Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2012 39; 502512
Review Article
The dental occlusion as a suspected cause for TMDs:
epidemiological and etiological considerations
J . C . T U R P * & H . S C H I N D L E R *Dental School, University of Basel, Basel, Switzerland, Dental School, University of
Heidelberg, Heidelberg and Institute for Mechanics, University of Karlsruhe, Karlsruhe, Germany
SUMMARY The relationship between the dental
occlusion and temporomandibular disorders
(TMDs) has been one of the most controversial
topics in the dental community. In a large epide-
miological cross-sectional survey the Study of
Health in Pomerania (Germany) associations
between 15 occlusion-related variables and TMD
signs or symptoms were found. In other investiga-
tions, additional occlusal variables were identified.
However, statistical associations do not prove cau-
sality. By using Hills nine criteria of causation, it
becomes apparent that the evidence of a causal
relationship is weak. Only bruxism, loss of poster-
ior support and unilateral posterior crossbite show
some consistency across studies. On the other hand,
several reported occlusal features appear to be the
consequence of TMDs, not their cause. Above all,
however, biological plausibility for an occlusal
Introduction
The evolution of dentistry as an academic discipline
has been closely linked to the development of
concepts about the dental occlusion (1, 2). Geometri-
cally and mechanically based ideas on that topic
predominated dentists thinking from early on (e.g.
35), although the propagated ideas were not always
compatible with the variability inherent to biological
systems, such as the masticatory apparatus. In his
remarkable text on dental occlusion, the anthropolo-
gist C. Loring Brace (6) concluded: Since the dawn of
modern dentistry, as it were, the idea of the perfect
Based on a presentation at CORE China 2011.
2012 Blackwell Publishing Ltd
aetiology is often difficult to establish, because
TMDs are much more common among women than
men. Symptom improvement after insertion of an
oral splint or after occlusal adjustment does not
prove an occlusal aetiology either, because the
amelioration may be due to the change of the
appliance-induced intermaxillary relationship. In
addition, symptoms often abate even in the ab-
sence of therapy. Although patients with a TMD
history might have a specific risk for developing
TMD signs, it appears more rewarding to focus on
non-occlusal features that are known to have a
potential for the predisposition, initiation or per-
petuation of TMDs.
KEYWORDS: bruxism, causality, craniomandibular
disorders, dental occlusion, malocclusion, odds ratio
Accepted for publication 17 February 2012
occlusion has shimmered in the imagination of the
dental profession somewhat like the Holy Grail of
Arthurian legend the unattainable height of earthly
aspiration (cf., Table 1).
Of particular interest for dental practitioners have
been the decade-long discussions about the assumed
role of the dental occlusion for the predisposition,
initiation and perpetuation (7) of temporomandibular
disorders (TMDs) (for overviews, see, for example, 8
10). In fact, a causal relationship was taken for granted
by many dentists, as exemplified by the following
statement from 1956: Because spasms in the temporal
muscles were eliminated with an interocclusal splint in
subjects who had gross occlusal interferences and an
excessive interocclusal space, and because these spasms
doi: 10.1111/j.1365-2842.2012.02304.x
 DENTAL OCCLUSION AND TMDS 503

Table 1. Criteria for an ideal occlusion as taught in the 1960s (100)

