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Review

Chronic neck pain and masticatory dysfunction

Jean-Franois Catanzariti, Thierry Debuse, Bernard Duquesnoy *

Rheumatology Department, Salengro Teaching Hospital, Andr Verhaeghe Center, Lille Teaching Hospitals, 59037 Lille cedex, France

Received 16 June 2004; accepted 18 October 2004

Available online 15 December 2004

Abstract

Chronic nonspecific neck pain is a common problem in rheumatology and may resist conventional treatment. Pathophysiological links

exist between the cervical spine and masticatory system. Occlusal disorders may cause neck pain and may respond to dental treatment. The

estimated prevalence of occlusal disorders is about 45%, with half the cases being due to functional factors. Minor repeated masticatory

dysfunction (MD) with craniocervical asymmetry is the most common clinical picture. The pain is usually located in the suboccipital region

and refractory to conventional treatment. The time pattern may be suggestive, with nocturnal arousals or triggering by temporomandibular

movements. MD should be strongly suspected in patients with at least two of the following: history of treated or untreated MD, unilateral

temporomandibular joint pain and clicking, lateral deviation during mouth opening, and limitation of mouth opening (less than three finger-

breadths). Rheumatologists should consider MD among causes of neck pain, most notably in patients with abnormal craniocervical posture,

signs linking the neck pain to mastication, and clinical manifestations of MD. Evidence suggesting that MD may cause neck pain has been

published. However, studies are needed to determine whether treatment of MD can relieve neck pain.

2004 Published by Elsevier SAS.

Keywords: Neck pain; Temporomandibular joints; Masticatory dysfunction; Craniomandibular imbalance

1. Introduction

Neck pain is a common reason for rheumatology visits.

The prevalence of neck pain in industrialized countries ranges

across studies from 34% to 50% [14]. The cost of managing

patients with neck pain has been estimated in France at 0.1%

of the gross national product [5]. However, the pathogenesis

of nonspecific neck pain is unclear, and few proven treat-

ments are available [6]. Neck pain refractory to appropriateconventional therapy or recurring at treatment discontinua-

tion may respond to dental procedures ranging from occlusal

restoration by prostheses, use of a removable intraoral splint

to disengage the occlusion, or reshaping of one or more teeth.

The rationale behind these interventions is that masticatory

dysfunction (MD) may cause neck pain. Controversy, about

this link is growing in magnitude and vehemence, reflecting

the paucity of valid scientific data.

2. Masticatory dysfunction

The masticatory system is a structural and functional unit

composed of the temporomandibular joints (TMJs), with their

disks and ligaments; the dental arcades, which contain soft

tissues rich in desmodontal mechanoreceptors; and the mas-

ticatory muscles, most of which are supplied by the trigemi-

nal nerve [7,8]. The term masticatory dysfunction encom-

passes a broad range of disorders associated with impairedmastication [7,8]. Thus, diagnostic investigations should be

selected by specialists according to the suspected disorder.

For instance, MRI is the best tool for evaluating alterations in

the TMJ disk and ligaments [7,8]. Reported causes of MD

vary across studies, in keeping with the multifactorial nature

of this condition [7]. Gola et al. [7] attempted to clarify the

causes of MD by distinguishing predisposing factors, trigger-

ing factors, and perpetuating factors. The main risk factors

are malocclusion (most notably loss of posterior teeth lead-

ing to lateral deviation of the mandible that pulls the TMJs

off center), stress-related behaviors (clenching or grinding

the teeth), and structural abnormalities (ligamentous laxity

or dysmorphism affecting the teeth, maxillary bone, and man-

dible) [710]. These factors may act by placing undue stress

* Corresponding author. Service de Rhumatologie, Hpital Salengro,

Centre Andr Verhaeghe, CHU de Lille, 59037 Lille cedex, France. Tel.:+33-3-20-44-69-26; fax: +33-3-20-44-54-62.

E-mail address: [email protected] (B. Duquesnoy).

