10.59987/ads/2018.3.95-105
Aims: Temporomandibular disorders (TMD) are a wide group of clinical conditions affecting the temporomandibular joint and the surrounding neuronal and musculoskeletal components. Cervical spine pain (CSP) has been proposed as a risk factor. Thus, the aim of this review is to analyse the available literature to document anatomical, pain and postural association between TMD and cervical spine.
Methods: A systematic review of the literature was performed on TMD and cervical spine, using the following inclusion criteria: studies of any level of evidence, reporting clinical or preclinical results and dealing with the anatomical, pain and postural association between TMD and cervical spine.
Results: A total of n=1150 articles was found. After duplicates exclusion, n=947 articles were selected. At the end of the first screening, following the previously described selection criteria, we selected n=55 articles eligible for full-text reading. Ultimately, after full-text reading, and reference list check, we selected n=25 articles following previously written criteria.
Conclusions: The literature available on the association between TMD and CSP presents major limitations in terms of great heterogeneity. Although a lot of studies focused on the genetic, biomechanical, and radiological background of the disease there is lack of consensus on one or multiple major actors. However, based on our analysis an association between TMD and cervical pain-related symptoms (headache, cervical pain, back pain) can be assumed. More studies are needed to understand the complex and multifactorial genesis of the association.
application/pdf
1971-1441
34
3
en
P. Cascone 
https://creativecommons.org/licenses/by-nc-nd/4.0
Annali di stomatologia
temporomandibular joint
Temporomandibular disorders and cervical spine: a systematic review
Text.Serial.Journal
https://www.annalidistomatologia.eu/ads
9
Review article
2022-08-09
2022-08-09
2018-09-01
2023-12-04
95-105
Ann Stomatol (Roma)
P. Cascone 
2018
10.59987/ads/2018.3.95-105
95
1971-1441
3
temporomandibular joint
en
105
Temporomandibular disorders and cervical spine: a systematic review
https://www.annalidistomatologia.eu/ads/article/download/34/22
9
                                                                                                  Review article



    Temporomandibular disorders and cervical spine:
    a systematic review




                                                                                               li
                                                                                             na
    Emanuele Chisari MD Student1                             list check, we selected n=25 articles following
    Enrico Buccheri MD Student1                              previously written criteria.
    Giuliana Cubisino MD Student1                            Conclusions: The literature available on the asso-




                                                                                           io
    Federica D’Arma MD Student1                              ciation between TMD and CSP presents major lim-
    Erika Catania MD Student1                                itations in terms of great heterogeneity. Although
    Carlo Di Paolo MD, DDS2                                  a lot of studies focused on the genetic, biome-




                                                                       az
    Piero Cascone MD, PhD2                                   chanical, and radiological background of the dis-
                                                             ease there is lack of consensus on one or multi-
                                                             ple major actors. However, based on our analysis
                                                             an association between TMD and cervical pain-re-




                                                                     rn
    1University of Catania, Medical school, Catania, Italy   lated symptoms (headache, cervical pain, back
    2 Oral and Maxillo Facial Sciences Department,           pain) can be assumed. More studies are needed
    “Sapienza” University of Rome, Rome, Italy               to understand the complex and multifactorial gen-
                                                             esis of the association.




                                                       te
                                                             Key Words: cervical spine, myofascial, pain, tem-
    Corresponding Author:                                    poromandibular disorders, temporomandibular
    Emanuele Chisari
                                                     In      joint.
    Department of General Surgery and Medical Surgical
    Specialties
    Section of Orthopaedics and Traumatology
    AOU Policlinico-Vittorio Emanuele, University            Introduction
                               ni

    of Catania
    95123 Catania, Italy                                     Temporomandibular disorders (TMD) are a wide
    E-mail: chisari.emanuele@gmail.com                       group of clinical conditions affecting the temporo-
                             io


                                                             mandibular joint and the surrounding neuronal and
                                                             musculoskeletal components (1). TMD prevalence is
                                                             attested to be higher than 5% (1). Lipton et al. (2) in
                           iz



