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Chronic neck pain and masticatory dysfunction
Jean-François Catanzariti, Thierry Debuse, Bernard Duquesnoy *
Rheumatology Department, Salengro Teaching Hospital, André Verhaeghe Center, Lille Teaching Hospitals, 59037 Lille cedex, France Received 16 June 2004; accepted 18 October 2004 Available online 15 December 2004
Abstract Chronic nonspeciﬁc neck pain is a common problem in rheumatology and may resist conventional treatment. Pathophysiological links exist between the cervical spine and masticatory system. Occlusal disorders may cause neck pain and may respond to dental treatment. The estimated prevalence of occlusal disorders is about 45%, with half the cases being due to functional factors. Minor repeated masticatory dysfunction (MD) with craniocervical asymmetry is the most common clinical picture. The pain is usually located in the suboccipital region and refractory to conventional treatment. The time pattern may be suggestive, with nocturnal arousals or triggering by temporomandibular movements. MD should be strongly suspected in patients with at least two of the following: history of treated or untreated MD, unilateral temporomandibular joint pain and clicking, lateral deviation during mouth opening, and limitation of mouth opening (less than three ﬁngerbreadths). Rheumatologists should consider MD among causes of neck pain, most notably in patients with abnormal craniocervical posture, signs linking the neck pain to mastication, and clinical manifestations of MD. Evidence suggesting that MD may cause neck pain has been published. However, studies are needed to determine whether treatment of MD can relieve neck pain. © 2004 Published by Elsevier SAS.
Keywords: Neck pain; Temporomandibular joints; Masticatory dysfunction; Craniomandibular imbalance
1. Introduction Neck pain is a common reason for rheumatology visits. The prevalence of neck pain in industrialized countries ranges across studies from 34% to 50% [1–4]. The cost of managing patients with neck pain has been estimated in France at 0.1% of the gross national product . However, the pathogenesis of nonspeciﬁc neck pain is unclear, and few proven treatments are available . Neck pain refractory to appropriate conventional therapy or recurring at treatment discontinuation may respond to dental procedures ranging from occlusal restoration by prostheses, use of a removable intraoral splint to disengage the occlusion, or reshaping of one or more teeth. The rationale behind these interventions is that masticatory dysfunction (MD) may cause neck pain. Controversy, about this link is growing in magnitude and vehemence, reﬂecting the paucity of valid scientiﬁc data.
2. Masticatory dysfunction The masticatory system is a structural and functional unit composed of the temporomandibular joints (TMJs), with their disks and ligaments; the dental arcades, which contain soft tissues rich in desmodontal mechanoreceptors; and the masticatory muscles, most of which are supplied by the trigeminal nerve [7,8]. The term “masticatory dysfunction” encompasses a broad range of disorders associated with impaired mastication [7,8]. Thus, diagnostic investigations should be selected by specialists according to the suspected disorder. For instance, MRI is the best tool for evaluating alterations in the TMJ disk and ligaments [7,8]. Reported causes of MD vary across studies, in keeping with the multifactorial nature of this condition . Gola et al.  attempted to clarify the causes of MD by distinguishing predisposing factors, triggering factors, and perpetuating factors. The main risk factors are malocclusion (most notably loss of posterior teeth leading to lateral deviation of the mandible that pulls the TMJs off center), stress-related behaviors (clenching or grinding the teeth), and structural abnormalities (ligamentous laxity or dysmorphism affecting the teeth, maxillary bone, and mandible) [7–10]. These factors may act by placing undue stress
* Corresponding author. Service de Rhumatologie, Hôpital Salengro, Centre André Verhaeghe, CHU de Lille, 59037 Lille cedex, France. Tel.: +33-3-20-44-69-26; fax: +33-3-20-44-54-62. E-mail address: firstname.lastname@example.org (B. Duquesnoy). 1297-319X/$ - see front matter © 2004 Published by Elsevier SAS. doi:10.1016/j.jbspin.2004.10.007
J.-F. Catanzariti et al. / Joint Bone Spine 72 (2005) 515–519
on the TMJ disk and ligaments, ultimately causing reducible or ﬁxed dislocation of the disk [7,8]. The prevalence of MD varies in considerable proportion across studies, in large part because there are no standardized diagnostic criteria. The prevalence of MD as detected by physical examination may be about 45% in the population at large, although only half these patients report symptoms . The multifactorial nature of CMD explains the broad range of treatments used and the absence of a consensus about management. Treatments seek to combat risk factors and their consequences (e.g., eccentric seating of the condyle, poor mandibular posture, and disk dislocation) [7–10]. Short-term symptomatic treatments have been advocated. Muscle relaxants alleviate painful spasm of the masticatory muscles and have been administered by local injection . Intraoral plates fashioned on a cast can be used to reduce masticatory muscle spasm