Masticatory System Research Articles

Will laser Doppler vibrometry be used in facial aesthetic diagnostics?

Dysfunctions of the temporomandibular joint are associated with disturbances in muscle activity and joint function. It is a coupled joint, so the blockage of one joint requires excessive mobility of the other, which can significantly affect the asymmetry of the lower facial third, or on facial aesthetics. The coexistence of hypertrophy of the masticatory muscles, such as the masseter and temporal muscles, can also influence the change in facial aesthetics and dental arches. Detailed diagnostics of the masticatory system dysfunction provide the opportunity to plan and implement the most effective treatment and restore proper facial aesthetics. Doppler laser vibrometry is a method that allows for vibration measurements without direct contact with the tested object. Doppler laser vibrometry operates on the principle of the Doppler effect and uses a helium‑neon laser. This enables measurements in various fields. In the study, the PDV-100 vibrometer was used. The work presents example studies in which Doppler laser vibrometry was employed, along with a brief description of available laser vibrometers. It also presents the results obtained during the measurement of skull vibrations. Differences in vibration frequency were demonstrated in individuals with temporomandibular joint disorders compared to the control group.

The pain ratio before and after the application of physiotherapy for dysfunction of temporomandibular joint

Introduction: Physiotherapy, a non-invasive method of conservative treatment, that includes manual therapy, exercises and physical procedures, is used in the treatment of temporomandibular dysfunction and polyarticular laxity. It has been proven that physiotherapy focused on temporomandibular dysfunction is an essential element of treatment that leads to a reduction in pain, an improvement in temporomandibular joint (TMJ) function, and an improvement in quality of life. Physiotherapy treatment aims to alleviate the symptoms and try to restore the normal function of the masticatory system, for which various techniques can be used. The aim of the study was to determine the type, intensity, and frequency of TMJ dysfunction pain before and after physiotherapy. Methods: The study was conducted in a private practice in Munich, Germany. All subjects who met the criteria for inclusion in the study completed a standardized questionnaire on TMJ dysfunction (TMJ disorder [TMJ/TMD] Questionnaire). The questionnaire was used to obtain data on the type and location of pain, duration of pain, and other symptoms related to the TMJ. The anamnestic data of the respondents who came to the doctor’s office with the symptoms mentioned were examined, and the orthodontic or dental findings were analyzed.Results: The analysis showed that before treatment some of the joints were affected in 28 subjects, while after treatment the joints were affected in 19 subjects. After treatment a significant decrease in affected TMJ was observed (χ2 = 9.516, p = 0.008). Ear pain occurred in 17 (54.84%) subjects before treatment, and in 5 (16.13%) after treatment. A significant reduction was observed at the p = 0.003 level. Pain around the eyes occurred in 9 (29.03%) of the respondents before treatment, and after treatment in 2 (6.45%) of the respondents. Facial pain was reported in 16.13% of the anamnestic data before the treatment, and it was not reported in any of the respondents after treatment. There was also a significant reduction in the occurrence of tinnitus (p = 0.004). The occurrence of headaches also decreased after treatment (p < 0.001). Ear pressure was present before treatment in 45.16% of cases, and after treatment in 22.58% of cases, so there was no significant decrease. Conclusion: Physiotherapy for people with TMJ dysfunction contributed significantly in reducing pain and alleviating other TMD symptoms.

The influence of the structure of the masticatory system on the presence and severity of the gag reflex in children with cerebral palsy.

Dysphagia, prevalent in 90% of children with neurological disorders, poses risks of medical complications and is associated with cognitive and psychosocial challenges. The absence of the sucking-swallowing reflex and variations in the gag reflex contribute to feeding difficulties. This study focuses on examining the impact of the gag reflex on the masticatory system structure in children with cerebral palsy, aiming to assess its significance. This observational study investigated the gag reflex and soft palate shape in 25 children with cerebral palsy (average age: 14 years). Inclusion criteria considered specific levels of the Eating and Drinking Ability Classification System (EDACS) and the Gross Motor Function Classification System (GMFCS). Exclusion criteria comprised hypotension, inflammation and tumors. The Castillo-Morales questionnaire assessed variables and statistical analysis (Spearman's rank correlation and non-parametric tests) utilizing PQStat v. 1.8.6.120 software. Findings did not reveal an association between the absence of the gag reflex and abnormal palate structure in children. Our results showed a correlation between higher tension of the buccinator muscles and mobility of the tongue on the structure of the palate. Children with neurological disorders, such as cerebral palsy, are a diverse group requiring specialized orthodontic treatment and close interdisciplinary collaboration.