    Summary                                                  1993 reported an evidence of a prevalence between
                                                             6 and 12%. Today recent epidemiological studies
    Aims: Temporomandibular disorders (TMD) are a            support an higher prevalence up to 25-30% or even
            Ed




    wide group of clinical conditions affecting the          higher (3-6). This group of disease is present in a
    temporomandibular joint and the surrounding              broad group of ages, with a peak of prevalence in 20-
    neuronal and musculoskeletal components. Cer-            40 aged woman (7). While its wide presence among
    vical spine pain (CSP) has been proposed as a            general population, only 5-10% of patients requires
    risk factor. Thus, the aim of this review is to anal-    treatment (8).
    yse the available literature to document anatomi-        The etiology is often multifactorial and can be usual-
 IC




    cal, pain and postural association between TMD           ly be associated with traumatic or atraumatic patient
    and cervical spine.                                      history. While there is evidence of genetic predispo-
    Methods: A systematic review of the literature           sition mainly related to catechol-O-methyltrans-
    was performed on TMD and cervical spine, using           ferase (COMT) low activity, adrenergic receptor
C




    the following inclusion criteria: studies of any lev-    polymorphisms (9-11), sexual dysmorphism, proba-
    el of evidence, reporting clinical or preclinical re-    bly associated to the distribution of estrogen recep-
    sults and dealing with the anatomical, pain and          tors (12), the exact pathogenesis of the disorder
    postural association between TMD and cervical            seems to be heterogenous and mainly unknown.
©




    spine.                                                   Cervical spine pain (CSP) has been proposed as a
    Results: A total of n=1150 articles was found. Af-       risk factor to develop TMD. In 1996 De Wijer et al.
    ter duplicates exclusion, n=947 articles were se-        (13) investigated this relationship in two subgroups
    lected. At the end of the first screening, following     of patients: 103 with CSP and 111 with TMD. They
    the previously described selection criteria, we se-      reported an overlap of the symptoms and suggested
    lected n=55 articles eligible for full-text reading.     to conduct further studies. Instead, Bevilaqua-
    Ultimately, after full-text reading, and reference       Grossi et al. (14) conducted a study in 2007 involv-

    Annali di Stomatologia 2018;IX (3):97-105                                                                    97
    E. Chisari et al.


    ing one hundred woman and they reported how                  editorials and expert opinions were excluded. The
    there is a lack of evidence of an higher risk for CSP        study selection was performed independently by
    patients to develop TMD. However, they have con-             three Authors (E.B., G.C., F.D.), any discrepancies in
    firmed the pathological connection between TMD               the selection process were resolved by discussion
    and CSP: this study demonstrates that TMD patients           amongst all the Authors. The senior investigators




                                                                                                     li
    often develop CSP related symptoms and signs. In             (P.C. and E.C.) were consulted to revise all the selec-
    addition, TMD seems to be linked with severity of            tion process.




                                                                                                   na
    CSP clinical presentation. Even though it could be
    possible a relationship between TMD and cervical             Data extraction and criteria appraisal
    spine disorders (CSD), it is unclear the real associa-       All data were extracted from article texts, tables and
    tion with clinical aspects of disease. The aim of this       figures. Three independent Authors reviewed each
    review is to analyse and report all the up-to-date ev-       article (E.B., G.C., F.D.). Discrepancies between the




                                                                                                 io
    idence (1) determining the presence of a clinically          four reviewers were resolved by discussion and con-
    relevant association between cervical spine and              sensus. The results of every stage of selection were
    TMD, (2) identifying risk factors associated with this       reviewed by the senior investigators (P.C. and E.C.).




