Prevalence and association of

headaches, temporomandibular joint

disorders, and occlusal interferences
M. Troeltzsch, DMD, MD,a M. Troeltzsch, DMD,b R.J. Cronin,
DDS, MS,c A.H. Brodine, DMD,d R. Frankenberger, DMD, PhD,e
and K. Messlinger, MD, PhDf
Friedrich Alexander University Erlangen-Nuremberg, Erlangen,
Germany; University of Texas Health Science Center at San
Antonio, San Antonio, Texas; University of Rochester, Eastman
Institute for Oral Health, Rochester, NY; Phillips-University
Marburg, Germany, Ansbach, Germany.
Statement of problem. Although an interaction of malocclusion, parafunction, and temporomandibular joint disor-
ders (TMD) can be inferred from the experience of daily practice, scientific evidence to corroborate this hypothesis
does not exist. However, there are indications that TMD and headaches may be intertwined.

Purpose. The purpose of this study was to identify the presence or absence of an association of occlusal interferences,
parafunction, TMD, or physiologic, muscular, or prosthodontic factors with the occurrence of headache.

Material and methods. In a private practice population of 1031 subjects (436 men and 595 women, mean age 49.6
years) the demographic parameters, headache and general pain history, habits and general personal information were
recorded. Clinical examination for dental, muscular, and temporomandibular joint pathology was accomplished. Data
were statistically analyzed using the Mann-Whitney U, Kruskal-Wallis, and Chi-Square tests (α=.05). A multinomial
logistic regression analysis was performed with respect to confounding variables.

Results. Headache affliction was found to affect women more frequently than men (1.7:1). Students and non aca-
demics were more prone to suffer from headache. Parafunction (P=.001), TMD (P=.001) and gross differences
between centric occlusion and maximum intercuspation of more than a 3 mm visible track marked with 8 μm articu-
lation foil (P=.001) significantly influenced the presence of headache. Headache intensity and frequency decreased
with age. While tension-type headache was most frequently diagnosed, the parameters studied were not significantly
associated with one certain headache diagnosis more frequently than others.

Conclusions. Stomatognathic factors of TMD, parafunction, and gross differences between centric occlusion and
maximum intercuspation of more than 3 mm are associated with headache. These findings should be interpreted with
caution due to the cross-sectional nature of this study. (J Prosthet Dent 2011;105:410-417)

Clinical Implications
This study suggests that headaches are associated with TMD and
occlusal discrepancies, but it does not suggest that their treatment
may reduce the occurrence of pain.

