Joint Bone Spine 72 (2005) 515–519

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

Review

Chronic neck pain and masticatory dysfunction

Jean-François Catanzariti, Thierry Debuse, Bernard Duquesnoy *
Rheumatology Department, Salengro Teaching Hospital, André 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 2. Masticatory dysfunction

Neck pain is a common reason for rheumatology visits.
The prevalence of neck pain in industrialized countries ranges
across studies from 34% to 50% [1–4]. 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 appropriate
conventional 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.
* Corresponding author. Service de Rhumatologie, Hôpital Salengro,
Centre André 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: bduquesnoy@chu-lille.fr (B. Duquesnoy).
1297-319X/$ - see front matter © 2004 Published by Elsevier SAS.
doi:10.1016/j.jbspin.2004.10.007
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 impaired
mastication [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) [7–10]. These factors may act by placing undue stress
516 J.-F. Catanzariti et al. / Joint Bone Spine 72 (2005) 515–519
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 may
be 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) [7–10]. 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 [7–10]. 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 on
an 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, and
anxiety 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, vestibular system, vision, and ocular motil-
ity) [8,12–14]. Changes in the position of the head and neck,
most notably at the craniocervical junction, modify both
occlusion patterns and jaw position [15–19]. On the other
hand, 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 fibers from the sensory 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 [23–26], 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 through
C3 (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 [29–31]. Furthermore, both patients with
neck pain and those with MD are typically women in their
30’s who are employed in the tertiary sector and report high
levels of stress [29–31].
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).
 J.-F. Catanzariti et al. / Joint Bone Spine 72 (2005) 515–519
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
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 [7–9,27] to look for lateral deviation
517
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 teeth
in 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 35–45 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 minor
intervertebral 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
518 J.-F. Catanzariti et al. / Joint Bone Spine 72 (2005) 515–519
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 test
involves 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 rehabilitation
should 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, although MD 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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