                                                                           az
    condition, (3) evaluating anatomical pain and postu-
    ral association.                                             Risk of bias and quality assessment
                                                                 Risk of bias assessment of all in vivo selected full-
                                                                 text articles was performed according to the ROBINS-




                                                                         rn
    Materials and methods                                        I tool for non-randomized studies (16). The ROBINS-I
                                                                 tool consists of three stage assessment of the studies
    Literature search strategy                                   included. First stage regards the planning of the sys-
    This systematic review was conducted according to            tematic review, the second stage is the assessment




                                                          te
    the guidelines of the Preferred Reporting Items for          of the common bias possibly found in these studies
    Systematic Reviews and Meta-Analyses (PRIS-                  and the latter is about the overall risk of bias (Supple-
    MA) (15). A comprehensive search was performed on            mentary material and Table 1). This assessment used
    four medical electronic databases (PubMed, Embase,
                                                        In       “Low,” “Moderate” and “High” as judgement keys:
    and Cochrane Library) by three independent Authors           “Low” indicated a low risk of bias, “moderate” indicat-
    (E.B., G.C., F.D.) from their date of inception to the       ed that the risk of bias was moderate, and “High” indi-
    20th of May 2018. Our main aims were: (1) determin-          cated a high risk of bias. In vitro and review studies
                                                                 were excluded by the risk assessment. �The assess-
                             ni
    ing the presence of a clinically relevant association
    between cervical spine and TMD, (2) identifying risk         ments were performed by 2 Authors (E.B., G.C.,) in-
    factors associated with this condition, (3) evaluating       dependently. Any discrepancy was discussed with
    anatomical, pain and postural association. Articles          the senior investigator (E.C. and P.C.) for the final
                           io


    from the inception of the databases to the 20th of May       decision. All the raters agreed on the results of every
    2018 were searched using the following key words:            stages of the assessment. Studies that were evaluat-
    [(Temporomandibular disorders OR TMD) AND (“cer-             ed at high overall risk of bias were excluded during
                         iz



    vical spine OR upper spine”)]. The reference lists of        screening process after discussion with the senior in-
    all included articles, previous literature reviews on the    vestigator (P.C.).
    topic and top hits from Google Scholar were reviewed
           Ed




    for further identification of potentially relevant studies   Statistical methods and analysis
    and were assessed using the inclusion and exclusion          Due to the heterogenous nature of the studies, the
    criteria. In addition, a search strategy document was        different outcomes evaluated, the lack of controlled
    added as supplementary material.                             studies, metanalysis and statistical analysis can not
                                                                 be done. Therefore, descriptive synthesis was under-
    Selection criteria                                           taken.
 IC




    Eligible studies for the present systematic review in-
    cluded those investigating the use of single-stage
    surgery for the revision of infected TKA. Primary            Results
    screening of the titles and abstracts were made using
C




    the following inclusion criteria: English language, and      Study selection
    studies of any level of evidence published in peer-re-       A total of n=920 articles was found according to the
    viewed journals reporting clinical or preclinical re-        previous described search strategy. Overall, after du-
    sults. Exclusion criteria included: articles written in      plicates exclusion n=798 articles were screened
©




    other languages or studies with a focus on surgical          through abstract and title reading after the removal of
    treatment. Additionally, we excluded studies in which        the duplicates. We selected n=55 articles eligible for
    data was not accessible, missing, without an avail-          full text reading. Ultimately, after full text reading, and
    able full text, or not well reported. We also excluded       reference list check, we selected n=25 articles to the
    all the remaining duplicates, and those with poor sci-       purpose of the present manuscript. A PRISMA (15)
    entific methodology, assessed as high risk of bias.          flow chart of the selection process and screening is
    Abstracts, case reports, conference presentations,           provided (Fig. 1).

    98                                                                               Annali di Stomatologia 2018;IX (3):97-105
    Temporomandibular disorders and cervical spine: a systematic review


    Supplementary material. Risk of bias assessment using ROBINS-I tool.

