Craniomandibular dysfunction or craniomandibular dysfunction ( CMD ), English Temporomandibular joint dysfunction ( TMJD ) , is an umbrella term for structural, functional, biochemical and psychological dysregulation of the muscle or joint function of the temporomandibular joints . These dysregulations can be painful or cause dizziness , headaches , sensitivity to light , panic attacks (racing heart) and stress in everyday life. Craniomandibular dysfunction can be both a cause and a consequence of stress. The German Society for Functional Diagnostics and Therapy defines CMD as a collective term for a number of clinical symptoms of the masticatory muscles and / or the temporomandibular joint and the associated structures in the mouth and head area. The exact diagnosis differentiates between: disorder of the chewing surfaces ( occlusopathy ), disorder of the masticatory muscles ( myopathy ) and disorder of the temporomandibular joint ( arthropathy ). In the narrower sense, it concerns pain in the masticatory muscles ("myofascial pain"), displacement of the cartilage disc in the temporomandibular joint ("disc displacement") and inflammatory or degenerative changes in the temporomandibular joint (" arthralgia , arthritis and arthrosis ").
In Germany, the term craniomandibular dysfunction has become established, a collective name for various musculoskeletal complaints in the craniomandibular system (chewing system), as well as cranio-vertebral dysfunction (CVD). In Switzerland the term myoarthropathy is preferred, in the English-speaking world Temporomandibular Disorders or Temporo-mandibular-Joint-Disease (TMDs, TMJ). The old name Costen Syndrome is outdated. The main point of contact for these symptoms is the dentist or the orthodontist , but many medical specialties are affected.
There are various classification systems, the Research Diagnostic Criteria for Temporomandibular Disorders (RDC / TMD) from 1992 having the greatest international distribution. Accordingly, a distinction is made between the following two areas ("axes"):
- AXIS I (physical diagnoses)
- Ia: Myofascial pain
- Ib: Myofascial pain with restricted jaw opening
- IIa: Anterior disc displacement with reduction with jaw opening
- IIb: Anterior disc displacement without reduction when the jaw is opened, with limited jaw opening.
- IIc: Anterior disc displacement without reduction when the jaw is opened, without restricted jaw opening.
- IIIa: arthralgia
- IIIb: activated osteoarthritis of the temporomandibular joint
- IIIc: osteoarthritis of the temporomandibular joint
- AXIS II (psychosocial diagnoses)
- Pain-related impairments in daily activities
- Depressive mood
- Nonspecific somatic symptoms
In January 2014, an international group of experts published an extended classification of craniomandibular dysfunction. This includes the 12 diagnoses of the Diagnostic Criteria for Temporomandibular Disorders and also includes 25 less common diagnoses.
The incidence of CMD is around 8% of the total population, with only around 3% requiring treatment because of these complaints. Symptoms of CMD are rare in infancy, but the incidence increases until puberty. As with other pain disorders, women of childbearing age are affected significantly more often than men. After the menopause, symptoms often subside and CMD is relatively rare in old age.
A variety of symptoms can make diagnosis difficult. The jaw muscles or the jaw joints are often painful when chewing. Other symptoms can include:
- Limited jaw opening
- Cracking or rubbing of the temporomandibular joints when opening or closing the jaw
- Radiating pain in the teeth, mouth, face, head, neck, shoulder or back, neck, spine and shoulder problems, restricted head rotation, headache
- Sudden problems with the fit of the teeth.
- uncomfortable earache
- Cardiac arrhythmias
- Chest pain (stinging in the chest caused by tension in the back)
- difficulties swallowing
- Eyes / visual impairment
The pathogenesis of craniomandibular dysfunction is based on ascending and descending symptoms. In the ascending chain z. B. Lateral deviation of the spine is transferred to the cervical spine and then to the temporomandibular joint. In the descending symptomatology, dental problems such as B. too high a crown, a wrong bite or a misaligned teeth on the temporomandibular joint, then transferred from there to the neck, the shoulder and the spine.
Since in most cases the causes are unclear, a multifactorial origin is suspected . Predisposing, triggering, and entertaining factors include biological, psychological, and social elements. Some of them are listed below, whereby new aspects will always arise in clinical and research:
- Developmental disorders of the jaw
- Postural disorders
- Loss of the vertical jaw relation
- Emotional stress
- Previous pain experiences
- Hypervigilance through activation of the sympathetic nervous system
- Macrotrauma from accidents
- Microtrauma due to disorders of the bite position
- Grinding teeth
- Excessive chewing gum consumption
- Sleep disorders , e.g. B. Obstructive Sleep Apnea Syndrome
- Reduction of the activity of the Descending Inhibitory Nociceptive System
- Post-traumatic stress disorder
- Misaligned teeth
- Tooth extraction
- Occlusion disorders due to prosthetic restoration (e.g. crowns that are too high, etc.)
- Orthodontic Treatments
The following procedure is currently recommended for diagnosing the CMD:
- A detailed consultation with a doctor using standardized questionnaires.
- A somatic examination of the jaw opening, masticatory muscles and temporomandibular joints (functional status).
- An instrumental functional analysis (API / CPI)
- An x-ray of the entire jaw (panoramic slice image) to rule out dental and oral surgical causes of the disease.
- Questionnaires for the identification of psychosocial impairments.
Due to the large number of causes of pain in the head area, an interdisciplinary diagnosis is useful if the diagnosis is unclear. Diseases from a wide variety of medical specialties must be excluded and an intensive consultative assessment is then essential.
The basic idea behind the treatment of CMD is a gentle and reversible approach. Scientifically recognized therapy concepts are used depending on the severity and individually tailored to the patient.
- Informing the patient about the context of the disease and making a correct diagnosis is the first and most important step in positively influencing the disease process. A cracking of the temporomandibular joint did not lead to pain in the temporomandibular joint, according to a study with 454 patients.
- Advice on self-treatment, such as soft food, stretching exercises , heat or cold applications, relaxation exercises or stress management , can help.
- An occlusion splint ( bite aid ) is often used by the dentist and can relax the chewing and head muscles and relieve the jaw joints. However, the benefit of the occlusion splint in CMD treatment has not been scientifically proven. Depending on the study, the effectiveness is proven or refuted.
- Sometimes pain-relieving, anti-inflammatory, muscle-relaxing or sleep -inducing drugs are necessary to stop the pain becoming chronic and to improve the quality of life.
- Transcutaneous electrical nerve stimulation (TENS) can help by relaxing the muscles and reducing pain.
- It is discussed whether trigger point infiltration of the muscles with various substances is useful and can bring lasting relief.
- Extensive dental restorations, orthodontic or surgical measures should only be used under the strictest indications.
- Targeted physiotherapy is used to regulate the muscle tone in the jaw and shoulder / neck muscles. The effects of posture deficits on the temporomandibular joint are corrected. The patient learns self-exercises to relax and prevent the increased muscle tone.
The use of botulinum toxin for the treatment of bruxism ( grinding of teeth), craniomandibular dysfunction and for the optical thinning of the face is warned as it can lead to massive damage to the jawbone . Botulinum toxin is injected into the masseter muscle to reduce muscle tension. A period of three months between injections, which is usually observed, is not enough to regenerate the lost bone. In some cases, the results show that the jawbone no longer regenerates even in the long term. The bone loss can lead to tooth loosening - up to and including loss of teeth - and increases the risk of fracture of the jawbone.
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