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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 17, Number 11, 2011, pp. 9951000 Review Articles


Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2010.0739

The Relationship Between


Dental Occlusion/Temporomandibular Joint Status
and General Body Health:
Part 1. Dental Occlusion and TMJ Status Exert
an Influence on General Body Health

Hyung-Joo Moon, DDS, MSD, PhD,1 and Yong-Keun Lee, DDS, MSD, PhD1,2

Abstract

Background: There have been varied studies that have suggested a relationship between dental occlusion/
temporomandibular joint (TMJ) status and general body health. Therefore, it is important to elucidate the
systematic relationships and corresponding action mechanisms between them.
Objectives: The purpose of this part of study was to review the relationships between dental occlusion/TMJ
status and systemic body health based on the published literature.
Methods: This study, based mostly on peer-reviewed specialist articles, has determined that dental occlusion/
TMJ status exerts an influence on (1) synchronization of head and jaw muscles with the muscles from other body
sites for proper body posture; (2) body stability such as body equilibrium (balance), center of gravity fluctuation,
and gaze stability; and (3) physical performance along with physical fitness.
Conclusions: Therefore, these relationships should be further investigated and extended to the whole body, and
the action mechanisms should be elucidated.

Introduction These connections and corresponding healing might play an


important role in complementary and alternative medicine

T he authors have treated the symptoms originating


from the disorders in temporomandibular joint (TMJ) and
occlusion for a number of years. During the course of these
(CAM).
CAM comprises a group of diverse medical and health
care systems, practices, and products. CAM treatments in-
treatments, it was found that restoring the dental occlusion clude whole-body treatment, mindbody medicine, biologi-
and TMJ status to their normal or natural condition resulted cally based practices, body manipulation, and other
in a change in general body health, in most circumstances therapeutic and vitality-stimulating practices.9 CAM of late
better than before. The general conditions that improved, as has attracted interest in the dental field.10,11 However, the
reported by the patients, included body posture such as left term integrative medicine in the dental field,9 in short, inte-
and right equilibrium, back pain, hyperhydrosis, hand tre- grative dentistry, would most likely be a better term for the
mor, gaze stabilization, gag reflex, blurred vision, and explanation of the connections between dental occlusion/
headache. Therefore, a connection was conjectured between TMJ and other parts of the body. Integrative medicine
dental occlusion/TMJ status and general body health based combines treatments from both of Western and alternative
on clinical findings and related reports.15 Such a connec- medicine for which there is a substantial body of high-
tion might be anatomical or related to various body sys- quality evidence for effectiveness.
tems, and certain of these connections have been reportedly There have been studies conducted on the relationships
observed in Western medicinebased investigations.18 between dental occlusion/TMJ and general body health. Al-
However, the mechanism of the healing effect after occlusal terations of the manducatory system, resulting from lesions in
or TMJ treatments on general body health still is not clear. the masticatory muscles or dentoalveolar ligaments, can