or to reposition the jaw in order to return the TMJ disks to their normal location [7,8]. This is the most widely used treatment. Alternatives include correction of abnormal jaw position by hard acrylic splints with guiding ramps that prevent lateral deviation of the mandible, thereby keeping the condyles properly centered [9,10]. When the symptoms abate, consolidation etiological therapy is offered: options include tooth reshaping, orthodontic treatment combined with maxillofacial surgery, prostheses to replace lost posterior teeth, rehabilitation therapy to improve tongue and mandibular function, and stress-management techniques [7–10]. These methods have been found highly effective in numerous open studies [7,8]. Controlled studies would be useful to determine the optimal treatment program in each situation. Adverse effects may occur, such as dependency on an intraoral occlusal splint or symptom exacerbation. These events seem uncommon, however, although no studies speciﬁcally designed to evaluate adverse events are available.
3. Neck pain and masticatory dysfunction The physical examination and imaging studies widely used in rheumatology may detect one or more causes in patients with neck pain. Examples include minor disk derangements, malalignment, degenerative disease, proprioceptive deﬁcits, muscle weakness, laxity, a poorly designed work station, and anxiety or depression responsible for symptom exacerbation . The next step is local or systemic administration of symptomatic medications. Rehabilitation therapy is often recommended also to strengthen the muscles, improve proprioception, and restore sagittal alignment. Manipulative therapy and advice about neck protection during occupational and other daily activities may be useful . In our experience, patients who fail to respond to this management program often have unilateral pain and one or two minor intervertebral derangements that resolve with manual physiotherapy or manipulation but invariably recur in the short-term at the same levels. Asymmetric craniocervical posture responsible for repeated mechanical stress to the neck is a possible cause [8,12,13]. Via the trigeminal nerve, the masticatory system is closely
connected to the craniocephalic stabilization systems (cervical proprioception, vestibular system, vision, and ocular motility) [8,12–14]. Changes in the position of the head and neck, most notably at the craniocervical junction, modify both occlusion patterns and jaw position [15–19]. On the other hand, the position of the craniocervical junction is inﬂuenced by the characteristics of the masticatory system [20,21]. Thus, MD may lead to compensatory changes in craniocervical posture and, therefore, to neck pain. Physiological and anatomic data establish the existence of close links between the masticatory system and the cervical spine. Trigeminal afferent ﬁbers from the proprioceptive mechanoreceptors located in the periodontal soft tissues project to the sensory complex of the ﬁfth cranial nerve in the brainstem and from there to the ﬁrst three segments of the cervical spinal cord (dorsal horns) and to the nucleus of the spinal accessory nerve, which contributes to innervate the trapezius and sternomastoid muscles, together with the C1 and C2 roots [7,8,22]. On the other hand, a contingent of ﬁbers from the sensory roots C1 through C3 projects to the trigeminal spinal nucleus . Synergy between the masticatory and cervical muscles has been demonstrated in several studies. Thus, contraction of the masseters is associated with increased electrical activity in the trapezius and sternomastoid muscles [23–26], which seem to maintain head and neck stability during occlusion . The isometric strength of head and neck ﬂexors varies with the position of the mandible, because the supra- and infra-hyoid muscles both lower the mandible and ﬂex the head . Gola et al.  speculated that an archaic trigemino-nuchal reﬂex may involve the trigeminal nerve, the spinal accessory nerve, and C1 through C3 (which innervate the suboccipital muscles, trapezius muscles, and sternomastoid muscles) . Thus, these muscles may contract in response to nociceptive signals from the trigeminal territory, due for instance to MD . A study by Delaat  provided support for this hypothesis by showing that active neck motion, most notably rotation, was signiﬁcantly restricted in patients with MD and that the most likely mechanism was reﬂex splinting of the cervical muscles. Thus, physiological and functional data support a role for the TMJs as a cause of neck pain. In addition, epidemiological studies found that MD was associated with a 2.37-fold increase in the risk of neck pain [29–31]. Furthermore, both patients with neck pain and those with MD are typically women in their 30’s who are employed in the tertiary sector and report high levels of stress [29–31]. 4. When and how should rheumatologists look for masticatory dysfunction in patients with neck pain? MD should be considered in patients with chronic nonspeciﬁc neck pain of more than 3 months’ duration. The following suggest MD as a possible cause to neck pain: asymmetric craniocervical posture, neck pain characteristics consistent with MD, clinical manifestations of MD, and presence of arguments supporting a causal link between MD and neck pain (Table 1).
