06 Oct Temporomandibular Joint Disorders And Physical Therapy Treatment
Have you ever experienced pain in or around your jaw from chewing, yawning, or even with simple mouth opening movements? Do you experience a clicking sensation when you open and close your mouth, or that you are unable to open your mouth as far as usual? If you experience any of the following signs or symptoms, you may be dealing with what is known as a temporomandibular disorder (TMD). Breaking down this term into multiple parts to understand its origin, “temporo” is derived from the term “temporal”, which is a bone on the outside portion of the skull, and the term “mandibular” is your jaw bone. These two bones meet and make up the temporomandibular joint (TMJ). When you think of a clinical condition related to the jaw and/or jaw pain, who is the first healthcare provider that comes to your mind who would manage that condition? Maybe a dentist or an orthodontist, right? In actuality, physical therapists have joined healthcare providers at the forefront of TMD treatment! In this article, you will learn all about temporomandibular joint disorders and physical therapy treatment as we discuss physical therapy as a first-line approach for TMD. We review how to optimally evaluate and treat this condition with our scope of practice or refer accordingly to the appropriate healthcare provider.
WHAT IS THE TEMPOROMANDIBULAR JOINT?
The temporomandibular joint is the most used joint in the body during daily function. Any time an individual is speaking, swallowing, or chewing, this joint is being used. On average, the temporomandibular joint is used up to 2000 times per day (1)! To give a brief anatomical overview, the TMJ is a diarthrodial joint that connects the temporal bone with the mandibular bone, with a fibrocartilaginous disk in-between these structures, as well as other attaching ligaments and enclosed joint capsules. You can feel this joint if you place one of your fingers just in front of your ear, and opening and closing your mouth repeatedly. It indeed is a synovial joint and is considered an extension of the spinal column due to its connection with the cervical spine (neck) via the skull.
TEMPOROMANDIBULAR JOINT SPECIAL FEATURES
Because the TMJ and the disk are both covered with fibrocartilage, both structures contain excellent reparative properties to the wear and tear that this joint undergoes on a daily basis. Naturally, this makes sense! We are constantly moving our mouths, so the joint needs to be surrounded by strong connective tissue! The second key feature of this joint is the disk, which separates this joint into superior and inferior cavities. As a result, various joint motions will occur in each of these cavities, which have to work in unison with one another for optimal, oral functioning.
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Temporomandibular Joint Disorders: MUSCLES OF MASTICATION
There are 4 muscles of mastication present in the human body, each of which assists in grinding, chewing, and tearing food to prepare it properly for swallowing and digestion. These 4 muscles are the masseter, temporalis, lateral pterygoid, and medial pterygoid. Due to the scope of this article, we will not discuss each muscle action in detail; however, it is important to note that overuse of these muscles, altered movement coordination or direct/indirect macrotrauma may lead to TMD issues such as myofascial pain disorder, masticatory muscle disorder, or myositis (1).
TEMPOROMANDIBULAR JOINT NORMAL KINEMATICS
The main function of the TMJ is to open and close the mouth as well as grind and tear food. The osteokinematics (mechanics of joint movement) of this joint include depression (mouth opening), elevation (mouth closing), protrusion (moving the jaw forward), retrusion (moving the jaw backward), and lateral excursion (moving the jaw to one side). As discussed above, there are 2 separate cavities present in the TMJ. What happens when an individual opens his or her mouth is rotation of mandibular bone posteriorly (backward) in the inferior cavity during the initial phase of mouth opening, followed by anterior translation (sliding forward) of the temporal bone in the superior cavity during the latter phase of mouth opening.
What can happen when an individual has an insult to the TMJ, such as chronic overuse, trauma, or other disease process, the normal kinematics of this joint may become altered (pathokinetmatics). As a result, specific types of Temporomandibular Disorders known as disc displacements with or without reduction may occur, which will be discussed later on (1-3).
WHAT IS TEMPOROMANDIBULAR JOINT DISORDERS (TMD)?
Similar to a term such as runner’s knee, for example, the term temporomandibular joint disorder (TMD) is an umbrella term, meaning there can be multiple causes of this condition. TMD was originally treated by dentists with interventions such as bracing, splints, or medications; however, since about the 1970s, physical therapists have become more prominent healthcare providers to assist in the evaluation, diagnosis, and management of this condition. Because this is a niche population as well as a unique joint, research is limited in this field, yet there is a collection of low to moderate evidence in relation to physical therapy treatment of the TMJ. Furthermore, while up to 25% of individuals may experience TMD in their lifetime, only 3-5% of individuals will seek medical treatment based on previous studies (1). Although the TMJ has some unique features, it is like any other synovial joint, which physical therapists are more than capable of treating due to their strong background in anatomy, biomechanics, and pathophysiology! Below are some of the most common causes and symptoms related to TMD (1-4).
