Oral Diseases (2002) 8, 1±2
Ó 2002 Munksgaard All rights reserved 1354-523X/01
GUEST EDITORIAL
Disorders of the temporomandibular joint.
What comes next?
FJ Pereira Jr
1
Department of Occlusion and Temporomandibular Disorders, UNIGRANRIO and Department of Temporomandibular Disorders,
Universidade EstaÂcio de SaÂ, Rio de Janeiro, Brazil
Osteoarthrosis (OA), a primarily non-in¯ammatory
joint disease, and internal derangement, an orthopedic
term de®ned as a localized mechanical fault which
interferes with the smooth action of a joint, are the most
frequent disorders a€ecting the temporomandibular
joint (TMJ). Degenerative changes and disk displace-
ment are, by far, the most common morphologic
changes among TMJ patients. The presence of degener-
ative changes is a necessary sign for the diagnosis of
osteoarthrosis while disk displacement is the main cause
of internal derangement. For decades, the associations
between these disorders on one hand and the changes
described on the other were highly investigated in several
studies and these morphologic changes were pointed out
as being the most likely causes for pain in the TMJ. The
recent experimental study by Imai et al (2001) in Oral
Diseases makes a further useful contribution.
As early as 1887 (Annandale, 1887) and 1918 (Pringle,
1918), disk displacement was already mentioned as a
causative factor for TMJ pain and dysfunction. Yet, it
was not until the late seventies that the association
between this condition and disturbances of the TMJ
became available to a larger number of clinicians and
researchers (Wilkes, 1978). Since then, our understand-
ing of the dysfunctional mechanisms associated with
disk displacement has shown a rapid and continued
development, mainly because of the improvements in
the quality and resolution of imaging techniques such as
arthrography and MRI. In 1987, disk displacement was
also reported in asymptomatic volunteers (Kircos et al,
1987). Later on, autopsy specimens belonging to a non-
TMJ patient population revealed the presence of disk
displacement and gross degenerative changes (Pereira
et al, 1994b). Despite the high prevalence of morpho-
logic changes observed, none of the individuals previ-
ously interviewed and examined had ever sought TMJ
treatment. They also reported few symptoms which
never interfered with their normal lives. These results
Correspondence: Francisco J Pereira Jr, Rua Visconde de PirajaÂ,
595/213 ± Ipanema, 22410-003 Rio de Janeiro, RJ, Brazil.
Fax: +55 21 2274-0189, E-mail: francp@attglobal.net
Received 24 January 2000; revised 28 February 2000;
accepted 16 October 2001
http://www.blackwellmunksgaard.com
raise the question whether or not disk displacement is a
pathologic entity or remains within the normal range of
anatomical or physiologic variation. As we approached
the end of the last millenium and new information
became available, it was clear that the frequency of
displaced disks in asymptomatic volunteers was much
lower when compared with the frequencies in patients
with TMJ disorders (Tasaki et al, 1996; Ribeiro et al,
1997). Is disk displacement a coadjuvant factor that
increases the chance of the development of TMJ pain in
some individuals? We still have little knowledge of the
pathophysiologic mechanisms underlying the develop-
ment of TMJ pain. Signi®cant histological di€erences
have been found between painful and asymptomatic
TMJs with disk displacement, con®rming an association
between pain and histological changes of the retrodiskal
tissues (Pereira et al, 1996). There was an histological
indication of higher mechanical loads in the retrodiskal
tissues of painful TMJs. In spite of this, very little is
known about the forces transmitted to the retrodiskal
tissues. Moreover, it remains necessary to test each of
the variables before these associations may be inter-
preted in terms of cause-e€ect.
Another challenge for this century is the inconsistencies
regarding the presence of degenerative changes and its
relation to diseases. Radiographic signs of degenerative
changes have been observed in the TMJ of patients with
OA (de Leeuw et al, 1995) and chronic in¯ammatory joint
diseases (Wenneberg et al, 1990), which implies that
degenerative changes may be a result of pathologic
processes. Conversely, they have been present in TMJs
belonging to non-TMJ patients (Pereira et al, 1994b). In
human autopsy material (Westesson and Rohlin, 1984)
and in rabbits (Ali and Sharawy, 1994), normal articular
surfaces have been associated with normal disk position
whereas joints with disk displacement had degenerative
changes. Another important issue in this regard is how the
presence of degenerative changes relates to senescence. In
a large study comprising 2296 individuals, the prevalence
of radiographic degenerative changes in joints from the
hands, feet and cervical spine was found to be 97% in
males and females over 64 years of age (Lawrence et al,
1966), while in autopsy specimens the frequency of
degenerative changes was higher in TMJs belonging to
 Disorders of the temporomandibular joint
FJ Pereira Jr
2
elderly persons compared with TMJs from young persons
(Pereira et al, 1994a). Strains of accelerated senescence
prone mice developed condylar degenerative changes
earlier than did strains of accelerated resistant mice (Chen
et al, 1989). It is clear that the development of degener-
ative changes in these animals is related not only to
chronological age but also to the accelerated senescence
phenomenum. All these ®ndings support the assumption
that degenerative changes are probably a result of
di€erent processes a‚icting the TMJ. If this is true, how
may each of these processes lead to the appearance of
these changes? How can we distinguish changes related to
age from pathologic or adaptive changes? Further TMJ
studies at the cellular and molecular level are necessary to
shed light on these issues.
Biochemical synovial ¯uid analyses open new fron-
tiers in TMJ pain research. Substances such as, calcito-
nin gene-related peptide, neuropeptide Y and
interleukin-1b have been identi®ed in the synovial ¯uid
pertaining to pathologic TMJs (Appelgren et al, 1995;
Suzuki et al, 1999). These investigations have shown a
great potential to reveal new aspects on the pathogenesis
of TMJ disorders. They may provide explanations about
pain and destruction mechanisms in the TMJ during the
in¯ammatory process and at the same time disclose why
patients with OA and chronic in¯ammatory joint disease
have a higher degree of articular destruction when
compared with asymptomatic individuals. These ®nd-
ings might help the development of more speci®c
diagnostic and treatment methods than the ones avail-
able at present, through the identi®cation of markers of
disease. As a result, these analyses may have a great
impact on to the development of antagonists to medi-
ators of pain and in¯ammation.
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Oral Diseases
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