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given by the physician when spray and stretch therapy is ineec-
https://t.me/med1917
tive. Local anesthetic, with or without corticosteroids, is used. A
series of 2 to 6 injections is usually required before discomfort
is relieved.
Because of its many causes and symptoms, the most ef-
fective treatment approach for MPDS is multidisciplinary.
149
Patient education and cognitive behavior therapy are key con-
30
tributing factors for a positive treatment outcome.
conditioning
is also recommended for stress reduction.
Aerobic re-
Trismus
When a patient demonstrates limited mouth opening (<
25 mm) and complains of pain in the masseter muscle area,
it is called myospasm or trismus. e cause of trismus is often
the result of trauma (eg, dental procedure, accident, or a stressful event). Patients seeking physical therapy should rst be instructed about the cause and prognosis of the condition to ease
their anxiety. Relaxation through imagery and diaphragmatic
breathing is the next step. Active opening with the application
of a heat pack is often benecial. e physical therapist may
also apply modalities such as ultrasound or TENS to relieve
acute spasms. Soft tissue mobilization, trigger point release,
spray-stretch with Ethyl-Chloride, and passive stretching may
be added to further relieve symptoms. Resisted mouth opening
by hand under chin for a 10-second hold before relaxing is also
benecial in decreasing the spasm of the masseter muscle. e
patient should be advised to stay on a soft diet to avoid excessive
contractions of the muscle for 1-2 weeks. Two to 4 sessions of
physical therapy within 1-2 weeks are recommended to ensure
optimal recovery.
Postoperative
After arthrocentesis, arthroscopic surgery, or orthognathic
surgery, the patient will require postoperative physical therapy
management to relieve symptoms, increase mouth opening, and
improve oral functions. Ice, ultrasound, LLL, or electrical stimulation may be applied to the aected area followed by manual
lymphatic drainage, soft tissue release, and gentle joint mobilization. A graded jaw-opening exercise program can be achieved
by active eorts assisted with stacks of tongue depressors, or
patient’s self-stretch with the thumb on upper teeth and index
150
nger on lower teeth, or the use of a therabite
(mechanical
device facilitating mouth opening). Lateral excursion ROM exercises along a stack of tongue depressors can be used as part of a
home exercise program to improve the amount of mouth opening. In addition to regaining ROM, attention must be given to
the normal kinematics of the TMJ during opening and closing
of the mouth.
151
Oh et al
studied the eects of postoperative physical
therapy and followed all patients for 7 months. ey concluded
that physical therapy had a positive eect in relieving pain and
152
restoring TMJ function after surgery. Abboud et al
reported
that immediate physical therapy, which consisted of perform-
ing full ROM exercises post-TMJ arthroscopy, resulted in better pain and mouth opening outcomes, than did a gradual and
153
controlled ROM program. De Meurechy et al
conducted a
systematic review to study the results of postoperative physical
therapy after open surgery for TMJ. ey concluded that physical therapy played an important role in achieving good postoperative results (eg, maximal mouth opening and pain score).
Ear Symptoms
e interrelationships between the TMJ, cervical spine,
and ear were discussed in the pathology section. Ear symptoms
such as tinnitus, stuness, and earache can be relieved by treatment to the TMJ and cervical spine area. Addressing the TMJ
and upper cervical spine with manual therapy techniques is especially important due to the connection of the C1, C2, and
81
C3 cervical nerves to the trigeminocervical nucleus. Jaber et al
retrospectively studied 123 patients with ear pain and reported
that a major etiologic source of ear pain was TMD and cervical spine degeneration (OA). ey recommended addressing
impairments of the cervical spine with physical therapy interventions as an eective treatment strategy for non-otogenic ear
pain.
154
Michiels et al
reported that cervical spine mobilization,
stretching of suboccipital muscles, postural exercises, deep neck
exor muscle training, self-mobilization, and home exercises
were eective physical therapy interventions in patients with
155
cervicogenic somatic tinnitus. Michiels et al
conducted a systematic review in 2016 on the eects of physical therapy treatment in patients with subjective tinnitus. ey found that positive treatment eects were reported with either cervical spine or
99
TMJ treatment. Michiels and another group of her colleagues
further recommended that the best available TMJ treatment
(including education, relaxation, stretching, and home exercises) was necessary for gaining maximal improvement in tinnitus
complaints.