- Repetitive overuse
- Degenerative changes in the joint
- Chronic stress
- Parafunctional habits of clenching, grinding, or bruxism
- Cervical Spine involvement
- Limited mouth opening
- Joint noises
- Neck discomfort/pain
- Difficulty swallowing
The biopsychosocial model is imperative when evaluating and treating patients for any healthcare practitioner. In addition to movement impairments or pure musculoskeletal contributions to clinical symptoms, psychological and social aspects can play a large role in an individual’s clinical presentation. Specifically, issues such as chronic stress as well as poor sleep quality has been related to various etiologies of pain. Listen to our [P]Rehab Audio Experience Episode with Dr. Nick Lambe to learn more about how you can improve your sleep health!
TEMPOROMANDIBULAR JOINT DISORDERS: ETIOLOGIES
When physical therapists are evaluating and deciphering treatment options for this condition, TMD is broken down into separate etiologies that include (1-5):
- Myogenic: This is related to symptoms originating from the muscles around the TMJ. It usually is associated with stress, anxiety, clenching, or bruxism. This is often bilateral (on both sides) if this is the primary disorder.
- Arthrogenic: This is related to symptoms originating fro the joint itself. Examples include joint arthritis, hypo/hypermobility, or joint pain with movements of the jaw.
- Disc Displacement with reduction: This occurs when the disc inside of the joint will abnormally move out of the space causing a ‘click’ sensation upon opening and closing the mouth.
- Disc Displacement without reduction: This occurs when there is a block in opening and leads to restrictions in the ability to open the mouth, which someone may refer to as their jaw ‘locking’.
- Cervical spine involvement: This generally occurs in all patients with TMD. Specifically, patients will experience upper cervical spine pain due to its close association with the TMJ in addition to head pain.
TREATMENT FOR TEMPOROMANDIBULAR JOINT DISORDERS
Currently, there is a variety of treatment options for temporomandibular joint disorders, but the literature is sparse, and no single treatment appears to be superior to another. Interdisciplinary care is essential for this condition as it is for other clinical pathologies as well. Meaning, more than one healthcare provider is often involved in the management of TMD, including physical therapists, dentists, primary care physicians, psychologists, and oral surgeons. More importantly, with advances in research over the years, there has been a paradigm shift in evidence-based interventions for TMD. In previous years, management was focused on bracing, surgery, and other biomedical models, whereas more recently, the biopsychosocial model has taken higher precedence (4). This includes treatment strategies such as physical exercises, psychological treatment such as managing stress, and pain neuroscience education. The communication between each healthcare provider is of the utmost importance to ensure optimal treatment is given to each individual. Next we will discuss evidence-based treatment options for TMD.
TMD Treatment: Rocabado’s 6×6
Temporomandibular joint disorders have been extensively studied by Dr. Mariano Rocabado, who created a well known 6×6 exercise program, which translates to 6 exercises, 6 repetitions per exercise, performed 6 times a day. A study from the International Journal of Physiotherapy in 2015 by Mulla et. al demonstrated that Rocabado’s technique was found to have statistically and clinically significant added effect with conventional TMJ exercises and showed a greater percentage of improvements in reducing TMJ dysfunction symptoms, pain, jaw, functional limitation, and increased TMJ ROM when compared with only TMJ exercises in subjects with TMD (5). Below we will show you each exercise with explanations of how to perform them!
Jaw Pain Exercises: Resting Position of the TMJ
If someone is dealing with difficulties with controlling how they open and/or close their mouth, jaw positioning exercises are a great starting point. Particularly this is great for patients with disc displacement issues, motor control or movement coordination issues, or stress in relation to abnormal jaw movements. An excellent cue we utilize to help patients perform the “resting position” of the joint is saying the letter “N”. By placing your tongue on the roof of your mouth and maintaining this position, this will help the jaw not only relax (you should feel your lips touching, but not your teeth!) but will also assist in keeping the TMJ in optimal alignment. This is an excellent exercise to practice before moving on to controlled opening. Work on breathing in and out of your nose with good posture as you perform this exercise.