a
Private Practice, Ansbach, Germany; Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
b
Private Practice, Ansbach, Germany; Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
c
Professor, Director, Graduate Prosthodontics Division, University of Texas Health Science Center at San Antonio.
d
Private Practice, Rochester; Assistant Professor, Prosthodontic Residency University of Rochester, Eastman Institute for Oral
Health.
e
Department Director, Department of Restorative Dentistry, Phillips-University Marburg.
f
Professor, Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
The Journal of Prosthetic Dentistry Troeltzsch et al
June 2011
Headache is a widespread ail-
ment. Both temporomandibular joint
disorders (TMD) and headache have
major impacts on the quality of life.1
Studies report a lifetime prevalence of
every headache type for 69% of men
and 88% of women.2-9 Lupoli and
Lockey10 report that 10 million Ameri-
cans cope with frequent headaches.
Although the etiological factors of
headaches are not fully understood,
vascular/neurologic factors, age, gen-
der, and muscular hypertension of
the masticatory and cervical muscles
are reported.2,11 Furthermore, dis-
orders in the temporomandibular
joint region have been suspected and
shown to influence the etiology, fre-
quency, intensity, and chronicity of
headache.10,12-22 In fact, the correla-
tion for headache patients who suffer
from TMD is strong.12 However, there
is controversy in the scientific litera-
ture regarding the etiology of TMD.
To date, controlled studies have failed
to prove an association between mal-
occlusion, parafunction, dental wear,
TMD, and headache.8, 23-30 Interest-
ingly, treatment of headache patients
who display coincident malocclusion
with occlusal splints seems to allevi-
ate their burden.31-33
The International Headache So-
ciety (IHS) has published criteria
for diagnosing the subgroups of
headache.34-35 Primary and second-
ary headache forms are defined,
and patients can be diagnosed with
more than one headache type. Both
migraine headache and tension-type
headache (T TH) have been associ-
ated with TMD.1 Surprisingly, pa-
tients that were diagnosed with T TH
displayed the least prevalence of si-
multaneous TMD, but patients with
concurrent diagnoses of migraine
headache and T TH showed the high-
est correlation with TMD.1 The reason
for that is still unclear. The literature
states that the trigeminal nuclei areas
for proprioceptive, mechanorecep-
tive, and pain sensations in the spinal
cord are in close proximity.36-43 Com-
plex mechanisms such as homo- and
heterosynaptic plasticity, sensitiza-
Troeltzsch et al
tion and modulation via interneuro-
nal input may eventually trigger an
overlap of spinal innervation from
muscular proprioceptive areas to pain
areas.38,40-43
As stated, clinical practice experi-
ence suggests that headache and den-
tal pathology are intertwined. Never-
theless, only a few studies44-46 indicate
such a correlation. The purpose of
this study was to identify the presence
or absence of an association of occlu-
sal interferences, parafunction, TMD,
or physiologic, muscular, or prosth-
odontic factors with the occurrence
of headache.
MATERIAL AND METHODS
This cross-sectional study was
conducted to examine possible as-
sociations between TMD and occlu-
sal interferences with the etiology of
headache. Over an 11 month period
(October 2008 until August 2009),
1031 patients were questioned and
examined. The study population con-
sisted of the patient base of an oral
and maxillofacial surgery practice in
Ansbach, Germany. All patients, with-
out exception, who presented and
consented to participate during the
11 month period, were included in
the study. However, after evaluation
of the headache diagnoses, patients
suffering from secondary headache
had to be excluded as the sparseness
of secondary headache subjects ruled
out reasonable statistical evaluation.
The authors received informed con-
sent from all patients who took part
in the study. Parental consent was
obtained for all patients under 18
years of age. All patients completed
a standardized, 2-part questionnaire.
The first part was completed by the
patient; the second part concerning
occlusion, the state of muscles, and
questions about TMD was completed
by the examiners. The questions were
designed in accordance with the Ger-
man version of the Research Diagnos-
tic Criteria for Temporomandibular
Disorders (RDC/TMD) 47 and the IHS
criteria.34,35 Furthermore, the form in-
411
cluded data such as gender, age, edu-
cation, and socioeconomic status as
the influence of demographic factors
on the etiology of TMD and headache
is scientifically controversial.2,48-51
