Temporomandibular Disorders and Facial Pain: A Psychophysiological Perspective

  • Alan G. GlarosEmail author


This article presents a psychophysiological perspective on temporomandibular muscle and joint disorders (TMJD) and facial pain. After a brief introduction to TMJD, the article presents data, largely derived from work carried out in my laboratory, that address four questions: (1) What are the consequences of parafunctional activities? (2) Do TMJD patients engage in parafunctional activities? (3) Why are TMJD patients unaware of these activities? and (4) What are the implications of these findings for treatment? The findings suggest that low-level parafunctions increase pain in otherwise pain-free individuals and can produce symptoms sufficiently severe to meet the diagnostic criteria for TMJD diagnoses of myofascial pain and/or arthralgia. Patients with certain forms of TMJD report very high levels of parafunctional tooth contact. Their lack of awareness of these behaviors may arise from uncertain definitions of the term “clenching”, from proprioceptive deficits, or from the presence of adjunctive behaviors. Preliminary work shows that reduction in tooth contact via habit reversal techniques may be a promising mechanism for reducing pain in these patients.


Pain Temporomandibular disorders EMG Etiology Treatment 



I thank my co-author colleagues for their many contributions. I also thank Asha Stevens and Chris Turner for their help. I’m grateful for the support of the National Institute of Dental and Craniofacial Research for much of the work reported in this article.


  1. Abou-Atme, Y. S., Zawawi, K. H., & Melis, M. (2006). Prevalence, intensity, and correlation of different TMJ symptoms in Lebanese and Italian subpopulations. The Journal of Contemporary Dental Practice, 7, 71–78.PubMedGoogle Scholar
  2. Al-Ani, Z., Gray, R. J., Davies, S. J., Sloan, P., & Glenny, A. M. (2005). Stabilization splint therapy for the treatment of temporomandibular myofascial pain: A systematic review. Journal of Dental Education, 69, 1242–1250.PubMedGoogle Scholar
  3. Ash, M. M., Jr, & Ramfjord, S. P. (Eds.). (1995). Occlusion (4th ed.). Saunders, Philadelphia.Google Scholar
  4. Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619–628. doi: 10.1016/0005-7967(73)90119-8.PubMedCrossRefGoogle Scholar
  5. Bogart, R. K., McDaniel, R. J., Dunn, W. J., Hunter, C., Peterson, A. L., & Wright, E. F. (2007). Efficacy of group cognitive behavior therapy for the treatment of masticatory myofascial pain. Military Medicine, 172, 169–174.PubMedGoogle Scholar
  6. Carlsson, G., & LeResche, L. (1995). Epidemiology of temporomandibular disorders. In B. J. Sessle, P. S. Bryant & R. Dionne (Eds.), Temporomandibular disorders and related pain conditions (pp. 211–226). Seattle, WA: IASP Press.Google Scholar
  7. Chen, C. Y., Palla, S., Erni, S., Sieber, M., & Gallo, L. M. (2007). Nonfunctional tooth contact in healthy controls and patients with myogenous facial pain. Journal of Orofacial Pain, 21, 185–193.PubMedGoogle Scholar
  8. Christensen, L. V. (1971). Facial pain and internal pressure of masseter muscle in experimental bruxism in man. Archives of Oral Biology, 16, 1021–1031. doi: 10.1016/0003-9969(71)90207-X.PubMedCrossRefGoogle Scholar
  9. Christensen, L. V. (1981a). Jaw muscle fatigue and pains induced by experimental tooth clenching: A review. Journal of Oral Rehabilitation, 8, 27–36. doi: 10.1111/j.1365-2842.1981.tb00472.x.PubMedCrossRefGoogle Scholar