Implants: the 'holy grail' or the solution of last resort?

Dentists today have an increasing number of ways to restore chewing function lost due to missing teeth. The loss of chewing function has many more consequences than one might initially think. Oral function concerns not only chewing but also proprioception and osseoperception, and it influences brain function too. With this in mind, preserving natural teeth is important, and it is unwise to choose implants in the first instance if a compromised tooth can be saved with some effort or chewing function can be restored with bridges on natural teeth. Options differ on this question: should implants be considered the 'holy grail' or a last resort? Conventional bridgework is still a very relevant treatment option that affects the dynamics of the masticatory system less than implant-supported constructions and also requires less maintenance. A self-critical attitude on the part of a dentist remains necessary if patients are to be treated optimally.

Relationship between tooth macrowear and jaw morphofunctional traits in representative hypercarnivores.

The mammalian adult dentition is a non-renewable resource. Tooth attrition and disease must be accommodated by individuals using behavioral, physiological, and/or musculoskeletal shifts to minimize impact on masticatory performance. From a biomechanical perspective, the musculoskeletal system becomes less efficient at producing bite force for a given amount of muscle input force over an individual's life, because tooth-food contact area increases as cusps wear. In this study we ask the question: does mandibular biomechanical performance show evidence of compensation with increasing tooth wear? We use representative taxa of three carnivoran ecomorphologies (meat specialist, scavenger, bone cracker) as a study system to compare morphofunctional data on tooth macrowear, jaw depth, bite mechanical efficiency, and jaw stress during biting. No significant shifts in adult mandibular corpus dimensions occurs in the sampled taxa as canine and carnassial teeth wear. In bone cracking spotted hyenas carnassial biting mechanical efficiency increases significantly with increasing tooth wear, with no significant change in mandibular stress. Analyses of the fossil carnivore Hyaenodon suggests an increase in canine biting efficiency with increased tooth wear, but this may reflect interspecific variation or phylogenetic contingency rather than a life history shift. Overall, these findings indicate that scavenging hyaenids and felid meat specialists do not exhibit morphofunctional compensation for the decreased mechanical capability of worn and dull teeth. Behavioral modifications, rather than musculoskeletal adjustments, may instead play a major role in maintaining food acquisition and processing capabilities for individuals surviving into advanced ontogenetic age and tooth wear. These observations highlight the mammalian masticatory system as having a dynamic performance profile through its useful lifespan, and encourage a more nuanced understanding of past and present carnivore guilds by considering wear-dependent performance changes as a possible source of selection.

Orofacial pain and dysfunction in patients with special needs, with a focus on interdisciplinarity.

People with special needs, like those with Down syndrome, Parkinson disease, or dementia, frequently suffer from orofacial pain conditions and dysfunction of the masticatory system. However, the accurate assessment of orofacial pain and dysfunction in such individuals is challenging. In this review, the complexities of assessing and managing orofacial pain and dysfunction in special needs populations will be described, along with their comorbid orofacial conditions like impaired oral health, salivary problems, and movement disorders of the masticatory system. In addition, the importance of maintaining or restoring a good quality of life will be highlighted, while the urgent need for oral care as part of palliative care will be stressed as well. To accomplish all this, interdisciplinary collaboration between medical doctors and dentists should be promoted in research, education, prevention, and care provision. Therefore, this review focuses specifically on this important topic.

Appearance-enhancing masticatory muscle exercises and their potential impact on masticatory muscle symptoms: A netnographic study and scoping review

ABSTRACT Objective Videos containing exercises for masticatory muscles to enhance esthetic appearance are published on social media platforms. The aim of the study was to find out the nature of the exercises and whether they could have an impact on the health of the masticatory muscles. Method For the netnography, social media videos of jaw area exercises were collected as material and reviewed. The literature review investigated the effect of voluntary masticatory muscle exercises. Results 71 videos were collected, with none referring to scientific evidence. Muscle exercises found by netnography were isometric exercise of the masseter muscles. The scoping review revealed isometric exercise of the masticatory muscles can cause symptoms in the masticatory system in temporomandibular disorder patients. Conclusion Non-professional masticatory muscle exercises should be considered in the etiology of muscle-related TMD. Dental professionals should to explore social media platforms to be aware of content about dental issues.

