Periodontitis and Temporomandibular Disorders

How Periodontitis and Temporomandibular Disorders are Linked

How Periodontitis and Temporomandibular Disorders are Linked

By Dr. Brad Eli

Periodontitis (PD) may impact temporomandibular joint disorders (TMDs), and TMDs may influence PD

Gum disease (periodontitis) and jaw joint problems (TMD) may have more of a connection than we thought. Even though they seem totally different, recent research shows that poor oral health can affect other aspects of your health. This means gum disease might play a role in jaw joint issues. Doctors from different specialties might need to work together for the clinical management of these related TMD problems.

Here, we explore the connections between periodontitis and TMDs and give you the important information you need to know.

Table of Contents

Periodontitis and Temporomandibular Disorders have a clear link in dental healthcare and oral hygiene

Periodontitis has a bidirectional relationship with TMDs. Chronic TMJ pain can prevent people from maintaining proper oral hygiene and seeking regular dental healthcare. At the same time, the chronic inflammation of periodontitis can perpetuate and advance TMJ disorders.

Three categories of TMDs that can overlap or exist alone:

  1. Intrinsic Joint Problems: These include internal derangement of the joint involving meniscus displacement, jaw dislocation, or injury to the articulating portion of the jaw (the mandibular condyle).
  2. Arthritis-related Joint Problems: These conditions include degenerative and inflammatory conditions that directly affect the TMJ. This can include both osteoarthritis and rheumatoid arthritis.
  3. Myofascial Pain: This is the most common TMD manifestation and is characterized by tenderness or pain in the muscles controlling jaw function. Importantly, this also includes headaches. There is an approximate 60% bidirectional cross-over between chronic headaches and TMDs.

Each of the above subtypes are associated with periodontitis in one way or another.

Table 1: Examples of How Periodontitis May Relate to TMD Subtypes
TMD Subtype Periodontitis-Related Mechanism References
Intrinsic Joint Problems Periodontitis causes jaw joint space changes over time

One-sided chewing due to periodontitis is linked to TMJ changes and pain

 “Comparative Analysis of the Temporomandibular Joints in Patients with Chronic Periodontitis Using Cone-Beam Computed Tomography (CBCT)” [1]

“Pattern analysis of patients with temporomandibular disorders resulting from unilateral mastication due to chronic periodontitis” [2]
Arthritis-Related Causal association between periodontitis and rheumatoid arthritis

Causal association between periodontitis and osteoarthritis

 “Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions” [3]

“Bidirectional Relationship Between Osteoarthritis and Periodontitis: A Population-Based Cohort Study Over a 15-year Follow-Up” [4].
Myofascial Pain Increased expression of chronic pain genes in periodontitis

High association between periodontitis and migraine headaches

 “Expression of chronic pain genes in apical periodontitis tissues” [5]

Precursor conditions to TMDs are also associated with periodontitis. Consider bruxism, which is chronic grinding and clenching of the teeth. Bruxism is a known risk factor for developing TMJ dysfunction and pain.

December 26, 2021, the National Institute of Health published Association of probable bruxism with periodontal status: A cross-sectional study in patients seeking periodontal care. Author Mehtap Bilgin Çetin reports on study findings after investigating the prevalence of bruxism in a group of patients seeking periodontal treatment. The study’s regression analysis suggests that probable bruxism is associated with periodontitis. It observed that “the prevalence of probable bruxism was 36.6% and probable bruxers showed higher odds of periodontitis.”

  • Common Risk Factors: Shared risk factors, such as stress and chronic systemic inflammation, may contribute to the development or exacerbation of both periodontitis and TMD.
  • Genetics: There is some evidence that genetic changes in certain cell structures are altered in both periodontitis and TMDs [7]. While other researchers have failed to find specific genetic factors for this apparent bidirectional link, they admit that epigenetic and biomechanical factors may be at play.
  • Bruxism: There is a statistical association between bruxism and periodontitis. Bruxism is the habitual grinding or clenching of teeth. Prolonged bruxism can contribute to TMDs by placing excessive stress on the jaw joint and surrounding muscles, leading to pain, discomfort, and dysfunction.
  • Biomechanical Stress: One clinical study found that untreated chronic periodontitis causing one-sided chewing can lead to both pain and structural temporomandibular joint (TMJ) changes. The authors recommend that immediate periodontal treatment is crucial to prevent potential secondary TMJ-related issues [2].
  • Joint Space Changes: One study looked at the mechanical effect of periodontitis on the TMJ position over time on computerized tomography (CT) scans. They found that with periodontitis, there are significant changes in the joint position as the disease progresses [1].
  • Systemic inflammation: Periodontitis involves inflammation of the gums and supporting structures, which may affect the temporomandibular joint (TMJ) and contribute to TMD symptoms, such as through its association with rheumatoid arthritis [3] and osteoarthritis [4].
  • Migraines: There is a significant association between periodontitis and migraine headaches [6]. One study found that periodontitis was associated with higher circulating calcitonin gene-related peptide (CGRP) levels in patients with migraines [8]. Importantly, CGRP is significantly associated with TMD pathology.