              Study             Confounding     Selection   Measurement Missing Measurement Reported            Overall
                                                            of Intervention Data of Outcomes Result
             Wu et al.             Moderate       Low         Moderate      Low       Moderate       Low       Moderate




                                                                                                     li
       Muñoz-García et al.           Low          Low         Moderate      Low       Moderate       Low       Moderate




                                                                                                   na
           Nielsen et al             Low          Low           Low         Low         Low          Low         Low
            Plesh et al.              Low         Low           Low         Low         Low          Low         Low
            Fejer et al.             Low          Low           Low         Low         Low          Low         Low
           Vissher et al.             Low         Low           Low         Low         Low          Low         Low




                                                                                                 io
          Munhoz et al.            Moderate       Low         Moderate      Low       Moderate       Low       Moderate
         La Touche et al.          Moderate     Moderate        Low         Low         Low          Low       Moderate




                                                                             az
       De Farias Neto et al.       Moderate       Low         Moderate      Low       Moderate       Low       Moderate
     Coskun Benlidayi et al.       Moderate       Low         Moderate      Low       Moderate       Low       Moderate
        Greenbaum et al.             Low          Low           Low         Low         Low          Low         Low




                                                                           rn
            Ries et al.              Low          Low           Low         Low         Low        Moderate    Moderate
          Halmova et al.           Moderate     Moderate        Low         Low         Low        Moderate    Moderate




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          Calixtre et al.          Moderate       Low           Low         Low         Low          Low         Low
          Da Costa et al.          Moderate       Low           Low         Low         Low          Low         Low
         Santander et al.          Moderate     Moderate
                                                        In      Low         Low         Low        Moderate    Moderate
            Inoue et al.           Moderate     Moderate        Low         Low         Low          Low       Moderate
            Testa et al.             Low        Moderate        Low         Low         Low          Low         Low
                                  ni
      Guarda-Nardini et al.        Moderate       Low           Low         Low         Low          Low         Low
        Von Piekartz et al.        Moderate       Low           Low         Low         Low          Low         Low
    Note: Moderate, the study is sound for a non-randomized study with regard to this domain but cannot be considered
                                io


    comparable to a well-performed randomized trial; Low, the study is comparable to a well-performed randomized trial with
    regard to this domain.
                              iz



    Included studies                                               tous and tendinous connections constituting a func-
    The included articles (13-38) mainly focus on                  tional compound who moves as a single unit (43). In
    anatomical, postural and pain relationship between             addition, what emerges from the recent literature is a
            Ed




    cervical spine and TMD. The main findings of the in-           possible involvement of common neurological affer-
    cluded articles were summarized (Tab. 1).                      ences mainly related to C1 and C2 segment which
    Of the included studies, one is a cohort study (17),           may act as one integrative functional unit to process
    three are prospective studies (18-20), one is an animal        cutaneous, deep, and visceral nociceptive information
    study (21), seven are retrospective studies (22-28), two       from craniofacial and afferent inputs (21).
    are twin retrospective studies (29, 30), two are cross-        In a study conducted by de Wijer et al. (13) was con-
 IC




    sectional studies (31, 32), six are previous reviews (33-      cluded that TMD with a myogenous involvement
    39) and three are case-control studies (40-42).                should no longer be viewed as a local disorder of the
    While all the studies analyse the different aspect of          stomatognathic system and need an evaluation also
    the relationship between cervical spine and TMD, the           of cervical spine and shoulder girdle. In 2016, anoth-
C




    outcome evaluated are heterogenous. However, in                er study (31) involving 86 patients with chronic neck
    order to undertake a descriptive analysis, our primary         pain or TMD, reported how chronic pain of one of
    outcome was pain, both as referred and objectively             these anatomical regions can spread hyperalgesia
    evaluated during clinical outcome, secondary out-              and pain in the other one.
©




    comes were results of patient referred information
    through surveys and questionnaires as descripted in            Postural
    more details in the studies.                                   Patient with TMD can often present cervical pain and
                                                                   postural asymmetry in the cranio-cervical area, that
    Anatomic                                                       influence the general posture of the body and the
    As regards anatomical associations, it is clear how            clinical significance of the temporomandibular disor-
    the two regions are linked through muscular, ligamen-          der (41). A systemic review of the 2009 confirmed

    Annali di Stomatologia 2018;IX (3):97-105                                                                             99
    E. Chisari et al.