Consumption of substances such as
alcohol, caffeine, and nicotine, and
the presence of psychological factors
including fear of the future, depres-
sion, psychiatric therapy, or use of an-
tipsychotic drugs were also analyzed
as the literature indicates that there
may be an influence.52
Each patient’s medical history was
queried for cardiovascular disease,
hypertension, diabetes, orthopedic
problems, and lung, kidney, and liver
disease because these were consid-
ered relevant after thorough literature
review.2 The prevalence of habits such
as chewing gum and nail biting were
also considered. As physical exercise
plays a major role in medical preven-
tion therapy, the patients’ activities
were screened concerning the type,
frequency, and duration of workouts,
even though there is limited evidence
that physical exercise has a protec-
tive effect on the etiology of a head-
ache.2,49,50,53,54
The patients answered the ques-
tionnaire in the absence of the exam-
iner. Subsequent to the questionnaire,
the patients underwent thorough
dental, orofacial, and cervical exami-
nation. The examinations were per-
formed by 3 general dentists and one
oral and maxillofacial surgeon, all of
whom examined the same parameters
according to a predetermined stan-
dard to which all examiners were cali-
brated prior to the study. Calibration
of the examiners was assured by mod-
el examinations, which were demon-
strated and controlled by the most
experienced examiner, the oral and
maxillofacial surgeon. The examiners
who were assigned patients without
systematic randomization, examined
and recorded various oral and tem-
poromandibular joint (TMJ) dysfunc-
tion parameters.2 The TMJ was exam-
ined for clicking and crepitus, pain
(both spontaneous and on TMJ load-
ing), mandibular range of motion, and
412
mandibular deviation upon mouth
opening and during mandibular pro-
trusion. The masseteric, temporal, del-
toid, trapezius, mylohoid, geniohyoid,
digastric, occipital, and medial and
lateral pterygoid muscles were exam-
ined for myogenic pain (both sponta-
neous and on the application of pres-
sure) and trigger points.
A history of bruxism, dental at-
trition, tooth impressions in the mu-
cosa of the tongue and cheek, as well
as recession and non carious cervical
lesions (NCCL) were recorded. Wear
was evaluated intraorally according to
criteria defined by Pullinger and Selig-
man.55 The presence of bruxism was
determined by report of the patient
and by clinical signs such as consis-
tent occlusal wear patterns on both
natural teeth and restorations. The
prosthodontic and restorative state
of the patient was considered. The
existence and the condition of fixed
and removable prostheses were not-
ed. Detection of premature contacts,
found by bimanual manipulation, in-
dicated that maximum intercuspation
(MI) was inconsistent with centric oc-
clusion (CO).56 The examiners record-
ed any tracks between the premature
centric occlusion contact and the MI.
If a track longer than 3 mm between
the premature contacts in CO and MI
position could clearly be identified, it
was considered clinically significant.
Prestudy calibration of the authors
revealed that tracks less than 3 mm
could not be reproducibly identified
by all examiners. The tracks were re-
corded by using a double layer of ar-
ticulation foil (Arti-Fol 8 μm; Bausch,
Cologne, Germany). Finally, the oc-
clusal vertical dimension and centric
relation deviations were recorded.
For the measurement of the verti-
cal dimension, a Boley caliper gauge
(Miltex Inc, York, Pa) was used. If the
difference between maximum inter-
cuspation and the mandibular resting
position was greater than 4 mm, it
was described as incorrect.
Headache diagnoses, if applica-
ble, were recorded according to IHS
criteria34,35 and where appropriate,
The Journal of Prosthetic Dentistry
single variables were combined in
groups to facilitate statistical analysis.
The statistical analysis was per-
formed using statistical software
(SPSS for Windows, 2009, Release
17.0; SPSS Inc, Chicago, Ill). Interval
scale data were examined using the
Kruskal-Wallis H test. Where neces-
sary, analysis by pairs was accom-
plished with the Mann-Whitney U
test. The Chi-square test was used for
nominal scaled data; the Phi and Cra-
mer’s V correlation coefficients were
computed to identify possible general
correlations; multinomial logistic re-
gression analysis was performed to
assess the individual association of
each variable on headache, and values
of α=.05 were considered statistically
significant. The odds ratios (OR) were
calculated, and the literature suggests
that an OR ≥ 2 is considered clinically