Everything we do must aim towards a minimum of muscle tension or exertion to obtain maximum efficiency
The stresses or forces should be directed in line with the long axis of the teeth. Adverse or lateral forces must be eliminated
The end result should be comfortable to the patient; he should be as unconscious as possible of the actual presence of teeth in his mouth
Stability of the teeth in the dental arches; the teeth should not become loose, migrate or otherwise change position adversely following
treatment
All of the component elements involved in occlusion should be in harmony with each other. No single component should dictate or
become master over the other components in any jaw position
A minimum of wear or degeneration and a maximum of health of all of the elements involved should follow completion of the treatment
Proper contact, contour and external tooth form should be achieved to maintain periodontal health in addition to occlusion per se
A narrow occlusal table should be attempted to better direct the forces over the long axis of the teeth to improve efficiency in function
The teeth should not be locked into any position; freedom of all excursive movements is essential
The skeletal arc of closure (C.R.O.) and the adaptive arc of closure (C.O.) should harmonise
The initial contact of the posterior teeth should be uniform in character and exactly at the same time. No tooth contact should either direct
or deflect such closure
All centric holdings cusps should contact their counterparts evenly. Ideally, the buccal cusps of the mandibular teeth and the lingual cusps
of the maxillary teeth are referred to as the centric holding cusps
This initial contact should be a multiplicity of small points rather than large areas of tooth contact
This initial contact should occur at the most closed vertical dimension, which is the established vertical dimension for any specific case
The teeth should be free to function as groups without interference from another group.
The incisors should be permitted to cut or incise very thin foods, such as lettuce, without posterior interference
The cuspids should be free to hold or tear foods efficiently without posterior or incisor interference
The posterior teeth should shred [sic!] and grind food efficiently without anterior interference, either incisors or cuspids
Vertical dimension must permit a physiological rest position with available free way space
The anterior teeth must be given consideration to harmonise the occlusion. The proper lingual concavity of the maxillary anterior teeth is
an essential ingredient along with the inter-relationship of the mandibular anterior teeth

re-occurred almost immediately on removal of the
splint, the aetiology for muscle spasms in the temporal
muscles is attributed to occlusal interferences and
an excessive interocclusal space (11).1 While the
basis of this specific assertion lay in the personal
interpretation of results of an electromyographic
study with volunteers (11), the great majority of
similar claims about a causal role of occlusal factors
resulted from (uncontrolled) observations among
patients (12, 13).
Inferences about such an association, however,
can only be made by resorting to epidemiological
studies. The largest cross-sectional investigation in
which, among other variables, occlusal parameters
and TMD signs and symptoms were analysed, was
the Study of Health in Pomerania (SHIP). It was
carried out between October 1997 and May 2001 in
Western Pomerania (Germany), and it included
4310 individuals between 20 and 81 years of age,
who were examined by calibrated dental clinicians
(14).
1
Wisely, the author added: This does not mean that other factors
cannot cause temporal muscle spasms (11).
Findings from the Study of Health in
Pomerania
The SHIP study differentiated 48 morphological and
functional occlusal variables plus four bruxism-related
features. To determine whether occlusal factors were
significantly associated with TMD signs or symptoms,
multivariate logistic regression methods were
employed. In their main analysis, the authors identified
seven features, namely four morphological occlusal
variables, two functional occlusal variables and one
parafunctional variable (Table 2). There was no coinci-
dence between the five relevant occlusal features found
in men as compared to the two variables detected
among women.
According to the authors, a result was considered
clinically relevant if the calculated odds ratio (OR) as a
measure that a particular occlusal factor is associated
with a TMD sign or symptom was >2 (risk factor) or
smaller than 05 (protective factor). Based on this
definition, one of the seven occlusal variables (males:
bilateral interferences on mandibular protrusion) could
be interpreted as being protective, while another
protective feature (females: bilateral non-working side

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504 J . C . T U R P & H . S C H I N D L E R

Table 2. Study of Health in Pomerania study: results of the multivariate logistic regression analyses as well as prevalences of independent
variables, based on 1226 observations in women and 1116 observations in men (15)

Occlusal variable Sex Prevalence (%) OR (95% CI)

Unilateral posterior open bite up to 3 mm (yes vs. no) m 10 80 (20324)

Negative overjet (yes vs. no) m 12 40 (11147)
Unilateral scissors bite (yes vs. no) m 36 22 (1143)
Edge-to-edge bite (yes vs. no) f 44 18 (1031)
Bilateral interferences on mandibular protrusion (yes vs. no) m 25 02 (0007)
Bilateral non-working side contact (yes vs. no) f 92 06 (0408)
Frequent tooth grinding (yes vs. no) m 170 24 (1344)

Occlusal factors were independent variables. Temporomandibular disorder signs or symptoms were dependent variables.
m, male; f, female; OR, odds ratio; CI, confidence interval.