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                                                                                                                  To be continued
    100                                                                                    Annali di Stomatologia 2018;IX (3):97-105
    Temporomandibular disorders and cervical spine: a systematic review


    continue from Table 1


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                                                                                               )03-0&3066
                                                                                                                   To be continued




    Annali di Stomatologia 2018;IX (3):97-105                                                                                   101
    E. Chisari et al.


    continue from Table 1


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                            iz



    that there is a probable relationship between the               with temporomandibular joint and muscle disorder
           Ed




    stomatognathic system and the general body posture.             (TMJMD). The 59% of people with TMJMD had two
    The main alteration of subjects with TMD was a cervi-           or more comorbid disorders like headache, neck or
    cal extensor muscle tension that can increase the               low back pains. In particular, the 54% of the patients
    pain perceived, the body posture and the clinical out-          with TMJMD had neck pain (22).
    come of the patients (38).
 IC




    Pain                                                            Discussion
    Guarda-Nardini et al. (20) described a reduction of
    pain after an intra-articular injection with hyaluronic         Genetic and environmental factors seem to contribute
    acid into temporomandibular joint (TMJ) in patients             to the pathogenic threshold of the TMD and neck dis-
C




    with TMJ osteoarthritis and concomitant cervical spi-           orders. In particular different twin studies reported
    ne pain. The pain improved in both areas after 3 and            strong evidence of this association, even though the
    6 months. Patients with chronic neck pain (CNP) and             underlying mechanism were not investigated (29, 30,
    TMD presented more widespread pain, hyperalgesia                33-35).
©




    in different regions of the body than patients with only        The reported evidence of the association between
    CNP or only TMD even though psychosocial factors                history of whiplash and TMD (36), the anatomical
    seems to be associated too (31). Pain and posture in            connections (43), the association of the postural al-
    the cervical spine/neck region should be assessed               teration affecting TM and cervical spine lack of high
    prior and after surgery for TMD to further clear this           profile studies (37). In contrast to this, available evi-
    relationship (32). A high-profile study that included           dence seems to support also a postural connection.
    189,977 people in US analysed the pain in subjects              This relationship could affect the clinical practise and

    102                                                                                Annali di Stomatologia 2018;IX (3):97-105
    Temporomandibular disorders and cervical spine: a systematic review




                                                                                                      li
                                                                                                    na
                                                                                                  io
                                                                             az
                                                                           rn
                                                          te
                                                        In
                               ni
    Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) flowchart of the systematic litera-
    ture review.
                             io


    should be known by al the medical professionals.               atognathic system after being treated with cervical
    A study of 2014 (23) reported how the cervical pos-            mobilization and stretching technique (19). Another
    ture (in particular the degree of cervical lordosis) cor-      study showed how myofascial pain in patients with
                           iz



    relate with the severity of functional pathologies of          TMD affects masticatory and neck muscles (42). In
    temporomandibular system (FPTS). Another study                 addition, a recent review (39) on manual therapy on
    held by La Touche et al. (17) confirmed the anatomi-           myofascial pain in TMD reported a strong evidence of
            Ed




    cal relationship by nociceptive innervation of trigemi-        its use in patients with TMD in both head and neck
    nal nerve and its influence on the relationship be-            regions.
    tween cervical spine and temporomandibular joint. In           Another pilot study (26), involving 22 subjects with
    particular, they reported how cervical posture change          TMD, showed how the rehabilitation can provide a
    affected maximal mouth opening (MMO) and the                   good effect in the cervical posture after a combination
    pressure pain threshold (PPT). Another study of De             protocol of six months of continuous mandibular ad-
 IC