What is Periodontitis?

In a simplistic sense, gingivitis is described as “early” gum disease and periodontitis as “advanced” gum disease. The two conditions follow a temporal sequence: first gingivitis, then periodontitis.

In periodontitis, the gums pull away from the teeth and form spaces (pockets) that become infected. The body’s immune system fights the bacteria as the plaque spreads and grows below the gum line. The toxins produced by the bacteria and the body’s natural response to infection start to break down the bone and connective tissue that holds teeth in place. As periodontitis advances, teeth may become loose and may eventually need to be removed.

Understanding the Greek and Latin roots of medical terms provides quick insights into their meanings. The root meaning of two crucial terms, “gingivitis” and “periodontitis”, along with their definitions according to Taber’s Medical Dictionary:

Table 2: Etymology and Definitions of Gingivitis and Periodontitis
Medical Term Root Words English Meaning Medical Definition
Gingivitis Gingivae (L)
-itis (G) 		Gums
Inflammation		 Inflammation of the gums, marked by gum redness and swelling, with a tendency to bleed
Periodontitis Peri- (G)
-odontes (L)
-itis (G)		 Around
Teeth
Inflammation		 Chronic inflammation and gradual destruction of the tissue surrounding the tooth and its socket

Gingivitis is caused by plaque, a sticky film of bacteria that forms on teeth. As noted above, the primary characteristics are red, swollen gums that tend to bleed when irritated. If gingivitis is not treated, it can progress to periodontitis.

What are the Symptoms of Periodontitis?

The most common symptoms of periodontitis are:

  • Gums that are red, purple, or swollen.
  • Bleeding gums.
  • Tenderness in the gums.
  • Halitosis (bad breath).
  • Gums that have pus.
  • Gums that recede from the teeth.
  • Gaps between the gums and the teeth.
  • Teeth that are loose or that fall out.
  • Teeth feel that they don’t fit together anymore.
  • Pain when chewing.

Note that the symptoms of periodontitis will vary based on the severity and progression of the disease.

What does periodontitis do to the jaw?

Periodontitis commonly causes gum recession; the infection can spread to the jawbone. Risks increase when bacteria destroys the jaw bone tissue, causing loose teeth and pain while chewing.

While periodontitis is sometimes referred to as “advanced gum disease,” much more than just the gums are involved. The tissue surrounding the tooth and its socket are collectively called the “periradicular tissue.”

Periradicular tissue is comprised of multiple structures:

  1. Alveolar bone: The portion of the mandibular or maxillary bone that surrounds the teeth.
  2. Alveolar-dental periosteum: The fibrous membrane that covers the alveolar bone around the tooth root.
  3. Cementum: The calcified connective tissue surrounding the tooth root’s outer surface.
  4. Periodontal ligament: The connective tissue attaching the cementum of the tooth to the alveolar bone, keeping the tooth in the bone socket. This ligament connects the tooth to the jaw. To function correctly, it must do this so that the tooth can withstand the considerable forces of mastication.

When periodontitis affects these periradicular tissues in advanced disease, the structures holding the tooth in place erode, resulting in tooth loss.

Is periodontitis painful?

The teeth, gums, periodontal ligament, and alveolar bone are all innervated by the trigeminal nerve. When there is pain, the nerve signals travel along the third branch of the trigeminal nerve to the trigeminal ganglion where all three branches of the trigeminal nerve meet. The signals travel up to the sensory cortex, where the perception of pain occurs.

Interestingly, despite the intense inflammation that drives periodontitis, the condition is frequently painless when it is chronic and slowly progressing. This paradox has been explained by various pain-reducing molecules released by bacteria and their effect on the local pain response.

Periodontitis and Orofacial Pain

Why does periodontal disease cause jaw pain?