Joint Bone Spine 72 (2005) 515519

http://france.elsevier.com/direct/BONSOI/

1297-319X/$ - see front matter 2004 Published by Elsevier SAS.

doi:10.1016/j.jbspin.2004.10.007


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on the TMJ disk and ligaments, ultimately causing reducible

or fixed dislocation of the disk[7,8]. The prevalence of MD

varies in considerable proportion across studies, in large part

because there are no standardized diagnostic criteria. The

prevalence of MD as detected by physical examination maybe about 45% in the population at large, although only half

these patients report symptoms [11]. The multifactorial nature

of CMD explains the broad range of treatments used and the

absence of a consensus about management. Treatments seek

to combat risk factors and their consequences (e.g., eccentric

seating of the condyle, poor mandibular posture, and disk dis-

location) [710]. Short-term symptomatic treatments have

been advocated. Muscle relaxants alleviate painful spasm of

the masticatory muscles and have been administered by local

injection [8]. Intraoral plates fashioned on a cast can be used

to reduce masticatory muscle spasm or to reposition the jaw

in order to return the TMJ disks to their normal location [7,8].

This is the most widely used treatment. Alternatives include

correction of abnormal jaw position by hard acrylic splints

with guiding ramps that prevent lateral deviation of the man-

dible, thereby keeping the condyles properly centered [9,10].

When the symptoms abate, consolidation etiological therapy

is offered: options include tooth reshaping, orthodontic treat-

ment combined with maxillofacial surgery, prostheses to

replace lost posterior teeth, rehabilitation therapy to improve

tongue and mandibular function, and stress-management tech-

niques [710]. These methods have been found highly effec-

tive in numerous open studies [7,8]. Controlled studies would

be useful to determine the optimal treatment program in each

situation. Adverse effects may occur, such as dependency onan intraoral occlusal splint or symptom exacerbation. These

events seem uncommon, however, although no studies spe-

cifically designed to evaluate adverse events are available.

3. Neck pain and masticatory dysfunction

The physical examination and imaging studies widely used

in rheumatology may detect one or more causes in patients

with neck pain. Examples include minor disk derangements,

malalignment, degenerative disease, proprioceptive deficits,

muscle weakness, laxity, a poorly designed work station, andanxiety or depression responsible for symptom exacerbation

[6]. The next step is local or systemic administration of symp-

tomatic medications. Rehabilitation therapy is often recom-

mended also to strengthen the muscles, improve propriocep-

tion, and restore sagittal alignment. Manipulative therapy and

advice about neck protection during occupational and other

daily activities may be useful [6]. In our experience, patients

who fail to respond to this management program often have

unilateral pain and one or two minor intervertebral derange-

ments that resolve with manual physiotherapy or manipula-

tion but invariably recur in the short-term at the same levels.

Asymmetric craniocervical posture responsible for repeated

mechanical stress to the neck is a possible cause [8,12,13].

Via the trigeminal nerve, the masticatory system is closely

connected to the craniocephalic stabilization systems (cervi-

cal proprioception, vestibularsystem, vision, and ocular motil-

ity) [8,1214]. Changes in the position of the head and neck,

most notably at the craniocervical junction, modify both

occlusion patterns and jaw position [1519]. On the otherhand, the position of the craniocervical junction is influenced

by the characteristics of the masticatory system [20,21]. Thus,

MD may lead to compensatory changes in craniocervical pos-

ture and, therefore, to neck pain. Physiological and anatomic

data establish the existence of close links between the masti-

catory system and the cervical spine.Trigeminal afferent fibers

from the proprioceptive mechanoreceptors located in the peri-

odontal soft tissues project to the sensory complex of the fifth

cranial nerve in the brainstem and from there to the first three

segments of the cervical spinal cord (dorsal horns) and to the

nucleus of the spinal accessory nerve, which contributes to

innervate the trapezius and sternomastoid muscles, together

with the C1 and C2 roots [7,8,22]. On the other hand, a con-

tingent of fibersfrom thesensory roots C1 through C3 projects

to the trigeminal spinal nucleus [8]. Synergy between the mas-

ticatory and cervical muscles has been demonstrated in sev-

eral studies. Thus, contraction of the masseters is associated

with increased electrical activity in the trapezius and sterno-

mastoid muscles [2326], which seem to maintain head and

neck stability during occlusion [27]. The isometric strength

of head and neck flexors varies with the position of the man-

dible, because the supra- and infra-hyoid muscles both lower

the mandible and flex the head [22]. Gola et al. [7] speculated

that an archaic trigemino-nuchal reflex may involve the

trigeminal nerve, the spinal accessory nerve, and C1 throughC3 (which innervate the suboccipital muscles, trapezius

muscles, and sternomastoid muscles) [7]. Thus, these muscles

may contract in response to nociceptive signals from the

trigeminal territory, due for instance to MD [7]. A study by

Delaat [28] provided support for this hypothesis by showing

that active neck motion, most notably rotation, was signifi-

cantly restricted in patients with MD and that the most likely

mechanism was reflex splinting of the cervical muscles. Thus,

physiological and functional data support a role for the TMJs

as a cause of neck pain. In addition, epidemiological studies

found that MD was associated with a 2.37-fold increase in

the risk of neck pain [2931]. Furthermore, both patients with

neck pain and those with MD are typically women in their

30s who are employed in the tertiary sector and report high

levels of stress [2931].