Transcutaneous electrical nerve stimulation therapy in the management of temporomandibular joint disorders

A collection of illnesses known as temporomandibular joint disorders (TMD) impact the masticatory system, which includes the temporomandibular joint (TMJ) and the masticatory muscles, functionally. Transcutaneous electrical nerve stimulation (TENS) is one of several known aetiologies that have unique therapy options. A review of TENS use in TMD patient care is included in the current paper. Among the effective therapy modalities for treating TMD is transcutaneous electrical nerve stimulation. It involves carefully exposing the skin's surface to electrical current, which relaxes tense muscles and lessens discomfort.

Sexual Dimorphism and Divergent Evolutionary Pathways in Primate Cranial Biomechanics: Insights From a Theoretical Morphology Framework.

The mammalian order Primates is known for widespread sexual dimorphism in size and phenotype. Despite repeated speculation that primate sexual size dimorphism either facilitates or is in part driven by functional differences in how males and females interact with their environments, few studies have directly assessed the influence of sexual dimorphism on performance traits. Here, we use a theoretical morphology framework to show that sexual dimorphism in primate crania is associated with divergent biomechanical performance traits. The degree of dimorphism is a significant covariate in biomechanical trait divergence between sexes. Males exhibit less efficient but stiffer cranial shapes and significant evolutionary allometry in biomechanical performance, whereas females maintain performance stability across their size spectrum. Evolutionary rates are elevated for efficiency in females whereas males emphasize size-dependent cranial stiffness. These findings support a hypothesis of sex-linked bifurcation in masticatory system performance: larger male crania and faster size evolution partially compensate for low efficiency and reflect a de-emphasis of mechanical leverage, whereas female crania maintain higher mechanical efficiency overall and evolve more rapidly in molar-based masticatory performance. The evolutionary checks-and-balances between size dimorphism and cranial mechanical performance may be a more important driver of primate phenotypic evolution than has been hitherto appreciated.

Digital methods for diagnosing dental occlusion disorders

Relevance. Occlusal disorders are not only predictors of oral diseases but are also associated with systemic conditions such as endocrine, cardiovascular, and cognitive disorders, highlighting their broader significance in medicine. The digitization of diagnostic processes and the integration of computer technologies into traditional methods offer promising advancements in assessing occlusal status. This makes the analysis of digital methods for diagnosing occlusal relationship disorders particularly relevant.Purpose. To evaluate digital methods and devices used for diagnosing occlusal relationship disorders.Material and methods. A systematic review was conducted, analyzing 40 scientific publications from 2016 to 2024 that focus on digital methods for diagnosing occlusal imbalance. The study assessed electronic devices that measure occlusal force by converting mechanical force into electrical signals using various sensors. These digital methods are employed to evaluate the functional state of the masticatory system, including the detection of temporomandibular joint disorders, mandibular fractures, and occlusal deformities, as well as to monitor occlusal force dynamics during treatment. Recent advancements in portable electronic sensors suggest potential applications for their integration with control chips into dental prostheses or occlusal stabilization splints, allowing real-time monitoring of tooth compression forces, potentially enhanced by artificial intelligence.Results. The development of new diagnostic methods and devices equipped with highly sensitive sensors for measuring masticatory pressure opens new avenues for identifying clinical parameters that were previously difficult to analyze. Recent advances in hardware technology, particularly those utilizing neural network analysis, have the potential to expedite accurate diagnosis and predict the risk of complications.Conclusion. Both in Russia and internationally, significant progress is being made in the development of digital methods for diagnosing occlusal imbalance. These methods are poised to become a priority in the future of dental practice. However, the adoption of digital occlusal methods into routine dental practice is currently hindered by challenges related to the availability of digital equipment in clinics and the insufficient digital skills of many dentists. Addressing these challenges is crucial for improving the quality of dental care for patients with occlusal disorders.

