Craniomandibular dysfunction (CMD) – the chameleon of dental medicine

Dr. med. dent. Cornelia Wolschner, Dentist, Berlin, Germany

Craniomandibular dysfunction (CMD), an umbrella term covering structural, functional, biochemical and psychological dysregulation of the muscle and joint function of the temporomandibular joints, has been “on everyone’s lips” for some time, to the extent that it could incorrectly be considered a new fashionable complaint. Yet, even in Stone Age teeth, excessive wear meant that the joint was subject to structurally deforming, degenerative processes. However the number of triggering, and especially iatrogenic, factors has definitely increased in recent times and man’s ability to compensate has declined in the face of numerous other stresses.

Earlier studies give the incidence of CMD in Germany as 8 % and the number of cases requiring treatment as 3 %. In addition to an increase in the number of cases, however, the age of those affected appears to be dropping markedly. While in the past women between 45 and 60 years of age made up the majority of patients, we are encountering an increasing number of young people and children, both male and female. In children we are increasingly encountering scoliosis and abnormal occlusion coinciding, giving rise to the German acronym KGISS (kinetic imbalance in children due to temporomandibular strain) by analogy with KISS (Kinetic Imbalance due to Suboccipital Strain) syndrome.

I would describe CMD as a chameleon as it can conceal itself in different disorders with a wide variety of symptoms and does not necessarily cause pain topically. When I was still training, disorders of the temporomandibular joint were usually dealt with as the domain of the oral surgeon, mainly as traumas, tumours and deformities. Functional disorders were a small, mysterious specialised field for orthodontists and gnathologists. Back in 1936 the American oral surgeon Costen had described a syndrome involving neuralgic headaches and earaches, ear pressure, ringing in the ears, burning sensation on the tongue and dizziness which frequently occur with abnormal occlusion and jaw movement. The link between dysfunction in the jaw and ear was explained through their close physical relationship as well as through the combined development of the neural system in the embryo.

CMD transcends well beyond the domain of dentistry and, in addition to ENT medicine, involves general medicine, ophthalmology, neurology and orthopaedics with physiotherapy and osteopathy.

I should like to present these connections and consider CMD from a holistic viewpoint. The aim of this paper is for the general therapists amongst you to detect CMD in your patients’ conditions and for the dentists to identify the critical factors in their patients’ general disorders and recognise their therapeutic responsibility for the overall state of their patients’ health in preventing or treating CMD.

Anatomy

Why is the temporomandibular joint so important?

It is one of the central junctions in the body: the connection between the brain and the abdomen, the control centre for information and the flow of energy.

In the immediate vicinity we find:

-Five important cranial nerves (the trigeminal and facial nerves supplying the articular and masticatory muscles as well as the glossopharyngeal, vagus and accessory nerves)

-vessels (carotid artery, sinuses of the dura mater)
-lymph tracts and meridians (GB, TW, SI, ST, with relevant points. The muscles of mastication and the joint are assigned to the stomach meridian which ends near Voll’s conductor pathway for joint degeneration at the 2nd toe).

Anatomically it is also closely linked to the ear, the parotid gland and also to the eye socket through the vascular and nerve supply and bone structures.

We usually talk simply of the temporomandibular joint but this is a double joint, in both senses: the right and left side must always move together and a particular anatomical feature of this joint, namely a flexible cartilaginous disk, is attached at the side to the ligament structures of the articular capsule, at the front to a masticatory muscle and at the rear to the connective tissue structure (which envelops blood vessels, nerves and autonomic pathways for joint and ear) and divides the joint cavity into an upper and lower chamber.

nerve supply and bone structures

This allows the condyles to move in a well differentiated threedimensional pivoting and sliding motion. So, with the help of versatile muscles of mastication, delicately coordinated movements are therefore possible delivering considerable controlled force when chewing, swallowing and speaking while protecting the tissue structures. The head is held stable all the while despite these jaw movements through wellcoordinated interaction with the neck muscles also involving the hyoid bone.

neck muscles

From a neurophysiological viewpoint the temporomandibular joints can be regarded as organs providing information on position and movement. A complex neuromuscular reflex system controls the delicate coordination of the muscles of mastication and those in the back of the neck.

Eversaul referred to the teeth as “organs for finetuning the spine”.

Disorders which alter this complex interaction are only successfully compensated over a certain period of time before functional disorders occur or tissue is damaged. The disk is affected with particular frequency as this complex structure is subject to great strain and so susceptible in the case of adverse factors or impaired metabolism.

If these anatomical and functional connections are considered, this accounts for the considerable variance in symptoms arising with pathologically altered structures and / or impaired locomotor function.

