Journal of Oral Rehabilitation 2003 30; 295–300
The relationship between the occlusal interference side
and the symptomatic side in temporomandibular disorders
T. FUJII Department of Removable Prosthodontics, Nagasaki University School of Dentistry, Sakamoto, Nagasaki-shi, Japan
SUMMARY This study aimed to investigate the rela-
tionship between the facial side of pain or clicking
symptoms and the side of occlusal interference, and
to examine the features of pain and clicking patients
in terms of frequencies of occlusal interferences in
relation to the symptomatic side. Occlusal condi-
tions in 31 pain patients and 40 clicking patients
were investigated just after the relief of pain or
clicking solely by means of bite plane therapy. The
symptomatic side did not associate with the side of
fewer occlusal contacts in intercuspal position, no
canine contact on the working side, occlusal contact
Introduction
It is still open as to how occlusion is concerned with
temporomandibular joint disorders (TMD), and various
ways of studying the role of occlusal factors in the
aetiology of TMD have been performed. Clinical reports
have focused on occlusal conditions at the time of
patients’ first visit (De Boever & Adriaens, 1983;
Droukas, Lindee & Carlsson, 1985; Pullinger, Seligman
& Gornbein, 1993), and in epidemiological studies
occlusal conditions with and without TMD have been
compared (Österberg & Carlsson, 1979; Droukas, Lin-
dee & Carlsson, 1984). However, another attempt to
examine the occlusal condition just after the relief of
TMD symptoms has been made (Fujii, 1999, 2000).
These results indicate that a low number of occluding
teeth in the intercuspal position (ICP) or a lack of
canine contact on the working side on laterotrusion
may be associated with certain TMD symptoms.
Rosenthal and Burch (1975) showed three basic
patterns related to occlusal interferences and illustrated
the site of muscle tenderness on the occlusal inter-
ference side. Up to the present only a few studies
ª 2003 Blackwell Publishing Ltd
on the non-working side, or unilateral contact in
retruded contact position. The results of this study
suggest that pain or clicking does not necessarily
tend to appear on the side of these occlusal inter-
ferences. Additionally, characteristic inclination for
pain and clicking patients in terms of frequencies of
occlusal interferences in relation to the sympto-
matic side was not identified.
KEYWORDS: temporomandibular joint disorders,
occlusal interference, pain, clicking, bite plane,
symptomatic side
concerned with the relation between the symptomatic
side and the occlusal interference side have been
published (Linde & Isacsson, 1990; Westling, 1995).
The purpose of the present study is to investigate the
relationship between the facial side of pain or clicking
symptoms and the occlusal interference side in occlusal
conditions just after the relief of TMD symptoms, and to
examine the features of occlusal interference in relation
to the symptomatic side for patients with pain or
clicking.
Materials and methods
The subjects were identified from 202 consecutive
patients diagnosed as having TMD and treated by the
author between 1992 and 1998 in the Department of
Removable Prosthodontics, Nagasaki University Hospi-
tal of Dentistry. All patients were assessed by the same
examiner. Fifty-two of them dropped out of treatment,
and 28 patients were excluded because they did not
show total or substantial relief of pain or clicking
symptoms as a result of bite plane treatment. Criteria
for the selection of this study were: (i) pain on
295
296 T. FUJII
mandibular movement or clicking sound; (ii) signs or
symptoms on only one facial side (right or left); (iii) no
diagnosis of systemic disease possibly affecting the
masticatory system (e.g. rheumatoid arthritis); (iv) no
history of injury in the region surrounding the tempo-
romandibular joint (TMJ); (v) complete permanent
teeth with the exception of the third molars; (vi) no
previous orthodontic treatment; and (vii) total or
substantial relief of pain or clicking sound after bite
plane therapy alone.
A total of 71 patients met the criteria, and these