contact) reached borderline relevance (15). On the
other hand, individuals with one of four other occlusal
variables (unilateral posterior open bite up to 3 mm;
negative overjet; unilateral scissors bite; self-reported
frequent tooth grinding) had more than one TMD sign
or symptom more frequently than subjects without
these findings. A fifth variable (edge-to-edge bite)
reached borderline relevance. It should be noted that
the prevalence of most of the identified occlusal
features was low (15).
Separate analyses were focused on either TMD
symptoms only or on signs only. The results are
summarised in Table 3. Based on the results of the
SHIP study, the authors concluded that the occlusion
played only a minor role in conjunction with TMD signs
and symptoms (15). They emphasised, however, that
because of a lack of time sequence, the reported
associations, observed here, while robust, should not be
interpreted as causal (16). Indeed, a statistical associ-
ation does not prove a causal association (17). The
question arises, thus, which aspects of an association
between two variables should be considered before the
decision is reached that the most probable interpreta-
tion of such a relationship is causation. In 1965, Hill
(18) brought up this issue by proposing epidemiologic
criteria, which, despite occasional criticism (19), are still
widely cited partly with minor variations in epidemi-
ological dictionaries and textbooks (e.g. 2023). A
while ago, Dao (24) and Stohler (25) briefly referred
to some, but not all, of Hills criteria in terms of the
purported relationship between occlusion and TMDs.
Although in his original publication, Hill (18) had
stressed that none of his nine viewpoints can bring
indisputable evidence for or against the cause-and-
effect hypothesis and none can be required as sine qua
non, it is comprehensible that the likelihood of a
causal association is small when most or all of these
criteria are absent. Hills suggestions appear therefore
very helpful (23) for further evaluating the alleged
relationship between occlusal factors and TMDs: Here
then are nine different viewpoints from all of which
we should study association before we cry causation
(18).
Hills criteria of causation
Criterion 1: strength of statistical observation between
assumed cause and effect
The strength of an association is measured by means of
the relative risk or the OR (23). Besides the results from
the SHIP study, relative few pertinent data with regard
to the supposed relationship between occlusal variables
and TMDs are available:
1 Relying on morphological occlusal data from dental
casts and clinical measurements in two different
female populations (n = 257 and n = 124, respec-
tively) with intra-capsular TMDs (disk displacement;
osteoarthrosis), which were compared with a popu-
lation of asymptomatic female controls (n = 51 and
n = 47, respectively), Pullinger and Seligman (26)
(Los Angeles, USA) identified in a multiple logistic
regression analysis the following occlusal factors with
a statistically significant OR 2:
a Anterior open bite (in patients with osteoarthro-
sis).
b Large sagittal slides from the retruded contact
position (RCP) into the intercuspal position (ICP)
(in patients with disk displacement or osteoar-
throsis).

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Table 3. Study of Health in Pomerania study, additional evaluations: results of the multivariate logistic regression analyses as well as
prevalences of independent variables

Occlusal variable Sex Prevalence (%) TMD variable OR (95% CI) Reference

Bilateral posterior open bite up to m f 03 Signs in general 40 (10155) (46)

3 mm (yes vs. no)
Loss of posterior occlusal support, m 72 Tenderness pain upon palpation 27 (1455) (16)
with antagonistic tooth contacts of at least one masticatory muscle
limited to the anterior teeth
(yes vs. no)
Loss of posterior occlusal support, m 72 Tenderness pain upon palpation 39 (14106) (16)
with antagonistic tooth contacts of at least one TMJ
limited to the anterior teeth
(yes vs. no)
Loss of posterior occlusal support m 248 Tenderness pain upon palpation of 23 (1341) (16)
with no antagonistic tooth at least one masticatory muscle
contacts (yes vs. no)
Loss of posterior occlusal support m 248 Tenderness pain upon palpation 27 (1168) (16)
with no antagonistic tooth of at least one TMJ
contacts yes vs. no
Presence of only one (of m 69 Palpation-dependent tenderness 111 (23534) (49)
originally four) posterior of at least three muscles
occlusal support zone
(yes vs. no)
Loss of posterior occlusal support, m 61 Palpation-dependent tenderness 131 (27634) (49)
with antagonistic tooth contacts of at least three muscles
limited to the anterior teeth
(yes vs. no)
Loss of posterior occlusal support m 204 Palpation-dependent tenderness 84 (17413) (49)
with no antagonistic tooth of at least three muscles
contacts yes vs. no
Self-reported bruxism (yes vs. no) m 292 TMJ tenderness or pain 19 (1134) (16)
Self-reported bruxism yes vs. no f 271 TMJ tenderness or pain 20 (1329) (16)
Spacing not because of tooth loss f 236 TMD symptoms in general 04 (0307) (101)
(yes vs. no)
Unilateral buccal non-occlusion f 37 TMD symptoms in general 01 (0009) (101)
(yes vs. no)
Self-reported frequent jaw m f 52 TMD symptoms in general 34 (2156) (47)
clenching (yes vs. no)
Self-reported frequent jaw m 52 TMD symptoms in general 42 (2185) (47)
clenching (yes vs. no)
Self-reported frequent jaw w 52 TMD symptoms in general 29 (1460) (47)
clenching (yes vs. no)

