Clyde D. Hillier

Temporomandibular Joint Dysfunction:

A Dental Overview

SUMMARYTemporomandibular joint dysfunction iscommon and often acutely painful. Because ofthe large and diverse symptom complexcreated by this disorder, patients frequentlyfirst seek relief from their physican ratherthan their dentist. In this artidetemporomandibular joint (TMJ) dysfunction isdefined and the presenting signs andsymptoms are discussed. Their etiology isdescribed in relation to the anatomy of thetemporomandibular joint. Examinationtechniques can help in the differentialdiagnosis. Current treatment ranges fromheat, local anesthesia and ultrasound toanxiolytics, transcutaneous nerve stimulationand nutritional supplementation. (Can FamPhysiacan 1985; 31:549-555)

SOMMAIRELa dysfonction de l'articulationtemporo-mandibulaire est frequente et souvent tresdouloureuse. A cause de la complexite et de ladiversite des symptomes engendres par ce desordre,les patients vont souvent, dans un premier temps,consulter leur medecin de famille plutot que leurdentiste. Dans cet artide, on definit la dysfonctionde l'articulation temporo-mandibulaire et on discuteles signes et symptomes de presentation. On decritleur etiologie en fonction de l'anatomie del'articulation temporo-mandibulaire. Les techniquesde l'examen peuvent aider a etablir le diagnosticdifferentiel. Les traitements actuels vont de lachaleur, I'anesthesie locale et les ultrasons auxanxiolytiques, la stimulation nerveuse par voietranscutanee et l'administration du'un supplementnutritif.

Key words: temporomandibular joint, pain,headache

Dr. Hillier practices generaldentistry in London, Ontario, andhas a special interest in TMJdysfunction and holistic approachesto dental health care. Reprintrequests to: 120 Wellington St.,London, ON. N6B 2K6.

EMPOROMANDIBULAR jointi dysfunction (TMJ syndrome) may

be defined as a loss of function in themasticatory system as a result of dele-terious changes in one or both tem-poromandibular joints and/or in themuscles of mastication. The changesfrequently seen in the muscles of mas-tication involve muscle spasm andpain which is often labelled myofascialpain dysfunction. The cardinalchanges in the temporomandibularjoints are clicking, crepitus, pain andlimitation of mandibular movement.

Solberg found that at least 70% of739 university students had signs ofmandibular dysfunction and that 5%required immediate treatment. '

Thiel and Posselt,2 3 reporting onnon-patient groups in a randomly se-lected population, found temporoman-dibular joint sounds in 52% and 41%of the samples respectively.

Clinical studies usually report agreater incidence of TMJ dysfunctionin females.46 Solberg et al.I found anincreased incidence in women of 10-15%. Tyldesley7 suggests that 80% ofchronic TMJ dysfunction is found infemales.

Whatever the actual numbers, TMJdysfunction is clearly an importantcause of severe, chronic pain for manypeople.

Recurrent headaches were reportedin 78% of female and 59% of maleTMJ patients, and judged to be moresevere in TMJ patients than in a con-trol group.8 Pain, particularly head-ache, is what motivates patients toseek the help of their physician.A patient may present other signs

and symptoms, including ear, neck

CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985

and facial pain; vertigo without nys-tagmus; tinnitus, clicking and crepita-tion within one or both temporoman-dibular joints. during mandibularmovement; burning and prickling sen-sations of the side of the tongue androof of the mouth; fatigue; difficulty inswallowing; spontaneous subluxationof the mandible; chronic sore throat;forgetfulness; changes in hearing abil-ity and 'clogged ears', and diversemuscle spasm throughout the body.TMJ dysfunction syndrome is

clearly a great imitator. Therefore,while definitive diagnosis and treat-ment most often requires a dentist, it isentirely appropriate that a patient firstsee a physician so that numerous medi-cal conditions can be ruled out.