1
Moon Dental Hospital, Seoul, Korea.
2
Institute for Clinical Performance of Biomaterials, Seoul, Korea.

995
996 MOON AND LEE

perturb visual stability and thus generate postural imbalance.1 The treatments of dental diseases seek to bring about a
The position and functioning of the mandible affect the center condition of harmony within the entire stomatognathic sys-
of gravity.2,3 Dental occlusion has been shown to be associated tem. In this sense, teeth are a set of gears anchored in bone,
with reduced lower extremity dynamic strength, agility and and the upper and lower jaws are attached to each other by
balance in elderly people.4 The proper functional occlusion of the TMJ.14 Powerful muscles guide and direct the movement
natural or artificial teeth has been shown to play an important of the lower jaw, allowing the teeth to carry out their func-
role in generating an adequate posture reflex through man- tions of chewing and speaking. If the TMJ and teeth are not
dibular stability, thereby preventing falls.5 Therefore, it is in synchrony, the masticatory muscles over time can literally
necessary to elucidate the systematic relationships and corre- destroy an otherwise healthy dentition.14,15
sponding action mechanisms between dental occlusion/TMJ
status and general body health.
TMJ and TMJ disorders
In this series of reviews (parts 1 and 2), the relationships
between dental occlusion/TMJ status and general body health According to the National Institute of Dental and Cra-
are scrutinized, based mostly on peer-reviewed articles, and a niofacial Research,16 there are several types of TMJ disorder:
conceptual theory that can explain this healing mechanism is (1) myofascial pain is the most common, which is charac-
proposed. In part 1, basic concepts related to dental occlusion terized by discomfort or pain in the muscle that controls the
from the viewpoint of integrative dentistry are introduced, jaw as well as the neck and shoulder muscles; (2) internal
and articles dealing the relationships between them are in- derangement of the joint; and (3) degenerative joint disease.
vestigated. In part 2, a conceptual theory to explain the rela- Myofascial pain, referred from hyperalgesic trigger points
tionships between them is proposed from the viewpoint of located in skeletal muscle and its associated fascia, is a
fascial connection.7 A fascia is a connective tissue that sur- common cause of persistent regional pain.17 A myofascial
rounds muscles, groups of muscles, blood vessels and nerves, component is frequently considered part of these pain syn-
binding those structures together like plastic sandwich dromes that involve TMJ. TMJ dysfunction caused by myo-
wraps.8 It consists of several layers: a superficial fascia, a deep fascial disorders with trigger points in masticatory muscles is
fascia, and a subserous (or visceral) fascia and extends unin- variously referred to as oromandibular dysfunction, myo-
terrupted from the head to the tip of the toes. Since the fascial fascial pain-dysfunction syndrome, the TMJ pain dysfunc-
connection through the whole body has already been intro- tion syndrome, or craniomandibular dysfunction. Trigger
duced,6 the focus of the present study was to emphasize the points in masticatory muscles are presumably caused by
importance of TMJ and dental occlusion for the building up malocclusion, misalignment of the jaws, habitual parafunc-
and maintenance of general body health through fascial con- tion of the jaws (clenching, bruxism, and jaw posturing),
nections. Future studies regarding the psychologic and emo- abnormal head and neck postures, or trauma.17
tional factors and CAM factors such as qi and the meridian Pinpointing the specific causes for a given TMJ disorder
system, cerebrospinal fluid, and other disciplines for these can prove difficult, due to the following reasons: (1) patients
connections might be followed additionally. often have more than one problem; (2) jaw pain can be re-
The purpose of this part of the study was to review the ferred from other areas, such as problems in the sinuses or
relationships between the dental occlusion/TMJ status and dental conditions; and (3) TMJ symptoms can result from a
general (systemic) body health based on specialist literature. systemic problem such as fibromyalgia, rheumatoid arthritis,
lupus, and so on.18 The originating causes of the TMJ dis-
Occlusion, TMJ, and TMJ Disorder orders can be categorized into the five groups such as dental,
injury, habit, stressful social situation, and emotional fac-
Occlusion
tors.18 Regarding the causes of TMJ disorders by injury,
The meaning of dental occlusion is simply the contact whiplash, traction appliances, and blows to the head, face, or
between the teeth. It is the relationship between the maxil- jaw have been proposed.18 TMJ disorders are known to be a
lary and mandibular teeth when they approach coming into possible sequela of motor vehicle accidents, particularly
contact with each other, as occurs during chewing or at when flexionextension injury occurs. The literature related
rest.12 The TMJ is the joint of the jaw. The name is derived to motor vehicle accidents, whiplash injury, and TMJ dys-
from the two bones that form the joint: the upper temporal function was reviewed.19 An analysis of the forces resulting
bone and the mandible. The unique feature of TMJ is that this from these rear-end (whiplash) motor vehicle accidents in-
joint is the only bilateral joint that crosses the midline.13 One dicates that tensile, compressive, and shear forces occur that
can move any right-sided joint such as arm, leg, hip, and so challenge the integrity of the soft tissues of the TMJ.20 Evi-
on without the moving the left corresponding joint. How- dence of significant injury to the TMJ, ear, and ophthalmic
ever, one cannot move the right TMJ without moving the left system has been also found following a soft-tissue hyperex-
TMJ, which has many implications in fascial connections, tension injury of the cervical spine.21
neuroanatomy, and neurophysiologic effects of the TMJ. Regarding causes of TMJ disorder by habits, bad posture,
It is suggested that there are five requirements for the ideal bad ergonomic habits at work, oral habits such as pencil
organic occlusion in gnathology,14 such as a centric jaw rela- biting, gum chewing or clenching, childhood habits such as
tion, immediate front teeth separation, proper cuspfossa re- thumb sucking, and poor diet and strenuous activities such
lationship, stable/even bite, and proper space (volume) inside as heavy lifting that strain the neck or the back have been
the mouth. Organic occlusion is an arrangement of the teeth cited.18 During a parafunctional swallowing, the oral seal is
such that they properly fit into the oral space without vio- achieved by contracting the obicularis and buccinator mus-
lating group uses of the teeth, length of the chewing muscles, cles against the tongue, which results in obvious hypertro-
interocclusal space, rest position, and condylar control. phy of the relevant muscles. Depending on the severity of
DENTAL OCCLUSION AND GENERAL BODY HEALTH: PART 1. CONNECTION 997