When dental patients’ gums recede, infection eats away the bone-supporting teeth roots, which intensifies tenderness in the gums. The jawbone density weakens. Meaning the person’s teeth no longer have sufficient support from the deteriorating periodontal tissues, which may cause orofacial pain.

Despite often being painless at the source, advanced periodontitis can lead to pain in several ways and should be considered in cases of chronic orofacial pain:

  • Dull pain: The chronic inflammation of periodontitis can lead to a dull, aching, episodic pain that is mild in nature.
  • Sharp pain: When a local infection flares up, periodontitis can cause sharp pain, such as with tooth root infections (called periapical abscess).
  • Jaw joint and muscle pain: Chronic periodontitis leads to jaw clenching and changes in the jaw joint and jaw muscle chances, leading to chronic TMJ-related pain.

Further, periodontitis leads to a form of inflammation called “neurogenic inflammation.” This is when specific molecules released by peripheral nerves result in a characteristic immune response. This neurogenic inflammation can lead to increased sensitivity to pain in other regions of the trigeminal nerve, even if not felt locally.

In a fascinating new discovery, researchers find that the bacteria that cause periodontitis secrete certain substances (extracellular vesicles) up through the nerve to the trigeminal ganglion. When this happens, all branches of the trigeminal nerve can become inflammed [9]. This may explain the association of periodontitis with diverse orofacial pain conditions, such as migraines, trigeminal neuralgia, and TMDs.

What are scaling and root planning?

One of the gold standard treatments for periodontitis is called scaling and root planning (SRP). In scaling, a special instrument is used to manually scrape the plaque and debris from below the gumline. Once this is complete, root planning is conducted by smoothing the tooth root so that the gum tissue can reattach.

The whole procedure typically takes 1-2 hours. While it is not always painful, studies show that people anxious about possible dental procedure pain increasingly experience pain with SRP [10].

Evidence signals that chronic periodontitis is related to multiple systemic health conditions.

Commonly associated diseases to chronic periodontitis:

  • Heart disease.
  • Gastrointestinal disease.
  • Respiratory disease.
  • Rheumatoid arthritis.
  • Temporomandibular disorders.
  • Diabetes and insulin resistance.
  • Lupus erythematosus.
  • Pregnancy complications.
  • Various cancers.
  • Trigeminal neuralgia.
  • Migraine headaches.
  • Anemia of chronic disease.
  • Alzheimer’s and Parkinson’s disease [11].

Periodontitis effect on the immune system is considered one of the main drivers of the above conditions. Each of these conditions are in some way related to chronic inflammation. Likewise, other systemic inflammatory diseases can increase the risk of developing periodontitis, so the effect is bi-directional.

The inflammation associated with chronic periodontitis may persist for months or years, leading to a prolonged low-grade inflammation. This persistent condition alters the balance of chemical mediators that regulate the immune system, affecting various bodily systems. Notably, treating periodontitis results in an improvement in this immune system imbalance [12].

Understanding how periodontitis and Temporomandibular Disorders are linked helps dentists treat gum disease with TMD prevention in mind.

How to Prevent Periodontitis?

Periodontitis is a preventable condition. Here are some simple interventions that can be taken to reduce the risk of periodontitis:

  • Maintain Excellent Oral Hygiene: Brush your teeth at least twice a day using fluoride toothpaste. Floss daily to remove plaque and debris from between teeth.
  • Regular Dental Check-ups: Schedule routine dental examinations and cleanings with your dentist. Early detection and intervention can help prevent the progression of periodontitis.
  • Healthy Lifestyle Choices: Adopt a balanced diet rich in fruits, vegetables, and whole grains. Limit sugary snacks and beverages, as sugar contributes to plaque formation.
  • Avoid Tobacco Products: Smoking and tobacco use are linked to an increased risk of periodontal disease. Quitting smoking can significantly improve oral health.
  • Manage Stress: Stress can contribute to bruxism (teeth grinding), which may exacerbate periodontal issues. Practice stress-reducing techniques such as meditation or yoga.
  • Proper Toothbrush and Technique: Use a soft-bristled toothbrush to avoid damaging the gums. Brush using a gentle circular motion to effectively clean teeth and gums.
  • Address Bruxism: If you grind your teeth, consider using a mouthguard at night to protect your teeth and jaw.
  • Stay Hydrated: Drinking water helps to rinse away food particles and bacteria, promoting oral health.
  • Manage Medical Conditions: Certain medical conditions, such as diabetes, can impact gum health. Manage these conditions effectively.