156
Van der Wal et al
published the results of their RCT
on the eects of orofacial treatment for TMJ-related tinnitus.
e orofacial treatment consisted of routine physical therapy
interventions for the TMJ and neck, and occlusal splint if indicated. ey concluded that a non-invasive orofacial treatment
approach was eective in reducing tinnitus severity in TMJ related somatosensory tinnitus.
Headaches
Head and facial pain may be caused by TMD or cervical
spine dysfunction. Tension headaches and cervicogenic headaches can be controlled by physical therapy interventions to
65,157
the cervical and TMJ area.
e combination of education,
electrophysical agents, massage, manual therapy, and exercise
programs are eective in relieving the symptoms of headaches.
Although a migraine headache is vascular in origin, there
158
is always a tension component. Franco et al
believed that mi-
graine was the most prevalent primary headache in individuals
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37
with TMD. Researchers have documented that the prevalence
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of TMD in migraine suerers ranged from 53% to 87%, and
was up to 91% in chronic cases.
62,63
Florencio et al
159
conducted
a cross-sectional study and reported that the severity of TMD
symptoms was greater in women with chronic migraine than in
those with episodic migraine. Management of TMJ and cervical
spine for relieving symptoms often can decrease the intensity
and frequency of a migraine headache. Garrigos-Pedro et al
160
used a randomized, single-blinded, clinical trial to study the
eects of a physical therapy protocol in patients with chronic
migraine and TMD. ey concluded that the combination of
cervical and orofacial treatment was more eective than cervical
treatment alone in improving PPT in the trigeminal region and
improving pain-free maximal mouth opening.
161
Hara et al
reported a signicant decrease in the intensity and frequency of headaches by using TMD management
for their patients. is outcome may have been related to the
improvement in facial pain intensity, maximal mouth opening,
and PPT. e association between headache intensity and facial
pain intensity provided guidance for headache management.
Acupressure over the frontal, temporal, zygomatic, and occipital areas, and medial orbital grooves, as well as the HoKu
point (web space between thumb and index nger), can often
relieve headaches. e 6x6 time contingent cervical spine and
TMJ exercise program is benecial in correcting and preventing
muscular tension. General relaxation, cognitive behavior therapy, and aerobic reconditioning are also vital components in
managing chronic headaches.
Vertigo/Dizziness
e mechanism between TMD and vertigo/dizziness was
discussed in the pathology section. Treatment for the TMJ always includes management of the cervical spine. When TMJ
and cervical spine symptoms are improved, the co-morbidity of
vertigo/dizziness may be decreased. Vestibular rehabilitation is
also benecial in managing these associated symptoms.
104
Chronic Pain
Research studies have reported that patients with TMD
also demonstrated an increase in psychological comorbidities
such as anxiety, depression, fear avoidance behavior, sleep dysfunction, and catastrophizing. If the psychological aspect is ignored, a chronic pain condition may develop. Persistent pain
longer than 6 months is dened as chronic pain by the IASP.
In these cases, a team approach is indicated. e more complex the case (multiple diagnoses, chronicity, emotional factors,
and frequent use of medication or health care personnel), the
60
greater the need for team management.
Physical therapists
are in a unique position to recognize the need for chronic pain
management in a timely manner, and initiate an appropriate
treatment course and referral. Education about the concepts
of chronic pain and the theory of central sensitization can enhance the patient’s understanding and improve adherence to the
management program. Other self-help tools such as postural
corrections, body mechanics instructions, daily home exercises,
etc can empower the patient in gaining a positive outcome. In
addition to routine physical therapy interventions, progressive
relaxation practices, and aerobic reconditioning are vital elements that should be included in the program. Special training
in managing patients with chronic pain will also improve the
physical therapist’s eectiveness in this arena.
Arthritides
Pain, limited mouth opening, and crepitus joint noises are
some of the clinical signs of arthritis of the TMJ. Physical therapy programs may include electrophysical agents to relieve symptoms, mobilization techniques and exercises to improve joint
mobility, and education for joint protection.
MEDICAL MANAGEMENT
Pharmacology
For moderate pain relief of TMD, the rst choice is acetaminophen (Tylenol, average daily dosage of 325-1000 mg).