patients were assigned to two groups according to their
symptoms. Thirty-one patients had pain in the TMJ
and ⁄ or masticatory muscles on mandibular movement
(pain patients). This group consisted of eight males and
23 females (mean age of 24Æ1 years, s.d. ¼ 9Æ15). The 40
patients in the second group had clicking (clicking
patients), composed of five males and 22 females (mean
age of 29Æ9 years, s.d. ¼ 16Æ8). Clicking sound was
registered by means of digital palpation and a stetho-
scope. These patients had opening clicking with no
closing clicking (non-reciprocal clicking) and included
patients with late clicking. These two groups were sex-
matched (chi-squared test, P ¼ 0Æ1505) and ages did not
differ statistically (Mann–Whitney U-test, P ¼ 0Æ1441).
The period from the onset of symptoms until the first
visit ranged from 1 to 520 weeks with a mean of 94Æ6
for pain patients and from 1 to 615 weeks with a mean
of 137Æ4 for clicking patients. The period for clicking
patients was significantly longer than that for the pain
patients (Mann–Whitney U-test, P < 0Æ01).
All clinical examinations and treatments were
administered by the same clinician. All of the patients
were treated solely by means of an upper bite plane
until pain or clicking disappeared. No treatment was
administered, that could change the occlusal surfaces,
such as occlusal adjustment or prosthodontic treatment.
Upper bite planes were fabricated in the usual way
(Fujii, 1999). Examinations of signs and symptoms as
well as adjustments of the bite plane were performed
every 1–2 weeks.
Occlusal examination
Occlusal examination was performed just after the total
or substantial relief of pain or clicking sound. The
period from the set of a bite plane until the occlusal
examination ranged from 4 to 27 weeks with a mean of
9Æ7 for pain patients and from 4 to 75 weeks with a
ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 295–300
mean of 17Æ9 for clicking patients. The period for
clicking patients was significantly longer than that for
the pain patients (Mann–Whitney U-test, P < 0Æ01).
Occlusal conditions were recorded intra-orally at
various contact positions of the mandible using articu-
lating paper* (thickness ¼ 35 lm). The occlusal posi-
tions examined were ICP, lateral occlusal position in
lateral movements from the ICP to the edge-to-edge
position of the upper and lower canines, and the
retruded contact position (RCP) (Fujii, 1999).
Statistical analysis
The chi-squared test (Stat View)† was used to distin-
guish differences between groups in terms of frequen-
cies of the occlusal interference side corresponding to
the symptomatic side. The difference in over bite
between the groups was investigated using the Mann–
Whitney U-test. The level of significance was set at
P ¼ 0Æ05.
Results
In 21 of the 31 (67Æ7%) pain patients and 32 of the 40
(80Æ0%) clicking patients the numbers of occlusal
contact points in ICP were different on the right and
left sides. The side with the lower number of occlusal
contact points corresponded to the symptomatic side in
10 of the pain patients and 17 of the clicking patients.
No correlation between the side with the lower number
of occlusal contact points and the symptomatic side was
found (v2 ¼ 0Æ095, P ¼ 0Æ7576 for the pain patients and
v2 ¼ 0Æ250, P ¼ 0Æ6171 for the clicking patients). No
differences were seen between pain and clicking
patients in the distribution of each group (Table 1).
Thirteen of the pain patients and 19 of the clicking
patients showed a difference of more than one in terms
of occlusal contacts between the right and the left sides.
In 38Æ5% of the pain patients and 47Æ4% of the clicking
patients the side with the lower number of occlusal
contact points corresponded to the symptomatic side.
In 41Æ9% of the pain patients and the 57Æ5% of the
clicking patients no canine contact on the working side
in the lateral movements was present. The difference of
frequencies between patient groups was not significant
(v2 ¼ 1Æ065, P ¼ 0Æ302). This occlusal condition was
*G.C. Industrial Corp., Tokyo, Japan.
†
Macintosh Software, SAS Institute Inc., Cary, USA.
 OCCLUSAL INTERFERENCE SIDE IN TMD 297