Low-level laser therapy parameters in the treatment of Orofacial pain in temporomandibular disorder

Temporomandibular disorder (TMD) comprises a group of dysfunctions of the masticatory system involving joint, myofascial, and even sensory alterations. The main symptom of TMD is orofacial pain, which has a negative impact on the quality of life of TMD sufferers, affecting their productivity at work and school, the quality of their sleep, their appetite, and their satisfaction with life. An alternative for the treatment of TMD is the low-level laser therapy (LLLT), which stimulates cellular functions and promotes therapeutic effects. However, there is no consensus in the literature. Objective: This review aimed to elucidate the parameters of low-level laser therapy in the treatment of orofacial pain in patients with temporomandibular disorder. Methods: A search was carried out for scientific articles published between 2013 and 2023 in the MEDLINE, PEDro, LILACS and SciELO databases. Results: A total of 21 studies were previously selected and after the eligibility criteria, 10 studies were included. Can be suggest a protocol for treating patients with temporomandibular disorder by low-level laser therapy with the following parameters: infrared wavelength, energy density less than 10 J/cm2, output power from 100 to 250 mW and at least 8 sessions of treatment. Conclusion: The low-level laser therapy improves orofacial pain in patients with temporomandibular disorder.

TMJ Changes Before and After Implant of Posterior Partial Edentulous Patients Free of TMD Signs Under the Scope of Cadiax Compact II Device

Introduction: Assessing occlusion and TMJ discrepancies presents a persistent challenge for health professionals due to the complexity of the conditions that include accurate: diagnostic methods, treatment, associated comorbidities. Researches are being delved in this field. Cadiax Compact II is one of the technological innovations that can analyze and provide a simple and minimally invasive way, enabling early preventive action and treatment with a long-term impact on the good functioning of the masticatory system. Objectives: The objective of this research is to evaluate TMJ changes among dental implant patients. A comparison of the implant impact on posterior partial edentulous patient is taken place by the aid of Cadiax Compact II. Cadiax Compact II investigates in parameters such as Immediate Side-Shift (ISS), Sagittal Condylar Guidance (SCG), and Transverse Condylar Guidance (TCG) that are derived from mandible movements (opening, closing, protrusion, retrusion, and lateral excursion). The objective is to evaluate the changes in TMJ before and after implants in partial edentulous (posterior teeth) patients. Methods: Condylography using Cadiax Compatct II device (Gamma Dental, Klosterneuburg, Austria) was conducted on 40 patients. R statistical software was used to perform statistical analysis to perform a cephalometric analysis. Results: Age groups covered are (<40), (40-49), (50-59), and (≥ 60). Alpha value, level of uncertainty, was chosen to be 0.05. There is no statistical evidence in the change of ISS, SCG, and TCG before and after implant in the age groups (<40) and (40-49); however, there is a significant statistical change in age groups (50-59) and (≥ 60) with p-value <0.05. Conclusions: This research extended from December 2022 to March 2024 to cover time changes on mandible bone structure. The research outcomes revealed that implant has pronounced impact on TMJ articulation during opening, protrusion, retrusion, and lateral movements through (ISS, SCG, and TCG or so-called Bennet Angle) variables. Evidence-based statical tests with p-value < 0.05 showed that (ISS, SCG, TCG, and Bennet Angle) variables changed in age groups (50-59) and (≥ 60) from abnormal ranges to the normal ranges after implant. However, no statistical evidence was approved of the implant impact on age groups (<40) and (40-49). Though these age groups have normal ranges before and after implants.

Counselling for patients with a temporomandibular disorder: A scoping review and concept analysis.

An integral component of comprehensive temporomandibular disorder (TMD) treatment involves what is commonly referred to in literature as patient counselling or patient education. Despite its importance, a clear definition of the concept is lacking. To describe the concept of counselling (i.e. what is it, what should it consist of, and when should it be given) through a concept analysis of the literature. All papers that include a description of counselling or education for TMD are included. Literature searches were performed in the electronic databases PubMed, Cinahl, and PsycInfo. A qualitative analysis was done using the principle-based concept analysis approach, where descriptions of counselling from the included papers were analysed by the researchers. A total of 71 articles were included. Based on the qualitative analysis of the included articles and descriptions of counselling, the following content themes were identified: (1) general information on TMD; (2) overuse of the masticatory system; (3) posture education; (4) lifestyle and psychosocial factors; (5) exercise- and thermotherapy; and (6) additional information and therapies. A definition and framework of counselling for TMD has been provided, which can be used in the clinic, research, and educational programs.

Assessment of the role of coronoid in restrictive jaw disorders and physiologic mandibular movements.

