CMD: Who’s Cracking The Case?

6. February 2018
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Craniomandibular dysfunction can be treated effectively in most cases. The problem lies elsewhere: those affected often have an exasperating journey of visits to various specialists already behind them, before the suspicion falls on CMD.

In Germany, about five to ten percent of adults suffer from craniomandibular dysfunction – referred to as CMD in short. This painful dysfunction of the masticatory system can be triggered by mental, structural, functional and biochemical factors.

The impact of treatment is usually good: about 70 percent of those affected, according to Andrea Diehl, a specialist in the German Society for Functional Diagnostics and Therapy, respond well to treatment: in 50 percent of patients therapy is successful, and it is moderately successful for 20 percent. However before a CMD is recognised at all, those affected have often endured an odyssey of countless visits to medical specialists.

Everything is a possibility, even CMD

That’s because at first glance the symptoms may mislead the examining doctor. Aspects described include facial and jaw pain, headache, neck and ear pain, pressure behind the eyes, in the sinuses, and toothache. The pains are diffuse, dull, come in waves and are persistent. They can occur when one is still or when moving. Those affected often report limited jaw opening, cracking and rubbing noises when opening and closing the jaw. Yet dizziness, photosensitivity, panic attacks and stress in everyday life can also be signs of the condition. If CMD is not treated, mandibular-arthrosis can arise.

Different causes

The cause of CMD is frequently an improper bite – and not just when clenching the teeth, but when chewing or talking. A defective bite can be innate, but can also be caused by orthodontic treatments, dental fillings, crowns or traumatic events such as accidents. The position of the bite is also involved in the positioning of the mandibular joint. This is a sliding and rotational joint that allows chewing, biting and talking. A slanted bite also affects the head joint and the cervical spine. Conversely, among other things, the consequences of trauma or different lengths of legs can alter the tone of certain muscle chains (paravertebrally). This shifts the joint axis of the temporomandibular joints and the joint space narrows. This then causes jaw pain.

Who suffers most often?

Studies show distinct gender-specific and age-related correlations. Anders Wänman and his team [Paywall] were able to show that it was most often women between the ages of 35 and 50 who suffered from CMD. For their study, the scientists interviewed about 800 patients between the ages of 35 and 75 and then clinically examined them.

Two years later, in 2015, Wänman and his colleagues published another study [Paywall] on this topic. According to this study, the likelihood of CMD increases continuously from adolescence onward. The highest prevalence is among middle-aged people, especially women. From the age of about 50, the risk of the condition decreases. Between May 2010 and October 2012 the scientists interviewed about 140,000 people from 10 to over 90 years of age. The patients had undergone a routine examination by the Public Dental Health Service in the Västerbotten district in Sweden.

Risk factor saxophone?

The risk of CMD is said to increase due to mental stress, psychosocial problems (eg. anxiety disorders), teeth grinding, and playing a wind instrument. The last mentioned aspect was revealed by Japanese scientists in 2016. The investigation involved 72 people who played a wind instrument and 66 non-players. How strongly the lips were pressed onto the mouthpiece was crucial with regard to CMD risk. What’s more, women with low BMI are also – according to another study from 2016 – supposed to have a higher CMD risk. However their dental status, such as their number of teeth, is said to have no influence.

How therapy works, who conducts treatment

Dental or orthodontic treatment is prominent in this context. This is because the origin of a CMD is virtually always a defective bite. Bite splints (occlusion splints) are supposed to relieve the temporomandibular joints. Jaw exercises used as a therapy are only gradually gaining acceptance.

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Bite splints are made of clear plastic. When the teeth are pressed together, the pressure is better distributed. In addition teeth grinding is prevented./ gentle07, pixabay

Some therapies become more effective if tension caused by defective posture in the jaw muscle, head joint and upper neck muscles can be released. Physiotherapy measures like massage and relaxation courses then also make sense. Therefore CMD therapists work – depending on the influencing factors – in cooperation with orthopaedists, osteopaths, physiotherapists, neurologists, psychologists, podiatrists and internists.

However, the approach to treatment is very individualised. “There are many different views on correct treatment. […] For good treatment, extensive knowledge of bite and having a three-dimensional orthodontic picture are necessary”, Stefanie Morlok, a dentist and CMD therapist, explains.

Too much interdisciplinarity?

Another opinion, which contrasts with the “mainstream” one in decisive aspects, is held by André von Peschke. The dentist is a specialist in the German Society for Functional Diagnostics and Therapy (DGFDT) and trained expert in the German Society for Prosthetic Dentistry and Biomaterials (DGPro). In his opinion, every illness is multifactorial and multicausal – whether it is athlete’s foot or a brain tumour. Specialists should be consulted only for CMD patients suffering severe postural deficiencies or severe mental illness. Normally, however, extended specialist examinations in all conceivable specialist areas are not necessary. This is because in the normal situation it’s only the bite of those affected which is not right.

The notion that someone with symptoms should consult a CMD dentist first, who then sets his interdisciplinary network in motion, does not match reality, says André Peschke. In actuality, those affected seek out one specialist after another. In the process the most diverse conditions such as herniated disc or brain tumours are eliminated as possibilities. With women in particular psychic problems are suspected as the reason for their symptoms. Finally, either through self-research or through other doctors, those affected get the indication that it could be CMD. Often by this time the examinations carried out by the various specialists reach a conclusion of no findings.

Psychosomatic medicine is not always the solution

Therefore it does not make sense to drag the person concerned once more through the “interdisciplinary examination mill”, the expert argues. Instead of that, the cause should first be searched out in the mouth: for example, were those new crowns, which were fixed at about the same time as the beginning of the complaints, professionally finished? “We are also resolutely against the trend of shoving patients with higher sensitivity to occlusion malformation into the field of psychosomatics – as has become more and more fashionable – when thousands of euros have already flowed into meaningless CMD diagnostics, yet the patient never gets better and the treating practitioner moreover offers no therapeutic concept, but then explains to the astonished patient that the problem must reside in his or her psyche, which would explain why he can no longer cope with his occlusion disorder”, Peschke argues. In reality a large proportion of “our” patients, who have been categorised as “beyond therapy”, had often been examined by various medical specialists who arrived at inconclusive findings.

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