Jaw Pain Exercises: Controlled Opening
This exercise is intended to reduce the amount of excessive translatory motion of the jaw as well as reduce the masticator muscle activity and joint overload.
To perform this exercise, place the anterior one-third of your tongue against the roof of your mouth with very slight pressure as if you were trying to make a “cluck” sound with the tongue and monitor your TMJ by placing both index fingers over each joint. Next, open and close your mouth until you feel the joint condyle (balls of the joint) move forward against your fingers. Do not leave your tongue from the palate. Perform the action of opening within this shortened range.
Jaw Pain Exercises: TMJ Stabilization Isometrics
This is an excellent exercise to work on the stability and control of the TMJ. Start by placing your two thumbs just underneath your chin, and gently resist the upward motion of your thumbs by using the muscles of mastication that help open your mouth. Hold this contraction for 5-10 seconds, and repeat as prescribed. You also can then place one hand on the side of your cheek and jaw bone area, and gently apply resistance against your jaw. Again, you will be countering that force with an isometric contraction of the muscles of mastication that help laterally deviate your jaw.
Jaw Pain Exercises: Shoulder Posture Correction
- HOW: Position yourself sitting tall with your hands supported on your thighs. Squeeze your shoulder blades back together, think about pinching a pencil between your shoulder blades, relax and repeat.
- FEEL: You should feel the muscles in between your shoulder blades getting a workout. You may also feel a stretch in your chest and the front of your shoulders.
- COMPENSATION: Do not shrug your shoulders, do not arch your low back excessively.
Jaw Pain Exercises: Chin Tuck
Begin by lying face up then perform a chin tuck. The chin tuck is created by pushing the small of your neck in towards the floor. Think about creating a double chin to perform a chin tuck. Pushing your tongue on the roof your mouth may make it easier for you to activate the neck muscles.
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Jaw Pain Exercises: Stabilized Upper Cervical Flexion
This exercise works on flexing the upper cervical spine. To perform this exercise, place your hands behind your head, just below your skull on your neck. Once in that position, tuck your chin gently and nod your head down slightly. What this does is it flexes the upper cervical spine. Hold for 5-10 seconds, then relax and repeat. You should feel slight pressure into your hands when you tuck your chin, and the muscles in the front of your neck working.
Temporomandibular Joint Disorders: CERVICOTHORACIC SPINE
The correlation between neck pain and TMD has been widely researched. There are a variety of theories as to why these two body regions may be involved with one another, potentially causing dysfunction. Particularly, it has been suggested that alterations in posture of the head and neck may predispose individuals to painful conditions such as TMD by varying the biomechanics and muscular balance of the craniocervical region. Moreover, one of the most common postural dysfunctions of the head and neck region known as “forward head posture” has been related to an increased load placed on the cervical spine, in addition to increased tissue tension of the cervical spine musculature (6). In a cross sectional study by Aloosi et al results demonstrated that roughly 89% of the patients from the sample who presented with TMD symptoms had neck pain concomitantly (7). Moreover, those patients also had a significant improvement in neck pain.
Physical therapy is an excellent way to combat neck symptoms that may be contributing to jaw pain. Particularly, the upper cervical spine is a common culprit that can be often correlated with TMD. Evidence based interventions for the cervical spine include deep neck flexor endurance training with a hallmark exercise being chin tucks with progressions, joint mobilizations of the cervical and thoracic spine, self-mobilization exercises, and postural awareness exercises. Below are some examples of some interventions that you can perform to address each of these potential underlying movement impairments.
Cervicothoracic Exercises: Prone Thoracic Extension
Cervicothoracic Exercises: Thread the Needle
Cervicothoracic Exercises: SNAG
TMD TREATMENT: STRESS MANAGEMENT AND PAIN NEUROSCIENCE EDUCATION
As TMD can often be secondary to stress, chronic pain, and other confounding factors, it is important to also address the psychological aspect of care. Stress can play a large role in someone’s life, which can heavily contribute to pain and discomfort as well. Stress management techniques such as relaxation, deep breathing, and meditation can help combat this negative part of an individual’s life.
Moreover, a continual up and coming topic within the field of physical therapy as well as surrounding all of healthcare is pain neuroscience education. Individuals with TMD often may have this disorder for a long period of time, leading to a cascade of chronic pain, central sensitization, hyperalgesia, and so forth. By implementing education as a key component of care for these patients, it can be extremely beneficial in the management of symptoms. To learn more about pain neuroscience education, read our blog post below!
