Temporomandibular Disorders in Children and Adolescents

Article information

J Korean Acad Pediatr Dent. 2024;51(4):321-335

Publication date (electronic) : 2024 November 25

doi : https://doi.org/10.5933/JKAPD.2024.51.4.321

Department of Pediatric Dentistry, School of Dentistry, Dental Research Institute, Seoul National University, Seoul, Republic of Korea

Corresponding author: Ji-Soo Song Department of Pediatric Dentistry, School of Dentistry, Dental Research Institute, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea Tel: +82-2-6256-3264 / Fax: +82-2-6256-3266 / E-mail: pedosong@snu.ac.kr

Received 2024 October 16; Revised 2024 October 25; Accepted 2024 October 27.

Trans Abstract

Temporomandibular disorder (TMD) is characterized by pain, dysfunction, and distress in the masticatory muscles and/or temporomandibular joints and associated structures. Despite its high prevalence in children and adolescents, exceeding 20%, TMD has not been extensively studied. Therefore, this review aimed to establish an overview of TMD in children and adolescents and describe its diagnosis and treatment. TMD more predominantly occurs in girls and has multifactorial etiologies, with several risk factors interacting differently at the individual level. TMD is associated with poor oral health-related quality of life and abnormal facial growth. The Diagnostic Criteria for TMD (DC/TMD) assessment protocol is used to diagnose TMD in young patients, and TMD can be effectively managed with conservative therapies such as patient education, home care, physical therapy, occlusal appliance therapy, and pharmacotherapy. During routine dental checkups, pediatric dentists can identify TMD in children and adolescents to reduce the occurrence of complications due to its chronic progression.

Keywords: Temporomandibular disorder; Children; Adolescent; Pediatric dentist

Introduction

Temporomandibular disorder (TMD) is a collective term for various clinical problems involving the masticatory muscles and/or temporomandibular joints (TMJs) and associated structures[1] with the following characteristics: (a) pain in the TMJ, periauricular area, or masticatory muscles; (b) TMJ noises during mandibular movement; and (c) deviations or restrictions in the range of motion of the mandible[2]. Following the odontogenic pain, TMD is one of the most prevalent sources of discomfort in the oral and maxillofacial areas[3].

Several studies have reported that signs and symptoms of TMD generally occurred between ages 20 and 40 years[4,5] but rarely in growing children[6]. However, the TMD prevalence in children and adolescents has been increasing worldwide; its signs and symptoms in young patients appear to be as frequent as in adults[7,8], and its related pain has also been reported in children and adolescents[6].

TMD typically causes pain, dysfunction, and distress in affected patients[9]. It can last for long periods and may induce irreversible facial musculature and jaw changes, although its long-term effects have not been fully elucidated[10]. Furthermore, TMD negatively affects children’ s oral health-related quality of life[11]. Therefore, early diagnosis of TMD is crucial to minimize its effects on the growth and development of children, despite the difficulties encountered during its diagnosis and treatment in young patients.

Since TMD in children and adolescents has not been extensively studied, this review aims to provide its overview and describe its diagnosis and treatment for pediatric dentists who are responsible for their overall oral health.

TMD prevalence

The TMD prevalence is not yet well understood in children and adolescents compared to adults. Studies that only used some questions or a questionnaire to assess TMD reported that its prevalence varied from 5.1% to 36.9% in adolescents aged 13 years and older[8,11-13]. In other studies that used clinical examination with a questionnaire, the prevalence also highly differed, ranging from 5.73% to 68%[14,15], and regardless of varying methodology and population, a prevalence rate of >20% has been reported[6,16-18]. In Korea, the 2010 National Oral Health Survey reported that the prevalence of TMD in Korean children and adolescents was 13.0%[19] and that few children younger than 10 years have also been diagnosed with TMD[20]. However, these prevalence rates may be underestimated because TMD is not typically considered a pediatric problem, and children tend not to visit clinics for TMD symptoms[18].

Consistent with adults, TMD tended to be more prevalent in females than males among children and adolescents[13,21,22]. The gender difference is insignificant at a young age but becomes evident with growth, showing considerable differences in late adolescence[23]. This gender difference might be caused by hormonal changes and physiologic variables[7] and might be associated with social factors, differences in pain sensitivity, as well as the tendency for females to seek TMD treatment more than males[18].

Clinical signs and symptoms of TMD

TMD is commonly diagnosed based on signs and symptoms, with TMJ noise (clicking, popping, or crepitus) being the most common clinical sign, followed by TMJ pain and masticatory muscle pain[2,19]. Impaired mandibular movement, limited mouth opening, headache, periauricular pain, facial pain, and jaw tenderness during jaw movement also commonly occur[16,24]. These signs and symptoms can be observed in all age groups and are usually mild, and their progression to severe pain and dysfunction is rare in young patients[25].

Meanwhile, headache was significantly associated with painful TMD[26], and some studies have reported that painful TMD was associated with emotional and somatic malfunctioning and promoted aggressive behaviors in young patients[27,28]. Moreover, some factors associated with pain from TMD becoming chronic are as follows: females with myogenous TMD, increasing age at presentation, graded chronic pain scale score of 3 or 4, higher pain intensity, higher pain interference, more widespread non-specific symptoms or higher number of pain locations, and concurrent psychiatric diagnosis or mood disturbance such as depression, anxiety, and anger[3]. Indeed, the longer the pain persists, the higher the risk of developing and intensifying cognitive, psychosocial, and behavioral factors. This can increase pain sensitivity and likelihood of persistent pain and decrease the chance of success with standard treatments[29].

TMD etiology

Recent scientific developments have emphasized the etiology of TMD away from a biomedical paradigm and toward a more intricate multifactorial biopsychosocial model considering the biological, psychological, and social factors[30]. TMD in children and adolescents is also associated with multifactorial etiologies, with several risk factors interacting differently at the individual level[31]. These factors are classified as predisposing, initiating, and perpetuating based on their role in TMD progression[3]. Structural, metabolic, and psychological conditions negatively affecting the masticatory system are considered predisposing factors because they can increase the risk of developing TMD. The initiating factors result in the onset of TMD and are associated with trauma, occlusal interference, or repetitive adverse loading of the masticatory system. Parafunction, hormonal, immunological, or psychological factors are considered perpetuating factors because they can sustain the condition, and these perpetuating factors may be closely related to any predisposing and initiating factors[23].