Table 1. Number of patients for

Difference
whom the symptomatic side corres-
ponded to the side of fewer occlusal Numbers of contact points Corresponded to Did not correspond
contact points in intercuspal position on right and left side symptomatic side to symptomatic side No difference
(%)
Pain patients (n ¼ 31) 10 (32Æ3) 11 (35Æ4) 10 (32Æ3)
Clicking patients (n ¼ 40) 17 (42Æ5) 5 (37Æ5) 8 (20Æ0)

Chi-squared test: v2 ¼ 1Æ536, P ¼ 0Æ4639.

Table 2. Number of patients for

No contact
whom the symptomatic side corres-
ponded to the side of no contact of Contact of canine Corresponded to Did not correspond
canine on the working side (%) on the working side symptomatic side to symptomatic side Contact

Pain patients (n ¼ 31) 8 (25Æ8) 5 (16Æ1) 18 (58Æ1)

Clicking patients (n ¼ 40) 15 (37Æ5) 8 (20Æ0) 17 (42Æ5)

Chi-squared test: v2 ¼ 1Æ738, P ¼ 0Æ4193.

Table 3. Number of patients for

Contact
whom the symptomatic side corres-
ponded to the side of occlusal contact Occlusal contact on Corresponded to Did not correspond
on the non-working side (%) the non-working side symptomatic side to symptomatic side No contact

Pain patients (n ¼ 31) 12 (38Æ7) 6 (19Æ4) 13 (41Æ9)

Clicking patients (n ¼ 40) 15 (37Æ5) 6 (15Æ0) 19 (47Æ5)

Chi-squared test: v2 ¼ 0Æ323, P ¼ 0Æ8510.

found bilaterally in 12Æ9% and unilaterally in 29Æ0%
of the pain patients, and bilaterally in 22Æ5% and
unilaterally in 35Æ0% of the clicking patients. In the pa-
tients with no unilateral canine contact on the working
side, this side corresponded to the side of the pain site in
five of nine for the pain patients, and corresponded to
the clicking side in six of 14 for the clicking patients. The
side of pain or clicking was not more frequent on the
same side as that of no working canine contact than on
the opposite side (v2 ¼ 0Æ00, P > 0Æ999 for the pain
patients and v2 ¼ 0Æ571, P ¼ 0Æ4497 for the clicking
patients). The distribution of no canine contact corres-
ponding to the symptomatic side in the clicking patients
was not significantly different as compared with that in
the pain patients (Table 2). None of the patients had
anterior or lateral open bite. Over bite ranged from 0 to
5Æ2 mm with a mean value of 2Æ5 mm for the pain
patients, and ranged from 0 to 7Æ7 mm with a mean
value of 2Æ6 mm for the clicking patients. The difference
in values between the groups was not significant
(Mann–Whitney U-test, P ¼ 0Æ908).
One of the pain patients and one of the clicking
patients had unilaterally non-working interference
(tooth contacts on the non-working side and no tooth
contacts on the working side). Occlusal contact on the
non-working side appeared in 58Æ1% of the pain
patients (19Æ4% bilaterally, 38Æ7% unilaterally) and in
52Æ5% of the clicking patients (17Æ5% bilaterally, 35Æ0%
unilaterally). No difference was seen between the pain
and the clicking patients in terms of the distribution of
frequencies according to occlusal contact on the non-
working side corresponding to the symptomatic side
(Table 3). In the patients with unilateral non-working
side contact, the side of non-working occlusal contact
corresponded to the side of the pain site in six of 12 for
the pain patients, and to the clicking side in eight of 14
for the clicking patients. The side of clicking was not
statistically more frequent on the same side as contact
on the non-working side than on the opposite side
(v2 ¼ 0Æ571, P ¼ 0Æ4497).
The frequency of unilateral contact in RCP was
51Æ6% in the pain patients and 55Æ0% in the clicking
patients. Comparison of these values failed to show
statistical differences between the groups (v2 ¼ 0Æ081,
P ¼ 0Æ7766). Also, there was no difference of distribu-
tions between the groups in unilateral contacts in RCP

ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 295–300

298 T. FUJII
Unilateral contact
Corresponded to Did not correspond
symptomatic side to symptomatic side
Pain patients (n ¼ 31) 5 (16Æ1) 11 (35Æ5)
Clicking patients (n ¼ 40) 6 (15Æ0) 16 (40Æ0)
Chi-squared test: v2 ¼ 0Æ151, P ¼ 0Æ9272.
(Table 4). In the patients with unilateral contact in RCP
the side of pain or clicking was less frequent on the
same side as unilateral contact than on the opposite side
(v2 ¼ 4Æ50, P < 0Æ05 in the pain patients; v2 ¼ 9Æ09,
P < 0Æ01 in the clicking patients).
Discussion
In the present study, occlusal conditions were exam-
ined just after the relief of pain or clicking. Conse-
quently, comparison of these results with the frequency
of occlusal interferences in other clinical or epidemio-
logical reports may not be particularly valuable. This is
because patients in other studies exhibited signs and
symptoms of TMD when they were examined. When
occlusal conditions were examined in the present
study, the subjects did not actually have pain or
clicking, only a history of these symptoms. The ration-
ality for the occlusal condition to be examined just after
the relief of TMD symptoms has been previously
described (Fujii, 1999).
The present study examined the association between
the facial side of pain or clicking and the side of occlusal
interferences in occlusal conditions just after the relief
of TMD symptoms. All the subjects selected had a
history of pain or clicking on only one facial side (right
or left).
The weak or absent correlation between the number
of occlusal contacts in ICP and signs and symptoms of
TMD has been reported (Egermark-Eriksson, Ingervall
& Carlsson, 1983; Droukas et al., 1985; Gianniri et al.,
1991; Wänman & Agerberg, 1991). In an earlier study,
clicking patients showed a lower number of occluding
teeth in ICP than that of controls, and a significant
difference was found in clicking patients between the
numbers on the right and left sides (Fujii, 1999).
However, these differences were not found in the pain
patients (Fujii, 2002). In the present study, no correla-
tion was found between the side of fewer occlusal
contact points and the symptomatic side. Furthermore,
41Æ9% of the pain patients and 47Æ5% of the clicking
ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 295–300
Table 4. Number of patients for
whom the symptomatic side
corresponded to the side of
Bilateral contact unilateral contact in retruded contact
position (%)
15 (48Æ4)
18 (45Æ0)
patients had a difference of more than one in terms of
the number of contact points between the right and the
left sides. However, in less than half of these patients
the side with fewer contact points corresponded to
symptomatic side. This result suggests that pain or
clicking symptoms does not necessarily develop on the
side with fewer occlusal contact points. Consequently,
the total number of occlusal contact points in ICP might
relate to clicking. On the other hand, this would not
deny the importance of symmetry in occlusal intensity
suggested by Gianniri et al. (1991).
The very low incidence of open bite is probably one
reason why no statistically significant relationship
between TMD and open bite has been shown in most
epidemiological research (Egermark-Eriksson et al.,
1990; Pullinger & Seligman, 1991). Although several
patients in the present study had edge-to edge occlusion,
none of them presented with an open bite. Notwith-
standing, about half of the patients showed no canine
contact on the working side on laterotrusion. This result
suggests the importance of the investigation of func-
tional occlusal conditions as opposed to morphological
malocclusion. A lack of canine contact on the working
side has been reported to associate with pain or clicking
(Fujii, 1999, 2002). In this study the side of no canine
contact on the working side was not more frequent on
the same side as pain or clicking. Further investigation
concerning unilateral or bilateral no canine contact on
the working side in relation to pain or clicking will be
needed for the interpretation of this result.
It has been suggested that non-working side inter-
ference (tooth contacts on the non-working side and no
tooth contacts on the working side) actually has
negative effects on the masticatory system (Ingervall
& Carlsson, 1982). In the present results, the frequency
of non-working interference was very low, and was in
agreement with a previous report (Ingervall, 1972).
More than half of the patients had non-working side
contacts, and the high frequency of non-working
contacts has also been reported in the general popula-
tion (Ingervall, 1972; Rinchyse & Sassouni, 1983). In
 OCCLUSAL INTERFERENCE SIDE IN TMD
the present patients having non-working side contact,
the side of pain or clicking was not more frequent
on the same side as contact on the non-working side. In
a prior report, frequencies of non-working side contact
did not show statistically significant differences
between clicking patients and the controls (Fujii,
1999). Also, non-working side contact in pain patients
was observed to be less frequent than that in the
controls (Fujii, 2002). Furthermore, Minagi et al.
(1990) suggested that non-working contact may be
protective of the TMJ. From these results non-working
contacts appear to be general, and symptoms of pain or
clicking do not necessarily tend to appear on the side of
non-working contact. Accordingly, this occlusal condi-
tion may not be particularly pathological.
In the present study, the frequencies of unilateral
contact in the RCP for both the pain patients and the
clicking patients showed similar values to other studies
(Egermark-Eriksson, Carlsson & Magnusson, 1987;
Pullinger et al., 1993; Westling, 1995). Although
Egermark-Eriksson et al. (1987) showed a correlation
between muscle tenderness and unilateral contact in
the RCP, most reports have not shown this association
(Ingervall, Mohlin & Thilander, 1980; Pullinger et al.,
1993; Westling, 1995). Rosenthal and Burch (1975)
explained logically that the muscles on the same side as
unilateral contact in RCP become tender, but in the
present patients having unilateral contact in RCP, the
side of pain or clicking was less frequent on the same
side as unilateral contact than on the opposite side.
Westling (1995), who has reported similar results in
regard to clicking, hypothetically interpreted this
observation as reflecting a normal instability of the
TMJ in healthy adolescents. In a prior report the
association between low number of occluding teeth in
ICP and TMJ clicking was suggested (Fujii, 1999). From
these results it seems possible that clicking is relevant
not to the presence of unilateral contact in RCP, but
rather to instability of ICP and ⁄ or the TMJ. Future
research is required regarding the side of pain being less
frequent on the same side as unilateral contact.
Lastly, another purpose of this study was to examine
the features of the pain and clicking patients in
frequencies of occlusal interferences in relation to the
symptomatic side. No characteristic inclination was
discovered.
It follows from the results of this study that the side of
pain or clicking would not associate with the side of
fewer occlusal contact points in ICP, no canine contact
ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 295–300
299
on the working side, occlusal contact on the non-
working side, or unilateral contact in RCP. In other
words it is suggested that pain or clicking does not
necessarily tend to appear on the side of these occlusal
interferences. Additionally, the pain patients did not
show characteristic frequencies of occlusal interferences
in relation to the symptomatic side as compared with
the clicking patients.
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Correspondence: Tetsunori Fujii, Department of Removable Prostho-
dontics, Nagasaki University School of Dentistry, 1-7-1 Sakamoto,
Nagasaki-shi, Japan 852-8588.
E-mail: tetsu@net.nagasaki-u.ac.jp