Nonsteroidal anti-inammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil) are used for reducing inammation and
muscle pain on a short-term basis. If a therapeutic eect is not
noted within 7 to 10 days, or if the patient develops gastrointestinal symptoms, the medication should be discontinued, and
a medical consult recommended. One of the most frequently
used NSAIDs is sodium diclofenac (Voltaren, 50 mg, 2-3 times
a day), which has been proven to reduce joint pain. Another
one is naproxen sodium (Naproxen, Naprosyn, or Aleve, 500
mg twice a day), which can also reduce joint pain and improve
clinical signs and symptoms of TMD.
Muscle relaxants such as Soma (carisoprodol), Robaxin
(methocarbamol), Flexeril (cyclobenzaprine), Valium (diazepam), and Baclofen (lioresal), can be used to relieve muscle
spasm and reduce pain. Tricyclic antidepressants, such as Elavil
(amitriptyline) and Pamelor (nortriptyline), can be used on a
longer-term basis for patients with sleep disturbance and chronic pain. Opioids, such as Ultram (tramadol), have been shown
to be eective for chronic pain conditions. However, the epidemic opioid crisis in recent years has alerted the medical professions to avoid prescribing such medication.
All medications should be used with caution because of
potential side eects. ese include gastrointestinal complications, hypertension, chemical dependency, rebound pain, pain
behavior reinforcement, and inhibition of the endogenous pain
control mechanism.
60,162
A dierent and safer pharmacological approach to relieve
TMJ pain is the use of topical agents. Topical diclofenac, used 4
times a day, has demonstrated its eectiveness in reducing TMJ
pain. For TMD related myofascial pain, there are many over the
counter topical creams that can be used to relieve skin sensitivity and muscle spasm (eg, capsaicin cream, Salonpas, Icy Hot,
Tiger Balm, Biofreeze, and even cannabidiol [CBD] cream, if
5,14
38
Academy of Orthopaedic Physical erapy, APTA.
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permitted). However, the study conducted by Winocur et al
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163
reported no signicant eects of capsaicin in relieving symptoms of TMD and there is no good evidence that any of these
products are benecial in relieving pain symptoms of TMD.
Potential allergic reactions need to be taken into consideration
when applying any cream to the facial area.
Trigger Point Injection
e use of injection of local anesthetics (1% procaine with-
out epinephrine) to the trigger point was introduced by Travell
61
and Simons.
is method has been used by many physicians
and dentists to relieve spasm and pain caused by the myofascial
structures.
Corticosteroid Injection
Intramuscular injection of corticosteroids (with anti-inammatory action) for myositis and other inammatory disorders has been used to provide relief, especially when NSAIDs
15
are not tolerated by the patient.
Hyaluronic Acid Injection
Hyaluronic acid (HA) injections have been widely used
in the treatment of TMD, by either joint injection or in combination with arthrocentesis and arthroscopic procedures. A
164
Cochrane review was conducted by Shi et al
to assess the
eectiveness of intra-articular injection of hyaluronate for the
management of TMD. e result was in favor of HA injection
for symptom relief and clinical improvement. When comparing
the eects of arthroscopy and arthrocentesis with and without
hyaluronate, the results were inconsistent. Compared to a platelet-rich plasma (PRP) procedure, HA is more readily available
165
and does not require invasive preparations.
Platelet-Rich Plasma
e usage of PRP in the orthopaedic eld for regenerative
therapy, anti-inammatory, analgesic, and antibacterial properties has gained positive attention in recent years. Hegab et al
166
reported that PRP injection was an eective treatment for OA
167
of the TMJ. Pihut et al
also reported that intra-articular injec-
tion of PRP for patients with severe TMJ pain was a valid pro-
19
cedure. Crockett et al
presented a case report that showed successful results of PRP when physical therapy management was
not able to stabilize a patient’s symptoms related to ADDwR.
Botulinum Toxin A Injection
Botulinum toxin A injection has been used in managing
TMD for pain relief or prevention of recurrent dislocations. It
can be used for trismus, masseter or temporalis muscle hyper-
168
trophy, and headaches and neck pain. Ziegler et al
reported
positive eects of botulinum injection into the lateral pterygoid
muscle for recurrent TMJ dislocations. However, a RCT con-
169
ducted by Nixdorf et al
for the management of chronic TMJ pain. Gerwin et al,
did not support the use of botulinum
170
after
a literature review, also concluded that there is insucient evidence to support the eects of botulinum on myofascial pain.
