The CMD Outpatient Clinic is a port of call for many patients with diagnoses ranging from teeth grinding to complex malfunctions of the masticatory system
Craniomandibular dysfunction (CMD) is often not detected or only after years, as teeth or jaw problems can have many causes. An interdisciplinary team of dentists, specialists and therapists is involved in diagnostics and therapy at the University Institute of Dentistry of the Carolinum Foundation (ZZMK, Carolinum), Goethe University Frankfurt.
The masticatory system in humans consists of teeth, jaws, muscles and two temporomandibular joints. Normally, it is a finely tuned system, where one component engages precisely with the other. Sometimes, however, the upper and lower jaw are misaligned, which leads to an incorrect distribution of force when chewing or speaking. The term that dentists use to describe problems with the masticatory system is ”craniomandibular dysfunction (CMD)”. “Craniomandibular” refers to the region between the skull (cranium) and lower jaw (mandible), and dysfunction describes the impaired or abnormal functioning of a body part, organ or system.
Effects on other parts of the body
According to CMD-Dachverband e. V., an umbrella organization for CMD patients and professionals, around seven million people are affected by the disorder in Germany alone. Despite its prevalence, CMD is still largely unknown among the general public and often overlooked even by physicians. There are several reasons for this: Firstly, the jaw has a number of compensatory mechanisms. “As a result, those affected often do not notice the symptoms or they are attributed to other parts of the body or to diseases, or the effects of incorrect force only become apparent after some time,” explains Dr. Steffani Görl, senior consultant at the Polyclinic for Dental Prosthetics (whose director is Professor Jan-F. Güth) at the Carolinum and head of the CMD Outpatient Clinic. Since the muscles of the masticatory system are functionally connected to the muscles in the neck and spine, dysfunction and static occlusion can affect the teeth and jaws as well as other regions of the body further away, such as the back.
Possible symptoms include cracking and crunching sounds in the temporomandibular joints, toothache, pain when chewing or difficulty when the person tries to open their mouth or eats tough or hard food. Many people have the sensation that their teeth no longer fit together properly. Nonspecific complaints, such as muscle tension, head, neck and back pain, dizziness, tinnitus or sleep disorders, can also occur.
Patients may face an odyssey
“Due to the unclear symptoms, many patients have an odyssey behind them, with numerous visits to different doctors before they are correctly diagnosed,” reports Dr. Steffani Görl. Patients frequently go first to primary care providers such as their GP, only to be referred to an otolaryngologist or neurologist. Often, patients are only advised to ask their dentist or orthodontist or to contact a university clinic when the specialists are stumped. “It often takes years for the craniomandibular system to be recognized as the cause of the complaints. Unfortunately, complaints such as pain are by then chronic and need treating by a pain specialist,” says Steffani Görl.
Established in 2007, the CMD Outpatient Clinic in Frankfurt has assisted many patients who have been suffering from unclear complaints for years and whose GPs, dentists or other specialists have been at a loss to help them. Patients often come to the clinic at their own initiative or on the recommendation of acquaintances, friends or relatives, and benefit from the combination of research, teaching and practice at the Carolinum.
Advanced technology to find the cause
Asking the patient detailed questions about their medical history (a process called anamnesis) can reveal important clues for the diagnosis: “Pain is usually triggered by the jaw muscles and the temporomandibular joints. The latter are also one of the main triggers of sounds, locking and cracking,” explains Görl. Reports from other doctors and therapists help get to the bottom of complaints.
When searching for the cause, clinical functional analysis plays the most important role and, based on this, manual structural analysis – i.e. the dentist performing a check on head and body posture, jaw mobility and occlusion, among others. They also examine the muscles and temporomandibular joints to see whether jaw movement or opening the jaw is restricted.
Instrumental functional analysis with special apparatus is a valuable addition. Thanks to advanced, radiation-free imaging methods and 3D techniques, dentists at the CMD Outpatient Clinic can analyze the individual patterns in the patient’s jaw movements in detail and detect even the smallest discrepancies in the interaction of teeth, jaw joints and chewing muscles. “Another advantage of these methods is visualization,” says Görl. “Patients can see 3D animations directly on the screen that show how their temporomandibular joints and teeth interact when they move in certain ways. This helps patients to understand,” she says.
Interdisciplinary approach and exchange
Craniomandibular dysfunction can have many different causes, which often go hand in hand. That is why, if required, doctors and therapists from various disciplines are involved in the diagnosis and treatment of patients at the Carolinum in Frankfurt. Physiotherapists, alternative practitioners and osteopaths, psychologists and psychotherapists, pain specialists, rheumatologists, oral and maxillofacial surgeons, speech therapists and orthodontists might be brought on board, for example.
