory activity: TMJ pain intensity of
good prognosis and require no treatment. The other variants of disk dis- 5 − 10 (NRS 0-10) or three or more jaw movements (of opening, lat-
placement may require both symptomatic treatment and functional erotrusion to the right and to the left and protrusion) causes TMJ
treatment. Disk displacement without reduction may cause inflamma- pain.
tion including severe pain in the acute phase. Usually this is combined
with a reduced ability to perform jaw movements, partly because of the Treatment
pain and partly because of the mechanical issue with a displaced disk. If arthritis is present, it is important to reduce or eliminate the
This condition is sometimes referred to as a “locked jaw”, which inflammation as soon as possible. This is to prevent chronification of
describes the patient experience with discomfort very well.17 pain, further tissue destruction and to reduce the risk for development
of micrognathia (in children and adolescents).
Limited translatory movement Anti-inflammatory pharmacological treatment is usually an efficient
Patients may show limited capacity to move the jaw in one or more way to rapidly reduce the degree of inflammation. However, it is very
of the jaw movements opening, laterotrusion to the right and to the left important to remember that only pharmacological treatment is usually
as well as protrusion. It is clinically important to find out why such a lim- not successful in the longer run. The pharmacological treatment there-
ited movement capacity is present and why it occurred.18 fore needs to with combined with another treatment modality such as
There may be several options and sometimes these can be combined. jaw exercise (which has anti-inflammatory effects in itself!), splint or
Certainly, an internal derangement such as a permanently displaced disk sensory stimulation.
may mechanically interfere with rotation and even more with the trans- For general practitioners, NSAIDs for two weeks are recommended as
latory movement. Joint adhesions, fibrous or osseous, also limits the jaw the pharmacological treatment. Please see your local/national recom-
movement to some or to an extensive extent. Such adhesions are often mendations for which drug to use. In Sweden, ibuprofen 400 mg 3-
not associated with pain on movement. 4 times a day or naproxen 250 mg 2 times a day are usually recom-
Osseous adhesions, i.e. ankylosis, is a life-threatening condition. The mended. Please also be aware of the slow-releasing Brufen Retard which
mouth opening capacity is often limited to 1-3 mm and these patients only requires two pills at night each day. If this pharmacological treat-
require surgical intervention, although the long-term prognosis is poor. ment is combined with for example jaw exercise, there is a possibility to
Fibrous adhesions are difficult to diagnose but may cause consider- reduce the inflammatory activity and to improve function also in the
able limitation of jaw movements. These are formed as part of the heal- long run.
ing after an inflammatory event. Just as a skin lesion may sometimes The trickiest part in TMJ arthritis is what to do if the patient has
turn into scar tissue, the intraarticular tissues may heal producing developed anterior open bite. This is a very difficult condition to have
fibrous adhesions. In chronic TMJ arthritis with flare-ups and remis- for the patient (chewing, speech and esthetical issues) but also very
sions, fibrous adhesions may cause considerable problems with jaw difficult for us dentists to manage. Especially if the TMJ pathology
movement.18 continues. Any occlusal adjustment is here strictly not recommended.
Expectation is usually the best way to manage these difficult cases
Other condtions since if you manage to eliminate/reduce the inflammation there is a
The TMJ may have other but more rare conditions, just as other good chance of a spontaneous normalization taking place over the
synovial joints. Examples are osseus ankylosis, fractures and neoplasms. coming three-six months. If such normalization occurs, it will most
The scope of this article is to provide a workflow for the general practi- probably not go back to the occlusion situation the patient had before
tioner for the most common TMJ conditions. If you suspect any of these the onset of arthritis but the resulting occlusion may very well be sat-
other conditions, refer these patients to a specialist, immediately. isfactory.

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P. Alstergren Seminars in Orthodontics 30 (2024) 267−270

Patients where you suspect a systemic disorder to cause TMJ arthritis Author contributions
should be referred to an orofacial pain specialist or rheumatologist. At the
orofacial pain specialist, intraarticular treatment with corticosteroids may All authors attest that they meet the current ICMJE criteria for
be considered in these cases. For patients with a rheumatologic disease, authorship.
the rheumatologist is usually consulted since the systemic treatment is
probably the most important for the TMJ prognosis in the long run. Funding

Temporomandibular joint osteoarthritis No funding or grant support received.