significant.57
Table I. Distribution of patients according to selected demographic factors
Income
No income
<$31,750
$31,750 – $63,500
$63,500 – $127,000
>$127,000
Refused to answer
Education
University/college degree
Nonacademic career
Student (high school/college/university)
Retired
Retired and university/college degree
Retired and nonacademic career
Other
General Satisfaction in Life
Yes
Yes, with reservations
No
Fear of Future
Yes
No
Volume 105 Issue 6
RESULTS
In total, 1031 patients were ex-
amined: 436 (42.3%) men and 595
(57.7%) women. The mean age was
49.6 (±13.2) years and 257 patients
were younger than 30 years, 474 be-
tween 30 and 60 years and 288 older
than 60 years. Table I summarizes the
primary aspects of examined demo-
graphic factors. Smoking was admit-
ted by 209 patients, 379 admitted
consuming alcohol frequently (more
than once a week), and 524 drank
coffee regularly. Stimulant consump-
tion was equally distributed between
genders. In response to physical activ-
ity questions, 675 subjects reported
that they exercised regularly. Of these,
262 exercised less than 2 hours per
week, 265 between 2 and 4 hours
and 148 more than 4 hours. Psycho-
logically, 86 patients suffered from se-
vere depression or were in psychiatric
Total
113
428
250
67
13
181
188
552
86
66
42
75
63
587
379
48
847
143
Troeltzsch et al
June 2011 413
treatment. However, 240 patients re-
Table II. Gender distribution of headache, TMD and ported that they experienced psycho-
psychiatric diagnoses (Chi-Squared analysis) logical impairment.
Male Female P While 334 patients felt physically
tense, only 33 had ever been in treat-
Headache 259 437 .001 ment for muscle relaxation. The ex-
TTH 208 287 .05 amination of the facial and cervical
Migraine 23 66 .04 muscle groups (deltoid, trapezius,
TTH and Migraine 20 65 .01 mylohoid, geniohyoid, digastric, oc-
Other 7 18 NA cipital, medial and lateral pterygoid
muscles) revealed pathology (myo-
TMD 154 255 .01
geloses, pain, sensitive trigger points,
Joint pain 18 40 .03
or combinations) in 436 patients. Af-
Joint clicking 97 142 .01
ter examination, 695 patients were di-
Movement restraint 2 1 .05
agnosed with some type of headache.
Mandible deviation 14 19 .05
Tension-type headache (T TH) was
Combinations 23 53 .02
most frequently diagnosed (48%),
Psychologic Impairment 26 60 .18 followed by migraine (1%). Only 85
Severe depression 19 34 .05 patients showed signs of both T TH
Mild depression 61 94 .05 and migraine. Some type of TMD was
None 340 422 .05 found in 409 patients. Table II dis-
plays the distribution of headache,
P<.05 indicates significant difference
TMD diagnoses, and psychological
impairment by gender.
Table III. Detailed description of dental/parafunctional/prosthodontic findings TMD were found significantly
more often in patients where mus-
Total cular pathology or parafunction,
Parafunction
specifically bruxism and incisal wear,
None 418
were detected. Regression analysis
Bruxers 46
disclosed significant associations.
Tooth impressions in tongue/cheek mucosa 59
Strong odds ratios were computed for
Incisal wear only 93
the variables: greater than 30 years of
Premolar/molar wear only 13 age (OR 4.29), a current student (OR
Incisal and premolar/molar wear 185 7.09), detection of any stated mus-
Bruxers and incisal wear 13 cular pathologies (OR 4.87), bruxism
Bruxers and incisal and premolar/molar wear 175 (OR 7.9), and horizontal deviations
between CO and MI (OR 25.9).
Dental Restorations While the prevalence of headache
Patients with crowns only 408 decreased with age, TMD occurrence
Patients with fixed dental prostheses (3-unit and more) only 34 was highest in the age group between
Patients with removable prostheses 62 30 and 60 years as shown in Table III.
Patients with fixed and removable prostheses 67 Although not statistically significant,
Patients with a combination of restorations/prostheses 123 TMD problems were more commonly
Parafunctional Habits
diagnosed on the left side. Signs of
No parafunctional habits 687
parafunction and wear were displayed
Gum chewing 265
in 613 patients, while 408 patients
Nail biting 40
had single or multiple unit fixed pros-
Gum chewing and nail biting 34
theses. Parafunctional habits were re-
No response 5
ported for 339 patients. Incorrect oc-
clusal vertical dimension was found in
Further Intricacies of the Stomatognathic System 44 patients.
Difference between MI and mandibular resting 204 The majority of headache patients
position ≥ 4 mm 44 did not show any statistically signifi-
Difference between MI and CO ≥ 3 mm cant signs of psychological impair-
ment. Significantly more patients
Troeltzsch et al
414 Volume 105 Issue 6