The psycho-emotional element considerably influences the TMD occurrence, associated with the effects of other physical health-related variables, such as systemic disorders, malocclusions, tooth loss, traumas, and microtrauma[7]. Patients with psychological problems such as anxiety, stress, feelings of sadness, somatization, and life dissatisfaction frequently perceive the muscular component of TMD[12,27,32], and adolescents with TMD pain had significantly greater sensitivity to pleasant and aversive somatic stimuli than the controls[33]. TMD coexists with various other conditions, including back or spine pain, chronic fatigue syndrome, spastic colons, sleep problems, migraines, and arthritis[34]. Conversely, a cohort study also demonstrated that patients with high self-esteem had less tendency to develop TMD[35].

Students have been reported to experience greater stress than the general population and are far more likely to have TMD and oral dysfunction. Exams, presenting research papers, the desire to become independent, financial difficulties, studying in an uncomfortable posture, and poor academic performance can be potential stressors[36]. Furthermore, TMD can be influenced by the environment in children and adolescents, and the family environment is significantly important. Painful TMD was reportedly associated with living with divorced or single parents[37], and parental depression during their children’s childhood was associated with pain-related TMD during early adulthood[38].

A functional mandibular overload variable, especially bruxism, is a major cause of TMD not only in adults but also in children and adolescents[25]. Bruxism is defined as the habitual or involuntary, nonfunctional forceful contact between the occlusal surfaces of maxillary and mandibular teeth, and is known to have multifactorial causes, including morphologic, psychologic, and pathophysiologic factors[25]. It may also be caused by the immaturity of the masticatory neuromuscular system[39]. Sleep bruxism typically occurs at 1 year of age, and tooth grinding during sleep declines linearly with age, from 14% in children to 8% in adults to 3% in the older population aged >60 years[25]. Therefore, juvenile bruxism is thought to be self-limiting and not to progress to adult bruxism[40], and no study has supported any kind of therapeutic options for bruxism in children[41]. However, it can also induce complications such as dental attrition, headache, TMJ dysfunction, and masticatory muscle soreness[42,43], and other oral habits such as the nails, lips, or object biting and general oral habits have also been reportedly associated with TMD[21,44,45]. Furthermore, parafunction prevention during early childhood is thought to be helpful to decrease TMD problems[46].

Other possible causal factors for TMD occurrence in children are occlusal interference and instability during mixed and young permanent dentition[47]. However, some studies have reported that these occlusal factors were only weakly associated with TMD signs and symptoms, and a lateral forced bite between the intercuspal contact position and retruded contact position in young patients could be potential local risk factors in TMD development[23]. In these positions, the articular fluid compression during condyle translation can induce the TMJ sound, such as clicking, without disc displacement, or pain, which is different from that of adults. The prevalence of TMJ noise seems to increase from primary to permanent dentition and is believed to be associated with prolonged muscle tension causing intracapsular changes and TMJ sound in older individuals[48]. TMJ noise in children and adolescents can also be caused by temporary disc contour incompatibility because of differential growth rates and calcification[49].

Malocclusion was formerly thought as one of the primary etiological impacts of TMD signs and symptoms; however, the importance of TMD malocclusion has been recently decreasing[7]. Some studies found an association between them[47,50], whereas other studies revealed no association[51,52]. Although no strong association was established, the most common malocclusions associated with TMD were excessive overjet, posterior crossbite, deep and open bites, and Angle classes II and III[1,4]. Aberrant occlusal contacts in patients with malocclusion may have an impact on how the condyle and fossa are connected. Furthermore, the asymmetrical activation of the masticatory muscles caused by different tooth contacts on the right and left sides may overload on one side more than the other[1,53]. In addition, patients with the dolichofacial type of craniofacial morphology demonstrated a tendency for the occurrence of masticatory muscle tenderness; however, any particular trait cannot be considered as predictive factors for TMJ dysfunction[31,54].

Studies evaluated the relationship between orthodontic treatment and TMD and revealed that traditional orthodontic interventions did not significantly contribute to the development or exacerbation of TMJ-related issues[30,35,55], although the TMD prevalence of patients seeking orthodontic treatment was high, with many individuals presenting the signs/symptoms of painful TMD[4]. More specifically, orthodontic or functional treatments targeting skeletal class II and class III malocclusions have not increased the TMD risk during the treatment phase, nor decreased TMD risk after completing the treatment[1]. For fixed orthodontic treatments with premolar extractions, posterior condylar positioning was observed posttreatment, but they did not demonstrate a higher prevalence of disc displacement[56]. Intermaxillary elastics in fixed orthodontic treatment increased the strain on the TMJ, particularly in class II patients, and clear aligners and orthodontic retainers increased the electromyographic activity in masticatory muscles. However, the potential relationship between this increased strain and development of TMD signs and symptoms remains unknown[57-59]. Nonetheless, it is noteworthy that certain conventional orthodontic techniques that disregard the functional occlusion principles have been remarkably identified as potential initiators and perpetuators of TMD[1,60].

Impacts of TMD

TMD is a serious public health issue because it is the primary reason for nondental orofacial pain[1,7] and the second most prevalent musculoskeletal problem behind chronic low back pain[61]. Several studies reported that TMD symptoms were significantly associated with poor oral health-related quality of life, low sleep quality, frequent sick leave from school, and pain chronicity in children and adolescents[11,62,63], and pain chronicity commonly causes reduced physical, social, and psychological functioning in young patients[64].

TMD is thought to potentially cause abnormal facial growth in growing children and adolescents. Studies have identified that open bite or hyperdivergent developmental patterns were associated with degenerative TMJ disorders and that this association is possibly caused by the early onset of TMD, revealing abnormal condyle development[1]. Degenerative joint disorders were thought to be associated with a mandibular ramus deficiency, a larger gonial angle, a clockwise mandibular rotation, a retrognathic appearance, and a vertically elongated facial pattern, resulting in a skeletal class II relation[31]. Besides the degenerative disorder, the anterior disc displacement without reduction may also be associated with the worsening of skeletal class II and mandibular asymmetry in skeletal open bite[65].