Diagnosis Declaration of Competing Interest

The criteria for degenerative joint disease (i.e. OA), according to DC/
TMD, is crepitus detected by the patient as well as the operator. Now, The authors declare that they have no known competing financial
OA may present with or without clinical signs of arthritis. If clinical signs interests or personal relationships that could have appeared to influence
of arthritis, please see the point above. the work reported in this paper.
The degree of crepitus may vary over time.
References
Treatment
1. Wilkie G, Al-Ani Z. Temporomandibular joint anatomy, function and clinical rele-
If crepitus is present to a degree that annoys the patients, a few treat- vance. Br Dent J. 2022;233(7):539–546. https://doi.org/10.1038/s41415-022-5082-
ment options may be considered: jaw exercise to strengthen the articular 0. OctEpub 2022 Oct 14. PMID: 36241801.
tissues or splint to (perhaps) reduce the load. At the specialist, intraartic- 2. Schiffman E, Ohrbach R, Truelove E, et al. International RDC/TMD Consortium Net-
work, International association for Dental Research; orofacial pain special interest
ular injections with hyaluronic acid may be considered but the scientific group, International Association for the study of pain. diagnostic criteria for temporo-
support is still limited. Hyaluronic acid is also quite expensive. mandibular disorders (DC/TMD) for Clinical and Research Applications: recommenda-
tions of the International RDC/TMD consortium Network* and orofacial pain special
interest groupy. J Oral Facial Pain Headache. 2014;28(1):6–27. https://doi.org/
Temporomandibular joint disk displacements 10.11607/jop.1151. WinterPMID: 24482784; PMCID: PMC4478082.
3. Ahmed N, Mustafa HM, Catrina AI, Alstergren P. Impact of temporomandibular
joint pain in rheumatoid arthritis. Mediators Inflamm. 2013;2013: 597419. https://
Diagnosis doi.org/10.1155/2013/597419. Epub 2013 Dec 9. PMID: 24363501; PMCID:
The DC/TMD lists four subdiagnoses to disk displacement: disk dis- PMC3864075.
4. Alstergren P, Fredriksson L, Kopp S. Temporomandibular joint pressure pain threshold
placement with reduction, disk displacement with reduction and inter-
is systemically modulated in rheumatoid arthritis. J Orofac Pain. 2008;22(3):231–238.
mittent locking as well as disk displacement without reduction and disk SummerPMID: 18780536.
displacement with reduction and limited mouth opening (<40 mm). 5. Voog U, Alstergren P, Leibur E, Kallikorm R, Kopp S. Impact of temporomandibular
joint pain on activities of daily living in patients with rheumatoid arthritis. Acta Odon-
tol Scand. 2003;61(5):278–282. https://doi.org/10.1080/00016350310005989.
Treatment OctPMID: 14763779.
Disk displacement with reduction and no locking or catching has a 6. Schiffman EL, Ohrbach R, Truelove EL, et al. The research diagnostic criteria for tem-
poromandibular disorders. V: methods used to establish and validate revised Axis I
good prognosis and require no treatment.
diagnostic algorithms. J Orofac Pain. 2010;24(1):63–78. WinterPMID: 20213032;
The other variants of disk displacement may require both symptom- PMCID: PMC3115779.
atic treatments and functional treatments. Usually, jaw exercise in com- 7. Alstergren P, Pigg M, Kopp S. Clinical diagnosis of temporomandibular joint arthritis.
J Oral Rehabil. 2018;45(4):269–281. https://doi.org/10.1111/joor.12611. AprEpub
bination with behavioral therapy, reducing parafunctions and to make
2018 Feb 15. PMID: 29392761.
the patient aware of the relation between TMD and stress, is of impor- 8. Carvalho RT, Braga FS, Brito F, Capelli Junior J, Figueredo CM, Sztajnbok FR. Tempo-