The Masticatory SystemHead posture is largely determined

by a balance in muscle tonus of thecervical/spinal musculature and theprimary and secondary muscles of

549

mastication. Changes in one anatomi-cal component, such as spasm of a cer-vical muscle, may easily causechanges in head posture and jaw posi-tion. Conversely, a change in mandi-bular position may change head pos-ture, leading to changes in cervical andspinal muscles. Lieb cites numerousexamples of dramatic improvements inspinal posture after mandibular reposi-tioning by dental treatment. 9

Figure 1 illustrates the essentialstructures of the temporomandibularjoint. Each TMJ is capable of two dis-tinct movements-rotation and slid-ing. The TMJ functions as a com-pound joint; the articular disc is a'third' bone. The mandibular condylearticulates with the disc to form a disc-condyle complex. Posterior rotation ofthe disc around the condyle is limitedby the superior head of the lateralpterygoid muscle. Anterior rotation ofthe disc is limited by the elastic tensionof the retrodiscal tissue. Medial and

lateral movement of the disc is limitedby the collateral capsular ligamentsand by the lateral temporomandibularligaments. As the mandible is openedand closed, ligamentous support andmuscle tonus should ensure that the in-ferior surface of the disc remains incontact with the head of the mandibu-lar condyle. The superior surface ofthe disc slides forward in contact withthe temporal bone. Thus, the TMJ maybe considered a double joint; one jointfunctions on top of another.

Functionally, the teeth may also beconsidered a part of the TMJ. Once theupper and lower teeth are in contact,the position of the mandibular condyleis largely determined by tooth formand the presence or absence of teeth.

Mandibular ClosingProblemsNormal joint function is illustrated

in Figure 2. When the mandibular po-

sition dictated by tooth contact is notcongruent with the mandibular posi-tion dictated by the temporomandibu-lar joint (or joints) and the tonus of themasticatory muscles, problems canbegin.

Inappropriate tooth contacts whichdeflect the mandible to the side, for-ward, or backward upon closing, re-sult in dyspnetic signals to the CNSfrom periodontal, joint capsule andmuscle proprioceptors.

Jankelson10 states that occlusion ofthe teeth is a physiological act whichoccurs every 60-70 seconds, beforedeglutition. If the mandible cannotcomplete that act because of the re-straint of wedging tooth surfaces,struggling movements are initiated.

Also, a lack of dental support is be-lieved to allow the mandibular con-dyles to be retruded in the TMJ duringperiods of tooth contact, resulting in

Fig. 1. Drawing illustrates essential structures thatconstitute the functioning temporomandibular joint.Note that the inclination of the articular eminence isabout 52 degrees from the horizontal supra-articularcrest. a. supra-articular crest b. temporal articularsurface, composed of nonvascular fibrous tissuec. articular disc d. condylar articular surface, composedof nonvascular fibrous tissue e. superior retrodiscallamina (elastic) f. inferior retrodiscal lamina(collagenous) g. retrodiscal loose connective tissueh. posterior capsular ligament (collagenous) i. condylaraxis of rotation j. discal collateral ligament(collagenous) k. superior lateral pterygoid muscle1. inferior lateral pterygoid muscle m. anterior capsularligament (collagenous) x. posterior margin of condylararticular facet

Fig. 1. reproduced with permission from Bell WE.Clinical management of temporomandibular disorders.Chicago: Year Book Medical Publishers, Inc., 1982.

Fig. 2. Normal temporomandibular joint function duringopening movement, as seen by arthrography. The discis the stippled structure between the condyle below,and the temporal bone above. A, mandible in the closedposition. B-D, progressive stages of opening. The-discslides forward with the condyle as it translates to, andsometimes over, the articular eminence. The superiorstratum of the bilaminar zone becomes stretched; theinferior stratum does not.

Figs. 2-8 reproduced with permission from Travell JG,Simons DG. Myofascial pain and dysfunction. Thetrigger point manual. Baltimore: Williams and Wilkins,1983.

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anterior displacement of the articulardisc. Farrar and McCarty"1 have esti-mated that 71% of patients with TMJsymptoms have some degree of an-terior disc displacement. Mandibularclosing deflections need not be exten-sive to cause TMJ problems.

The loss of vertical dimension re-sulting in condylar retrusion or bite in-terferences may not be directly relatedto the number of lost posterior teeth.For instance, the loss of four teeth willnot necessarily create a greater prob-lem than the loss of two teeth.Franks12 has observed that tooth lossincreases the likelihood of TMJ dys-function; the maximum incidenceoccurs with the loss of three to fiveteeth.

If the articular disc is displaced for-ward during intercuspation, as the jawis opened again, the mandible trans-lates forward and the condyle is be-lieved to bump up over the posteriorlip of the disc, producing an openingclick. The disc-condyle complex willthen function relatively normally untilthe condyle moves back off the disc onmandibular closing, creating a 'recip-rocal click' (see Fig. 3).