Patients with facial skeletal asymmetries have a higher incidence of TMD[66]. The shift of menton was found to be significantly associated with TMJ disc position on magnetic resonance imaging (MRI), with more deviation to the side with disc displacement[67]. Unilateral anterior disc displacement of the TMJ observed in adolescents can result in mandibular asymmetry, especially on the same side[68]. Conversely, mandibular asymmetry has also been described as a contributing factor to TMD, emphasizing the close relationship between function and morphology[69].

TMD diagnosis

In 1992, Dworkin and LeResche developed the Research Diagnostic Criteria for TMDs (RDC/TMDs) as a standard tool for clinical research, aimed at enhancing the consistency of TMD studies conducted worldwide[36]. The RDC/TMD protocol consists of two axes based on the biopsychosocial model of TMD etiology[18]. Axis I deals with the physical properties of TMD, whereas Axis II refers to the psychological components. In 2014, TMD experts agreed to establish an expert-based DC/TMD to compensate for the slightly low validity of Axis I in RDC/TMD and finalize the new Axis I diagnostic algorithm and new Axis II instruments[29]. This assessment protocol can be used in both clinical and research settings and establishes a systematic approach to diagnosing TMD[70]. It has four major components: (1) The history and clinical examination, including the collection of a comprehensive medical history, assessing the patient’s symptoms, and performing a physical examination. During examination, the clinician assesses signs and symptoms associated with TMD, including jaw muscle tenderness, pain during jaw movement, jaw clicking, and range of motion changes. (2) Imaging studies, like X-rays, computed tomography (CT), and MRI, which are important to diagnose TMD, as they can detect structural abnormalities or degenerative changes in the TMJ and surrounding tissues. Panoramic radiographs detect gross hard tissue changes but are not sufficiently sensitive to diagnose degenerative changes. CT imaging detects bony abnormalities within the TMJ with high sensitivity, and MRI can visualize the soft tissues, specifically the TMJ disc position and contours (Fig. 1)[71]. (3) Psychological testing can promote understanding of psychological factors that may influence the patient’s symptoms. (4) The laboratory test can be used to rule out other systemic conditions that may cause the patient’s symptoms. Since diagnosing TMD is highly complex, the clinicians must integrate information obtained from DC/TMD to make an appropriate diagnosis; however, they should not rely solely on DC/TMD[18].

Fig 1.

Degenerative joint disease of both TMJs in a 10-year-old male patient. (A) Bony changes are not clearly observed in the panoramic radiograph, (B) the cortical bone appears hazy on both mandibular condyles, and the surfaces show slight irregularities in the computed tomography images, and (C) the magnetic resonance images reveal cortical erosion and reduced bone marrow signal at the articular surfaces of both mandibular condyles.

DC/TMD includes the following 12 common TMDs: myalgia and its three subtypes (local myalgia, myofascial pain with spreading, and myofascial pain with referral), arthralgia, headache attributed to TMD, four disc displacement disorders (disc displacement with reduction, disc displacement with reduction with intermittent locking, disc displacement without reduction with limited opening, and disc displacement without reduction without limited opening), degenerative joint disease, and subluxation. The diagnostic criteria for each TMD are shown in Tables 1 - 9[29]. Disc displacement, degenerative joint disease, and subluxation can be diagnosed using imaging examination results in addition to history taking and clinical examination. The International Network for Orofacial Pain and Related Disorders methodology, formerly known as the International RDC/TMD Consortium Network, establishes the clinical examination protocol[72].

Table 1.

Diagnostic criteria for myalgia

Table 2.

Diagnostic criteria for the three subtypes of myalgia

Table 3.

Diagnostic criteria for arthralgia and headache attributed to temporomandibular disorder

Table 4.

Diagnostic criteria for disc displacement with reduction

Table 5.

Diagnostic criteria for disc displacement with reduction with intermittent locking

Table 6.

Diagnostic criteria for disc displacement without reduction with limited opening

Table 7.

Diagnostic criteria for disc displacement without reduction without limited opening

Table 8.

Diagnostic criteria for degenerative joint disease

Table 9.

Diagnostic criteria for subluxation

DC/TMD is designed for adult patients and is difficult to apply directly to children and adolescents because the ability to report past and future pain experiences is influenced by age and developmental stage[73]. Parents can help provide proxy reports; however, their observations can be somewhat distanced from the child’s actual experience. Thus, the comprehensive and short forms of DC/TMD can be applied to children aged 6 - 9 years and adolescents aged 10 - 19 years, using an age-specific version of the questionnaire for screening TMD and general health, with shortened clinical examination procedures and simplified language[63,74]. The results for the comprehensive and short form DC/TMD are the same in both child and adolescent versions, except for the results of lateral and protrusive mandibular movements, as shown in Table 3, 4, and 8.

Treatment for TMD

TMD should be managed correctly and promptly in the young age group to minimize its impact. However, only very little research has been conducted on the treatment methods for TMD in children and adolescents, and systematic reviews and published guidelines reported widely varied therapeutic recommendations for TMD. The treatment goals are to restore function, reduce pain, minimize aggravating or contributing factors, and enhance the quality of life, and effective early management of acute TMD can prevent the potential onset of chronic pain[71].

In patients with disc displacement with reduction, many patients may not experience pain and only exhibit TMJ clicking sounds, and no treatment is generally necessary aside from reassurance and explanation. For other diagnoses, conservative and reversible therapies are known to effectively alleviate most TMD signs and symptoms in patients, including children and adolescents[75]. Irreversible therapies such as occlusal adjustments, orthodontics, and surgery are not recommended in growing patients.