READ: THE SCIENCE OF PAIN
Temporomandibular Joint Disorders: When To Refer As Physical Therapists
As with any evaluation that a physical therapist performs, following the Guide to Physical Therapist Practice is of utmost importance. Specifically within the guide, as primary care providers, it is our job to understand if a patient is appropriate for treatment or requires further consultation. With TMD, there are situations when a patient may need to be referred to a dentist, medical physician, maxillofacial surgeon, or psychologist. Some common examples include bite changes, marked occlusal changes, underlying systemic disease, or jaw trauma. Having an interdisciplinary team is optimal to ensure that a patient not only receives a proper evaluation but also is directed towards the most appropriate healthcare professional to manage his or her condition appropriately.
As you have read throughout this article, there are many different reasons why someone may experience jaw pain and other head/neck associated symptoms, including bad habits of chewing/bruxism, cervical spine impairments, chronic stress, chronic pain, poor movement coordination, or even overuse. This article serves as a guide to educate you on what the TMJ is, how TMD may occur, and what YOU can do in order to promote positive outcomes! If this has become a chronic, recurrent issue for you that you are having trouble managing independently, be sure to seek consultation with a healthcare provider who can give you a proper examination, evaluation, and treatment plan that is most suited to your needs!
- Murphy, M. K., Macbarb, R. F., Wong, M. E., & Athanasiou, K. A. (2013). Temporomandibular Disorders: A Review of Etiology, Clinical Management, and Tissue Engineering Strategies. The International Journal of Oral & Maxillofacial Implants, 28(6). doi:10.11607/jomi.te20
- Sharma, S., Pal, U., Gupta, D., & Jurel, S. (2011). Etiological factors of temporomandibular joint disorders. National Journal of Maxillofacial Surgery, 2(2), 116. doi:10.4103/0975-5950.94463
- Shaffer, S. M., Brismée, J., Sizer, P. S., & Courtney, C. A. (2014). Temporomandibular disorders. Part 1: Anatomy and examination/diagnosis. Journal of Manual & Manipulative Therapy, 22(1), 2-12. doi:10.1179/2042618613y.0000000060
- Gil-Martinez, A., Paris-Alemany, A., López-De-Uralde-Villanueva, I., & Touche, R. L. (2018). Management of pain in patients with temporomandibular disorder (TMD): Challenges and solutions. Journal of Pain Research, Volume 11, 571-587. doi:10.2147/jpr.s127950
- Mulla, N. S., Babu, K. V., Kumar, N. S., & Rizvi, S. R. (2015). Effectiveness of Rocabado’s Technique for Subjects with Temporomandibular Joint Dysfunction – A Single Blind Study. International Journal of Physiotherapy, 2(1), 365. doi:10.15621/ijphy/2015/v2i1/60050
- Silveira, A., Gadotti, I. C., Armijo-Olivo, S., Biasotto-Gonzalez, D. A., & Magee, D. (2015). Jaw Dysfunction Is Associated with Neck Disability and Muscle Tenderness in Subjects with and without Chronic Temporomandibular Disorders. BioMed Research International, 2015, 1-7. doi:10.1155/2015/512792
- Aloosi, S. N., Mohammad, S. M., Qaradakhy, T. A., & Hasa, S. O. (2016). Contribution of Cervical Spine in Temporomandibular Joint Disorders: A Cross-Sectional Study. JBR Journal of Interdisciplinary Medicine and Dental Science, 04(05). doi:10.4172/2376-032x.1000204
About The Author
Sherif Elnaggar, PT, DPT, OCS
[P]Rehab Head of Content
Sherif graduated from Temple University with a Bachelor’s of Science Degree and a concentration in Kinesiology. He then received his Doctorate of Physical Therapy Degree from DeSales University, graduating with honors of the professional excellence award and research excellence award. After his graduate studies, he served as Chief Resident of the St. Luke’s Orthopedic Physical Therapy Residency Program. Sherif is a Board Certified Orthopedic Clinical Specialist. Sherif focuses on understanding how movement impairments are affecting function while also promoting lifestyle changes in order to prevent recurrences of injury. His early treatment interests include running related injuries, adolescent sports rehab, and ACL rehab in lower extremity athletes. He also has been involved in performance training for youth soccer players. Outside of working as a physical therapist, he enjoys traveling, running and cycling, following Philadelphia sports teams, and spending time with his family.