If condylar retrusion becomeschronic, the retrodiscal tissue and col-lateral ligaments of the joint may bestretched. The articular disc may then

be displaced further forward. As thisoccurs, the reciprocal clicks may beheard progressively later on openingand earlier on closing.

If the disc is displaced so far an-teriorly that the condyle cannot over-ride the posterior border of the disc,mandibular opening may be prevented(see Fig. 4).

Condylar impingement on the retro-discal tissue may result in ligamentousdamage, joint inflammation with sig-nificant effusion into the joint andpain, 13 which may be localized or re-ferred to surrounding musculature.

Origin of Pain* Conversely, many authors believe

that much of the pain and dysfunctionof TMJ problems is of myogenic ori-gin. 14-17 Pain and dysfunction havebeen shown to result from myofascialtrigger points in shortened mus-cles. 16, 18 These authors have explicitlyidentified muscles that refer to thetemporomandibular joint and to otherparts of the head and face.

Arlen'9 has described the otoman-dibular syndrome, in which the patientcomplains of pain in and around theear, fullness in the ear, hearing loss,tinnitus and loss of equilibrium. Thesesymptoms are explained by distur-bances in neuromuscular function of

the tensor tympani muscle, which in-serts a tendinous attachment onto theneck of the malleus; and the tensor pa-lati muscle which functions to open theeustachian tube. Both these muscles,like the muscles of mastication, are in-nervated by the trigeminal nerve.Some of the symptoms seen in oto-

mandibular syndrome can also be ex-plained by Pinto's20 discovery that afibro-elastic ligamentous structure (themandibular-maleolar ligament) origi-nates in the neck of the malleus andspreads in a cone shape forward anddownward to insert into the mediopos-terior part of the TMJ capsule andmeniscus. Therefore movement of theTMJ capsule and meniscus can resultin movement of the tympanic mem-brane.

Psychophysiological TheoriesClinicians treating TMJ disorders

cannot but be impressed with their pa-tients' psychological distress. Severalinvestigators believe that psychologi-cal factors are more important than oc-clusal factors .21 Two psychophysio-logical theories of TMJ dysfunctionhave developed.One theory holds that there is a pre-

existing personality which is prone toTMJ dysfunction and pain.21 Propo-nents of this theory may ignore ana-tomical/dental considerations, empha-

Fig. 3. Mechanism of early click due to slight anterior Fig. 4. Mechanism of blocking mandibular depression atdisplacement of the articular disc. A, rest position. B, as one point due to marked anterior displacement of thethe condyle begins to translate forward, it must articular disc. A, rest position. B, as the condyleoverride a thickness of posterior disc material, causing translates forward, it impinges on the disc, but isa click. This seats the condyle in the central, thin part of unable to ride over it. C and D, this blocks full forwardthe disc. C and D, after the click, mandibular opening translation, and thereby, full jaw opening.and translation of the condyle proceed with apparentlynormal disc mechanics.

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sizing treatment such as musclerelaxants, psychotherapy, hypnosis,biofeedback and behavior modifica-tion.The second psychophysiological

theory proposes that the psychologicalphenomena seen in TMJ syndrome arethe result of the syndrome.21 Grieder22et al. state that long-term sufferers ofTMJ dysfunction usually develop anx-iety neurosis and severe depression.De Steno23 suggests that for thesechronic sufferers a cyclic effect maydevelop in which the psychologicalcomponent can dominate.

In looking for a 'TMJ personality',Mosak found that TMJ distress syn-drome is primarily somatogenic. Thephysical factor predominated in 80%of the subjects studied. Mosak con-cluded: "Psychological symptoms as-sociated with the TMJ syndrome ap-pear to be the patient's response notonly to the physical pain but also to hisloss of the sense of wellbeing, to hisdeteriorating social situation, and to'the run-around I get from dentists anddoctors' .24

Travell and Simoons warn the physi-cian against assuming that psychologi-cal factors are primary. They point out

that it is all too easy for the physicianto blame the patient's psyche for thephysician's inability to recognize all ofthe medical and neurophysiologicalfactors that are contributing to the pa--tient's myofascial pain; this "wrongassumption can be-and often is-frightfully devastating to the pa-tient" 25