Restricted mouth opening has major health implications, such as malnutrition, difficulty in speech, and poor oral hygiene resulting in a functional shortage of the masticatory system. Reduced mouth opening can occur due to trismus, as in the oral submucous fibrosis (OSMF) condition. Excision of fibrous bands in OSMF leads to reestablishment of the mouth opening. Other than trismus, temporomandibular joint (TMJ) ankylosis is another common condition that causes fibrosis or bony ankylosis between articular surfaces. Coronoidectomy is a useful procedure that various authors nowadays apply. It is the most popular surgical procedure used as a conventional method of treatment, which includes the detachment of temporalis muscle. A group of 15 patients with OSMF and TMJ ankylosis with written informed consent were selected for the study and were operated on under general anesthesia. Preoperative and postoperative assessment was done for bite force management, measuring and comparing mandibular movements, and the electromyography (EMG) study. Statistical analysis shows the increase in maximum mouth opening and lateral excursions in OSMF and TMJ ankylosis patients on the seventh, 15th, 90th days, and six months postoperatively treated either without coronoidectomy and with coronoidectomy; however, there was no significant difference was found in mean EMG and bite force readings in both groups. The present study concludes that the coronoidectomy not only increases the mouth opening, but masticatory efficacy is also improved with an increase in mandibular movements postoperatively in patients with OSMF and TMJ ankylosis.

Diagnosis and Treatment of Temporomandibular Disorders

Temporomandibulr disorders(TMDs) is a comprehensive term that encompasses functional disorders affecting the masticatory system, including the temporomandibular joint and masticatory muscles. This term contains various diseases, and the presence of multiple etiologies makes the diagnosis and treatment of TMDs more complex. Therefore, this paper aims to explore the classification and diagnosis of TMDs, with a focus on the DC/TMD. Additionally, this paper investigated the definitive treatment and supportive therapy for TMDs.

Estrogen Hormones' Implications on the Physiopathology of Temporomandibular Dysfunction.

Background/Objectives: Temporomandibular dysfunction syndrome consists of several disorders of the masticatory system, namely those of the muscles, the joint itself, as well as the dental and periodontal system. This syndrome is often characterized by pain and an inability to perform functions within the dental-maxillary apparatus, which creates a certain degree of disability in patients. Women are more susceptible to this syndrome than men and hormonal factors, particularly estrogen, are central to its etiology and physiopathology. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Scopus, Embase, and Web of Science databases regarding articles published from January 2008 to December 2023. Two authors conducted searches in the mentioned databases based on a pre-established search strategy using agreed-upon keywords. Additionally, each review author performed the selection process of eligible studies based on established inclusion criteria. The Newcastle-Ottawa scale and Risk of Bias tool 2 were used to assess each article for its methodological quality. Results: Of the 1030 records found in the four bibliographic databases, 22 studies were included in this review. Polymorphism in the alpha estrogen receptor appears to be significantly more prevalent in women with temporomandibular dysfunction, suggesting a genetic predisposition. There is a significant role of estrogen in the physiopathology of TMD-related pain. Women with polycystic ovary syndrome (PCOS) have a significantly higher incidence of TMD, accompanied by elevated inflammatory factors and decreased progesterone levels. In premenopausal women, there is scientific relevance to the association between beta-estradiol levels and TMD development and progression. The effects of estrogen hormones on temporomandibular dysfunction remain highly debated and challenging. Conclusions: These findings emphasize the importance of considering hormonal factors, genetic predisposition, and reproductive life stages in understanding and managing temporomandibular dysfunction. Further research is needed to elucidate the specific mechanisms underlying these associations.

Ontogenetic biomechanics of tufted (Sapajus) and untufted (Cebus) capuchin mandibles.