Symptoms of CMD

The earlier name, myoarthrodiscopathy, breaks down the disorder into structural and anatomical elements:

myopathy, changes in the muscles of mastication, muscle tension / muscle spasm, contracture, hypertrophy, myogelosis

arthropathy, arthritic change in the fossa or condyle discopathy: cartilage damage, damage to the ligament structures, disk displacement with/without reduction with/without limited opening or closure of the mouth.

Clinically we record the key symptoms pain and functional disorder.

Pain: muscles of mastication, joint, jaw, teeth, ears, head, face

Functional disorder: asymmetrical or limited movement in the lower jaw, joint noises

Local concomitant symptoms in the shape of muscle hypertrophy and also tooth and periodontal damage are often encountered.

Secondary symptoms are encountered throughout both the stomatognathic and postural systems.

Symptoms of CMD

CMD symptoms

Common series of symptoms

Teeth

Parafunctions: clenching and grinding leads to damage to the dental substance, hypersensitivity or pain, tooth migration or loosening, even loss, the resulting malocclusion aggravates the CMD

Jaw, temporomandibular joints, bite

Tension pain in the muscles, neuralgiform pain, trigger zones, difficulty opening mouth or limited opening, trismus or lockjaw, clicking or friction rub sounds in the joint, arthrosis/arthritis, unstable jaw position with uneven contact areas on teeth

Mouth, pharynx, throat

Impaired sensitivity in lips, tongue, pharynx, problems swallowing, sore throat, hoarseness, constant urge to clear the throat, globus sensation, voice and speech disorder, impaired sense of taste, burning sensation on tongue, dry mouth

Ears

Tinnitus, reduced hearing, dizziness, pain radiating to middle ear or inflammation of the middle ear due to aeration problems caused by joint swelling or muscle tension

Eyes

Impaired vision, pain, light sensitivity due to muscle tension, as a consequence of a cranial defect but also cause of bad posture to compensate for defective vision

Face, head

Impaired sensibility: sensitivity to touch, neuralgia or sensation of numbness, pressure in head, headaches, migraine

Back of neck, shoulder

Stiff neck, pain in back of neck, possibly with limited movement of head and cervical spine, wryneck

Pain in shoulders, possibly radiating with numbness in arms and fingers Spine, sacroiliac joint, hips, knee, ankle joints

Back pain caused by muscle tension or blocked joint, discopathy, scoliosis, joint pain following altered body statics

Neurological disorders

Paraesthesia, numbness, burning sensation, neuralgia possible in all the affected parts of the body

Cardiac irregularity, change in blood pressure

Aside from pain directly in the joint or the muscles of mastication, the only symptoms from this list the patient usually associates with CMD are clicking sounds and extreme changes on opening the mouth such as trismus or lockjaw.

Clicking and rubbing

Clicking noises in the temporomandibular joint may be caused by various factors. They are generally due to the disk “slipping” as the condyle moves. Less commonly they occur when there is a change in the other ligament structures or when there is insufficient synovial fluid in the joint.

If, when closing the mouth, the disk slips slightly or completely forward from the joint head, the mouth is unable to open completely. When opening the mouth, the disk usually springs back onto the joint head (“disk displacement with reduction”), generally accompanied by clicking of the joint. If, when opening the mouth, the disk does not spring back onto the joint head (“disk displacement without reduction”), the jaw is locked with limited opening.

Yet unevenness in the joint hollow or on the joint head may also cause clicking sounds or friction rub during this movement.

As a rule this is due to bone rubbing on bone abnormally if the layers of cartilage covering the head and hollow of the temporomandibular joint are no longer in place and insufficient synovial fluid is produced. This type of arthrosis may be a purely local process resulting from craniomandibular dysfunction. It may also be a sign of general arthropathy (e.g. rheumatoid arthritis).
Painless sounds in the temporomandibular joint which are not accompanied by further symptoms or abnormalities do not usually require treatment.

Trismus (acute, chronic or recurrent, unior bilateral)

Two elements may be responsible for limited opening of the mouth: the muscles of mastication, whether acutely inflamed, increased in tone as a reflex reaction to pain, spastic and shortened or irreversibly contracted long term due to excessive strain or following injury and/or the temporomandibular joint itself through anterior disk displacement (with/without reduction). A prolonged period of temporomandibular joint clicking often precedes this process.

It is important to distinguish the precursor of genuine trismus:

Many patients with CMD suffer from bruxism mainly at night (grinding or clenching the teeth). This results in strong muscle activity which goes well beyond the normal extent of chewing function as regards the force and duration of the exertion. It is often difficult to open the mouth in the morning as the muscles are appreciably fatigued and spastic due to their “high intensity activity” during the night.

