Temporomandibular Disorder (TMD) is an umbrella term used to refer to a variety of interlinked disorders related to the temporomandibular joints (TMJ) and the muscles in the craniofacial area and related structures. They all exhibit common symptoms, such as discomfort and a reduced opening of the jaw. In addition, other craniofacial symptoms could also be present and should be analyzed for early diagnosis of TMD. In light of the extra-craniofacial signs associated with TMD the study was designed to assess the intensity of pain in the neck muscles of those suffering from TMD and compare it to how severe the condition is.

Methods and materials

The study included 44 participants. participated in the study and assessed for the severity of TMD according to the dysfunctional and amnestic aspects that comprise the Helkimo index in separate. The pain was assessed bilaterally across five groups of neck muscles throughout the study using manual palpation. The intensity of pain felt in the neck muscles was associated with severity subjective and objective signs of TMD and was compared to patients who did not have TMD.


The Chi-square test showed the statistically significant correlation between the intensity of discomfort in all five groups of neck muscles as well as the degree of TMD. The intensity of pain increased with the intensity of TMD which resulted in the total of 59.09 percent of TMD patients experiencing different levels of pain in the neck musculature , and a p value of 0.0001 percent which was statistically significant. There was no sign of pain in the neck muscles was seen in patients who did not have TMD.


Based on the study results on the study, it was found that the degree of TMD directly correlates with the degree of pain experienced by various categories of the neck muscle. 59.09 percent of patients suffering from TMD had different degrees of pain in their neck muscles. The intensity and the distribution of neck pain muscles increased with the increase in degree of TMD.


Temporomandibular Disorder (TMD) is an umbrella term used to refer to a variety of interlinked disorders that affect the temporomandibular joints (TMJ) and muscles in the craniofacial area and the associated structures. They all exhibit common symptoms like discomfort and a reduced jaw opening [11. According to Rieder and colleagues. 33 to 50% of patients showed one or more of the signs of TMD. However, the percentage of patients who require professional care range from 10 percent [22. If patients suffering from temporomandibular disorder or TMD are able to present their discomfort to the physician, they may consider the source of pain as similar to its location. The pain may be linked to another location [33. This type of pain could be due to an otologic or neurologic source or even be a result of the neck muscles and can be the cause and the symptom of TMD [44. Functional and neuroanatomical connections among the cervical and masticatory areas are discussed as the causes of the underlying neck and jaw pain [55. The majority of referred pain occurs in the neck and head region, and frequently confuses the physician and the patient. The majority of patients with these symptoms of pain referred to the general doctor or otolaryngologist, but not to an orthodontic specialist; therefore, an the need for a proper referral is essential6.

Furthermore, TMD is also reported to affect posture negatively due to neuroanatomical signs and further emphasising the requirement for an integrated approach to the diagnosis and treatment for TMD ([7]. Fortunately, these patterns of pain are somewhat similar and comparable between patients and allow experts to learn about these instances to quickly detect the cause of the pain [8-98-9. Through the palpation of muscles and trigger point, Wright and co. have identified specific pain points for different muscles, with neck muscles being among the most commonly identified [33. The majority of studies that are published on TMD are associated with malocclusion, dental as well as Orthodontic treatment. But, just a handful of studies have been conducted to examine the symptoms that are extra-craniofacial for TMD which could assist in the identification of TMD for patients who seek Orthodontic treatment and assist in the prevention of the progress of TMD [1010. De Laat et al. observed that on examination, between 2 and 37% of the patients suffering from TMD experienced neck muscle pain in the sternocleidomastoid as well as the upper trapezius, in addition to other shoulder and cervical muscles. This was rare in the group that was a control [1111. It is evident that neck pain could be experienced by patients suffering from TMD as well, which is why there was the need to determine precisely the intensity of neck muscles pain to the degree of TMD since no research published in the literature has found an exact correlation between the same. Hence, this study was designed.

