Updated Review Costen’s Syndrome:
Clinical Relationship between Dentistry
Caio Bortoloci1, Ana Beatriz Moimáz2, and Mirto Prandini3*
1Departament of Odontologia, UNOESTE, Universidade do Oeste Paulista - Presidente Prudente, São Paulo, Brazil
2 Departament of Medical, UNIFAI, Centro Universitário de Adamantina - Adamantina, São Paulo, Brazil
2Departament of Neurology and Neurosurgery UNIFESP, Universidade Federal do Estado de São Paulo, São Paulo, Brazil
Submission: May 14, 2020; Published: June 11, 2020
*Corresponding author: Mirto Prandini, Departament of Neurology and Neurosurgery UNIFESP, Universidade Federal do Estado de São Paulo, São Paulo, Brazil
How to cite this article: Caio B, Ana Beatriz M, Mirto P. Updated Review Costen’s Syndrome: Clinical Relationship between Dentistry and Medicine. Adv
Dent & Oral Health. 2020; 12(5): 555846. DOI: 10.19080/ADOH.2020.12.555846
Introduction: Costen syndrome is a term used to describe the functional and structural changes that occur involving the temporomandibular articulation causing a variable symptomatology including hemi cranial pain and masticatory disturbances.
Objectives: In view of the and importance of the issue, the incidence over 50% of populations and variability of symptoms we decided to update some new information regarding its etiology and treatments proposed.
Methods: A research was carried out based on papers published in English and Portuguese literature from 2005 to 2017.
Conclusion: A series of procedures and new therapies were presented. However, we think that even after decades, Costen syndrome still remains one obscure issue.
Costen’s syndrome was first named and described in 1934 by James Costen. Based on 11 cases, he was the first to suggest that changes in dental conditions were responsible for several symptoms from otological origin. The author found the occurrence of cases that presented symptoms in the region of the temporomandibular joints (TMJ) as pain of musculoskeletal origin, crackling and crackling), otological symptoms such as tinnitus and difficulties in opening the mouth as well as significant cause of unilateral headache . Symptomatology goes beyond a structural relationship, as it encompasses knowledge from more than one specialty in the health field, thus making treatment with only one specialist difficult. Although several conditions can determine its advent, there is basically a disharmony of the stomatognathic system caused by several factors such as the consequences of tooth loss poorly adapted prostheses, parafunctional habits such as bruxism, , postural alteration of the jaw and neck in addition to psychological factors that cause an increase in muscle activity causing spasms and fatigue. Quinto 1999 .
This bibliographic review was carried out by searching online databases, such as Scielo, PubMed, using the keywords syndrome, Costen and temporomandibular disorder (TMD), from 2005 to 2017, in English and Portuguese idioms, totaling 20 articles.
James Costen in 1934, based in embryology and anatomophysiology studies in order to elucidate a more accurate diagnosis for patients with complaints affecting the temporomandibular region. The close anatomical and functional relationship between TMJ structures and those of the auditory system provides a basis for inducing a causal relationship between TMDs and auditory function disorders Thus, for the temporomandibular joint to be able to functioning harmoniously, it is necessary that dental occlusion and neuromuscular balance act in agreement . Pinto  reported an anatomical explanation for such a wide range of multidisciplinary symptoms. It is mentioned the existence of a link between a ligament that communicates the condyle and articular
disc with the middle ear, lateral to the chorda tympani nerve
. Anatomically, the TMJ region is adjacent to the ear, requiring a
proper positioning inside the mandibular fossa. Therefore, in cases
of occurrence of any external or internal stimulus that affects
this harmony joint leading to its displacement, this will result in
damage to nearby structures causing symptomatic consequences
to the individual . Therefore, as already observed, it can be
concluded that the etiology of Costen’s Syndrome is multifactorial,
since several aspects are present, as tooth loss, poorly adapted
prostheses, dental wear, deficient restorations, bruxism and parafunctional
habits (nail biting, finger sucking, biting objects) both
generating disocclusion. It also may be mentioned the presence of
psychological factors that cause increased activity, or muscle tone,
which leads to the development of muscle spasms .
The variability of etiological factors resulted in a clinical picture
quite extensive, subject to great variability. Based on a literature
review conducted in 2010 by Barreto, we can point out some
more frequent signs and symptoms of TMD. Complaints such as
clicks, ear fullness (muffled hearing sensation), tinnitus, vertigo,
vertical decrease in occlusion (measure of the distance between
two points on the face, and the most common symptom is pain
with different characteristics, such as otalgia, myalgia and headache.
There are, therefore, several differential diagnoses . The
link between temporomandibular disorders and craniofacial
symptoms is increasingly quite evident, providing to dentistry
professionals the possibility to investigate and put into practice
the knowledge acquired in this area. Badim describes that TMJ
dysfunction is any change in normal movement, whether with or
without symptoms .
It is known that the diagnosis of TMD is syndromic, that is, it
is necessary a set of signs and symptoms that define the clinical
manifestations of the affected region, regardless of the etiology.
Costen’s Syndrome has a high prevalence since epidemiological
research has shown that more than 50% of the population has had
at least one or more signs of TMD. Due to its wide range of factors,
it has not yet been possible to establish a standardized diagnosis
. With regard to the diagnosis of TMD, there is still no reliable
method of diagnosis and measurement of the presence and severity
of TMD. Nevertheless, for the diagnosis of individual cases,
anamnesis remains the most important step in formulating the
initial diagnostic impression. The anamnesis requires a complete
identification of predisposing factors, initiating factors and perpetuating
factors . The dental surgeon, together with a multidisciplinary
team involving otolaryngologists and neurologists,
should pay attention to the anamnesis as the most important point
in the diagnosis, needing special attention to the involvement or
not of psychosomatic, emotional factors (anxiety, depression and
stress), social factors, as many cases of TMD have emotional substrate
. Leeuw (2010), proposed the importance of physical
examination in the diagnosis, which consists of palpation of the
TMJ, musculature, active movement recognition and joint noise
analysis when performed by trained professionals. In addition, the
study of sleep (polysomnography) and radiographic images of the
TMJ are seen as important auxiliary tools means in the evaluation
of the joint .