DD:In very rare cases tumours may cause limited movement of the lower jaw.

Lockjaw
If the articular capsule is particularly elastic (e.g. due to impairment of the connective tissue, prior excessive strain, arthritic flattening of the articular tubercle, acute traumatic), when the mouth is opened wide, the condyle moves out of the joint hollow on one or both sides and, due to reflex muscle tension, only moves back with difficulty or even not at all. In extremely rare cases posterior disk displacement may prevent the jaw closing.

Causes of CMD

Cause and symptom cannot always be clearly separated as it is often a selfreinforcing process.

Structural and functional triggers

Problems in the biomechanical equilibrium of the masticatory system: imperfect occlusion due to poorly aligned jaw, following loss of teeth, loose teeth or tooth migration, through incorrect height of fillings or dentures

loss of teeth

Muscular dysfunction due to general orthopaedic problems, incorrect posture, also incorrect ocular development.
Injuries, status post accidents, tissue damage following surgery.

orthopaedic problems

Biochemical components

Metabolic disturbance and inflammations whether local or systemic with general disorders, acidaemia, allergies, hormonal factors

Psychological factors, neurological disorders

Bruxism to manage stress

abnormal occlusion

In addition to classic stress bruxism, which leaves visible traces in the muscles as well as teeth, psychological stress is often seen as a fairly discrete triggering cofactor of a previously compensated abnormal occlusion.

The anxiety and depression caused by CMD, if accompanied by severe pain, restricted movement or dizziness, is often underestimated.

The upper and lower jaw form a dynamic functional unit which must be kept in balance at all times.

The lower jaw is only connected flexibly to the skull via the two temporomandibular joints and various muscle groups. Its end position in relation to the skull is determined by the dental arches, which set the end position of the temporomandibular joints in their articular cavities, and the position of these cavities which are formed from the lower part of the temporal bone and so part of the movable skull system.

Significance of occlusion
Significance of occlusion – why is bite so important?

The temporomandibular joints are certainly subject to considerable ongoing stress as they move constantly yet even when chewing or speaking the teeth make only minimal contact and only moderate pressure is applied. At rest there is ideally a slight distance between the teeth and all structures adopt a dynamically balanced relaxed position. When swallowing however (approx. 2000 times each day!), numerous muscles are activated in a coordinated manner to move the lips, cheeks, tongue, soft palate, pharynx, larynx, vocal cords and oesophagus. The dental arches close and we bite briefly to set the lower jaw for the process of swallowing. This acts like a neurological reset, programming the movement pattern of the muscles involved. Consequently, if the occlusion is abnormal, dysfunctional patterns are established leading to a change in the muscle system and to CMD. Bruxism can have an even more risky effect: when the teeth are clenched or ground, pressure up to 30 times greater than normal chewing pressure (2 – 3 kp/cm2 ca. 40 min/d) often develops for hours.

Brodie’s well-known diagram

Clinical aspects and interactions

Descending and ascending imbalance

Descending:

As the muscles of mastication and those in the back of the neck form a functional unit to stabilise the head during all jaw movements, a direct link is frequently encountered between poorly aligned bite and defective position of the back of the neck. An incorrect bite which does not dovetail harmoniously into the functional and static interaction between the skull and body can lead to problems adapting, affecting even the ankles.

Vertical imbalance according to Barre

Deviation from the perpendicular shows the primary imbalance, an indication of ascending or descending chain.

Ascending:

Orthopaedic malposition

Alongside typical knee and back pain, pelvic misalignment may also be accompanied by pain in the shoulders, back of the neck and headaches.

Orthopaedic malposition with altered posture and displacement of the levels of the body encourage incorrect head position and muscular dysfunction.

As well as the temporomandibular joints, the sacroiliac joints, lower lumbar spine, mid thoracic vertebrae and upper cervical vertebrae (especially the atlas and axis) should be examined in the case of both descending and ascending imbalance.

Diagram showing statics of the body

statics of the body

It is important for orthopaedic specialists and physiotherapists to work together to treat these causal links.


Quick CMD check

This short test can be performed by any therapist and is suitable for establishing a case of CMD, although it does not differentiate further.

History of pain: where, when, radiation

Inspection of teeth: symmetry, bite, dental chart Observation of jaw movement when opening and closing mouth

Palpation of joint, muscles Mobilisation: Mobility of joints in head

Bite test Mersemann method modified after Wolschner

Findings on overall statics, possibly manual tests of pelvic position, leg length

Dental diagnosis
After taking a thorough patient history, dental diagnosis includes functional status with manual and instrumental functional analysis of the patient and models, OPG Xray, if necessary MRI, CT or DVT scan.