In summary, TMJ dysfunction syn-drome has been etiologically related toocclusal (bite) interferences, retrudedcondyles and psychological distress.However, the extensive dental litera-ture dealing with the relative impor-tance of these causes is often contra-dictory. Greene comments: "Rarely inthe history of dentistry have so manylabored for so long, only to end withsuch extreme disagreement. Aftermore than half a century, the myo-fascial pain dysfunction syndromecontinues to be one of the most contro-versial areas in dentistry".26

DifferentiationDifferent clinicians frequently focus

on their pet causes and treatment.Adding to the confusion is the fact pa-tients frequently have retruded con-dyles, bite interferences and great

psychological stress, but no TMJ dis-comfort.De Steno describes a "TMJ triad"

of components which are necessary forthe development of TMJ pain and dys-function:231. Tissue alterations include dental at-trition, loss of posterior occlusion,iatrogenic changes, local pathology,arthritis and other systemic diseases.2. Predisposing factors include genetic(intrinsic) and acquired (extrinsic) ele-ments such as trauma, deleterioushabits and nutritional changes.3. Psychological factors may prime thepatient for TMJ syndrome.

Establishing a tentative diagnosis ofTMJ dysfunction first necessitatesruling out systemic diseases such ascardiovascular, renal, and arthriticdisease. Sonkin27 asserts that hypo-thyroidism is frequently overlooked inthe diagnosis of patients with general-ized muscle symptoms.

Local pathology, as in the ears,nose, sinuses, throat or cervical spinemust next be investigated. Specific ab-normalities to consider include trige-minal and glossopharyngeal neuralgia,vascular headaches, temporal arteritis,fracture of the styloid process, ossifi-

Fig. 5. Referred pain patterns from trigger points (x's) in Fig. 6. The x's locate trigger points in various parts ofthe left temporalis muscle (essential zone solid, the masseter muscle. The solid areas show essentialspillover zone stippled). A, anterior "spokes" of pain referred pain zones, and the stippled areas are spilloverarising from the anterior fibers (trigger point one pain zones. A, superficial layer, upper portion. B,region). B and C, middle "spokes" (trigger point two superficial layer, mid-belly. C, superficial layer, lowerand trigger point three regions). D, posterior portion. D, deep layer, upper part-just below thesupra-auricular "spoke" (trigger point four region). temporomandibular joint.

5.

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cation of the styloid ligament and in-jury of the auriculotemporal nerve.

It may be helpful to keep the follow-ing points in mind in assessing theTMJ patient's history:1. TMJ pain is often deep and moredifficult to locate than that of most eardiseases.2. A high frequency hissing type oftinnitis is frequently found. 193. Patients frequently report an abnor-mal sound perception which Arlen de-scribes as slight, episodic "waxingand waning" of sound. 194. When moving their heads, some pa-tients feel off balance but do not showthe vertigo typical of Meniere's dis-ease or labyrinthitis.5. Movement of the mandible may actas a triggering device.6. A history of episodic limitation ofmovement or locking of the jaw iscommon.7. Patients often discover that they canget relief by separating their upper andlower teeth, as in lip or cheek biting.

Adler28 has proposed that the clini-cian ask the patient the following ques-tion; "If I had a magic wand or magic

pill which would eliminate your symp-toms immediately and irrevocably,what would be different in your life?"The patient's answer may be useful inassessing the psychological compo-nent of the problem. For instance, ifthe patient replied that his/her mar-riage problems would be over, thathe/she would return to school and thentravel extensively, one might suspect apredominantly psychological compo-nent.

ExaminationClinical examination to confirm

TMJ dysfunction should begin with avisual analysis of posture. A highereye in conjunction with a lowershoulder and hip on the ipsilateral sidewill often coincide with greater condy-lar retrusion on that side.29The muscles of the head, neck,

back, chest and legs should be exam-ined for the presence of tenderness,spasm and trigger points. TMJ patientsfrequently present marked tendernessof the muscles of their back and thecalves of their legs as well as the mus-cles more proximal to their jaw.

I .....},..,

Fig. 7. Referred pain pattern (solid) and location of theresponsible trigger point (x) in the left medial pterygoidmuscle. A, external areas of pain to which the patientcan point. B, anatomical cut-away to show the locationof the trigger point area in the muscle, which lies on theinner side of the mandible. C, coronal section of thehead through the temporomandibular joint, lookingforward, showing internal areas of pain.