Nonsurgical TMD management consists of a combination of patient education, a homecare plan, physical therapy, occlusal appliance therapy, and pharmacotherapy[75]. Patient education involves explanation of the following information to patients and parents in simple and clear language: (1) the nature of the disorder; (2) initiating, predisposing, and perpetuating factors; (3) TMJ anatomy; (4) treatment modalities; and (5) treatment goals. Homecare plan consists of (1) dietary habit modification (e.g., avoidance of chewing hard food), (2) application of cold and/or warm compresses, (3) avoidance of habits overloading the masticatory muscles and TMJ (e.g., chewing gum or pencils, clenching, and other parafunctional habits), and (4) maintenance of the jaw in resting position with teeth apart and relaxed masticatory muscles. Physical therapy is a noninvasive and conservative therapy to relieve musculoskeletal pain and restore function by modifying the sensory input, reducing inflammation, increasing the range of motion of the jaw, promoting tissue repair and regeneration, and aiding the reestablishment of oral motor function[76]. The types of physical therapy include manual manipulation, massage, TMJ distraction and mobilization, therapeutic exercises, coolant therapy with spray and stretch, ultrasound therapy, and transcutaneous electrical nerve stimulation.

Occlusal appliance therapy utilizes customized acrylic devices that typically fit onto the maxillary teeth to reduce TMJ pain, increase jaw movement range, and improve the joint function[75]. The most common types are stabilization appliances, anterior positioning appliances, and anterior bite appliances[77]. An occlusal appliance combined with brief information is an effective treatment for myofascial pain according to DC/TMD in adolescents[78,79]. Relaxation and home training can also be effective; however, adolescents are more motivated to use occlusal appliances than relaxation and home training[79]. No studies have evaluated the effectiveness of treatment in children with primary and mixed dentition, and clinicians should consider the potential negative consequences for younger patients[9].

Pharmacotherapy aimed to reduce pain and improve function. In adults, medications such as nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, hyaluronic acid, and adjunctive agents such as muscle relaxants, antidepressants, and benzodiazepines are commonly used[75]. Current studies do not recommend the use of opioids to manage chronic TMD, and data on the use of medications for managing TMJ disorders in children are limited[71].

Acute TMD can be managed with patient education and pharmacotherapy with nonsteroidal anti-inflammatory drugs; however, chronic TMD may require a multimodal approach including physical therapy, behavior evaluation, and pharmacotherapy[71]. Psychological factors can not only trigger TMD but also perpetuate and affect its long-term prognosis. Therefore, psychological distress management has been reported to alleviate TMD symptoms, signs, and chronic pain[80,81]. Furthermore, better treatment outcomes have been observed in adolescents with chronic pain when depression is treated early[82].

Conclusion

The prevalence of TMD in children and adolescents is high, exceeding 20%, and predominantly occurs in girls. It has multifactorial etiologies, with several risk factors interacting differently at the individual level. TMD is associated with poor oral health-related quality of life and abnormal facial growth. TMD in young patients is diagnosed using the DC/TMD assessment protocol, and TMD can be effectively managed with conservative therapies, such as patient education, home care, physical therapy, occlusal appliance therapy, and pharmacotherapy.

Pediatric dentists are in a unique position to detect TMD in children and adolescents early because they conduct regular checkups for this age group. Not only performing routine oral examinations, they can also conduct clinical assessments to screen TMD and take detailed histories, enabling them to identify TMD early and reduce complications that may arise from its chronic progression in growing children and adolescents.

Acknowledgements

I would like to express my gratitude to Professor Jo- Eun Kim for providing the figure images used in this study.

Notes

Conflicts of Interest

The author has no potential conflicts of interest to disclose.

References

1. Aldayel AM, Algahnem ZJ, Alrashidi IS, Nunu DY, Alzahrani AM, Alburaidi WS, Alanazi F, Alamari AS, Alotaibi RM. Orthodontics and temporomandibular disorders: an overview. Cureus 15:E47049. 2023;

2. Gonçalves DA, Dal Fabbro AL, Campos JA, Bigal ME, Speciali JG. Symptoms of temporomandibular disorders in the population: an epidemiological study. J Orofac Pain 24:270–278. 2010;

3. Durham J, Newton-John TRO, Zakrzewska JM. Temporomandibular disorders. BMJ 350:h1154. 2015;

4. Lai YC, Yap AU, Türp JC. Prevalence of temporomandibular disorders in patients seeking orthodontic treatment: a systematic review. J Oral Rehabil 47:270–280. 2020;

5. Xie Q, Li X, Xu X. The difficult relationship between occlusal interferences and temporomandibular disorder - insights from animal and human experimental studies. J Oral Rehabil 40:279–295. 2013;

6. Al-Khotani A, Naimi-Akbar A, Albadawi E, Ernberg M, Hedenberg-Magnusson B, Christidis N. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain 17:41. 2016;

7. Alrizqi AH, Aleissa BM. Prevalence of temporomandibular disorders between 2015-2021: a literature review. Cureus 15:E37028. 2023;

8. Marpaung C, van Selms MKA, Lobbezoo F. Prevalence and risk indicators of pain-related temporomandibular disorders among Indonesian children and adolescents. Community Dent Oral Epidemiol 46:400–406. 2018;

9. Christidis N, Ndanshau EL, Sandberg A, Tsilingaridis G. Prevalence and treatment strategies regarding temporomandibular disorders in children and adolescents-A systematic review. J Oral Rehabil 46:291–301. 2019;

10. Rongo R, Ekberg E, Nilsson IM, Al-Khotani A, Alstergren P, Conti PCR, Durham J, Goulet JP, Hirsch C, Kalaykova SI, Kapos FP, Komiyama O, Koutris M, List T, Lobbezoo F, Ohrbach R, Peck CC, Restrepo C, Rodrigues MJ, Sharma S, Svensson P, Visscher CM, Wahlund K, Michelotti A. Diagnostic criteria for temporomandibular disorders (DC/TMD) for children and adolescents: an international Delphi study - Part 1-Development of Axis I. J Oral Rehabil 48:836–845. 2021;

11. Inglehart MR, Patel MH, Widmalm SE, Briskie DM. Self-reported temporomandibular joint disorder symptoms, oral health, and quality of life of children in kindergarten through grade 5: Do sex, race, and socioeconomic background matter? J Am Dent Assoc 147:131–141. 2016;