this habit, the teeth may be sucked lingually, often causing The biomechanical effects on cervical vertebral columns
the crossbites associated with TMJ disorder.22 during mastication were calculated, which confirmed that
Since the TMJ lies in close proximity to the brain, ears, vertical occlusal alteration could influence stress distribution
eyes, and balancing system, the seating of the mandible in in the cervical columns.34 Lateral inclination of the occlusal
the mandibular fossa is of considerably greater importance plane and imbalance between the right and left masticatory
than is often appreciated. Dizzy spells, ringing in the ears, muscles antagonistically act on displacement of the cervical
headaches, pains, and noises in the head may all be related to spine (i.e., the morphological and functional characteristics in
poor condyle posture in the joint.14 These symptoms also patients with mandibular lateral displacement may play a
include the blurring of vision, otalgia, tinnitus, hyperacusis, compensatory role in posture control).35 Possible associations
aerotitis media, deafness, staggering gait, vertigo, dizziness, between trunk and cervical asymmetry and facial symmetry
nausea, vomiting, abdominal pain, blackouts, and even loss were reported.36 It was found that frontal head position in
of consciousness.23 relation to the true vertical is stable in that the angle between
the supraorbital and vertical lines is constantly maintained
Relationship Between Occlusion/TMJ close to 90 regardless of moderate trunk asymmetry, indi-
and General Body Health cating that visual perception control is most important in
orienting the head in the frontal plane.36
The subgroups of general body conditions correlated with
A relationship between dental occlusion and posture
dental occlusion/TMJ may be divided into three parts: (1)
control has been postulated,37,38 and it was subsequently
synchronization of the head and jaw muscles with muscles at
confirmed that there is a close relationship between occlusal
other parts for the purpose of proper body posture; (2) body
support and head posture.2 The influences of head and body
balance (equilibrium); and (3) physical performance. All of
posture on the mandibular rest position, range of functional
the following reports support the notion that there are sys-
movements, and initial tooth contact were documented.39
tematic relationships between dental occlusion/TMJ and
Clinical studies showed that the jaw and neck muscles work
general body health.
together in a relatively stereotypical fashion during rhythmic
movements.40,41 These studies suggest that orofacial sensory
Synchronization of the head and jaw muscles
information, especially the periodontal input, modifies neck
with muscles at other parts of the body
muscle activity, which is thought to be an important neural
Electromyographic studies show that patients with TMJ substrate for the coordination of masticatory function.42 The
disorder often have abnormal patterns of muscle activity.24 The effects of the specific modalities of sensory inputs to the teeth
functional coupling of the stomatognathic system with the neck on the motor activity of neck muscles were tested, and it was
muscles is well known. Patients suffering from occlusal or TMJ suggested that periodontal inputs play an important role in
disorders frequently report dysfunction and pain in their neck controlling neck muscle motor activity.43
muscles.25,26 Among the neck muscles, the role of the sterno- The relationships between orthopedic findings such as
cleidomastoid muscle is to maintain and change the posture of unequal leg length, pelvic obliquity, columnar diseases and
the head. The activity of the sternocleidomastoid muscle is head posture, and dental findings such as occlusion, man-
synchronized with the jaw-closing muscles in both mastication dibular position, TMJ and masticatory muscles were re-
and involuntary clenching.27 Tenderness of the sternocleido- viewed.44 As a result, most of the publications lacked good
mastoid muscle is often found in patients with TMJ disorders, evidence, although there has been an expression of great
and pain in the region of the sternocleidomastoid muscle was interest in the possible relationships between orthopedic and
improved by occlusal treatments.2830 An imbalance of the dental findings. The hypothesis that there is a relationship
sternocleidomastoid muscle activity, leading to neck pain, can between the TMJ, osteoarthritis/osteoarthrosis, head pos-
be induced by a unilateral loss of occlusal support.2 These ture, and dentofacial morphology was tested and the results
findings suggest a systematic relationship between occlusal did suggest an association among all of them.45
status and the sternocleidomastoid muscle. In summary, it can be concluded that there is a necessary
Traumatic minor cervical strains are commonplace in systematic synchronization of the head and jaw muscles with
high-impact sports, and premature degenerative changes the muscles of other parts of the body to maintain proper
have been documented in sports players exposed to recur- body posture.
rent impact trauma or repetitive forces. It is evident that
impairments in position sense are observed in individuals
Dental occlusion/TMJ and body stability
who have experienced whiplash-type injuries and individu-
als with chronic head and neck pain of nontraumatic origin Body equilibrium (balance), center of body gravity fluc-
such as cervical spondylosis.31 The biomechanical influences tuation, and gaze stabilization have been utilized as assess-
of head posture on the cervical column and craniofacial ment criteria to determine the influence of occlusion/TMJ on
complex during masticatory simulation were quantified us- the stability of the body. At the outset, basic information
ing three-dimensional finite-element analysis.32 Results regarding body stabilization needs to be briefly considered.
showed that alteration of head posture was directly related Human beings assume a relatively unstable postural state
to stress distribution on the cervical column, but may not when in the standing position, because the supporting
always directly influence the occlusal state. The influence of plantar area is narrow; therefore, the maintenance of stand-
altered neck muscle function on the morphology of the cra- ing position is related to the center of gravity fluctuation, a
niocervical area was studied in the rat. The findings are in- phenomenon that is said to be controlled by information
dicative of postnatal functional adaptation of periosteally from the ocular region, three semicircular canals, and anti-
mediated bone morphogenesis in the craniocervical area.33 gravity muscles.46,47 In addition, the center of gravity is
998 MOON AND LEE