Fig. 8. The referred pain pattern (solid) of trigger points(x's) in the left lateral pterygoid muscle.

Particular attention should be thenpaid to the muscles of mastication. Asmuscles are being examined, it is use-ful to visualize the areas to which trig-ger points may refer pain. For in-stance, the lateral pterygoid, masseter(deep), medial pterygoid and sterno-cleidomastoid (clavicular) muscles allmay refer pain directly to the ear andtemporomandibular joint.25

Suspected referred pain may beverified by injection of the affectedmuscle with local anesthetic. A 0.5%solution of procaine without vasocon-strictor may be used for this.The referral patterns for the major

muscles of mastication are illustratedin Figures 5-8.

Both temporomandibular jointsshould be palpated while the mandibleis at rest. The amount of pain elicitedwill indicate the amount of inflamma-tion within the joint. While the clini-cian's fingers are still over the joints,the mandible should be opened andclosed, and moved from side to side.Again the location and amount of painshould be noted, together with anyroughness in movement.

CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985 553

The patient should repeat thesemovements while the examiner listensto each joint with a stethoscope. Theexaminer should note crepitus andclicking.

Next the patient should be asked toopen and close his/her jaw and themaximum interincisal opening shouldbe checked. Normally, the fullyopened jaw should admit the patient'sfirst three knuckles (non-dominanthand) in a tier between the upper andlower incisors. The interincisal dis-tance should also be measured(average = 42 mm).A deviation of the mandible during

opening and closing movements mayoccur with myospasm, fibrosis or limi-tations of condylar movement withinthe joint.

As the patient closes, a retrudedcondyle can often be palpated with afinger placed against the anterior wallof the external auditory meatus. Thispalpation may be very painful as theteeth come together.A comparison of lateral jaw move-

ments with maximum interincisalopening may provide valuable clues tothe reason for limited movement. Pa-tients should be asked to open theirmouths slightly and then slide theirjaw as far to each side as they can. Themaximum shift from the midline ineach direction should be carefullynoted.

The normal ratio of lateral excursionto interincisal distance is approxi-mately 10 mm: 40 mm or 1:4. A de-creased ratio (for example, 1:3) indi-cates extracapsular restriction, whilean increased ratio (for example, 1:6)suggests restriction of movementwithin the joint.The patient should also be asked to

close slowly until the teeth 'justtouch'. Then the patient should closecompletely (maximum intercuspation)and any pain, noise, or shift in themandible should be noted. The pres-ence of positive signs may indicate abite interference and an early stage ofjoint damage.

RadiologyRadiographic visualization of the

temporomandibular joint has greatvalue, both in ruling out joint pathol-ogy such as arthritic change and inconfirming malposition and disc de-rangement.

Transcranial and panoramic projec-tions of the temporomandibular joints

are readily available with ordinarydental X-ray equipment. Althoughthey have limitations, if properly takenand interpreted these techniques pro-vide a great deal of information.A transcranial series should include

at least three positions of the mandi-ble:1. Mandibular rest position2. Closed, clenched position3. Maximum open positionBecause mandibular position is criticalto proper interpretation, this seriesshould be taken by someone with den-tal training.

Radiological findings will be mostdramatic in patients with late stageTMJ dysfunction. Berrett notes thefollowing findings:30-The condyle is consistently de-creased in size (flattened).-Hypertrophic sclerosis and lipping(asteophyte formation) occur.-Deforming degenerative arthritis iscommon.More critical evaluation of the ar-

ticular disc space is afforded by to-mography. Arthrography applied tocinefluoroscopic techniques has re-cently become popular in assessingdisc derangements and perforations ofthe articular disc. However, thesetechniques are not suggested for initialscreening and treatment.A confirmed working diagnosis of

temporomandibular joint dysfunctionrequires the collaboration of a physi-cian and a dentist-and often nu-merous medical and dental specialists.

TreatmentTreatment is aimed at reducing one

or more of the etiological components:extrinsic predisposition, tissue alter-ation or psychological factors. Proce-dures should be kept simple andshould be reversible until positive con-firmation of the diagnosis is made.