12. Marpaung C, Lobbezoo F, van Selms MK. Temporomandibular disorders among Dutch adolescents: prevalence and biological, psychological, and social risk indicators. Pain Res Manag 2018:5053709. 2018;

13. Hongxing L, Astrøm AN, List T, Nilsson IM, Johansson A. Prevalence of temporomandibular disorder pain in Chinese adolescents compared to an agematched Swedish population. J Oral Rehabil 43:241–248. 2016;

14. Pereira LJ, Pereira-Cenci T, Pereira SM, Cury AA, Ambrosano GM, Pereira AC, Gavião MB. Psychological factors and the incidence of temporomandibular disorders in early adolescence. Braz Oral Res 23:155–160. 2009;

15. Sönmez H, Sari S, Oray GO, Çamdeviren H. Prevalence of temporomandibular dysfunction in Turkish children with mixed and permanent dentition. J Oral Rehabil 28:280–285. 2001;

16. Bertoli FMP, Bruzamolin CD, Pizzatto E, Losso EM, Brancher JA, de Souza JF. Prevalence of diagnosed temporomandibular disorders: a cross-sectional study in Brazilian adolescents. PLoS One 13:e0192254. 2018;

17. de Melo Júnior PC, Aroucha JMCNL, Arnaud M, Lima MGdS, Gomes SGF, Ximenes R, Rosenblatt A, Caldas AdF Jr. Prevalence of TMD and level of chronic pain in a group of Brazilian adolescents. PLoS One 14:e0205874. 2019;

18. Minervini G, Franco R, Marrapodi MM, Fiorillo L, Cervino G, Cicciù M. Prevalence of temporomandibular disorders in children and adolescents evaluated with Diagnostic Criteria for Temporomandibular Disorders: a systematic review with meta-analysis. J Oral Rehabil 50:522–530. 2023;

19. Kim AH, Lim HD, An SY, Lee JW, Ra JY. Symptoms of temporomandibular disorders in the Korean children and adolescents. J Oral Med Pain 41:35–40. 2016;

20. Kim H, Kim J, Lee D, Yang Y. Analysis of Temporomandibular joint disorders in children and adolescents: diagnosis and treatment pattern by age. J Korean Acad Pediatr Dent 51:185–196. 2024;

21. Motghare V, Kumar J, Kamate S, Kushwaha S, Anand R, Gupta N, Gupta B, Singh I. Association between harmful oral habits and sign and symptoms of temporomandibular joint disorders among adolescents. J Clin Diagn Res 9:ZC45–48. 2015;

22. LeResche L, Mancl LA, Drangsholt MT, Huang G, Korff MV. Predictors of onset of facial pain and temporomandibular disorders in early adolescence. Pain 129:269–278. 2007;

23. Magnusson T, Egermarki I, Carlsson GE. A prospective investigation over two decades on signs and symptoms of temporomandibular disorders and associated variables. Acta Odontol Scand 63:99–109. 2005;

24. Rauch A, Schierz O, Körner A, Kiess W, Hirsch C. Prevalence of anamnestic symptoms and clinical signs of temporomandibular disorders in adolescents - Results of the epidemiologic LIFE Child Study. J Oral Rehabil 47:425–431. 2020;

25. Barbosa TD, Miyakoda LS, Pocztaruk RD, Rocha CP, Gavião MBD. Temporomandibular disorders and bruxism in childhood and adolescence: review of the literature. Int J Pediatr Otorhinolaryngol 72:299–314. 2008;

26. Khan K, Muller-Bolla M, Anacleto Teixeira Junior O, Gornitsky M, Guimarães AS, Velly AM. Comorbid conditions associated with painful temporomandibular disorders in adolescents from Brazil, Canada and France: a cross-sectional study. J Oral Rehabil 47:417–424. 2020;

27. Al-Khotani A, Naimi-Akbar A, Gjelset M, Albadawi E, Bello L, Hedenberg-Magnusson B, Christidis N. The associations between psychosocial aspects and TMDpain related aspects in children and adolescents. J Headache Pain 17:30. 2016;

28. Al-Khotani A, Gjelset M, Naimi-Akbar A, Hedenberg-Magnusson B, Ernberg M, Christidis N. Using the child behavior checklist to determine associations between psychosocial aspects and TMD-related pain in children and adolescents. J Headache Pain 19:88. 2018;

29. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, List T, Svensson P, Gonzalez Y, Lobbezoo F, Michelotti A, Brooks SL, Ceusters W, Drangsholt M, Ettlin D, Gaul C, Goldberg LJ, Haythornthwaite JA, Hollender L, Jensen R, John MT, De Laat A, de Leeuw R, Maixner W, van der Meulen M, Murray GM, Nixdorf DR, Palla S, Petersson A, Pionchon P, Smith B, Visscher CM, Zakrzewska J, Dworkin SF. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache 28:6–27. 2014;

30. Suvinen TI, Reade PC, Kemppainen P, Könönen M, Dworkin SF. Review of aetiological concepts of temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Eur J Pain 9:613–633. 2005;

31. Manfredini D, Segù M, Arveda N, Lombardo L, Siciliani G, Rossi A, Guarda-Nardini L. Temporomandibular joint disorders in patients with different facial morphology. J Oral Maxillofac Surg 74:29–46. 2016;

32. de Paiva Bertoli FM, Bruzamolin CD, de Almeida Kranz GO, Losso EM, Brancher JA, de Souza JF. Anxiety and malocclusion are associated with temporomandibular disorders in adolescents diagnosed by RDC/TMD. A cross-sectional study. J Oral Rehabil 45:747–755. 2018;

33. Wahlund K, List T, Ohrbach R. The relationship between somatic and emotional stimuli: a comparison between adolescents with temporomandibular disorders (TMD) and a control group. Eur J Pain 9:219–227. 2005;

34. Loster JE, Osiewicz MA, Groch M, Ryniewicz W, Wieczorek A. The prevalence of TMD in Polish young adults. J Prosthodont 26:284–288. 2017;