positioned at a high point in the human being, because the fluence of occlusion/TMJ on the physical performance of the
heavy skull is located at the highest point of the vertebral body. Empirically, coaches advise sports players to wear
column,48 which makes balancing difficult. Complex ner- occlusal splints or mouthguards during competitions in or-
vous interactions regulate the function of oculocephalic der to increase motor performance in such sports as base-
synergetic centers, which can help in maintaining a proper ball,59 long distance running,60 and football.61 It was also
masseter muscle tone in order to maintain the mandibular reported that proper teeth clenching plays an effective role in
axis in the correct position.49 the enhancement of sports performance.62 Improvement in
In addition to these findings, it has been suggested that postural control under the centric relation occlusion resulted
occlusion and head position affect the center of gravity, re- in superior shooting performance in shooters.1 The centric
sulting in an increased risk of falling.50.51 When individuals relation occlusion is the mandibular position in which the
are in an upright position, continuous oscillations are gener- head of the condyle is situated as far superior and anterior as
ated to maintain balance. Sensorial afferents are provided it possibly can within the mandibular fossa.
from proprioceptive, tactile, vestibular, and visual receptors. The relationships between dental occlusal status and
Proprioception of the mandibular system arises from the physical fitness in elderly adults were investigated, and it
masticatory muscular system and dentoalveolar ligaments. was reported that leg extensor power, stepping rate, and
Therefore, poor or absent dental occlusion may decrease one-leg standing time were useful indicators for evaluating
proprioception in this area, interfering with the proper sta- lower extremity dynamic strength, agility, and balance
bility of the head posture.1 Head movements may be related function, respectively.4 The relationship between the pres-
to orofacial functioning, which is predominantly controlled by ence of occlusal support in edentulous subjects and their
somatosensory inputs from the orofacial area.43 Propriocep- capacity for physical exercise was investigated, and it was
tion of the mandibular system has a great effect on postural concluded that reconstruction of occlusal support at a de-
control,52 and postural control is significantly impaired after sirable mandibular position had significance not only for the
unilateral conduction anesthesia of the mandibular nerve. restoration of masticatory function but also for the mainte-
It is thought that tooth loss is a risk factor for postural nance of physical exercise.63
instability, and that the incisors and molars play different In summary, it can be concluded that dental occlusion/
roles.53,54 Physiologically, mechanical receptors in the peri- TMJ condition influenced physical performance.
odontal membrane control mandibular movements and co-
ordinate the masticatory function,55,56 and this is related to Conclusions
the motor activity of neck muscles.43 These further suggest
Based on the specialist literature, dental occlusion/TMJ
that proprioceptive sensation from the periodontal ligament
status influenced systemic body activities such as synchro-
receptor plays a role in body balance control.54
nization of the head and jaw muscles with other parts of
Modifications of the position of the center of foot pressure
muscles to achieve proper body posture, body-stabilizing
during normal standing caused by the occlusal condition were
activities such as body equilibrium, gravity fluctuation and
investigated.39 Poor or inadequate dental occlusion might be a
gaze stability, and physical performance such as muscle ac-
predisposing factor for falls in older people, and improving
tivity, physical fitness, and motor performance. Therefore,
occlusion deserves attention as an approach to the prevention of
the action mechanism for these evident relationships should
falling in elderly patients.5 A relationship between dental oc-
be further investigated. Furthermore, in addition to Western
clusion and fallings among the elderly with dementia has also
medicinebased references, therapeutic practices from the
been demonstrated.5,57 These findings show that elderly indi-
viewpoint of CAM should be further investigated in order to
viduals who lack proper dental occlusion are at a higher risk of
set up an approach of integrative dentistry for the TMJ.
falling than those whose dental occlusion has been maintained.
Therefore, it was suggested that a dental examination should be
Disclosure Statement
included in the standard health examination for elderly persons,
especially those with symptoms of dementia.5 No competing financial interests exist.
The center of gravity fluctuation caused by experimentally
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