Table IV. Total numbers presented by outcome variable of patients suffering from headache

Total Headache No
Variable Number (Primary Headache) Headache

Female gender 595 437 158

Age 14 – 30 years 257 214 43

Age 31 – 60 years 474 334 140
Age 61 + years 288 141 147

Nonacademic career 552 390 162

Student (high school/ 86 74 12

college/university)

Muscular pathology 436 372 64

(myogenic pain/trigger
points/combinations)

Bruxism 71 63 8

Bruxism and incisal and 179 169 10

premolar/molar wear

Horizontal differences 44 43 1
between CO and MI
greater than 3 mm

Moderate consumption 218 102 116

of alcohol/coffee

who felt physically tense (28.4%), or
were diagnosed with muscular (36%)
or TMJ pathology (14%) also suffered
from recurrent headache. The com-
puting of correlation coefficients and
regression analysis showed significant
associations among age, gender, edu-
cational aspects, stimulant consump-
tion, TMD, horizontal differences be-
tween MI and CO greater than 3 mm,
and masticatory and cervical muscle
pathology with the appearance of
headache. Variables such as young
age, female gender, educational level,
severe parafunction, muscle or TMJ
pathology, and greater than 3 mm dif-
ference between CO and MI correlated
with a higher prevalence of every kind
of headache, and increased the risk of
the occurrence of migraine and ten-
sion-type headache, separately and in
The Journal of Prosthetic Dentistry
combination. The highest frequency
of occurrence of T TH and migraine
headache was observed with severe
parafunction and horizontal differ-
ences longer than 3 mm between
MI and CO, with a highly significant
(P≤.001) association. Healthy TMJs
and moderate consumption of stim-
ulants seemed to have a protective
effect on the evolution of headache.
Table IV and V depict descriptive sta-
tistics by relevant outcome variables
and the odds ratios for the prevalence
of headaches.
The data did not indicate any
significant prevalence of headaches
in patients who were suffering from
chronic pain in any region of the body
other than head, neck, face, and the
stomatognathic system.
DISCUSSION
The purpose of the study was to
explore associations between TMD,
aberrant stomatognathic function
and the occurrence of headache. Cor-
relations can be assumed due to the
findings of the study. Therefore, the
hypothesis that there is an interrela-
tionship between headache, TMD,
and occlusal interferences is ac-
cepted. Of the 1031 patients in this
study, 67.4% claimed to suffer from
frequent headaches. As reported pre-
viously,24,6,7,35 this study demonstrated
that tension-type headache was most
frequently diagnosed, women were
significantly more affected by primary
headache, headache decreased with
age, and there was a higher prevalence
of headache in patients who felt physi-
Troeltzsch et al
June 2011
Table V. Odds ratios and corresponding P - Values of significant vari-
ables for prevalence of headache (95% confidence interval in parenthe-
ses), (referent category always event of suffering from primary head-
ache) generated in multinominal logistic regression analysis
Variable
Female gender
Age 14 – 30 years
Age 31 – 60 years
Age 61 + years
Nonacademic career
Student (high school/college/university)
TMJ pathology (except clicking)
Muscular pathology
(myogenous pain/trigger points/combinations)
Absence of TMJ pathology
Bruxism
Bruxism and incisal and premolar/molar wear
Horizontal differences between CO and
MI greater than 3mm
Moderate consumption of alcohol/coffee
P<.05 indicates significant difference
cally tense, and who simultaneously
exhibited muscular pathology or TMD.
The effect of muscle pathology
on headache has been previously pub-
lished.5,13,20 Graff-Radford19 contends
that TMD elicit or exacerbate headache
because of an overlap of innervations
with the trigeminal nerve. As previ-
ously stated, the trigeminal nuclei for
mechanoreceptive, proprioceptive,
and pain sensations are in close prox-
imity.36,37,40 Interneurons between the
different nuclei areas, namely spinal
trigeminal nuclei oralis, interpolaris,
and caudalis, have been identified,
and their importance in the pro-
cessing of orofacial proprioceptive
and pain information has been de-
scribed.41-43 Tense muscles, inflamed
TMJ structures, or bruxism, detected
Troeltzsch et al
415
gether.10,12,13,16,18,20-22 In the examined
population, TMD were influenced by
muscular pathology and parafunc-
tion. Although there is agreement
that muscular pathology impacts
TMD,30 the contention that parafunc-
OR P tion has an influence on TMD is dis-
puted by the data that Seligman and
1.91 (1.47;2.5) .001
Pullinger,25 De Meyer et al,8 and Schi-
erz et al23 provided. The contention
4.29 (2.66;4.9) .001
is supported by the studies of Celic
2.73 (1.9;3.9) .001
et al,36 Nagamatsu-Sakaguchi et al,45
0.3 (0.12;1.6) .03
and Scrivani et al.46 More well-con-
trolled studies are needed to clarify
2.45 (1.4;4.3) .001
this issue. Consistent with previous
studies,26-28 the current study found
7.09 (3.2;15.1) .001
that neither malocclusion nor gross
differences between MI and CO were