J.-F. Catanzariti et al. / Joint Bone Spine 72 (2005) 515–519 Table 1 Main arguments supporting craniomandibular dysfunction in patients with neck pain Asymmetric craniocervical posture Malalignment of the cervical spine, usually in the coronal and horizontal planes Time pattern of the pain Jaw movements exacerbate the neck pain Pain worse at night and upon awakening (bruxism) Temporomandibular joint dysfunction Snapping, clicking, squeaking; locking Sensation of restricted mouth opening; teeth grinding or clenching Temporomandibular joint instability Pain in and about the joints Myalgia, most notably in the masseters and temporalis muscles Jaw deviation to one side during mouth opening or closing, sometimes with a bayonet-like trajectory Jaw deviated to one side when the mouth is closed with the teeth in contact (frenums of the upper and lower lips not aligned) Joint sounds during jaw movements Pain upon palpation of a temporomandibular joint or of the masticatory muscles Asymmetric and asynchronous contraction of the temporalis muscles when the teeth are slowly clenched Clicking or snapping of the joint, best felt when the examiner inserts a ﬁnger in the external auditory meatus on each side4
Asymmetric craniocervical posture is visible as deviation of the neck, usually in the coronal and horizontal planes [12,13]. Scoliosis or visual dysfunction can produce a similar appearance and should be ruled out . The stepping test described by Fukuda  is useful for documenting postural imbalance but is not speciﬁc of MD-related neck pain. The patient is asked to step in place 50 times, lifting the thighs to about 45°, with the eyes closed and the arms stretched forward horizontally, in a room free of visual or auditory stimuli that could provide information on direction [27,33,34]. Rotation of the body should not exceed 30° and translation 50 cm. Greater displacements are abnormal [33,34] and indicate postural asymmetry . MD-related neck pain is usually located high in the neck, unilateral, and associated with one or two mild intervertebral derangements at the same levels [8,12,13]. The pain may be more severe after meals. Pain at night and upon awakening may occur in patients with bruxism, as this symptom predominates during sleep [8,27]. Abnormalities indicating MD are usually unilateral [7,8]. A history of treated or untreated MD, jaw injury (e.g., direct impact on the chin), or dental work preceding the onset of pain is suggestive. Symptoms should be sought, as patients often fail to report them spontaneously [7,8,27]. They may consist in snapping, clicking, or squeaking of the TMJs; episodes of locking; a sensation of restricted mouth opening; bruxism with grinding or clenching of the teeth; TMJ instability; pain in and about the TMJs; and myalgia, most notably in the masseters and temporal muscles. These last three symptoms are particularly suggestive when they are unilateral. Careful observation of the patient during mouth opening and closing is useful [7–9,27] to look for lateral deviation
of the mandible during mouth opening, which may occur with a bayonet-like trajectory; lateral deviation of the mandible with the mouth closed and teeth clenched, seen as malalignment of the upper and lower labial frenums; sounds from a TMJ during movements of the mandible; attrition of the teeth in patients with bruxism and overdevelopment of the masseters in those with a teeth-clenching habit; or occlusal imbalance caused by loss of posterior teeth. Palpation may show abnormalities, which are usually unilateral [7,8,27]. Pain may occur upon palpation of a TMJ or of the masticatory muscles (chieﬂy the masseters and temporalis muscles). The temporalis muscles are best examined with the patient lying supine and the examiner standing behind the patient and placing the palms over the temples; the patient is then asked to clench the teeth slowly and as hard as possible, a maneuver that may reveal asymmetric and asynchonous contraction of the temporalis muscles. With a ﬁnger of each hand placed in the external auditory meati, the examiner may feel a clicking in the TMP , a sign described as diagnostic of occlusal disorders. The range of jaw motion should be evaluated. The interincisor opening is normally 35–45 mm. The temporalis muscle, posterior part of the sternomastoid muscle, and superomedial part of the orbital arcade are tender to pressure; together, these three points constitute the “dental triad” described by Hartmann and Cucchi . These are the