35. Macfarlane TV, Kenealy P, Kingdon HA, Mohlin BO, Pilley JR, Richmond S, Shaw WC. Twenty-year cohort study of health gain from orthodontic treatment: temporomandibular disorders. Am J Orthod Dentofacial Orthop 692:E1–8. 2009;

36. Dworkin SF. Research diagnostic criteria for temporomandibular disorders: current status & future relevance. J Oral Rehabil 37:734–743. 2010;

37. Østensjø V, Moen K, Storesund T, Rosén A. Prevalence of painful temporomandibular disorders and correlation to lifestyle factors among adolescents in Norway. Pain Res Manag 2017:2164825. 2017;

38. Pelkonen ESJ, Mäki PH, Kyllönen MA, Miettunen JA, Taanila AM, Sipilä KK. Pain-related symptoms of temporomandibular disorders in the offspring of antenatally depressed mothers and depressed parents: a 31-year follow-up of the Northern Finland Birth Cohort 1966. Eur J Pain 17:1048–1057. 2013;

39. Antonio AG, Pierro VS, Maia LC. Bruxism in children: a warning sign for psychological problems. J Can Dent Assoc 72:155–160. 2006;

40. Kieser JA, Groeneveld HT. Relationship between juvenile bruxing and craniomandibular dysfunction. J Oral Rehabil 25:662–665. 1998;

41. Storari M, Serri M, Aprile M, Denotti G, Viscuso D. Bruxism in children: What do we know? Narrative review of the current evidence. Eur J Paediatr Dent 24:207–210. 2023;

42. Lee YH. Relationship analogy between sleep bruxism and temporomandibular disorders in children: a narrative review. Children (Basel) 9:1466. 2022;

43. Manfredini D, Lobbezoo F. Relationship between bruxism and temporomandibular disorders: a systematic review of literature from 1998 to 2008. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109:E26–50. 2010;

44. Karibe H, Shimazu K, Okamoto A, Kawakami T, Kato Y, Warita-Naoi S. Prevalence and association of self-reported anxiety, pain, and oral parafunctional habits with temporomandibular disorders in Japanese children and adolescents: a cross-sectional survey. BMC Oral Health 15:8. 2015;

45. Vanderas AP. Relationship between craniomandibular dysfunction and oral parafunctions in Caucasian children with and without unpleasant life events. J Oral Rehabil 22:289–294. 1995;

46. Şermet Elbay Ü, Demirturk Kocasarac H, Elbay M, Kaya C, Uğurluel C, Baydemir C. Temporomandibular disorders and oral parafunction in children living with their parents and children living in institutional protective care: a comparative study. Int Dent J 67:20–28. 2017;

47. Thilander B, Rubio G, Pena L, de Mayorga C. Prevalence of temporomandibular dysfunction and its association with malocclusion in children and adolescents: an epidemiologic study related to specified stages of dental development. Angle Orthod 72:146–154. 2002;

48. Farsi NM. Symptoms and signs of temporomandibular disorders and oral parafunctions among Saudi children. J Oral Rehabil 30:1200–1208. 2003;

49. Tuerlings V, Limme M. The prevalence of temporomandibular joint dysfunction in the mixed dentition. Eur J Orthod 26:311–320. 2004;

50. Perrotta S, Bucci R, Simeon V, Martina S, Michelotti A, Valletta R. Prevalence of malocclusion, oral parafunctions and temporomandibular disorder-pain in Italian schoolchildren: an epidemiological study. J Oral Rehabil 46:611–616. 2019;

51. Farella M, Michelotti A, Iodice G, Milani S, Martina R. Unilateral posterior crossbite is not associated with TMJ clicking in young adolescents. J Dent Res 86:137–141. 2007;

52. Pereira LJ, Pereira-Cenci T, Del Bel Cury AA, Pereira SM, Pereira AC, Ambosano GM, Gavião MB. Risk indicators of temporomandibular disorder incidences in early adolescence. Pediatr Dent 32:324–328. 2010;

53. Sonnesen L, Bakke M, Solow B. Bite force in pre-orthodontic children with unilateral crossbite. Eur J Orthod 23:741–749. 2001;

54. Pereira LJ, Gavião MB, Bonjardim LR, Castelo PM, van der Bilt A. Muscle thickness, bite force, and craniofacial dimensions in adolescents with signs and symptoms of temporomandibular dysfunction. Eur J Orthod 29:72–78. 2007;

55. Mohlin BO, Derweduwen K, Pilley R, Kingdon A, Shaw WC, Kenealy P. Malocclusion and temporomandibular disorder: a comparison of adolescents with moderate to severe dysfunction with those without signs and symptoms of temporomandibular disorder and their further development to 30 years of age. Angle Orthod 74:319–327. 2004;

56. Alhammadi MS, Fayed MS, Labib A. Three-dimensional assessment of condylar position and joint spaces after maxillary first premolar extraction in skeletal Class II malocclusion. Orthod Craniofac Res 20:71–78. 2017;

57. Gurbanov V, Bas B, Öz AA. Evaluation of stresses on temporomandibular joint in the use of Class II and III orthodontic elastics: a three-dimensional finite element study. J Oral Maxillofac Surg 78:705–716. 2020;

58. Liu P, Wu G, Liu J, Jiao D, Guo J. Assessment of oral parafunctional behaviors and electromyographic activities of the masticatory muscles in young female patients with orthodontic Invisalign treatment. Int J Clin Exp Med 10:15323–15328. 2017;

59. Manfredini D, Lombardo L, Vigiani L, Arreghini A, Siciliani G. Effects of invisible orthodontic retainers on masticatory muscles activity during sleep: a controlled trial. Prog Orthod 19:24. 2018;

60. Kandasamy S, Greene CS. The evolution of temporomandibular disorders: a shift from experience to evidence. J Oral Pathol Med 49:461–469. 2020;

61. Wieckiewicz M, Shiau YY, Boening K. Pain of temporomandibular disorders: from etiology to management. Pain Res Manag 2018:4517042. 2018;

62. Barbosa TS, Leme MS, Castelo PM, Gavião MB. Evaluating oral health-related quality of life measure for children and preadolescents with temporomandibular disorder. Health Qual Life Outcomes 9:32. 2011;