Materials & Methods


This observational study was conducted in the Department of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College, Wardha, with approval from Datta Meghe Institute of Medical Sciences Ethical Committee (approval number DMIMS(DU)/IEC/2020-21/257). The total number of adults (18-30 years old) were selected randomly in the department of outpatients (OPD). The size of the sample was calculated using the Cochran formula for the size of the sample calculation: the formula is n= Z2a/2 xpx(1-p)/E2 in which Z2a/2 is the degree of significance with 95 95% range of confidence, while p represents the proportion of patients suffering from multiple issues, and the E represents the margin error (7 7 percent). Patients who met the criteria for inclusion were those with dentition that is permanent and over 18 years old and having either a class I or class 2 (vertical) bone structure. Patients who were excluded included those who had an experience of Orthodontic treatment and psychological disorders, a histories of trauma due to TMJ as well as TMJ surgery, as well as patients suffering from bony problems.

They were classified into four groups according to the dysfunctional component (objective signs) in the Helkimo index one group – patients suffering from mild TMJ dysfunction patients, group two – those who have moderate TMJ dysfunction Group three – Patients suffering from extreme TMJ dysfunction, and group four – patients with none TMJ dysfunction. In addition, based on an amnestic part of the Helkimo index subjective symptoms of those patients was classified into mild, no and severe types. The study’s design is shown in Figure 1.


The Helkimo index classified patients their subjective and objective signs into mild, no moderate, severe, and no categories. The neck muscle of all patients was assessed for pain patterns with manual palpation, sustaining firm fingers across the length of the muscle. Trapezius (Figure 2) and Splenius capitis (Figure 3) and the sternocleidomastoid (Figure 4) the frontal digastric (Figure 5) and posterior digastric muscles (Figure 6.) were both palpated. It was also noted. For each muscle group with any indications of pain one score was assigned. For those without pain, a, a score of zero was given. In this way, five categories of muscles were evaluated (Table 1.). Then, the study graded the general neck pain in a scale of 10. The score of 0 signified that there is no discomfort in neck. while 1-3 indicated moderate pain, 4-6 suggested moderate pain and 7 or more indicates severe neck discomfort (Table 2.). The pain of the neck muscle was found to be associated with the degree of TMD when examining those subjective as well as objective signs in isolation. For the purpose of observation All precautions universally recommended and protocols for infection control were followed. A written and informed permission was sought from each of the patients.

Muscle Scoring to determine if there is no pain = 0; presence of pain = 1.
Right Left
Trapezius 0-1 0-1
Sternocleidomastoid 0-1 0-1
Splenius capitis 0-1 0-1
Anterior digastric 0-1 0-1
Posterior digastric 0-1 0-1
The total out of 10 Minimum score=0,Maximum score=10

Grading of pain intensity
Score Inference
0 No neck pain
1-3 A mild pain in the neck muscles
4-6 Pain in the neck muscles that is moderate
7 and over Neck muscles are painful and painful


The statistical analysis was performed using descriptive and inferential statistics with Chi-square tests. The software used for the analysis used was SPSS Version 27.0 (IBM Corporation., Armonk, NY, USA), and p<0.05 was considered to be the threshold of significance that showed a statistically significant correlation between the degree of pain across all five neck muscles and the severity of TMD. The intensity of pain increased with the intensity of TMD.

TMD Grading is determined by Helkimo index

The Helkimo index is comprised of two components: the amnestic part (subjective signs) along with the dysfunctional clinical component (objective manifestations). The results of the grading included: of 44 cases when examining the objective symptoms 11 cases (25 percent) all had no TMD symptoms or mild TMD symptoms mild, moderate TMD symptoms, or severe TMD symptoms and. Out of the 44 cases examined 10 instances (22.73 percent) did not have any subjective symptoms 20 instances (45.45 percent) were suffering from mild subjective symptoms and 14 instances (31.82 percent) were suffering from extreme personal manifestations (Table 3.).

Symptom severity The number of patients in each group
Dysfunctional component Amnestic component
There are no symptoms 11 10
Mild symptoms 11 20
Moderate symptoms 11
The symptoms are severe. 11 14

Correlation between neck pain muscle and the degree in subjective TMD signs (clinical amnestic components)

Of 14 TMD patients who suffered from intense subjective symptoms Five patients (35.71 percent) suffered from severe discomfort in their neck muscles Seven patients (50 percent) suffered moderate pain in their neck musculature, and a patient (7.14 percent) both had mild or no pain in the neck muscles or a scapular. Of 20 patients with mild symptoms subjectively One patient (5 percent) suffered from severe pain Four patients (20 percent) suffered moderate pain seven patients (50 percent) were experiencing mild pain as well as eight people (40 percent) were pain-free in their neck muscles. Of 10 patients who had no subjective symptoms, none patients experienced any severe or moderate pain within the neck muscles. On the other hand, one patient (10 percent) suffered from moderate neck pain. 10 patients (90 percent) had no complaints about neck muscles (Table 4 Figure 7).