  10. Christensen, L. V. (1981b). Progressive jaw muscle fatigue of experimental tooth clenching in man. Journal of Oral Rehabilitation, 8, 413–420. doi: 10.1111/j.1365-2842.1981.tb00515.x.PubMedCrossRefGoogle Scholar
  11. Chung, S. C., Kim, Y. K., & Kim, H. S. (2000). Prevalence and patterns of nocturnal bruxofacets on stabilization splints in temporomandibular disorder patients. Cranio, 18, 92–97.PubMedGoogle Scholar
  12. Ciancaglini, R., Gherlone, E. F., & Radaelli, G. (2001). The relationship of bruxism with craniofacial pain and symptoms from the masticatory system in the adult population. Journal of Oral Rehabilitation, 28, 842–848. doi: 10.1046/j.1365-2842.2001.00753.x.PubMedCrossRefGoogle Scholar
  13. Clark, G. T., Adler, R. C., & Lee, J. J. (1991). Jaw pain and tenderness levels during and after repeated sustained maximum voluntary protrusion. Pain, 45, 17–22. doi: 10.1016/0304-3959(91)90159-U.PubMedCrossRefGoogle Scholar
  14. Crider, A. B., & Glaros, A. G. (1999). A meta-analysis of EMG biofeedback treatment of temporomandibular disorders. Journal of Orofacial Pain, 13, 29–37.PubMedGoogle Scholar
  15. Crider, A., Glaros, A. G., & Gevirtz, R. N. (2005). Efficacy of biofeedback-based treatments for temporomandibular disorders. Applied Psychophysiology and Biofeedback, 30, 333–345. doi: 10.1007/s10484-005-8420-5.PubMedCrossRefGoogle Scholar
  16. Drangsholt, M., & LeResche, L. (1999). Temporomandibular disorder pain. In I. K. Crombie, P. R. Croft, S. J. Linton, L. LeResche & M. Von Korff (Eds.), Epidemiology of pain: A report of the task force on epidemiology of the international association for the study of pain (pp. 203–233). Seattle, WA: IASP Press.Google Scholar
  17. Dworkin, S. F., & LeResche, L. (1992). Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. Journal of Craniomandibular Disorders, 6, 301–355.PubMedGoogle Scholar
  18. Fogle, L. L., & Glaros, A. G. (1995). Contributions of facial morphology, age, and gender to EMG activity under biting and resting conditions: A canonical correlation analysis. Journal of Dental Research, 74, 1496–1500.PubMedGoogle Scholar
  19. Gavish, A., Halachmi, M., Winocur, E., & Gazit, E. (2000). Oral habits and their association with signs and symptoms of temporomandibular disorders in adolescent girls. Journal of Oral Rehabilitation, 27, 22–32. doi: 10.1046/j.1365-2842.2000.00484.x.PubMedCrossRefGoogle Scholar
  20. Glaros, A. G. (1996). Awareness of physiological responding under stress and nonstress conditions in temporomandibular disorders. Biofeedback and Self-Regulation, 21, 261–272. doi: 10.1007/BF02214737.PubMedCrossRefGoogle Scholar
  21. Glaros, A. G. (2007). EMG biofeedback as an experimental tool for studying pain. Biofeedback, 35, 50–53.Google Scholar
  22. Glaros, A. G., Baharloo, L., & Glass, E. G. (1998a). Effect of parafunctional clenching and estrogen on temporomandibular disorder pain. Cranio, 16, 78–83.PubMedGoogle Scholar
  23. Glaros, A. G., & Burton, E. (2004). Parafunctional clenching, pain, and effort in temporomandibular disorders. Journal of Behavioral Medicine, 27, 91–100. doi: 10.1023/B:JOBM.0000013646.04624.8f.PubMedCrossRefGoogle Scholar
  24. Glaros, A. G., Forbes, M., Shanker, J., & Glass, E. G. (2000). Effect of parafunctional clenching on temporomandibular disorder pain and proprioceptive awareness. Cranio, 18, 198–204.PubMedGoogle Scholar
  25. Glaros, A. G., Glass, E. G., & Williams, K. B. (1998b). Clinical examination findings of temporomandibular disorder patients: A factor analytic study. Journal of Orofacial Pain, 12, 193–202.PubMedGoogle Scholar