4. When and how should rheumatologists look for

masticatory dysfunction in patients with neck pain?

MD should be considered in patients with chronic nonspe-

cific neck pain of more than 3 months duration. The follow-

ing suggest MD as a possible cause to neck pain: asymmetric

craniocervical posture, neck pain characteristics consistent

with MD, clinical manifestations of MD, and presence of

arguments supporting a causal link between MD and neck

pain (Table 1).

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Asymmetric craniocervical posture is visible as deviation

of the neck, usually in the coronal and horizontal planes

[12,13]. Scoliosis or visual dysfunction can produce a simi-

lar appearance and should be ruled out [32]. The stepping

test described by Fukuda [33] is useful for documenting pos-

tural imbalance but is not specific of MD-related neck pain.The patient is asked to step in place 50 times, lifting the thighs

to about 45, with the eyes closed and the arms stretched for-

ward horizontally, in a room free of visual or auditory stimuli

that could provide information on direction [27,33,34]. Rota-

tion of the body should not exceed 30 and translation 50 cm.

Greater displacements are abnormal [33,34] and indicate pos-

tural asymmetry [27].

MD-related neck pain is usually located high in the neck,

unilateral, and associated with one or two mild intervertebral

derangements at the same levels [8,12,13]. The pain may be

more severe after meals. Pain at night and upon awakening

may occur in patients with bruxism, as this symptom pre-dominates during sleep [8,27].

Abnormalities indicating MD are usually unilateral [7,8].

A history of treated or untreated MD, jaw injury (e.g., direct

impact on the chin), or dental work preceding the onset of

pain is suggestive. Symptoms should be sought, as patients

often fail to report them spontaneously [7,8,27]. They may

consist in snapping, clicking, or squeaking of the TMJs; epi-

sodes of locking; a sensation of restricted mouth opening;

bruxism with grinding or clenching of the teeth; TMJ insta-

bility; pain in and about the TMJs; and myalgia, most nota-

bly in the masseters and temporal muscles. These last three

symptoms are particularly suggestive when they are unilat-

eral. Careful observation of the patient during mouth open-

ing and closing is useful [79,27] to look for lateral deviation

of the mandible during mouth opening, which may occur with

a bayonet-like trajectory; lateral deviation of the mandible

with the mouth closed and teeth clenched, seen as malalign-

ment of the upper and lower labial frenums; sounds from a

TMJ during movements of the mandible; attrition of the teethin patients with bruxism and overdevelopment of the mas-

seters in those with a teeth-clenching habit; or occlusal imbal-

ance caused by loss of posterior teeth. Palpation may show

abnormalities, which are usually unilateral [7,8,27]. Pain may

occur upon palpation of a TMJ or of the masticatory muscles

(chiefly the masseters and temporalis muscles). The tempo-

ralis muscles are best examined with the patient lying supine

and the examiner standing behind the patient and placing the

palms over the temples; the patient is then asked to clench

the teeth slowly and as hard as possible, a maneuver that may

reveal asymmetric and asynchonous contraction of the tem-

poralis muscles. With a finger of each hand placed in the exter-

nal auditory meati, the examiner may feel a clicking in the

TMP [27], a sign described as diagnostic of occlusal disor-

ders. The range of jaw motion should be evaluated. The inter-

incisor opening is normally 3545 mm. The temporalis

muscle, posterior part of the sternomastoid muscle, and

superomedial part of the orbital arcade are tender to pres-

sure; together, these three points constitute the dental triad

described by Hartmann and Cucchi [8]. These are the abnor-

malities most easily demonstrated by physicians who are not

specialized in TMJ disease. Other signs may be present. We

consider that MD is likely when at least two of the following

are present: history of treated or untreated MD, pain and

sounds from a single TMJ, bayonet-like trajectory of the man-dible upon mouth opening, and interincisor distance smaller

than 35 mm when the mouth is open. The possibility that MD

may be overdiagnosed in patients with neck pain should be

borne in mind. For instance, unilateral TMJ pain may be

caused by minor intervertebral derangement at the C2

C3 level [35]. The physical examination shows unilateral TMJ

pain and pain high in the neck on the same side. The source

of the pain is in the cervical spine: the anterior branch of

C2 innervates a wide area extending from the temporal region

to the angle of the mandible [35]. Similarly, reflex myalgia of

the temporalis muscle may be misleading. Painful spasm of

the anterior fascicle of the temporalis muscle indicates minorintervertebral derangement of the upper cervical spine; how-

ever, the same finding in the posterior fascicle points to a

masticatory disorder [36]. Other manifestations of MD should

be sought to establish the correct diagnosis.

