Transitioning to chronic temporomandibular disorder pain: A combination of patient vulnerabilities and iatrogenesis.

backgroundBased on a variety of studies conducted in recent years, some of the factors that might contribute to the negative treatment responses of some TMD patients have been elucidated.

methodsThis paper describes known vulnerability factors that make individuals susceptible to developing temporomandibular disorders (TMDs), as well as those that contribute to the perpetuation of such problems. In addition, the topic of iatrogenesis is discussed as a major contributor to the negative outcomes that can be seen in this field.

resultsAt the patient level, anatomical, psychosocial and genetic factors may contribute to individual vulnerability. The anatomy and pathophysiology of muscles, joints, disc and nerves may all be involved in predisposing to TMD symptoms, especially when the patients have pain elsewhere in the body. Among the psychosocial factors, some features may be elucidated by the DC/TMD axis II, while others (eg illness behaviour, Munchausen syndrome, lack of acceptance of non-mechanical approaches) require careful evaluation by trained clinicians. Genetic predisposition to first onset TMDs and to chronification of symptoms has been identified for individuals with certain psychological traits, presence of comorbid conditions and certain abnormal clinical manifestations. Regarding iatrogenesis, sins of omission may influence the clinical picture, with the main ones being misdiagnosis and undertreatment. Joint repositioning strategies, occlusal modifications, abuse of oral appliances, use of diagnostic technologies, nocebo effect and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification of TMDs. The patients who present with massive occlusal and jaw repositioning changes combined with persistent severe orofacial pain are not a rarity within TMD and orofacial pain canters; these patients are the most difficult ones to manage because of this horrific combination of negative factors.

conclusionsThe information presented in this paper will help clinicians to understand better why some individuals develop temporomandibular disorders, why some of them will progress to becoming chronic patients, and what the appropriate responses may be.