The neck muscles are strained and painful. Amnestic component Total
There are no symptoms Mild Extreme
No Pain 9(90%) 8(40%) 1(7.14%) 18(40.91%)
Mild Pain 1(10%) 7(35%) 1(7.14%) 9(20.45%)
Moderate Pain 0(0%) 4(20%) 7(50%) 11(25%)
Extreme Pain 0(0%) 1(5%) 5(35.71%) 6(13.64%)
Total 10(22.73%) 20(45.45%) 14(31.82%) 44(100%)
&2-value 27.27, p-value=0.0001, Significant

Correlation between neck pain muscles as well as the objective TMD manifestations (clinical disordered component)

Of the 11 TMD patients, taking into account the symptoms objectively of severe dysfunction Six patients (42.86 percent) suffered from severe neck pain. Four patients (36.36 percent) had moderatepain, one patient (9.06 percent) was suffering from mild pain and one was pain-free. In 11 patients suffering from moderate dysfunction, none suffered from severe neck pain. six patients (42.86 percent) experienced moderate pain in their necks, while three patients (27.27 percentage) and two (18.18 percentage) had no or mild neck pain and two patients (18.18%) had no or mild neck pain. In the 11 patients who had mild dysfunction, there was no one who was suffering from neck pain that was severe, one patient (7.14 percent) was suffering from moderate neck pain 4 patients (36.36 percent) suffered from mild pain as well as six (54.55 percent) were pain-free. In the 11 patients who had no impairment, 10 patients (90.91 percent) were pain-free and one patient (9.09 percent) suffered from mild neck discomfort (Table 5 and Figure 8).

The neck muscles are strained and painful. Dysfunctional Component Total
No Dysfunction Mild Moderate Extreme
No Pain 10(90.91%) 6(54.55%) 2(18.18%) 0(0%) 18(40.91%)
Mild Pain 1(9.09%) 4(36.36%) 3(27.27%) 1(9.06%) 9(20.45%)
Moderate Pain 0(0%) 1(7.14%) 6(42.86%) 4(36.36%) 11(25%)
Extreme Pain 0(0%) 0(0%) 0(0%) 6(42.86%) 6(13.64%)
Total 11(25%) 11(25%) 11(25%) 11(25%) 44(100%)
&2-value 42.68, p-value=0.0001, Significant

In those 44 TMD cases, taking into account their subjective as well as objective symptoms,40.91 percent (of patients) (18 patients) did not experience pain in the neck muscles. 20.45 percent (nine patients) (nine patients) suffered from mild pain, 25 percent (11 patients) had moderate pain, 25% (11 patients) were experiencing moderate pain and 13.64 percent from patients (six patients) suffered from severe pain, concluding that 59.09 percent of TMD patients reported various degrees of pain in the neck muscle, with an P-value of 0.0001 percent, which is significant.


The current study was designed to determine the degree of neck pain and the degree of TMD. In the beginning, to categorize TMD patients based on severity and severity, it was decided to use the Helkimo index was applied comprised in an amnestic part (assessing the subjective manifestations) and an impairment component (assessing the objective manifestations). This component, which is amnestic in nature, determined by an instrument that asks questions on TMJ noises jaw rigidity, discomfort in the masticatory muscles and jaw joints, among other. The dysfunctional part includes an examination of the patient by examining mandibular movements, touching the masticatory muscles and evaluating the frequency of clicking and the luxation. The final grade is determined by the level of dysfunction using a 25-point scale. Both of these components were associated with the severity of neck pain [1212. Affiliating objective and subjective symptoms with the neck muscles was crucial since the early stages of TMD might present as just subjective symptoms. But, the muscle pain in the neck may remain present and provide an early indication of TMD [1313.