As head of the CMD Outpatient Clinic, Steffani Görl has led interdisciplinary CMD consultations twice a year since 2007. At these meetings, the participants discuss complex cases, plan treatment and present new study findings, diagnostic methods, as well as innovative remedies and aids. She finds the consultations very enriching for everyone involved: “We can learn a lot from other disciplines.”
Significance of psychological aspects
Few people contemplate that CMD can also be caused by stress, anxiety, depression or trauma-related disorders. “Psychological tension is very often associated with increased muscular tension,” explains Dr. Moritz de Greck, specialist in psychosomatic medicine and psychotherapy and head of the Psychosomatics Unit at of the Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt. Increased tension is often manifested in teeth grinding and clenching. This might cause wear or tear to the teeth, but also head, jaw, neck or back problems. In such cases, a dental splint alone is not enough. “It is important that patients recognize the causes of stress and deal with them. Coping strategies, such as endurance sports or relaxation techniques, can also be helpful,” explains de Greck. If the underlying cause is trauma, starting appropriate therapy can be helpful.
Importance of physiotherapy
Physiotherapy, too, plays an important role in diagnosing and treating CMD. “Especially with cervical spine disorders and headaches, a CMD problem is often involved,” says Mirjam Aichholz-Kuntz. Such disorders can be both a cause and a consequence of a malfunction in the temporomandibular joints. CMD can also sometimes be a contributing factor if a patient has already received physiotherapy for a cervical spine disorder, but the symptoms recur again and again, for example. As an alternative practitioner and physiotherapist, Aichholz-Kuntz advises that the jaw should always be examined in such cases.
In such cases, a holistic analysis based on prototherapy© can explore possible causes in the whole body and deliver recommendations on the optimal sequence for treating the disorder. This makes it possible to plan, together with the patient concerned, the most promising combination of therapies from all the disciplines involved. “Sometimes, physiotherapy is enough to alleviate or eliminate CMD symptoms. If the problem is malocclusion, that is, the teeth are misaligned, dental measures are prioritized. Physiotherapy can accompany the process and often at least ensure that invasive dental treatment is minimized,” says Aichholz-Kuntz.
A dental splint helps
Food intake and communication are among the body’s most important life-sustaining functions. This makes the craniomandibular system a top priority, and it has considerable compensatory mechanisms in the event of dysfunction. “We can support these self-healing powers with a dental splint,” says Görl. “This allows us to position the lower jaw in such a way that the joint is relieved and the damaged structures can regenerate.”
The dentists and dental technicians at the Carolinum use both state-of-the-art digital scanning and CAD/CAM techniques alongside traditional plaster models to analyze jaw movement and make corresponding splints. Steffani Görl explains that both methods have advantages and disadvantages. “Gypsum wears down, which makes it difficult to produce a second splint. By contrast, we can use data an unlimited number of times and easily transfer them electronically to another dentist.” In many cases, she says, a combination of digital and traditional methods in the manufacturing process can be helpful.
Patience and cooperation
Wearing a dental splint usually requires a lot of patience. CMD patient Gerda Heilmann, 79, also learned this: She suddenly developed problems with her temporomandibular joints after having several dental bridges fitted. The dentures did not fit properly, which had led to a shift in her bite. “It was really bad. I couldn’t chew anymore and was in severe pain,” she recalls. After years, she finally found help at the Carolinum, although the therapy “took considerable time”. To gradually work out the best possible and most comfortable jaw position, the dental splint, which was manufactured especially for her, had to be adjusted several times. Thanks to her good cooperation, Gerda Heilmann is now symptom-free and only wears the splint at night to prevent problems from recurring.
Steffani Görl emphasizes that the prognosis for CMD depends largely on the patient’s cooperation. It helps a great deal when the patient understands that their behavior can influence the course of the disorder. “As a dentist, I have to keep the whole patient in mind and at the same time make sure they are aware of the part they play in their treatment.”
| Type of complaints | Frequency in percent |
| Pain | 4,6 |
| Temporomandibular joint sounds | 18,6 |
| Restricted jaw opening | 3,4 |
| Difficulty closing jaw | 1,9 |
| Morning jaw stiffness | 2,0 |
| Treatment needed for CMD | 3,2 |
About / Dr. med. dent. Steffani Görl M.Sc., born in 1969, is a senior consultant at the Polyclinic for Dental Prosthetics at the University Institute of Dentistry of the Carolinum Foundation, Goethe University Frankfurt. Görl has been head of the CMD Outpatient Clinic since 2007 and a specialist in functional diagnostics and therapy at the German Society for Functional Diagnostics and Therapy (DGFDT) since 2014. The Carolinum was recognized as DGFDT training center in the same year. Steffani Görl is involved in dental training and completed her Master of Science in Esthetic Dentistry at Goethe Dental School in 2022.
s.goerl@med.uni-frankfurt.de
The author / Stella Cornelius-Koch, born in 1967, graduated in communication studies and is a freelance medical journalist in Bremen.
s.cornelius@medical-mirror.de