Acupuncture
Acupuncture has long been used for pain management
even though the actual mechanism of action is still unclear.
171
Wong and Cheng
reported that the combination of splint
therapy, trigger point injection, and acupuncture was benecial
172
in managing TMD. In 2011, Bu et al
investigated 96 patients
with TMD using electroacupuncture pulse stimulation and
massage therapy. ey concluded that the therapeutic eect of
massage therapy combined with electroacupuncture was better
173
than electroacupuncture pulse stimulation alone. Jung et al
conducted a systemic review and meta-analysis of randomized
sham-controlled trials. From the 7 RCTs that met their inclusion criteria, they concluded that the evidence of acupuncture
as a value treatment for TMD was limited and needed to be fur-
174
ther studied with better research designs. Itoh et al
conducted
an RCT and reported that trigger point acupuncture might be
more eective for chronic TMJ pain management than sham
acupuncture.
175
Fernandes et al
conducted a systematic review to study
the eects of acupuncture in the management of TMJ myofascial pain. Despite the weak scientic evidence, they suggested
that acupuncture might be able to relieve signs and symptoms
of myofascial pain in TMD. Some researchers believed that acupuncture was more eective when the needles were applied to
the local orofacial points, rather than to the peripheral or distal
points. Some researchers also proved that the supercial application of a needle into the skin released hypoalgesics, such as
serotonin and opioids, suggesting why acupuncture works.
Obstructive Sleep Apnea and Airway Screenings
Obstructive sleep apnea (OSA) is a breathing disorder
characterized by repetitive pauses of breathing during sleep due
to a blockage in the airway. is blockage can be caused by
improper development or malfunction of the throat muscles,
the tongue, tonsils, the TMJ, or the soft palate. During sleep,
the air that manages to squeeze through the blockage can create a loud snorting (snoring). is condition is often seen in
people who are overweight or obese, or sometimes, who have
TMD. Restorative sleep is important for pain control, healing,
relaxation, and optimal function. Patients with TMD who also
experience sleep disturbance should be referred for a sleep study.
A sleep study can accurately diagnose OSA. In mild cases, the
use of a specially designed dental appliance (for mandibular advancement) can control the symptoms. In other cases, the use of
a continuous positive airway pressure (CPAP) or bilevel positive
airway pressure (BiPAP) machine may be indicated. Surgery to
correct a deviated septum of the nose is another way to correct
some cases of sleep apnea or snoring.
In addition to sleep specialists (physicians; ear, nose, &
throat [ENT] specialist; doctor of dental surgery [DDS]), my-
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39
ofunctional therapists are trained in addressing mouth, jaw,
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tongue, throat, swallowing, speech, sleep hygiene, etc. A team
approach is recommended for patients who present with OSA
along with TMD.
DENTAL MANAGEMENT
Occlusal Adjustment
Occlusal adjustment involves adjusting the biting surfaces of teeth by grinding the enamel (outer layer of the teeth).
Occlusal adjustment is an irreversible approach that is aimed
at achieving a more equilibrated state for teeth contact and
comfort. It has been used for treatment of TMD; however, its
ecacy has not been proven by any well-designed research. e
Cochrane review conducted by Koh and Robinson
no evidence to show that occlusal adjustment can prevent or
relieve TMDs. erefore, it is not recommended as the rst line
of management of TMD.
106,176,177
Splint Therapy
Acrylic resin interocclusal appliances (splints) have long
been used in dentistry for the treatment of TMD. e intended
purposes of the splints are relaxing masticatory muscle spasm,
altering clenching behavior, reducing bruxing, redistributing
occlusal forces, preventing wear of enamel, and repositioning
178,179
the condyle.
ere are 2 schools of thought in splint therapy: the stabilization theory (eg, Michigan type splint) and the
repositioning theory (eg, Farar type splint, Gelb type splint).
e stabilization splint is a full-arch maxillary or mandibular
at plane hard acrylic resin appliance with anterior guidance
60,180
(lateral and protrusive).
e stabilization splint attempts to
keep the mandible in the centric occlusion position to relax the
masticatory muscles that in turn stabilizes the condyle-disk-fossa relationship. is type of splint is worn at night and as much
as possible during the day (except when eating), if tolerated
by the patient. Repeated adjustment is indicated until a stable
mandibular position is attained. e repositioning splint is a
full arch mandibular acrylic resin appliance. e repositioning
splint aims at maintaining the condyle in a forward position
(approximately 1 to 3 mm) from centric occlusion. It is worn
180
at all times including when eating.