Signs and symptoms of TMD are TMJ pain, clicking or crepitus, headaches myofascial pain, a reduced mandibular motion and masticatory muscle exhaustion and the restriction of mouth opening. These are regularly assessed [1414. But, additional facial symptoms such as muscle pain in the neck as well as neural signs and ear-related issues may be seen in patients suffering from TMD and could be a sign that they are the development of TMD [15,16and 16. In the past, a study by Bargatto and colleagues. in assessing the relationship between neck pain and TMD for office-based workers found that neck muscle pain was associated with TMD but work-related computer use is a major aggravating factor [1717. This could be related to our findings of neck pain occurring at 10% in non-TMD patients, which could be caused by other factors that TMD. There are however few studies that directly link neck pain with the degree of TMD. One such study was carried out by Wright who evaluated the referred pain of the craniofacial area in patients suffering from TMD and found that 85 percent of patients were afflicted with referred craniofacial pain upon palpation of muscles, that included the trapezius, which was among the more affected muscles [33. Our study assessed the trapezius muscles and other neck muscles like the sternocleidomastoid muscle anterior and posterior digastric muscles and the splenius capsitis muscle bilaterally, which can detect general neck pain intensity as per an index of the craniomandibular region [18The index is a measure of the severity of neck pain.

The study found that the intensity of neck pain was increased as intensity of TMD was increased. A majority of the patients with minor to moderately subjective TMD symptoms reported moderate to mild pain in the neck muscles. One patient who had mild subjective symptoms complained of severe neck pain. This might require examination for factors that are not related to TMD, like anxiety or genetic according to Yalcinkaya and colleagues. as well as Fejer and. respectively, in two separate studies that concluded that neck pain could be worsened by anxiety, or it could be due to genetics [19,2020]. Patients suffering from severe subjective TMD symptoms had varying degrees of neck muscle pain however, more than 50% of them experienced moderate to severe discomfort. This is similar to what Olivo found who found that those who had a greater degree of jaw impairment had a higher degree of neck-related impairments as well [2121. These findings suggest that even if not frequently examined and analyzed, neck pain muscles could be a co-occurring sign in patients suffering from TMJ dysfunction , and may provide an early clue to the nature and severity of TMD. The manual palpation of the neck muscles, which is one of the most straightforward methods of assessment [22], when regularly conducted when examining TMD cases, is essential for diagnosing TMD and open the door to prompt intervention in managing TMD [2323. Since there has been no research in the past that linked the severity of neck pain as a result of symptom to TMD degree, this research can serve as a foundation to develop a standard diagnosis protocol to evaluate TMD.

Some limitations of this study are that there was no radiographic evaluation similar to MRI was conducted in the course of clinically assessing TMD. Combining radiographic and clinical assessment would result in a conclusive diagnosis and better correlation with pain in neck muscles. If a thorough diagnose of TMD is established from the craniofacial as well as extra-craniofacial signs, the appropriate treatment procedure can be implemented. Based on the degree of TMD and the severity of its symptoms, either a non-pharmacological or pharmacological treatment is possible. Pharmaceutical approaches consist of using analgesics as pain relief or muscle relaxants for patients suffering experiencing pain in the neck or jaw muscles. Nonpharmacological solutions include occlusal-splints as well as physiotherapy and electrocutaneous transcutaneous nerve stimulation, among other. Extreme TMD cases might require additional surgery.


From the results of the investigation, the researchers determined that neck pain was co-existing with TMD in the majority of cases. The intensity of TMD was in direct correlation with the pain experienced by various categories of neck muscles including the splenius capsitis the trapezius, the sternocleidomastoid as well as the anterior and posterior digastric muscles. The degree and severity of neck pain muscles increased as the intensity of TMD. However those who did not suffer from TMD had less discomfort in the neck muscles. Not just the symptoms that are objective as well as the subjective ones have a direct connection to TMD and also affected the personal and social life of the patients. Neck pain is often thought of as an early sign of developing TMD. The neck muscles can be of crucial significance for diagnosing. It can aid in the early detection, diagnosis and scheduling treatment for patients suffering from TMD. It opens the way to identify undiagnosed cases and prompt treatment in these cases to minimize the risk of. The inclusion of neck muscle examinations in the diagnosis procedure of TMD could result in greater quality of life for these patients.