63. Nilsson IM, Ekberg E, Michelotti A, Al-Khotani A, Alstergren P, Conti PCR, Durham J, Goulet JP, Hirsch C, Kalaykova S, Kapos FP, King CD, Komiyama O, Koutris M, List T, Lobbezoo F, Ohrbach R, Palermo TM, Peck CC, Penlington C, Restrepo C, Rodrigues MJ, Sharma S, Svensson P, Visscher C, Wahlund K, Rongo R. Diagnostic criteria for temporomandibular disorders-INfORM recommendations: comprehensive and short-form adaptations for children. J Oral Rehabil 50:99–112. 2023;

64. Rabbitts JA, Holley AL, Groenewald CB, Palermo TM. Association between widespread pain scores and functional impairment and health-related quality of fife in clinical samples of children. J Pain 17:678–684. 2016;

65. Ooi K, Inoue N, Matsushita K, Mikoya T, Minowa K, Kawashiri S, Tei K. Relations between anterior disc displacement and maxillomandibular morphology in skeletal anterior open bite with changes to the mandibular condyle. Br J Oral Maxillofac Surg 58:1084–1090. 2020;

66. Khojastepour L, Omidi M, Vojdani M, Bagheri K. Investigating possible correlation between condylar asymmetry and clinical dysfunction indices in patients with temporomandibular dysfunction using cone-beam computed tomographic. J Craniomaxillofac Surg 47:438–442. 2019;

67. Yamada K, Hiruma Y, Hanada K, Hayashi T, Koyama J, Ito J. Condylar bony change and craniofacial morphology in orthodontic patients with temporomandibular disorders (TMD) symptoms: a pilot study using helical computed tomography and magnetic resonance imaging. Clin Orthod Res 2:133–142. 1999;

68. Xie Q, Yang C, He D, Cai X, Ma Z, Shen Y, Abdelrehem A. Will unilateral temporomandibular joint anterior disc displacement in teenagers lead to asymmetry of condyle and mandible? A longitudinal study. J Craniomaxillofac Surg 44:590–596. 2016;

69. Ikeda M, Miyamoto JJ, Takada JI, Moriyama K. Association between 3-dimensional mandibular morphology and condylar movement in subjects with mandibular asymmetry. Am J Orthod Dentofacial Orthop 151:324–334. 2017;

70. Emodi-Perlman A, Eli I, Smardz J, Uziel N, Wieckiewicz G, Gilon E, Grychowska N, Wieckiewicz M. Temporomandibular disorders and bruxism outbreak as a possible factor of orofacial pain worsening during the COVID-19 pandemic - concomitant research in two countries. J Clin Med 9:3250. 2020;

71. American Academy of Pediatric Dentistry. Temporomandibular disorders in children and adolescents, including those with special health care needs. Available from URL: https://www.aapd.org/research/oral-health-policies--recommendations/acquired-temporomandibular-disorders-in-infants-children-and-adolescents/ (Accessed on October 4, 2024).

72. International Network for Orofacial Pain and Related Disorders Methodology. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) Clinical Examination Protocol. Available from URL: https://inform-iadr.com/wp-content/uploads/2024/01/DC-TMD-Examiner-Protocol-2013_06_02.pdf (Accessed on October 26, 2024).

73. Jaaniste T, Noel M, von Baeyer CL. Young children’s ability to report on past, future, and hypothetical pain states: a cognitive-developmental perspective. Pain 157:2399–2409. 2016;

74. Ekberg E, Nilsson IM, Michelotti A, Al-Khotani A, Alstergren P, Rodrigues Conti PC, Durham J, Goulet JP, Hirsch C, Kalaykova S, Kapos FP, King CD, Komiyama O, Koutris M, List T, Lobbezoo F, Ohrbach R, Palermo TM, Peck CC, Penlington C, Restrepo C, Rodrigues MJ, Sharma S, Svensson P, Visscher CM, Wahlund K, Rongo R. Diagnostic criteria for temporomandibular disorders-INfORM recommendations: comprehensive and short-form adaptations for adolescents. J Oral Rehabil 50:1167–1180. 2023;

75. Scrivani SJ, Khawaja SN, Bavia PF. Nonsurgical management of pediatric temporomandibular joint dysfunction. Oral Maxillofac Surg Clin North Am 30:35–45. 2018;

76. McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther 86:710–725. 2006;

77. Klasser GD, Greene CS. Oral appliances in the management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107:212–223. 2009;

78. Wahlund K, List T, Larsson B. Treatment of temporomandibular disorders among adolescents: a comparison between occlusal appliance, relaxation training, and brief information. Acta Odontol Scand 61:203–211. 2003;

79. Wahlund K, Nilsson IM, Larsson B. Treating temporomandibular disorders in adolescents: a randomized, controlled, sequential comparison of relaxation training and occlusal appliance therapy. J Oral Facial Pain Headache 29:41–50. 2015;

80. Karibe H, Goddard G, Aoyagi K, Kawakami T, Warita S, Shimazu K, Rudd PA, McNeill C. Comparison of subjective symptoms of temporomandibular disorders in young patients by age and gender. Cranio 30:114–120. 2012;

81. Landry BW, Fischer PR, Driscoll SW, Koch KM, Harbeck-Weber C, Mack KJ, Wilder RT, Bauer BA, Brandenburg JE. Managing chronic pain in children and adolescents: A clinical review. PM R 7(11 Suppl):S295–315. 2015;

82. Kashikar-Zuck S, Cunningham N, Peugh J, Black WR, Nelson S, Lynch-Jordan AM, Pfeiffer M, Tran ST, Ting TV, Arnold LM, Carle A, Noll J, Powers SW, Lovell DJ. Long-term outcomes of adolescents with juvenile-onset fibromyalgia into adulthood and impact of depressive symptoms on functioning over time. Pain 160:433–441. 2019;

Article information Continued

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Myalgia
Description		Pain originating from the muscle affected by jaw movement, function, or parafunction, and replication of pain occurring with provocation testing of the masticatory muscles.
Criteria	History	1. Pain in the jaw, temple, in the ear, or in front of the ear AND
	History	2. Pain modified with jaw movement, function, or parafunction.
	Exam	1. Confirmation of pain location(s) in the temporalis or masseter muscle(s) AND
		2. Report of a familiar pain in the temporalis or masseter muscle(s) with at least one of the following provocation tests:
		A. Palpation of the temporalis or masseter muscle(s) OR
		B. Maximum unassisted or assisted opening movement(s).