    Farias correlated the symptoms of TMD group pa-                vancement appliance (MAA) and a program of postu-
    tients with a specific cervical posture alteration (i.e.       ral re-education.
    flexion of the Atlas) resulting in an hyper-lordosis of        The reported pain is another chapter of the relation-
    the cervical spine (18). This was further supported by         ship between the temporomandibular joint, and in
C




    other similar studies on cervical spine lordosis (24)          general the orofacial region, and the cervical or
    and the cervical ROM in patients with TMD (40).                neck/shoulder region.
    These alterations are probably the main reason be-             The results of this literature review seem promising.
    hind the success of rehabilitation therapy in these pa-        In particular in one study (27), involving 171 patients
©




    tients. Indeed, the cranio-cervical rehabilitation, espe-      with TMD, showed a relationship between the pain in
    cially if supported by manual therapy, seems to im-            the temporomandibular joint with disk displacement
    prove the pain in the patients with myofascial tem-            and ipsilateral muscle tenderness in orofacial and
    poromandibular disorders (25). In 2016, a study in-            neck/shoulder region. The EMG (electromyography)
    volving twelve women affected by TMD reported sig-             alterations of masseter muscles in people with non-
    nificant changes in pain-free maximum mouth open-              specific neck pain evidenced how a cervical disease
    ing, self-reported pain, and functionality of the stom-        can develop a TMD or orofacial pain (28).


    Annali di Stomatologia 2018;IX (3):97-105                                                                            103
    E. Chisari et al.


    While the rationale behind this relationship is still un-                8.    Levitt SR, McKinney MW. Validating the TMJ scale in a na-
    clear, we can assume that the anatomical and neuro-                            tional sample of 10,000 patients: demographic and epi-
    logical connections between cervical spine and TMD                             demiologic characteristics. J Orofac Pain [Internet]. 1994 [cit-
                                                                                   ed 2018 Jun 20];8(1):25-35. Available from: http://www.
    are clinically significant. TMD seems to be a risk factor
                                                                                   ncbi.nlm.nih.gov/pubmed/8032327
    to develops myofascial pain, hyperalgesia and chronic
                                                                             9.    Nackley AG, Tan KS, Fecho K, Flood P, Diatchenko L, Maixn-




                                                                                                                       li
    neck pain. In addition, TMD seems to intensify CVP                             er W. Catechol-O-methyltransferase inhibition increases pain
    and associated symptoms. Studies on posture relation-                          sensitivity through activation of both β2- and β3-adrenergic




                                                                                                                     na
    ship require more high-profile studies. A complete                             receptors. Pain [Internet]. 2007 Apr [cited 2018 May
    evaluation of both these clinical conditions must in-                          5];128(3):199-208. Available from: http://www.ncbi.nlm.nih.
    clude an accurate physical exam of both regions.                               gov/pubmed/17084978
    Since there is a lack of evidence about of the possible                  10.   Diatchenko L, Nackley AG, Slade GD, Bhalang K, Belfer I, Max
    common etiology and pathogenesis of these disorders,                           MB, et al. Catechol-O-methyltransferase gene polymor-




                                                                                                                   io
                                                                                   phisms are associated with multiple pain-evoking stimuli. Pain
    we strongly encourage further clinical and molecular
                                                                                   [Internet]. 2006 Dec 5 [cited 2018 May 5];125(3):216-24.
    studies on patients affected by these disorders.                         11.   Diatchenko L, Anderson AD, Slade GD, Fillingim RB, Sha-




                                                                                         az
                                                                                   balina SA, Higgins TJ, et al. Three major haplotypes of the
    Abbreviations                                                                  β2 adrenergic receptor define psychological profile, blood
    TMD, temporomandibular disorders.                                              pressure, and the risk for development of a common mus-
    CSP, cervical spine pain.                                                      culoskeletal pain disorder. Am J Med Genet Part B Neu-
    COMT, catechol-O-methyltransferase.                                            ropsychiatr Genet [Internet]. 2006 Jul 5 [cited 2018 May




                                                                                       rn
    CSD, cervical spine disorders.                                                 5];141B(5):449-462. Available from: http://www.ncbi.nlm.nih.
                                                                                   gov/pubmed/16741943
    MAA, mandibular advancement appliance.
                                                                             12.   Milam SB, Aufdemorte TB, Sheridan PJ, Triplett RG, Van
    EMG, electromyography.
                                                                                   Sickels JE, Holt GR. Sexual dimorphism in the distribution
    CNP, chronic neck pain.




                                                                     te
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    Annali di Stomatologia 2018;IX (3):97-105                                                                                                105