abnormalities most easily demonstrated by physicians who are not specialized in TMJ disease. Other signs may be present. We consider that MD is likely when at least two of the following are present: history of treated or untreated MD, pain and sounds from a single TMJ, bayonet-like trajectory of the mandible upon mouth opening, and interincisor distance smaller than 35 mm when the mouth is open. The possibility that MD may be overdiagnosed in patients with neck pain should be borne in mind. For instance, unilateral TMJ pain may be caused by minor intervertebral derangement at the C2– C3 level . The physical examination shows unilateral TMJ pain and pain high in the neck on the same side. The source of the pain is in the cervical spine: the anterior branch of C2 innervates a wide area extending from the temporal region to the angle of the mandible . Similarly, reﬂex myalgia of the temporalis muscle may be misleading. Painful spasm of the anterior fascicle of the temporalis muscle indicates minor intervertebral derangement of the upper cervical spine; however, the same ﬁnding in the posterior fascicle points to a masticatory disorder . Other manifestations of MD should be sought to establish the correct diagnosis. Available clinical tests for establishing a causal link between neck pain and MD [37,38] are widely used in clinical practice, although they have not been validated. They seek to show that alleviation of the masticatory system disorder relieves the neck pain. In the occlusion disengagement test, or Meerseman test, nociceptive stimuli generated by the teeth are eliminated by separating the dental arcades, for instance by absorbent cotton wool pads [37,38]. The patient should be asked to swallow and walk in order to settle the jaw in the new position . The rheumatologist examines the patient
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before and after disengaging the occlusion to look for an improvement in the cervical signs, most notably increased range of rotation and resolution of the evidence of minor intervertebral derangement (e.g., reﬂex pain in the subcutaneous tissue and muscles) . The occlusion correction test involves temporarily correcting the occlusal abnormality then checking as above whether the neck symptoms improve . A description of the methods used to correct occlusion would be beyond the scope of this article. An example is restoration of normal contact in patients who have lost posterior teeth. The main drawback of these tests is the risk of false-positive ﬁndings due to a placebo effect and of false-negative ﬁndings due to ﬁxed restriction of cervical motion (e.g., related to severe osteoarthritis or deformities). In sum, in a patient with refractory chronic nonspeciﬁc neck pain, recurrent minor intervertebral derangement at the same level, clinical evidence suggesting MD, and a positive occlusion disengagement test, the advice of a specialist should be sought to conﬁrm the MD and its link to the cervical pain (occlusion correction test). The validity of these patient selection criteria has been established in a randomized controlled trial . With these criteria, fewer than 10% of patients with chronic neck pain are candidates for dental interventions . Therefore, caution is in order before recommending dental work, particularly as patients with chronic pain tend to show considerable enthusiasm for any new treatment. Suboptimal patient selection may lead to the unnecessary use of cumbersome, time-consuming, and costly treatments that fail to produce meaningful beneﬁts. Finally, even when dental intervention is warranted, other treatments such as rehabilitation should be continued. We have shown that proprioceptive neckmuscle rehabilitation improves the results of dental interventions in some patients with neck pain .
  
  
  
5. Conclusion The possibility that chronic neck pain may respond to dental interventions is encouraging, particularly, as few new treatments are available for mechanical spinal disorders. However, only a minority of patients with chronic neck pain are likely to beneﬁt from dental interventions. In many patients, MD merely combines with other factors to exacerbate the neck pain. Thus, although MD should be looked for in patients with refractory neck pain, the enthusiasm of some patients for alternative therapies may need to be curbed by assurances that a more conventional but also far simpler approach may prove beneﬁcial.
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