Occlusal factors were independent variables, TMD signs or symptoms were dependent variables.
m, male; f, female; OR, odds ratio; CI, confidence interval; TMD, temporomandibular disorder.

c Overjet above 6 or 7 mm (in patients with osteo-
arthrosis).
d Midline discrepancy (in patients with osteoarthrosis).
e Unilateral posterior crossbite (in patients with disk
displacement).
f Five or more missing posterior teeth (in patients
with osteoarthrosis).
g First molar asymmetry (in patients with osteoar-
throsis).
2 In a casecontrol study within a 2-year prospec-
tive cohort (n = 280 dental students), Marklund
and Wanman (27) (Umea, Sweden) discovered (by
using multiple logistic regression models) that the
following occlusal features were linked to TMJ signs or
symptoms (mainly clicking sounds) and or myofascial
signs or symptoms (mainly pain upon palpation):
a Crossbite (newly developed or persistent TMJ
signs or symptoms).

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506 J . C . T U R P & H . S C H I N D L E R
b Mandibular instability in the ICP (persistent TMJ
signs or symptoms; persistent myofascial signs or
symptoms).
c Lateral slide in centric 1 mm between RCP and
ICP (persistent TMJ signs or symptoms).
d A mediotrusive side interference, that is, a single
contact between maxillary and mandibular teeth
on the mediotrusive side which inhibits contact on
the laterotrusive side, at 3 or 9 mm lateral excur-
sion (newly developed myofascial signs or symp-
toms).
e Unilateral contact pattern in the RCP (persistent
myofascial signs or symptoms).
f Self-reported bruxism (newly developed or persis-
tent TMJ signs or symptoms).
It should be noted that self-reported bruxism is a
very poor measure of actual bruxism, because self-
reports may under- or overestimate bruxing
behaviour (28).
3 On the basis of two population-based cross-sectional
studies (n = 3033; age range: 1074 years), John et al.
(29) (Halle Saale, Germany) found (by using multi-
ple logistic regression and fractional polynomial
regression analyses) that overbite, including open
bite, and overjet, including mandibular prognathism,
were not significantly associated with an increased
risk of self-reported TMD pain, limited mandibular
opening or TMJ noises.
4 In a clinic-based casecontrol study from Halle Saale
(adult TMD patients n = 154; adult control subjects
n = 120; age range: 1376 years), multiple logistic
regression analysis revealed that incisal tooth wear
(assessed on dental casts) was not significantly asso-
ciated with TMDs. A stratified analysis by sex
revealed an OR = 1 in men (no association) and an
OR = 068 in women (a non-significant trend towards
a beneficial effect of tooth wear) (30).
Criterion 2: temporal relationship of the association: the
exposure (cause) always precedes the outcome (effect)
Disease (effect, that is, TMD signs and or symptoms)
must follow exposure (cause, that is, an occlusal factor).
In contrast to the assumption that occlusal features are
causing TMDs, the opposite order may occur: TMDs lead
to occlusal disturbances. For example, as a consequence
of temporomandibular pain, the mandible may shift into
a less painful, more comfortable position, resulting in
premature occlusal contacts (31). Similarly, a therapy
with oral appliances may result in undesired occlusal
changes (3235). Moreover, morphological changes
within the temporomandibular joints (25, 36), for
example because of osteoarthrosis or rheumatoid arthri-
tis of the TMJs, may lead to occlusal disharmonies,
including anterior open bite, large sagittal RCP-ICP
slides, large overjet and midline discrepancy. All these
events may cause the perception of an acute malocclu-
sion recognised as a change in occlusal relationship of
the teeth imposed by the temporomandibular disorder
and about which the patient is consciously aware (37).
Besides, studies have shown that after the insertion
of experimentally induced occlusal interferences, acute
short-lasting TMD signs and or symptoms may or may
not evolve (38, 39). Furthermore, artificial occlusal
interferences may reduce instead of increase the
electromyographic activity in the masseter muscles of
awake asymptomatic volunteers. Hence, as Stohler (25)
inferred, occlusal changes are not necessarily sufficient
to cause symptoms.
Criterion 3: biological gradient (doseresponse relationship):
an increasing level of exposure in amount or time increases the
risk
No scientific data are available, showing that a greater