  26. Glaros, A. G., Kim-Weroha, N., Lausten, L., & Franklin, K. L. (2007a). Comparison of habit reversal and a behaviorally-modified dental treatment for temporomandibular disorders: A pilot investigation. Applied Psychophysiology and Biofeedback, 32, 149–154. doi: 10.1007/s10484-007-9039-5.PubMedCrossRefGoogle Scholar
  27. Glaros, A. G., & Lausten, L. (2003). Temporomandibular disorders. In M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A practitioner’s guide (3rd ed., pp. 349–368). New York: Guilford Press.Google Scholar
  28. Glaros, A. G., Owais, Z., & Lausten, L. (2007b). Parafunctional activity and TMD pain: A potential mechanism for the effectiveness of splint therapy. Journal of Oral Rehabilitation, 34, 97–104. doi: 10.1111/j.1365-2842.2006.01660.x.PubMedCrossRefGoogle Scholar
  29. Glaros, A. G., Tabacchi, K. N., & Glass, E. G. (1998c). Effect of parafunctional clenching on TMD pain. Journal of Orofacial Pain, 12, 145–152.PubMedGoogle Scholar
  30. Glaros, A. G., & Waghela, R. (2006). Psychophysiological definitions of clenching. Cranio, 24, 252–257.PubMedGoogle Scholar
  31. Glaros, A. G., Williams, K., & Lausten, L. (2005a). The role of parafunctions, emotions and stress in predicting facial pain. The Journal of the American Dental Association, 136, 451–458.PubMedGoogle Scholar
  32. Glaros, A. G., Williams, K., Lausten, L., & Friesen, L. R. (2005b). Tooth contact in patients with temporomandibular disorders. Cranio, 23, 188–193.PubMedGoogle Scholar
  33. Glass, E. G., Glaros, A. G., & McGlynn, F. D. (1993). Myofascial pain dysfunction: Treatments used by ADA members. Cranio, 11, 25–29.PubMedGoogle Scholar
  34. Glass, E. G., McGlynn, F. D., & Glaros, A. G. (1991). A survey of treatments for myofascial pain dysfunction. Cranio, 9, 165–168.PubMedGoogle Scholar
  35. Gramling, S. E., Neblett, J., Grayson, R., & Townsend, D. (1996). Temporomandibular disorder: Efficacy of an oral habit reversal treatment program. Journal of Behavior Therapy and Experimental Psychiatry, 27, 245–255. doi: 10.1016/S0005-7916(96)00027-4.PubMedCrossRefGoogle Scholar
  36. Haggerty, C., Glaros, A. G., & Glass, E. G. (2000). Ecological momentary assessment of parafunctional clenching in temporomandibular disorder. Journal of Dental Research, 79, 605.Google Scholar
  37. Helkimo, E., Carlsson, G. E., & Carmeli, Y. (1975). Bite force in patients with functional disturbances of the masticatory system. Journal of Oral Rehabilitation, 2, 397–406. doi: 10.1111/j.1365-2842.1975.tb01539.x.CrossRefGoogle Scholar
  38. Huang, G. J., LeResche, L., Critchlow, C. W., Martin, M. D., & Drangsholt, M. T. (2002). Risk factors for diagnostic subgroups of painful temporomandibular disorders (TMD). Journal of Dental Research, 81, 284–288.PubMedCrossRefGoogle Scholar
  39. Kogawa, E. M., Calderon, P. S., Lauris, J. R., Araujo, C. R., & Conti, P. C. (2006). Evaluation of maximal bite force in temporomandibular disorders patients. Journal of Oral Rehabilitation, 33, 559–565. doi: 10.1111/j.1365-2842.2006.01619.x.PubMedCrossRefGoogle Scholar
  40. Koh, H., & Robinson, P. G. (2003). Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database of Systematic Reviews (Online : Update Software), CD003812.Google Scholar
  41. Lyons, M. F., Rouse, M. E., & Baxendale, R. H. (1993). Fatigue and EMG changes in the masseter and temporalis muscles during sustained contractions. Journal of Oral Rehabilitation, 20, 321–331. doi: 10.1111/j.1365-2842.1993.tb01614.x.PubMedCrossRefGoogle Scholar