The conservative treatment should be always the first option.
Surgical treatment should be considered as the last option, as a
small percentage of cases are candidates for this . The choice
for the most invasive procedures should be left to cases of failure
in results. It is important mentioning the individuality of each
case and the patient´s close participation in adhering to the treatment
imposed by the multidisciplinary team. Recently, there has
been a great evolution in results, especially if we consider multidisciplinarity.
Procedures such as occlusal adjustment, orthodontics,
electrotherapy, botulinum toxin, laser therapy, pharmacological
treatment, acupuncture, cryotherapy, heat therapy, muscle
relaxant drugs, chiropractic, psychological treatment must be
taken in account . The TMJ surgical procedure is indicated in
specific cases, such as ankylosis, fractures and certain congenital
or developmental disorders. According to Badim et al (2002), the
problem is installed in the interarticular disc, which, for some reason,
is displaced, causing the clinical picture already mentioned. In
these cases, the surgery is limited to removing the articular disc,
carefully preserving branches of the facial nerve through its identification
aided by a nerve stimulator.8 Damaged structures in the
TMJ have a limited capacity for regeneration, as is the case with
articular disc cartilage. Stem cell research has shown very promising
results in this area with the development of chondrogenic
Costen’s Syndrome has a high prevalence; epidemiological research
has shown that more than 50% of the population has at
least one or more signs of TMD. Due to its wide range of factors,
it has not yet been possible to establish a standardized diagnosis
. The symptoms of Costen’s syndrome go beyond a structural
relationship, as it encompasses knowledge from more than
one specialty in the health field, thus making diagnosis and treatment
with only one professional difficult. According to studies by
Costen, temporomandibular disorders (TMD) are completely related
to disocclusion, being associated with the loss of the vertical
dimension of occlusion . Over time and new studies, it was
found that the etiology of TMD is multifactorial, and may cover
several factors, such as structural, muscular, or neural origin. The
existence of a great diversity of treatments imposes the need for
patient exposure on the possibilities of success, as well as the advantages
and disadvantages of each method Due to this variability
in methods, it is emphasized that each procedure should have its
own indication, based on well-defined criteria as well as patient
As we can see, after decades of the studies initiated by Costen,
some etiological factors of TMD remain unclear, requiring further
studies. The integration of a multidisciplinary team is essential
to confirm the hypotheses raised so far and thus provide quality
of life to the patient. With this work we intend to demonstrate
that the isolated study of each case, the indication of the correct
therapy and the patient’s collaboration are of fundamental
importance for the success of the treatment. Fortunately, we
have a very wide range of techniques and equipment at hand that
can bring relief from symptoms as well as restore TMJ function.
The treatment of the painful phase, with relative rest of the joint
and symptomatic medication, provides pain relief in 90% of
the proposed therapies associating the use of occlusal device,
masticatory and cervical therapy and prosthetic rehabilitation
showed significant improvements in the symptoms reported by
the patient . Surgery should be avoided in cases of bruxism
unless psychological treatment has had no effect and the patient
remains with the dysfunction . Care with facial innervation
(especially the frontal branch) is important. Neuroapraxia (or
trauma due to nerve distension) is common, and paralysis of
the homologous eyebrow may need a recovery period of up to 6
months. The use of the stimulator has been of enormous value
in the identification and preservation of the nerve . In about
85% of cases there is an emotional factor triggering the pain.
Psychobehavioral or psychosocial factors, such as anxiety, stress,
and depression, are currently considered as the main etiological
factors of TMD .
Costen JB (1936) Neuralgias and Ears Symptoms associated with disturbed function of the temporomandibular joint. J Amer Med Ass p. 55-57.
Quinto AC (1999) Classificação e Tratamento das Disfunções Temporomandibulares: Qual o papel do fonoaudiólogo no tratamento dessas disfunções? [Monografia]. São Paulo: Centro de Especialização em fonoaudiologia clínica p. 23.
Costen JB (1934) A syndrome of ear and sinos symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhinol Laryngol 43: 1-15.
Rocha APF, Nardelli MR, Rodrigues MF (2002) Epidemiologia das desordens temporomandibulares: estudo da prevalência da sintomatologia e sua inter-relação com an idade e o sexo dos pacientes. São Paulo Ver Serviço 2(1): 5-9.
Barreto DC, Barbosa AR, Frizzo ACF (2010) Relação entre disfunção temporomandibular e alterações auditivas. CECAF 12(6): 1067-1076.
Badim J, Xavier RSF (2002) Disfunção da Articulação Temporomandibular (ATM). Rev Bras Cir Plástica 17(1): 51-68.
Toledo BAS, Capote TSO, Campos JADB (2008) Associação entre disfunção temporomandibular e depressã Cienc Odontol Bras 11(4): 75-79.
Siqueira JTT, Teixeira MJ (2002) Dor orofacial: Diagnóstico, terapêutica e qualidade de vida. 2nd São Paulo: Editora Maio.
Mello MA (2005) Correlação entre Sintomas Otológicos e Disfunção Temporomandibular. [Monografia]. Florianópolis: Universidade Federal de Santa Catarina. Especialização em Disfunção Temporomandibular e Dor Orofacial p. 45.