2.55 (1.6;3.9) .001
significantly more prevalent in TMD
patients. Surprisingly, parafunction
4.87 (3.57;6.65) .001
was strongly associated with the prev-
alence of headache; and patients with
a gross difference between MI and
0.4 (0.26;0.6) .08
CO had the highest coincidence with
primary headache. This is remarkable
3.12 (1.25;7.7) .001
since an association between TMD
and headache is presumed, despite
7.9 (3.9;16.1) .001
various study results that concluded
there is either no or only a weak rela-
25.9 (7.9;84) .001
tionship between occlusal parameters
and TMD.5,12,24,29,30 Extensive litera-
ture review found only 2 studies that
0.44 (0.26;0.75) .001
reported similar results.9,44 Neverthe-
less, there is evidence in the literature
that headache patients are self-re-
in TMD patients,5,13,20 cause continu- ported bruxers,14, 16 and both bruxing
ous strong mechanoreceptive input to and headache decrease with age.2,3,8,9
many processing neurons in the spinal Treatment with occlusal splints has
cord.41 Among those are a wide dy- been reported to reduce headache in-
namic range of neurons that not only tensity and frequency.31-33
receive diverse input, but also project Ciancaglini et al9 asserted that
to different processing neurons, in- lengthy muscular stimulation by para-
cluding pain neurons.42,43 Sustained function may lower the thresholds of
neuronal stimulation triggers mecha- pain sensation. Congruent findings
nisms of synaptic plasticity,38 and were published by Arima et al58 and
eventually new synaptic pathways are Christensen et al.59 An independent
created.43 That may explain the occur- relation between occlusal factors
rence and perpetuation of headache and headache is plausible. However,
in patients whose stomatognathic as previously stated, this study was
system is disturbed in any way. The a cross-sectional study without sys-
relation between TMD and the oc- tematic randomization. Therefore, se-
currence of headache is still a matter lection bias cannot be ruled out and
of scientific contention, even though cause-effect conclusions must be con-
there is increasing evidence that TMD sidered with care. To explore the as-
and headache frequently appear to- sociations of occlusion headache and
416
TMD further, well-controlled random-
ized longitudinal studies are necessary.
Furthermore, consistent with the
literature,2,49,50,53,54 physical exercise,
and psychological or general health
status did not influence the preva-
lence of headache. Of the analyzed
demographic factors, only education
level showed any effect on the etiol-
ogy of headache. These discoveries
are in contrast with published data.
The literature states that demograph-
ic factors, such as income, education,
general satisfaction and future fears
and hopes are strongly associated
with the prevalence of headache.49,51
Moderate consumption of coffee
and alcohol was less likely to be as-
sociated with headaches. Hagen et
al51 reported that high caffeine con-
sumption reduced the risk of frequent
headaches in comparison to low caf-
feine consumption, and hinted that
caffeine had analgesic properties. In
the presented data, regression analy-
sis showed a protective effect of mild
coffee consumption on the etiology
of headache. The authors did not
identify any association between psy-
chological impairment and TMD or
headache, even though it has previ-
ously been described.60
The results of the present study
indicate strong relationships be-
tween stomatognathic disorders and
headache. Still, the study has limita-
tions. The design is cross-sectional,
determining the state of the patient
at only one point in time. The con-
current occurrence of headache and
other problems may be by chance. No
systematic process of randomization
was applied; thus, there is a risk of
selection bias. In addition, while the
significance may be strong for some
results, the reader should note the
extent of the confidence intervals and
the number of patients suffering from
such problems. Due to the limited
number of subjects who displayed
gross occlusal aberrations, statistical
significance is weak and the chance
that these observations are coinci-
dental cannot be ruled out.
The Journal of Prosthetic Dentistry
CONCLUSIONS
Within the limitations of this study
the following conclusions were drawn:
1. Parafunction and differences
between CO and MI, identified by
clearly visible tracks longer than 3
mm, are related to the occurrence of
headache. These findings are in con-
trast with previously published lit-
erature and must be interpreted with
care due to the design of this study.
2. Consistent with previous litera-
ture, female gender, middle age (30 to
60 years), and muscular pathology,
such as myogenic pain, trigger points,
or combinations have an influence on
prevalence, frequency, and intensity
of headache.
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Corresponding author:
Dr Matthias Troeltzsch
Maximilianstrasse 5
91522 Ansbach
GERMANY
Fax: +49-981-77102
Email: matthias_troeltzsch@hotmail.com
Copyright © 2011 by the Editorial Council for
The Journal of Prosthetic Dentistry.