tance. If conservative treatment is not successful, surgical interventions romandibular joint alterations and their orofacial complications in patients with juve-
like arthroscopy may be considered. nile idiopathic arthritis. Rev Bras Reumatol. 2012;52(6):907–911. DecEnglish,
Portuguese. PMID: 23223701.
9. Peck CC, Goulet JP, Lobbezoo F, et al. Expanding the taxonomy of the diagnostic crite-
Temporomandibular joint adhesions ria for temporomandibular disorders. J Oral Rehabil. 2014;41(1):2–23. https://doi.
org/10.1111/joor.12132. JanPMID: 24443898; PMCID: PMC4520529.
10. Kraus VB, Blanco FJ, Englund M, Karsdal MA, Lohmander LS. Call for standardized
Diagnosis definitions of osteoarthritis and risk stratification for clinical trials and clinical use.
Osteoarthritis Cartilage. 2015;23(8):1233–1241.
Joint adhesions, fibrous or osseous, limits the jaw movement to some
11. Mobasheri A, Bay-Jensen AC, van Spil WE, Larkin J, Levesque MC. Osteoarthritis year in
or to extensive extent. It is often not associated with pain on movement. review 2016: biomarkers (biochemical markers). Osteoarthrit Cartilage. 2017;25(2):199–208.
Diagnosis of osseus ankylosis is usually very clear on CBCT or MR 12. Larheim TA. Diagnostic imaging of the TMJ. editor. In: Busaidy, ed. OMSKU V TMJ
Disorders. V. Oral and maxillofacial surgery knowledge update (OMSKU V). American
whereas fibrous adhesions are difficult to diagnose.
Association of Oral and Maxillofacial Surgeons; 2014.
13. Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibu-
Treatment lar joint: etiology, diagnosis, and treatment. J Dent Res. 2008;87(4):296–307.
14. Emshoff R. Pathophsiology of intracapsular inflammation and degereration. In: Greene, Las-
The first option is always jaw exercise, especially with stretching kin, eds. Treatment of TMDs: Bridging the Gap Between Advances in Research and Clinical Patient
involved. If this is not successful and the patient still experience discom- Management. Chicago: Quintessence Publishing Co, Inc; 2013:33–46.
fort, surgery may be considered. However, surgery where you cur the 15. Wang XD, Zhang JN, Gan YH, Zhou YH. Current understanding of pathogenesis and
treatment of TMJ osteoarthritis. J Dent Res. 2015;94(5):666–673.
fibrous adhesions cause more inflammation in the joint with a risk for
16. Kalaykova S, Lobbezoo F, Naeije M. Two-year natural course of anterior disc displace-
new formation of fibrous adhesions. ment with reduction. J Orofac Pain. 2010;24(4):373–378. FallPMID: 21197509.
Osseous ankylosis is a life-threatening condition. The mouth opening 17. Kalaykova SI, Lobbezoo F, Naeije M. Risk factors for anterior disc displacement with
capacity is often limited to 2-5 mm and these patients require surgical reduction and intermittent locking in adolescents. J Orofac Pain. 2011;25(2):153–160.
SpringPMID: 21528122.
intervention, although the long-term prognosis is not good. The novel 18. Zhang S, Liu X, Yang C, et al. Intra- articular adhesions of the temporomandibular
TMJ prostheses may be an alternative with some promise but more joint: relation between arthroscopic findings and clinical symptoms. BMC Musculoske-
research is warranted. let Disord. 2009;10:70. https://doi.org/10.1186/1471-2474-10-70. Jun 17PMID:
19534789; PMCID: PMC2702314.
19. The national board of health and Welfare’s National guidelines (in Swedish), https://
Patient consent www.socialstyrelsen.se/kunskapsstod-och-regler/regler-och-riktlinjer/nationella-rikt-
linjer/riktlinjer-och-utvarderingar/tandvard/.
20. Swedish academy for temporomandibular disorders national treatment guidelines,
Patient consent is not required. www.mau.se/dctmd.

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