number of presumably unfavourable occlusal features
are associated with a higher prevalence or intensity of
TMD symptoms or signs. With other words, a gradient
effect is absent (25).
Criterion 4: experiment (reversible associations): the condition
can be altered (prevented, improved, worsened) by an
appropriate experimental regime
Clinical research has shown that myofascial pain of the
masticatory muscles and or TMJ arthralgia can be
favourably addressed by interventions that target the
dental occlusion. The most widespread approach con-
sists of the nocturnal use of a stabilisation appliance,
which has proven therapeutic efficacy and effectiveness
(40), although current evidence is still inconclusive
about the question of whether the observed improve-
ment during and after stabilisation therapy is greater
than the one achieved by a non-occluding palatal
appliance (i.e. a placebo splint) (41).
As an alternative, albeit irreversible, option for
an occlusal intervention, the elimination of occlusal
interferences by occlusal adjustment has been
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proposed. Based on clinical trials, it has been reported
that in children and adolescents (42) as well as female
adults (43) regular adjustments over a period of 4 years
reduced the incidence of TMD symptoms and signs
significantly.
This seemingly reversible association between occlu-
sal variables and TMDs, however, can be explained by a
biomechanical effect only indirectly related to the
occlusion (see Criterion 6).
Criterion 5: consistency of the observed association across
studies: the association has been repeatedly observed in
independent studies, that is, in different individuals and
settings under different methods
Consistency is important to assess whether an observed
association between two variables appeared because of
chance or error. Okeson (44) analysed 57 study articles
published between 1979 and 2000 which had investi-
gated the relationship between occlusal variables and
TMD symptoms and or signs. He found that 22 articles
reported no association between occlusal factors and
TMDs, while in 35 studies a relationship was detected.
He noted, however, that a variety of occlusal conditions
were identified, such as Angle class II, Angle class III,
anterior crossbite, anterior open bite, deep bite, centric
slides, lack of slide between RCP and maximum ICP,
asymmetric RCP-ICP slides and RCP-ICP slides >1 mm.
Similarly to the SHIP study and the results summarised
under Criterion 1, no consistent occlusal feature was
noticeable in these 35 study reports.
Lack of consistency of reported associations between
morphological or functional occlusal variables and TMD
signs or symptoms was also a finding of subsequent
systematic analyses of the literature published by Gesch
et al. (15, 4547). In their own epidemiological inves-
tigations (15, 16, 46, 47, 49, 101), 15 different variables
were identified; however, each occlusal feature was
found not more than once.
Only three occlusion-related variables have shown
some consistency among some studies:
1 Self-reported bruxism (16, 27), that is, jaw clenching
(47) and or tooth grinding (15). This finding, how-
ever, should be weighed against the report of John
et al. (30) on the lack of a significant association
between incisal tooth wear as a result of bruxism
(48) and TMDs. In addition, self-reports about tooth
clenching and jaw grinding should be interpreted
with caution.
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DENTAL OCCLUSION AND TMDS 507
2 Loss of occlusal support zones (16, 26, 49). It should
be noted that the shortened dental arch (i.e. all
molars are missing, whereas all anterior teeth and all
premolars are present) is not associated with a greater
risk for TMD problems (5052), although the loading
of the TMJs is increased as compared to the additional
presence of the first molars (53).
3 Unilateral posterior (maxillary lingual) crossbite,
involving one or more posterior teeth (26, 5456).
In Pullingers and Seligmans analysis (26), this
occlusal feature was significantly associated with
disc displacement. In a study by Tecco et al. (56)
(Chieti-Pescara, Italy), patients (n = 1134; age range:
515 years) with unilateral posterior crossbite had a
significantly higher prevalence of masticatory mus-
cle discomfort or pain, TMJ arthralgia, pain during
mastication and or impairment of jaw opening than
individuals without crossbite or with bilateral cross-