  42. Magnusson, T., Egermark, I., & Carlsson, G. E. (2000). A longitudinal epidemiologic study of signs and symptoms of temporomandibular disorders from 15 to 35 years of age. Journal of Orofacial Pain, 14, 310–319.PubMedGoogle Scholar
  43. Marklund, S., & Wänman, A. (2008). Incidence and prevalence of myofascial pain in the jaw-face region: A one-year prospective study on dental students. Acta Odontologica Scandinavica, 66, 113–121. doi: 10.1080/00016350802010372.PubMedCrossRefGoogle Scholar
  44. Miltenberger, R. G., Fuqua, R. W., & McKinley, T. (1985). Habit reversal: Replication and component analysis. Behavior Therapy, 16, 39–50. doi: 10.1016/S0005-7894(85)80054-X.CrossRefGoogle Scholar
  45. Nicholson, R. A., Lakatos, C. A., & Gramling, S. E. (1999). EMG reactivity and oral habits among facial pain patients in a scheduled-waiting competitive task. Applied Psychophysiology and Biofeedback, 24, 235–247. doi: 10.1023/A:1022282829829.PubMedCrossRefGoogle Scholar
  46. Nicholson, R. A., Townsend, D. R., & Gramling, S. E. (2000). Influence of a scheduled-waiting task on EMG reactivity and oral habits among facial pain patients and no-pain controls. Applied Psychophysiology and Biofeedback, 25, 203–219. doi: 10.1023/A:1026402720856.PubMedCrossRefGoogle Scholar
  47. Nilsson, I. M. (2007). Reliability, validity, incidence and impact of temporormandibular pain disorders in adolescents. Swedish Dental Journal, (183), 7–86.Google Scholar
  48. Nilsson, I. M., List, T., & Drangsholt, M. (2007). Incidence and temporal patterns of temporomandibular disorder pain among Swedish adolescents. Journal of Orofacial Pain, 21, 127–132.PubMedGoogle Scholar
  49. Osterberg, T., & Carlsson, G. E. (2007). Relationship between symptoms of temporomandibular disorders and dental status, general health and psychosomatic factors in two cohorts of 70-year-old subjects. Gerodontology, 24, 129–135. doi: 10.1111/j.1741-2358.2007.00162.x.PubMedCrossRefGoogle Scholar
  50. Pedroni, C. R., De Oliveira, A. S., & Guaratini, M. I. (2003). Prevalence study of signs and symptoms of temporomandibular disorders in university students. Journal of Oral Rehabilitation, 30, 283–289. doi: 10.1046/j.1365-2842.2003.01010.x.PubMedCrossRefGoogle Scholar
  51. Peterson, A. L., Dixon, D. C., Talcott, G. W., & Kelleher, W. J. (1993). Habit reversal treatment of temporomandibular disorders: A pilot investigation. Journal of Behavior Therapy and Experimental Psychiatry, 24, 49–55. doi: 10.1016/0005-7916(93)90008-K.PubMedCrossRefGoogle Scholar
  52. Pincus, T., Vlaeyen, J. W., Kendall, N. A., Von Korff, M. R., Kalauokalani, D. A., & Reis, S. (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: Directions for the future. Spine, 27, E133–E138. doi: 10.1097/00007632-200203010-00020.PubMedCrossRefGoogle Scholar
  53. Plesh, O., Curtis, D. A., Hall, L. J., & Miller, A. (1998). Gender difference in jaw pain induced by clenching. Journal of Oral Rehabilitation, 25, 258–263. doi: 10.1111/j.1365-2842.1998.00270.x.PubMedCrossRefGoogle Scholar
  54. Roark, A. L., Glaros, A. G., & O’Mahony, A. M. (2003). Effects of interocclusal appliances on EMG activity during parafunctional tooth contact. Journal of Oral Rehabilitation, 30, 573–577. doi: 10.1046/j.1365-2842.2003.01139.x.PubMedCrossRefGoogle Scholar
  55. Rugh, J. D., & Drago, C. J. (1981). Vertical dimension: A study of clinical rest position and jaw muscle activity. The Journal of Prosthetic Dentistry, 45, 670–675. doi: 10.1016/0022-3913(81)90426-1.PubMedCrossRefGoogle Scholar