Periodontal Procedures in TMD Patients

If you already have a TMD condition and need periodontitis treatment, several steps may help prevent TMD flare ups surrounding the procedure.

  1. Tell Your Provider: It’s critical that tell your periodontist about your TMD condition. This can prompt them to give you more breaks during your procedure so there is not as much strain on your jaw joint.
  2. Pre-Surgical Care: Pain with periodontal procedures is directly related to anxiety levels. Anxiety always makes TMD pain worse. For this reason, use stress-reducing techniques like mindfulness to reduce your procedure-related stress.
  3. Post-Surgical Care: Periodontal procedures like SRP can take several hours and may exacerbate TMD pain. Post-surgical use of an oral appliance and cold packs can help prevent TMD flair ups. TMD self-care kits like the Speed2Treat Home Healing Kit are perfectly suited for this purpose.

CONCLUSION: Periodontitis and TMDs Have a Mutual Connection

Advancements in our understanding of oral-systemic connections underscore the need for further awareness. If you already have a TMD, maintaining good gum health has two benefits:

  1. It lowers the overall inflammation connected to periodontitis, decreasing a factor that could worsen your TMD.
  2. It lessens the chance of needing potentially painful dental treatments for periodontitis. If you have untreated periodontitis, there is an increased risk of developing a TMJ disorder.

This evolving awareness highlights the interconnected nature of oral and systemic health, urging a comprehensive approach to address the complexity of periodontitis and its potential impact on TMJ-related concerns. For patients with pre-existing TMDs, measures are available that can help prevent painful flair-ups related to periodontitis treatment.

Learn Additional Causes of TMJ Pain

Author bio:

Author Dr. Brad EliDr. Brad Eli, DMD, MS graduated from UCLA’s postdoctoral Orofacial Pain program. He specializes in the field of orofacial pain, temporomandibular disorders, and headache treatment and is a member of the Academy of Sport Dentistry (ASD). Dr. Eli has also been on the educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals. He will be presenting at the 2024 annual meeting of ASD.

 

References

[1] Xiaoqian Guo, et al., “Comparative Analysis of the Temporomandibular Joints in Patients with Chronic Periodontitis Using Cone-Beam Computed Tomography (CBCT),” Jan 2021, https://pubmed.ncbi.nlm.nih.gov/33159659/

[2] Jeon HM, et al., “Pattern analysis of patients with temporomandibular disorders resulting from unilateral mastication due to chronic periodontitis,” Aug 2017 https://pubmed.ncbi.nlm.nih.gov/28861285/

[3] de Molon RS, Rossa C, Thurlings RM, Cirelli JA, Koenders MI. “Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions,” Setp 2019, https://pubmed.ncbi.nlm.nih.gov/31540277/

[4] Kevin Sheng-Kai Ma, et al., “Bidirectional Relationship Between Osteoarthritis and Periodontitis: A Population-Based Cohort Study Over a 15-year Follow-Up,” July 2022, https://pubmed.ncbi.nlm.nih.gov/35958545/

[5] Jordano Francio, et al., “Expression of chronic pain genes in apical periodontitis tissues,” May 2023, https://pubmed.ncbi.nlm.nih.gov/37183358/

[6] Huang Kai Huang, et al., “Increased Risk of Migraine in Patients with Chronic Periodontitis: A Population-Based Cohort Study,” 2021 https://www.mdpi.com/1660-4601/18/4/1921

[7] Mariana Bezamat, et al., “Aquaporin locus (12q13.12) might contribute to susceptibility of temporomandibular joint disorder associated with periodontitis,” March 2020 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229245

[8] Linda Sangalli, James Fricton DDS, MS, “Calcitonin Gene-Related Peptide-Mediated Trigeminal Ganglionitis: The Biomolecular Link between Temporomandibular Disorders and Chronic Headaches,” July 2023, https://www.mdpi.com/1422-0067/24/15/12200

[9] Ha JY, et al., “Periodontitis promotes bacterial extracellular vesicle-induced neuroinflammation in the brain and trigeminal ganglion,” 2023 doi:10.1371/journal.ppat.1011743

[10] Khalid Gufran, et al., “Pain Assessment and Need for Analgesics after Scaling and Root Planing in Patients with Stage II and Stage III Periodontitis,” June 2023, https://www.mdpi.com/1648-9144/59/7/1203

[11] Bhuyan R, et al., “Periodontitis and Its Inflammatory Changes Linked to Various Systemic Diseases: A Review of Its Underlying Mechanisms,” May 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10179599/