Transitioning to chronic temporomandibular disorder pain: A combination of patient vulnerabilities and iatrogenesis

Abstract

Background Based on a variety of studies conducted in recent years, some of the factors that might contribute to the negative treatment responses of some TMD patients have been elucidated. Methods This paper describes known vulnerability factors that make individuals susceptible to developing temporomandibular disorders (TMDs), as well as those that contribute to the perpetuation of such problems. In addition, the topic of iatrogenesis is discussed as a major contributor to the negative outcomes that can be seen in this field. Results At the patient level, anatomical, psychosocial and genetic factors may contribute to individual vulnerability. The anatomy and pathophysiology of muscles, joints, disc and nerves may all be involved in predisposing to TMD symptoms, especially when the patients have pain elsewhere in the body. Among the psychosocial factors, some features may be elucidated by the DC/TMD axis II, while others (eg illness behaviour, Munchausen syndrome, lack of acceptance of non‐mechanical approaches) require careful evaluation by trained clinicians. Genetic predisposition to first onset TMDs and to chronification of symptoms has been identified for individuals with certain psychological traits, presence of comorbid conditions and certain abnormal clinical manifestations. Regarding iatrogenesis, sins of omission may influence the clinical picture, with the main ones being misdiagnosis and undertreatment. Joint repositioning strategies, occlusal modifications, abuse of oral appliances, use of diagnostic technologies, nocebo effect and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification of TMDs. The patients who present with massive occlusal and jaw repositioning changes combined with persistent severe orofacial pain are not a rarity within TMD and orofacial pain canters; these patients are the most difficult ones to manage because of this horrific combination of negative factors. Conclusions The information presented in this paper will help clinicians to understand better why some individuals develop temporomandibular disorders, why some of them will progress to becoming chronic patients, and what the appropriate responses may be.

Ultrasound Imaging of Head/Neck Muscles and Their Fasciae: An Observational Study

“…In such a way the motor tests are normal, but the correct movement is obtained using the temporalis and masseter muscles in a different way. This probably highlighted that these muscles act in coordination compensating each other to maintain excellent The misbalance in the craniocervical muscles changes the movement strategy provoking a deteriorated function but compensated, with an overload that determines nociceptive impulses which imply the activation of non-coordinated stabilizing muscles of the cervical spine (4,24). Consequently, there is increased activation of the superficial muscle such as SCOM which supports respiration exacerbating the functional misbalance.…”

“…The misbalance in the craniocervical muscles changes the movement strategy provoking a deteriorated function but compensated, with an overload that determines nociceptive impulses which imply the activation of non-coordinated stabilizing muscles of the cervical spine ( 4 , 24 ). Consequently, there is increased activation of the superficial muscle such as SCOM which supports respiration exacerbating the functional misbalance.…”

“…Based on the previous studies and on the present study, the activation of different muscles in compensatory patterns, detectable with a US assessment can highlight postural adjustments used to maintain the functional activity that is not statistically significant if not contextualized within the individual postural and movements patterns. The individual alterations may be vulnerability factors that as Manfredini et al ( 4 ) wrote: “even if anatomical factors may not be directly changed, the clinician can at least try to adapt/reduce the load or overuse, obviously considering psychosocial factors, which makes patients more vulnerable.” The findings of the present study did not intend to provide a cause or explanation for the development of TMJ dysfunction but want to underline the role of US imaging in a global evaluation of this relationship. Indeed, US imaging provides real-time static and dynamic assessment of the muscles as well as a more accessible and cost-effective option than other types of imaging ( 25 , 26 ).…”

“…The etiology of this dysfunction is usually imputed to a parafunctional activity in the stomatognathic system (2). The scientific literature is strong and consistent to support the role of different factors such as psychosocial, genetic issues, and muscle-related overload, in the pathophysiology of TMJ disorders (3,4). Intensive use and prolonged high activity of these muscles manifest in an increase of the ultrasonographic thickness of the masseter muscle and increased maximal bite force values (5).…”

Gut Bless Your Pain—Roles of the Gut Microbiota, Sleep, and Melatonin in Chronic Orofacial Pain and Depression

“…There are multiple vulnerability factors that may perpetuate pain and facilitate the transition to chronic conditions, with a certain degree of unpredictability at the individual level [ 219 ].…”