  56. Schmitter, M., Rammelsberg, P., & Hassel, A. (2005). The prevalence of signs and symptoms of temporomandibular disorders in very old subjects. Journal of Oral Rehabilitation, 32, 467–473. doi: 10.1111/j.1365-2842.2005.01449.x.PubMedCrossRefGoogle Scholar
  57. Shimshak, D. G., & DeFuria, M. C. (1998). Health care utilization by patients with temporomandibular joint disorders. Cranio, 16, 185–193.PubMedGoogle Scholar
  58. Shimshak, D. G., Kent, R. L., & DeFuria, M. (1997). Medical claims profiles of subjects with temporomandibular joint disorders. Cranio, 15, 150–158.PubMedGoogle Scholar
  59. Storm, C., & Wänman, A. (2006). Temporomandibular disorders, headaches, and cervical pain among females in a Sami population. Acta Odontologica Scandinavica, 64, 319–325. doi: 10.1080/00016350600801915.PubMedCrossRefGoogle Scholar
  60. Stowell, A. W., Gatchel, R. J., & Wildenstein, L. (2007). Cost-effectiveness of treatments for temporomandibular disorders: Biopsychosocial intervention versus treatment as usual. The Journal of the American Dental Association, 138, 202–208.PubMedGoogle Scholar
  61. Townsend, D., Nicholson, R. A., Buenaver, L., Bush, F., & Gramling, S. (2001). Use of a habit reversal treatment for temporomandibular pain in a minimal therapist contact format. Journal of Behavior Therapy and Experimental Psychiatry, 32, 221–239. doi: 10.1016/S0005-7916(02)00004-6.CrossRefGoogle Scholar
  62. Turner, J. A., Mancl, L., & Aaron, L. A. (2006). Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial. Pain, 121, 181–194. doi: 10.1016/j.pain.2005.11.017.PubMedCrossRefGoogle Scholar
  63. van der Meulen, M. J., Lobbezoo, F., Aartman, I. H., & Naeije, M. (2006). Self-reported oral parafunctions and pain intensity in temporomandibular disorder patients. Journal of Orofacial Pain, 20, 31–35.PubMedGoogle Scholar
  64. Villarosa, G. A., & Moss, R. A. (1985). Oral behavioral patterns as factors contributing to the development of head and facial pain. The Journal of Prosthetic Dentistry, 54, 427–430. doi: 10.1016/0022-3913(85)90565-7.PubMedCrossRefGoogle Scholar
  65. Waltimo, A., & Kononen, M. (1993). A novel bite force recorder and maximal isometric bite force values for healthy young adults. Scandinavian Journal of Dental Research, 101, 171–175.PubMedGoogle Scholar
  66. Yamada, K., Hanada, K., Fukui, T., Satou, Y., Ochi, K., Hayashi, T., et al. (2001). Condylar bony change and self-reported parafunctional habits in prospective orthognathic surgery patients with temporomandibular disorders. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, 92, 265–271. doi: 10.1067/moe.2001.117558.CrossRefGoogle Scholar
  67. Yamasaki, K., Harada, S., Higuchi, I., Osame, M., & Ito, G. (2005). Fatigue and damage to the masseter muscle by prolonged low-frequency stimulation in the rat. Archives of Oral Biology, 50, 1005–1013. doi: 10.1016/j.archoralbio.2005.05.001.PubMedCrossRefGoogle Scholar
  68. Zarb, G. A., Bolender, C. L., Eckert, S. E., Jacob, R. F., Fentn, A. H., & Mericske-Stern, R. (2004). Complete dentures and implant-supported prostheses. In Prosthodontic treatment for edentulous patients (12th ed.). St. Louis, MO: Mosby.Google Scholar

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© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Kansas City University of Medicine and BiosciencesKansas CityUSA

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