Available clinical tests for establishing a causal link

between neck pain and MD [37,38] are widely used in clini-

cal practice, although they have not been validated. They seek

to show that alleviation of the masticatory system disorder

relieves the neck pain. In the occlusion disengagement test,

or Meerseman test, nociceptive stimuli generated by the teeth

are eliminated by separating the dental arcades, for instance

by absorbent cotton wool pads [37,38]. The patient should be

asked to swallow and walk in order to settle the jaw in the

new position [38]. The rheumatologist examines the patient

Table 1

Main arguments supporting craniomandibular dysfunction in patients with

neck pain

Asymmetric craniocervical posture

Malalignment of the cervical spine, usually in the coronal and horizontal

planes

Time pattern of the pain

Jaw movements exacerbate the neck pain

Pain worse at night and upon awakening (bruxism)

Temporomandibular joint dysfunction

Snapping, clicking, squeaking; locking

Sensation of restricted mouth opening; teeth grinding or clenching

Temporomandibular joint instability

Pain in and about the joints

Myalgia, most notably in the masseters and temporalis muscles

Jaw deviation to one side during mouth opening or closing, sometimes

with a bayonet-like trajectory

Jaw deviated to one side when the mouth is closed with the teeth in

contact (frenums of the upper and lower lips not aligned)

Joint sounds during jaw movements

Pain upon palpation of a temporomandibular joint or of the masticatory

muscles

Asymmetric and asynchronous contraction of the temporalis muscles

when the teeth are slowly clenched

Clicking or snapping of the joint, best felt when the examiner inserts a

finger in the external auditory meatus on each side4

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before and after disengaging the occlusion to look for an

improvement in the cervical signs, most notably increased

range of rotation and resolution of the evidence of minor inter-

vertebral derangement (e.g., reflex pain in the subcutaneous

tissue and muscles) [35]. The occlusion correction testinvolves temporarily correcting the occlusal abnormality then

checking as above whether the neck symptoms improve [39].

A description of the methods used to correct occlusion would

be beyond the scope of this article. An example is restoration

of normal contact in patients who have lost posterior teeth.

The main drawback of these tests is the risk of false-positive

findings due to a placebo effect and of false-negative findings

due to fixed restriction of cervical motion (e.g., related to

severe osteoarthritis or deformities). In sum, in a patient with

refractory chronic nonspecific neck pain, recurrent minor

intervertebral derangement at the same level, clinical evi-

dence suggesting MD, and a positive occlusion disengage-

ment test, the advice of a specialist should be sought to con-

firm the MD and its link to the cervical pain (occlusion

correction test). The validity of these patient selection crite-

ria has been established in a randomized controlled trial [39].

With these criteria, fewer than 10% of patients with chronic

neck pain are candidates for dental interventions [39]. There-

fore, caution is in order before recommending dental work,

particularly as patients with chronic pain tend to show con-

siderable enthusiasm for any new treatment. Suboptimal

patient selection may lead to the unnecessary use of cumber-

some, time-consuming, and costly treatments that fail to pro-

duce meaningful benefits. Finally, even when dental interven-

tion is warranted, other treatments such as rehabilitationshould be continued.We have shown that proprioceptive neck-

muscle rehabilitation improves the results of dental interven-

tions in some patients with neck pain [39].

5. Conclusion

The possibility that chronic neck pain may respond to den-

tal interventions is encouraging, particularly, as few new treat-

ments are available for mechanical spinal disorders. How-

ever, only a minority of patients with chronic neck pain are

likely to benefit from dental interventions. In many patients,MD merely combines with other factors to exacerbate the

neck pain.Thus, althoughMD should be looked for in patients

with refractory neck pain, the enthusiasm of some patients

for alternative therapies may need to be curbed by assurances

that a more conventional but also far simpler approach may

prove beneficial.

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DOLOR DE CUELLO Y DISFUNCIÓN MATICATORIA