Palliative therapy is designed to al-leviate pain and muscle spasm and tolimit functional demands on the TMJ,while the physician establishes thediagnosis and arranges the medical,dental and other consultations needed.The success of some palliative thera-pies is in itself highly diagnostic.Palliative Therapies

Limitation of movement should berecommended to patients if not alreadydictated by pain. Patients should stickto soft but nutritious foods duringacute periods.Heat should be applied to sore mus-

554

cles and joints for 15-20 minutes fourtimes a day. This will increase localcirculation and reduce muscle spasm,besides providing a sedative effect.

Ultrasound increases heat to deepstructures, particularly bone, menisciand joint capsules.31

Cryotherapy. Cold is believed to beeffective by reducing the concentrationof histaminics in the skin, by raisingthe cutaneous skin threshold and by of-fering controlled tactile/thermal stim-uli, thereby modifying pain inten-sity.32Spray and stretch. A vapocoolant

spray of Fluori-Methane directed tothe skin over a muscle trigger point iseffective in inhibiting pain and spinalstretch reflexes, therefore permittingstretching of the muscle and inactiva-tion of its trigger points.The jet stream of spray is directed at

an acute angle (30°) and is swept overthe skin parallel to the muscle coveringthe entire muscle length in one direc-tion (toward referred pain). Two orthree sweeps is usually maximum. Theskin should then be warmed.25

Local anesthetic can be injected intoactive trigger points. A 0.5% solutionof procaine without vasoconstrictor isrecommended. Immediately after in-jection, the muscle is passivelystretched.25

Analgesics and anxiolytics. In addi-tion to the wide variety of analgesicsavailable, an antihistamine such aspromethazine may help the TMJ pa-tient who is having difficulty sleeping.Corticosteroids may be useful if jointinflammation is present. Markovichreports that 10-25 mg amitriptyleneacts as a good anxiolytic-antidepres-sant and as a potent analgesic.33

Tetanizing and sinusoidal currentshave been used to stop muscle spasmand recover gradual rhythmic move-ment.32

Electrogalvanic stimulation is welltolerated even by patients in greatpain. Muscle relaxation is obtainedquickly with much relief.32

Transcutaneous nerve stimulationhas also proven effective in pain re-duction. Optimal treatment is nine to12 minutes several times per day.32Nutritional supplementation. As the

prevalence of unrecognized hypovita-minosis is very high,25 it is prudent toensure that TMJ patients receive agood quality vitamin supplement aswell as dietary supervision. Hypervita-minosis A may also cause bone or jointpain and severe throbbing headache,

CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985

which could be confused with TMJsymptoms.25

Bite plane (mandibular orthopedicrepositioner). The placement of a den-tal appliance to disclude the teeth oftenproduces a dramatic reduction of TMJpain and dysfunction. Such appliancesare designed to eliminate bite interfer-ences and/or prevent the mandibularcondyle from moving into a retrudedposition, thereby preventing jointstress and allowing normal restinglength of the muscles of mastication.

Biofeedback training may helpsome patients become aware of un-necessarily sustained muscle contrac-tion which affects the TMJ and relatedmusculature.

Psychotherapy is often very valu-able in helping the patient learn newperspective and skills, with concomi-tant reduction in anxiety and frustra-tion. Many of my patients have donewell when seeing a family counsellorto whom I frequently refer. They seemvery comfortable with the counsellor'sgrowth oriented model which contrastswith the doctor/patient, illness/treat-ment models of traditional medicineand dentistry.

Once normal condylar position hasbeen restored and muscle spasm hasbeen eliminated, a dentist can begindefinitive therapy specific to the prob-lem.

Specific Treatment

Occlusal correction (coronal re-shaping) can eliminate bite interfer-ences and prevent further symptoms orjoint damage.

Condylar repositioning can beachieved by several techniques includ-ing dentures, occlusal bonding, thefabrication of crowns and bridges,overdentures and orthodontic therapy.

Surgical correction of intercapsularderangements of the disc and condylehave been performed with increasingsuccess recently. Farrar and McCartyreport a 94% success rate after 377such procedures over six years.34

ConclusionAs the first line health care pro-

vider, the family physician who isaware of temporomandibular joint dys-function syndrome can be invaluableto the patient by recognizing this pain-ful syndrome, providing palliativetherapy, taking essential steps in thedifferential diagnosis and referring thepatient to a dentist and other therapists

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