bite.
Criterion 6: biological plausibility: the association is in line
with currently accepted knowledge about pathobiological
processes
A biologically plausible explanation why occlusal vari-
ables should lead to TMDs is questionable because of
various reasons:
1 During the development of the primary, mixed and
permanent dentitions, the dental occlusion and
intermaxillary relations are subject to continuous
changes (57). Nevertheless, TMD signs and symptoms
are rare among children, although TMD incidence
gradually increases during adolescence (5860)
despite the fact that during this developmental phase
the occlusion is more stable than in the years before.
If TMD signs and symptoms are present during
childhood or adolescence, they are usually mild (61).
2 Orthodontic treatment during adolescence is often
associated by considerable occlusal alterations. None-
theless, this therapy does neither increase nor
decrease the risk of developing TMDs later in life
(62).
3 Even though in the general population differences
with regard to the occlusal status between girls and
boys as well as women and men, respectively, are
absent (63), girls are more frequently affected by
TMDs than boys (59, 60). This sex-related difference
is also observable among adults: TMD-related pain is
508 J . C . T U R P & H . S C H I N D L E R
Fig. 1. Age and sex distribution of 2928 female and 500 male patients living in the Seattle area who were referred for temporomandibular
disorder problems (58).
much more prevalent among women as opposed to
men (6467) (Fig. 1). Interestingly, these arguments
were already put forward in the early 1960s (68).
4 The permanent dentition shows a great amount of
occlusal variability, so that variation can be considered
the rule (57, 69). This is also reflected by the results of
the SHIP study, where findings of malocclusion in
varying number and severity were present in 922% of
subjects aged between 20 and 49, while an anatom-
ically correct occlusion was only found in 78% (70).
Such findings make it practically impossible to differ-
entiate TMD patients from normal individuals based
on defined occlusal characteristics (71).
5 In a systematic review of population-based investiga-
tions, Gesch et al. (45) identified four valid and
relevant study articles (7275). There were indica-
tions that three deviations from what is perceived to
be an ideal occlusion may even be protective for
TMDs, namely Angle class II division 2 malocclusion
(74), deep bite (74) and anterior crossbite (75).
6 For a long time, clinicians have claimed that the
decrease in TMD symptoms and signs following either
the insertion of an oral appliance or systematic
occlusal adjustment was because of the elimination
of unfavourable occlusal features and to a harmon-
isation of the occlusion. In the light of the accumu-
lated evidence from experimental and clinical
research, however, an alternative explanation may
be more likely. While both types of intervention differ
with regard to their reversibility, they have two
features in common: (i) Both approaches alter the
three-dimensional intermaxillary relationship. (ii) By
doing so, they change the recruitment patterns within
the masticatory muscles (76, 77) as well as the position
of the mandibular condyles within the TMJs (78). As a
consequence, stress concentrations in defined muscle
regions are altered and localised painful areas are less
loaded (79), thus reducing the severity and or inci-
dence of pain. According to this model, the therapeutic
success is unrelated to occlusal features; instead, it is
caused by a change (increase or decrease) in the
mandibular position (79, 80).
7 The temporal relationships mentioned earlier (Crite-
rion 2) merit attention: occlusal findings may be the
result of TMDs.
Criterion 7: coherence: the association is compatible with the
generally known facts about the natural history and biology
of the disease
The cause-and-effect interpretation must be explain-
able by the known facts about the natural history and
pathobiology of TMDs. However, TMD signs and or
symptoms are self-limiting; temporomandibular pain
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often abates with time even in the absence of occlusal
or non-occlusal therapy (81, 82), which casts doubt on
the occlusal aetiology.
Criterion 8: specificity of an association: a single putative cause
produces a specific effect
Specificity of an association relates to the predictable