As shown, the patient’s overall state of health must be considered here. If necessary the patient should be referred for interdisciplinary treatment by cotherapists.

Treating CMD

Dental treatment

-Eliminating triggers of acute pain and inflammation, local disruptive factors

-Splint treatment Repositioning the lower jaw when biting together, thereby relieving temporomandibular joints, teeth and periodontium, muscular relief, harmonising the occlusal plane and axes of the body

-Restoring stable occlusion

Interdisciplinary treatment

-Orthopaedics, physiotherapy, osteopathy, physical measures Psychotherapy, instructions on relaxation techniques, selfexamination

Changing situations causing stress, movement patterns and customary posture

Interdisciplinary treatment is quite rightly always called for with complex disorders yet is frequently hard to achieve in practice precisely because, with acute symptoms, appointments often cannot be coordinated at short notice. Consequently it is advisable for the principal individual treating the patient to provide as comprehensive a treatment as possible.

Supportive holistic therapy

Acupuncture, bioresonance, craniosacral therapy/osteopathy, electroacupuncture, homoeopathy, oral acupuncture, neural therapy, kinesiology, orthomolecular medicine, herbal remedies

Bioresonance offers general therapists and also dentists an excellent means of filling this gap and providing supportive therapy both for the causes and symptoms of acute pain and chronic degenerative changes. Another very useful application is for relaxing the muscles prior to recording the bite in prosthetic work.


Bioresonance therapy programmes

The classics, 530 and 570

H+Di, 52 kHz (530 – ten indications, 570 – seven indications)

The 52 kHz frequency is extremely versatile, a whole page full of indications in the manual, programs for joints: 321, 391, 530, 531, 536, metabolism: 530 nutrient points: 391, 530, 570, 801, allergies: 530, 945, 977, 984, 997 organs and tissues: 321, 391, 530, 531, 535, 921, inflammation: 570 autonomic and neurological disorders: 535, 570, 571, 801, 921

→ Program 530 is very effective but must be used very carefully precisely due to its broad spectrum of activity!

The supplementary programs with the most frequent success 531 – 534 back of head, back of neck, cervical spine, hips; 915, 918, 951 releasing blocks 371, 502 sudden loss of hearing; 527 tinnitus; 431 dizziness; 581 spine 460, 630 muscular pain; 941 muscle coordination 970 cervical spine, blood pressure, chakra, toxins

Meridian programs

271 triple warmer; 291 SI; 331 ST; 371 GB 200, 201 LY; 230, 231 nerves; 320, 321 joint degeneration; 340, 341 connective tissue

Head, spine and joints

3054 jaw; 519, 524, 3011 eyes 502, 3072, 3073 back of neck; 581 spine; 331 cervical spine; 536 shoulder blade 620, 3051 block in hips; 3065 lumbar spine; 211 block in sacrum

Tissues and structure
922, 923, 927, 931 951, 3124, 3125 cell regeneration; 341, 3016 connective tissue 341, 440, 550 intervertebral disks

Pain and inflammation
3058, 3059, 3060 headache, 3090, 3091 joint pain; 425, 426 pain 503, 3037 inflammation; 610, 930, 3066 lymph

Metabolism, nutrient points
3106, 861 acidaemia; 802 oxygen 211 vitamin D; 570 Mg; 580 Ca; 600 Zn; 816 Q10 530 protein; 240 Vitamin B complex

Autonomic nervous system and neurology
127, 128, 900 harmonising, vitality; 580, 583 quadrant energy balance 960 autonomic dysregulation; 535 depression, laterality 432, 3093, 3094, 3095 shock; 3020 blood pressure; 3084 stress reduction 431, 3098 dizziness; 465 Sjögren’s syndrome 423, 911, 3074, 3075, 3077 nerves


Electrode position

The ideal way to treat the entire functional system is to place the modulation mat on the patient’s back.

As for all the other applicators, as usual a decision must be made on an individual basis whether to use the input or output.

The roller applicator and Sissi Karz’ application method have proved particularly successful with myopathy.

The adhesive applicators are highly effective with discopathy, isolated pain in the joints and on trigger points.

Bilateral therapy over the whole jaw and face area can also be applied very well with the spectacletype applicator.

It is often worthwhile placing a slim surface applicator on the back of the neck.