Local Myalgia
Description		Pain originating from the muscle as described for myalgia with pain localized only at the palpation site when using the clinical examination protocol[72].
Criteria	History	The same as for myalgia.
	Exam	1. The same as for myalgia AND
	Exam	2. Report of pain localized to the palpation site.
Myofascial Pain with Spreading
Description		Pain originating from the muscle as described for myalgia with pain spreading beyond the palpation site but within the muscular boundary when using the clinical examination protocol[72].
Criteria	History	The same as for myalgia.
	Exam	1. The same as for myalgia AND
	Exam	2. Report of pain spreading beyond the palpation site but within the muscular boundary.
Myofascial Pain with Referral
Description		Pain originating from the muscle as described for myalgia with referred pain beyond the muscular boundary being palpated when using the clinical examination protocol[72].
Criteria	History	The same as for myalgia.
	Exam	1. The same as for myalgia AND
	Exam	2. Report of pain at a site beyond the muscular boundary being palpated.

Arthralgia
Description		Pain originating from the joint affected by jaw movement, function, or parafunction, and replication of pain occurring with provocation testing of the TMJ.
Criteria	History	The same as for myalgia.
	Exam	1. Confirmation of pain localized in the TMJ(s) area AND
		2. Report of a familiar pain in the TMJ with at least one of the following provocation tests:
		A. Palpation of the lateral pole or around the lateral pole OR
		B. Maximum unassisted or assisted opening, right or left lateral movements, or protrusive movement(s)^*.
Headache Attributed to TMD
Description		Headache in the temple area secondary to pain-related TMD affected by jaw movement, function, or parafunction, and its replication occurring with provocation testing of the masticatory system.
Criteria	History	1. Headache of any type in the temple AND
	Exam	2. Headache modified with jaw movement, function, or parafunction.
		1. Confirmation of headache location in the temporalis muscle(s) AND
		2. Report of a familiar headache in the temple area with at least one of the following provocation tests:
		A. Palpation of the temporalis muscle(s) OR
		B. Maximum unassisted or assisted opening, right or left lateral, or protrusive movement(s).

Disc Displacement with Reduction
Description		An intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position, the disc is positioned anterior to the condylar head, and the disc reduces upon mouth opening. Medial and lateral disc displacement may also be present. Disc reduction may result in clicking, popping, or snapping noises. A history of disc locking in the closed position with mastication interference precludes this diagnosis.
Criteria	History	1. In the last 30 days, any TMJ noise(s) present with jaw movement or function OR
	History	2. Patient report of any noise present during the examination.
	Exam	1. Clicking, popping, and/or snapping noise during both opening and closing movements, detected with palpation during at least one of three repetitions of jaw opening and closing OR
		2. Clicking, popping, and/or snapping noise detected with palpation:
		A. During at least one of three repetitions of opening or closing movement(s) AND
		B. During at least one of three repetitions of the right or left lateral or protrusive movement(s)^*.
Imaging		1. The posterior band of the disc is located anterior to the 11:30 position and the intermediate zone of the disc is positioned anterior to the condylar head in the maximum intercuspal position AND
Imaging		2. The intermediate zone of the disc is located between the condylar head and articular eminence on full opening.

Disc Displacement with Reduction with Intermittent Locking
Description		An intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position, the disc is positioned anterior to the condylar head, and the disc intermittently reduces with mouth opening. When the disc is not reduced with mouth opening, intermittent limited mandibular opening occurs. In cases of limited opening, a maneuver may be required to unlock the TMJ. The medial and lateral disc displacement may also occur. Clicking, popping, or snapping noises may be observed due to disc reduction.
Criteria	History	The same as for disc displacement with reduction.
Criteria	Exam	The same as for disc displacement with reduction.
Imaging		The same as for disc displacement with reduction if intermittent locking is not observed during imaging. If locking occurs during imaging, an imaging-based diagnosis of disc displacement without reduction will be achieved, and clinical confirmation of reversing intermittent locking is required.

Degenerative Joint Disease
Description		A degenerative disorder involving the joint characterized by articular tissue deterioration with concomitant osseous changes in the condyle and/or articular eminence.
Criteria	History	1. In the last 30 days, any TMJ noise(s) present with jaw movement or function OR
	History	2. Patient report of any noise during the examination.
	Exam	Crepitus detected with palpation during at least one of the following: opening, closing, right or left lateral, or protrusive movement(s)^*.
Imaging		The TMJ CT criteria are positive for at least one of the following: subchondral cyst(s), erosion(s), generalized sclerosis, or osteophyte(s). Flattening and/or cortical sclerosis is considered an indeterminant finding for degenerative joint disease and may indicate normal variation, aging, remodeling, or a precursor to frank degenerative joint disease.

Subluxation
Description		A hypermobility disorder involving the disc-condyle complex and the articular eminence: while opening the mouth, the disc-condyle complex is positioned anterior to the articular eminence and cannot return to a normal closed mouth position without requiring a manipulative maneuver. The duration of dislocation may be momentary or prolonged. Subluxation is defined as the ability of a patient to reduce the dislocation himself/ herself, whereas luxation refers to the patient’s needs for assistance from the clinician to reduce the dislocation and normalize jaw movement. This disorder is also referred to as “open lock”.
Criteria	History	1. In the last 30 days, jaw locking or catching in a widely opened mouth position, even for a moment, resulting in inability to close from the wide-open position AND
	History	2. Inability to close the mouth from a wide-open position without a self-maneuver.
	Exam	Although no examination findings are required, when this disorder is clinically diagnosed, examination is positive when the patient cannot return to a normally closed mouth position without the patient performing a manipulative maneuver.
Imaging		Imaging criteria are positive for the condyle positioned beyond the height of the articular eminence with the patient being unable to close his/her mouth.