phenomenon that a specific occlusal variable leads to a
specific TMD sign or symptom. Okeson (44) found that
the occlusal variables identified in 35 studies were not
limited to TMD patients, but were commonly found in
symptom-free populations. On the other hand, TMD
signs and or symptoms may result from non-occlusal
influences, and there is a great variety of different TMD
diagnoses that may occur. Hence, the specificity criterion
is not met.
Criterion 9: analogy
A more or less analogous model is the purported
relationship between orthopaedic findings (e.g. postural
disorders, leg-length inequality or pelvis obliquity) and
TMD signs and symptoms (e.g. 83). However, such
correlations are not supported by scientific data of high
quality (8486).
Conclusions
The currently available evidence suggests that the
influence of the occlusion on the genesis and the
development of TMD problems is low. This conclusion
is not at all new, though, but has been ignored by an
appreciable part of the dental community.
A low influence, however, means that occlusal
features may contribute to a small percentage to
temporomandibular signs and or symptoms. Thus, an
absence of any relationship should not be inferred
because this would imply an absence of any relation-
ship between form and function (26). Marklund and
Wanman (27) add that such a simplistic view of the
dental occlusion may be harmful to the individual
patient with long-standing TMD signs and symptoms.
Hence, the occlusal door is indeed still ajar (87).
Particularly, the research findings of Le Bell et al. (88)
may merit further investigation: In their randomised
double-blind trial (88), they found that, compared to
subjects without a TMD history, individuals with a
former TMD history (and subsequent successful therapy)
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DENTAL OCCLUSION AND TMDS 509
may have a greater risk of developing TMD signs
(tenderness upon palpation) but not symptoms in
response to an acute occlusal change. Furthermore, an
earlier TMD history was strongly associated with occlusal
discomfort and masticatory problems after the introduc-
tion of artificial interferences (89). A possible explana-
tion for these observations may be the decreased adaptive
capacity of the formerly compromised structures of the
masticatory system (90). Under these circumstances, an
acute occlusal alteration might act like a stumbling
block (91). It should be borne in mind, however, that
acute occlusal interventions differ from a long-standing
occlusal situation, where an existing occlusion with
working, non-working, retrusive and protrusive pre-
mature contacts may have been present for years.
Consequently, a more relaxed attitude towards per-
ceived deviations of the dental occlusion from cut and
dried concepts (1) is warranted.
There is, on the other hand, good evidence that from
an etiological (and clinical) standpoint non-occlusal
variables are more relevant than occlusal ones (26).
Therefore, the aetiology of TMDs has correctly been
described as multifactorial (92, 93). Among others,
systemic, metabolic, structural, traumatic, psychologi-
cal, social and behavioural influences have been
identified as possible predisposing, initiating and main-
taining factors for TMDs (94). It appears, however, that
terms such as multifactorial or multicausal serve
more often than not as an alibi for the lack of
knowledge about the aetiology of the TMD problem
of the individual patient who is sitting in the dental
chair. Therefore, future research should focus less on
the dental occlusion, but more intensely on, for
example, genetic (95, 96), hormonal (97), pain-related
pathophysiological (98), psychosocial (99) and cultural
(96) factors, as it is the case in musculoskeletal and
other pain problems outside the face. At the same time,
a greater reluctance for making unsubstantiated claims
about occlusal factors and TMD signs and or symptoms
is supported by the current literature. Such an attitude
would certainly be desirable for the benefit of patients
(and non-patients), because with such an approach
overdiagnosis and overtreatment is likely to be
avoided.
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Correspondence: Prof Dr Jens C. Turp, Klinik fur Rekonstruktive
Zahnmedizin und Myoarthropathien, Universitatskliniken fur Zahn-
medizin, Hebelstrasse 3, CH-4056 Basel, Switzerland.
E-mail: jens.tuerp@unibas.ch
2012 Blackwell Publishing Ltd