CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ycra20

Overcoming temporomandibular joint clicking and

pain

Giath Gazal

To cite this article: Giath Gazal (2020) Overcoming temporomandibular joint clicking and pain,
CRANIO®, 38:4, 209-211, DOI: 10.1080/08869634.2020.1769440

To link to this article: https://doi.org/10.1080/08869634.2020.1769440

Published online: 30 Jun 2020.

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CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
2020, VOL. 38, NO. 4, 209–211
https://doi.org/10.1080/08869634.2020.1769440
GUEST EDITORIAL
Overcoming temporomandibular joint clicking and pain
Joint clicking is not a serious disease, but it can be
troublesome for young adults. Dentists who do not
know how to deal with these cases will cause distrust
and a sense of loss in such patients [1]. Therefore,
general dental practitioners have a medical responsi-
bility to treat these cases in a systematic and effective
way. If they lack information or expertise, they should
undergo the necessary training to overcome any weak-
ness in their diagnosis or treatment.
Medical records have shown an increase in temporo-
mandibular joint clicking among the younger generation
[2]. An underlying cause was studied in the past, and the
main factors included the hypertonicity of mastication
muscles, in particular, the lateral pterygoid muscle, high
stress level, poor habits (gum chewing, bruxism, and
chewing hard candy), and poor dentition, which leads
to disc displacement with reduction (DDwR) [2–4]. In
young adults, TMJ clicking and pain is usually caused by
clenching the jaws and grinding teeth. Young people are
sensitive and emotional and do not have enough experi-
ence to help them solve or challenge problems they
encounter in their lives [2]. So, they spend days and
nights worrying, without getting rest. This sort of stress
leads them to unconsciously grind teeth and aggressively
occlude the jaws as a result of the hyperactivity of masti-
cation muscles [3,4]. Dentists routinely treat such patients
with a splint or muscle relaxation appliance to wear at
night to help reduce clenching and grinding.
A study by Almashraqi et al. [3] reported that a khat
or gum chewing habit may be a risk factor for tempor-
omandibular joint disorders. Self-reported TMJ click-
ing in teenagers was associated with a natural tendency
to aggressive physical behavior and concerns with body
image. Adolescents seeking care have greater non-spe-
cific physical symptoms and body image concerns and
tend to report more frequent TMJ sounds [4].
The idea of using a splint for treating patients with
TMJ disc displacement with reduction (DDwR) arose
out of the fact that the thickness of a splint can push
the condyle downward and forward, creating enough
space to recapture the displaced disc [1–3]. Wearing an
anterior repositioning splint (ARS) or hard stabiliza-
tion splint (HSS) causes the condyle to move forward
and downward, while the disc gradually moves
© 2020 Taylor & Francis Group, LLC
backward [5]. Consequently, anterior repositioning of
the mandible improves the spatial relationship between
the disc and condyle in patients with clicking joints
[1,4]. In addition to anterior and inferior movement of
the condyle, transitory posterior movement of the disc
also occurs [2]. Liu et al. [5] found that disc movement
was noticeably substantial (2.23 mm posteriorly) in
joints with DDwR for the ARS position. On the other
hand, the displaced disc only moved back 0.75 mm for
the HSS position. The frequency of successful “disc
recapture” with position 2 was significantly higher
than position 3 (Figure 1). One possible explanation
for the reduction of the displaced disc with ARS might
be the disappearance of the stiffness in the retrodiscal
tissues [5].
Wearing an anterior repositioning splint is consid-
ered to be one of the effective methods for the treat-
ment of disc displacement with reduction. The occlusal
appliance works by achieving the occlusal disengage-
ment, restoring vertical dimension of occlusion, muscle
relaxation, and joint unloading [4]. Clinical examina-
tions after two years reported that the conditions were
stable, and magnetic resonance imaging (MRI) showed
thickening of the retrodiscal tissues, including extra
fibrous tissue, resulting in a pseudodisc [6]. Thus,
treatment using ARS can stimulate tissue fibrosis and
the formation of a pseudodisc. One possible explana-
tion for fibrous tissue formation is the replacement of
the blood vessels and nerves in the bilaminar zone with
more fibrous tissue.
The first choice for treatment of TMJ clicking and
tenderness is generally a soft diet and analgesic medi-
cation such as oral/gel ibuprofen, which has been used
for decades [2,7,8]. If this treatment is not effective,
a soft stabilization splint (SSS) is made for use as
a second option for a period of six months [7]. If
healing is slow, the third option would be physiother-
apy and/or acupuncture. Stress reduction therapy could
be of benefit for young adults [5]. A study by He et al.
[9] stated that temporomandibular joint clicking
sounds originate from the stiffness of lateral pterygoid
and temporalis muscles. By using a hard stabilization
splint, functional recovery of the masticatory muscles
occurs through the elimination of discrepancy between
210 GUEST EDITORIAL
Figure 1. Representative three bite positions: Maximum intercuspation (Position 1), anterior repositioning splint position
(Position 2), and stabilization splint position (Position 3).
the centric relation (CR) and maximum intercuspa-
tion (MIC).
However, anterior repositioning splints (ARSs) have
been used successfully for treating the popping jaw
(disc displacement with reduction), and centric stabili-
zation splints are the best choice for treating a locking
jaw (disc displacement without reduction) [8].
Although anterior repositioning splints have been
used for decades as a conventional therapy for
DDwR, this therapy requires regular and repeated eva-
luation for risk of posterior open bite long-term
[10,11]. Many studies in literature favor the use of
HSS over ARS because it has fewer problems after
treatment [9–12]. In contrast, soft splints (SS) should
be used more in cases of myofascial pain dysfunction
syndrome (MPDS) than intracapsular temporomandib-
ular disorders (TMDs).
A network meta-analysis (NMA) of randomized
controlled trials (RCTs) was conducted by Al-
Moraissi et al. [13] to assess the effectiveness of various
types of occlusal splints in the management of TMDs
and to rank them according to their effectiveness. The
outcome of this study reported that the multimodal
therapy consisting of counseling therapy (CT) + hard
stabilization splint (HSS) produces the maximum
improvement for TMD patients [13]. Duration of treat-
ment is approximately 8 weeks. First, the patient
should wear a stabilization splint 24 hours a day for
the first 4 weeks [7–9]. Second, the patient must wear
the splint while eating and sleeping for another
2 weeks. Third, the patient wears the splint only while
sleeping for the last 2 weeks. In contrast, a study by
Akbulut et al. [14] evaluated the effects of the 3.0 mm
thickness splint therapy on temporomandibular joint
disorders. They found that 3.0 mm splint therapy
should be used for at least 6 months and worn for
a minimum of 12 hours a day to achieve remarkable
results [14].
In conclusion, both anterior repositioning splints
and hard stabilization splints are effective for the
treatment of TMJ clicking. However, a treatment
approach using an anterior repositioning splint can
stimulate tissue fibrosis and the formation of
a pseudodisc. Moreover, an anterior repositioning
splint requires regular and repeated evaluation with
the risk of a posterior open bite long-term. It is
recommended to start therapy with a hard stabiliza-
tion splint to achieve a fast and reliable outcome, in
addition to a lower risk of side effects.
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Giath Gazal, PhD
College of Dentistry, Taibah University, Al Madina Al
Munawara, Kingdom of Saudi Arabia
gazal73@yahoo.co.uk