Cortical bone geometry is commonly used to investigate biomechanical properties of primate mandibles. However, the ontogeny of these properties is less understood. Here we investigate changes in cortical bone cross-sectional properties throughout capuchin ontogeny and compare captive versus wild, semi-provisioned groups. Tufted capuchins (Sapajus spp.) are known to consume relatively hard/tough foods, while untufted capuchins (Cebus spp.) exploit less mechanically challenging foods. Previous research indicates dietary differences are present early in development and adult Sapajus mandibles can resist higher bending/shear/torsional loads. This study utilized microCT scans of 22 Cebus and 45 Sapajus from early infancy to adulthood from three sample populations: one captive Cebus, one captive Sapajus, and one semi-provisioned, free-ranging Sapajus. Mandibular cross-sectional properties were calculated at the symphysis, P3, and M1. If the tooth had not erupted, its position within the crypt was used. A series of one-way ANOVAs were performed to assess differences between and within the sample populations. Mandible robusticity increases across ontogeny for all three sample populations. Sapajus were better able to withstand bending and torsional loading even early in ontogeny, but no difference in shear resistance was found. Semi-provisioned, free-ranging Sapajus tend to show increased abilities to resist bending and torsional loading but not shear loading compared to captive Sapajus. This study helps advance our understanding of the primate masticatory system development and opens the door for further studies into adaptive plasticity in shaping the masticatory apparatus of capuchins and differences in captive versus free-ranging sample populations.

EXPLORING THE INTERPLAY BETWEEN TEMPOROMANDIBULAR JOINT (TMJ) FUNCTIONALITY AND IMPACTED THIRD MOLARS: A SCOPING REVIEW

Background: The TMJ and impacted third molars are integral to the masticatory system, yet their specific influence on each other remains a captivating area requiring comprehensive exploration.This scoping review investigates the intricate relationship between impacted third molars and temporomandibular joint (TMJ) functionality. Methodology: Implemented following the Arksey and OMalley Framework, a systematic search across PubMed, Scopus, and ProQuest databases to identify studies exploring the relationship between impacted third molars and temporomandibular joint disorders (TMD). Inclusion criteria covered clinical studies, prevalence studies, and randomized control trials, focusing on patients with impacted third molars and TMD. Results: A rigorous screening process identified 11 relevant studies, including systematic reviews, prevalence studies, and randomized control trials. Key factors influencing TMD outcomes encompassed third molar location, degree of impaction, surgical difficulty, patient demographics, and psychological status. Conclusions: The intricate interplay between impacted third molars and TMJ functionality, reveals a complex relationship influenced by various factors. Certain types of impaction (Disto-verted), supra-erupted third molars, and extracting specific types (horizontal) of impacted third molars may positively impact TMJ-related symptoms. Further research, particularly randomized clinical trials, is essential to validate these associations and contribute to evidence-based guidelines for TMD management.

Temporary Skeletal Anchorage Devices and Cone Beam Tomography in Orthodontics—Current Application and New Directions of Development

Continuous progress in dentistry and orthodontics is crucial to ensuring high-quality diagnosis and treatment of patients, especially since malocclusions occur in up to half of the population. In addition to limiting the physiological functions of the masticatory system, they are often an aesthetic defect that may directly affect the well-being and even self-esteem of patients, especially in their teenage years and early adulthood. A holistic model of perceiving and treating orthodontic diseases, such as the Biocreative Orthodontic Strategy, focusing not only on the correction of the defect itself but also taking into account the least possible interference in the physiology of the masticatory system, limiting the use of appliances to a minimum, and taking into account the patient’s preferences, is a special alternative to conventional therapeutic models. In this review, we are presenting the current knowledge regarding the applications of temporary skeletal anchorage devices (TSAD) and cone beam computed tomography (CBCT) in orthodontics.

Challenged by the jaw – an interview study on patients’ experiences of temporomandibular disorders in rheumatic inflammatory diseases

Purpose Rheumatic inflammatory diseases affecting the temporomandibular joint and the masticatory system (TMD) have been described as painful and limiting. However, the condition is often overlooked in primary care. The objective of this qualitative study was to explore and describe TMD-related experiences and perceptions of persons with rheumatic inflammatory disease, and to put this into a rehabilitation perspective. Materials and methods Seven participants with rheumatic inflammatory disease and concomitant TMD were interviewed using a semi-structured interview guide. Giorgi’s phenomenological method was used for analysis of the material. Results The general structure of the results after phenomenological reduction indicated that the phenomenon could be described as the process of being challenged by the jaw. Five themes emerged from the analysis; 1. Physical challenges of the jaw and the struggle to retain control, 2. Shame and social challenges, 3. Worrying about the future, frustration, grief, and loss of freedom, 4. Defiance, endurance, and efforts to maintain self-esteem, and 5. Health-care experiences. Conclusions TMD in rheumatic inflammatory diseases are complex problems associated with various challenges to the sufferer. An increased awareness of the condition and earlier interventions could reduce both suffering and worsening of the condition.