The point applicator is used for treating the acupuncture points. The goldfinger can be used in the retromolar area of the upper jaw in a similar manner to oral acupuncture, especially with children and young people.

Combined therapy

As with many indications, incorporating therapeutic substances via channel 2 is a good way of reinforcing therapy. I have found dental foci nosodes, homoeopathic remedies, orthomolecular substances and Bach flower remedies to be particularly beneficial.

Bioresonance can also be successfully combined with acupuncture: treating the ear acupuncture points with the point applicator is an excellent means of involving the whole spine. The body points in the relevant region can also be treated with the point applicator.

Gleditsch’ method of oral acupuncture in the retromolar area is able to release blocks very swiftly and is traditionally carried out with procaine but alternatively homeopathic remedies can also be used; the effect can be increased by customising the content of the output cup.

oral acupuncture 1 oral acupuncture 2 oral acupuncture 3

Mouth points

Case studies

Case 1
Female patient, aged 24

Recurrent trismus and bouts of intense joint pain following cycling accident when she fell on her face and bruised her chin badly, no fractures but slight chipping of the cutting edges of the lower front teeth, first presented three weeks after the accident.

Status of dental function, impressions for splint treatment and BICOM® in 1st session according to testing: basic therapy, 922, 530, 3016 (connective tissue), 241 (shock), Arnica C30, Ruta C30 in channel 2, adhesive applicators on temporomandibular joints at input, narrow flexible applicator in back of neck at output in addition to mat.

At 2nd session one week later patient reported marked improvement, no longer any trismus, ability to open her mouth only slightly restricted and occasional pain in the joints associated with movement.

Myoceptor splint fitted in lower jaw and BICOM®: 931, 930, 630, cartilago comp. (Wala) in channel 2, narrow flexible applicator at input, roller applicator at output and mat.

At 3rd session patient reported she no longer had any symptoms.

Case 2
Female patient, aged 53

Deep overbite with closed bite, previously compensated slight compression of temporomandibular joints, now acute sharp jaw and joint pain, muscle trembling, severely restricted head movement, radiating pain in back of neck, strong feeling of weakness, noticeable doughlike swelling in back of neck and at cervicothoracic junction, bouts of hot flushes.

Currently under a lot of stress at work, felt swamped.

BICOM®: 915, 918, 930, 900, channel 2: energetic fitmaker, narrow flexible applicator in back of neck at input, square flexible applicator on sternum.

In the 2nd session two days later patient reported definite relief, BICOM®: 570, 581 (spine), 960 (autonom.), 3084 (stress).

3rd session: 970, 941, 3066 (lymph)

Subsequently continuing improvement to original state. Patient now receiving further dental treatment.

Case 3
Male patient, aged 58

Dizziness for three weeks, distinct worsening of tinnitus which patient had suffered for many years but which had not bothered him much in the past; three months previously new crowns fitted in lower jaw with insufficient height on left side.

1.BICOM®: basic therapy, 951, 527, 431, 941, narrow flexible applicator at input in back of neck, spectacletype applicator at output, mat
2.BICOM® one week later: 915, 371, 527, 431, 3098 with adhesive applicators on joint
3.BICOM®: 530, 941, 900
Now marked improvement. Patient can have further dental treatment.

Case 4
Female patient, aged 19

Recurrent lockjaw after surgery on wisdom teeth nos. 48 and 38 in one session:

1.BICOM®: 3095 (shock), 610 (lymph), 910, 927, 3125 (cell regen.)
2.BICOM®: 340, 3016 (connective tissue), 931, 630
Treatment with spectacletype applicator at input, placed inverted over mouth and jaw, mat.


Further reading

Köneke (2010) Craniomandibuläre Dysfunktion [Craniomandibular dysfunction], Quintessenz Verlag

Hülse, Neuhuber, Wolff (2005) Die obere Halswirbelsäule [The upper cervical spine], Springer Verlag

Kares, Schindler, Schöttl (2001) Der etwas andere Kopfschmerz [The rather different headache], ICCMODeutschland

Siebert (1992) Gesichtsund Kopfschmerzen [Facial pain and headaches], Hanser Verlag

Schöttl (1991) Die craniomandibuläre Regulation [Craniomandibular regulation], Hüthig Verlag

Siebert (1987) Zahnärztliche Funktionsdiagnostik [Functional diagnostics in dentistry], Hanser Verlag

Morgan, House, Hall, Vamvas (1985) Das Kiefergelenk und seine Erkrankungen [The temporomandibular joint and its disorders], Quintessenz V.

Schwenzer, Grimm (1981) Spezielle Chirurgie [Special surgery], Georg Thieme Verlag

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