e theory is for the repositioning splint to maintain the mandible in a temporary therapeutic position, and in the case of an ADDwR, the click is
eliminated and therefore allows the disk to reposition.
type of splint should be worn on a 24-hour-a-day basis for 3
months, and then, its use gradually can be reduced as symptoms
improve.
ere are 2 kinds of acrylic appliances: hard and soft. Disagreement exists regarding the use of splints and the benets of
the 2 dierent types of splints. Pettengill et al
soft and hard stabilizing appliances may be equally useful in
reducing masticatory muscle pain in the short-term. e only
dierence is that some researchers believe soft appliances are
less expensive and easier to fabricate than hard appliances.
176,177
found
181
178
suggested that
is
178
e current general consensus among dentists is that the choice
of splint therapy is based on the educational background and
clinical experience of the clinician. e type of splint choice also
will be based on the outcome desired.
Splint therapy requires continual adjustment, especially
while a patient is receiving physical therapy because of the alteration of balance in the masticatory system. For myogenous
TMD, patients are advised to wear the splint only at night as
it is mainly during the rapid eye movement cycle that patients
appear to clench or grind their teeth. e splint needs to be
adjusted periodically because of the surface wear caused by the
grinding behavior. As the masticatory muscles reach a more relaxed stage and the mandible stays in a more balanced position,
the use of the splint can then progressively be reduced. It usually
182
takes 2 to 3 months for successful splint therapy.
A resting
splint can be used permanently.
180
Clark et al
reported that a stabilization splint and physical therapy provided eective management for most patients
with painful muscles and TMD. Less improvement was noted
in reducing joint noises with the repositioning splint. Turp et
183
conducted a qualitative systematic review and reported that
al
a stabilization splint (a full-coverage hard acrylic occlusal appliance) was benecial in decreasing symptoms in most patients
with masticatory muscle pain. However, a stabilization splint
did not appear to yield a better clinical outcome than a soft
splint, physical therapy, or acupuncture.
182
Al-Ani et al
conducted a Cochrane review on stabilization splint therapy for TMJ pain syndrome. ey reported that
there was insucient evidence either for or against the use of
stabilization splint therapy for the treatment of TMD when
compared to other interventions (eg, exercises, acupuncture, behavioral therapy). However, it appeared that stabilization splint
therapy might be benecial in reducing pain when compared
to no treatment. ey suggested that further, well-conducted
RCTs, with a larger sample size and longer follow-up duration,
were necessary to draw conclusions regarding the benets of stabilization splint therapy.
184
Niemela et al
conducted an RCT to assess the ecacy
of stabilization splint treatment on TMD. ey concluded that
the addition of stabilization splint did not lead to extra benets
beyond oering only counseling and masticatory muscle exercises.
185
Simmons et al
used an MRI to study the eects of anterior repositioning appliances (ARA) for the treatment of an anteriorly displaced disk. ey reported that ARA therapy provided
signicant pain relief in patients with reducing and nonreducing disks and was eective in recapturing the displaced disks
186
that reduced upon mouth opening. But, Puralasetty et al
reported that prolonged use of repositioning splints for internal disk derangement and OA could cause irreversible negative
eects on occlusion, skeletal structure, and muscle dynamics.
187
Zhang et al
cy of splint therapy for the management of TMD. ey found
used a meta-analysis to investigate the eca-
40
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that patients with maximal mouth opening less than 45 mm
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showed a signicant change with splint therapy, which did not
occur for those with maximal mouth opening more than 45
mm. e meta-analysis also showed that splint therapy reduced
clicking and the frequency of TMJ pain. ey concluded that
splint therapy was recommended for the treatment and control
of TMD.
Another kind of splint is the nociceptive trigeminal inhibition-tension suppression system (NTI-tss) splint. is is a
small pre-fabricated stop that ts between the maxillary and
mandibular incisors. It is indicated for relieving tension of the
masticatory muscles and preventing bruxism. However, adverse
eects such as aspiration, ingestion, and occlusal changes have
been documented for the NTI-tss device. Stapelmann et al
188
conducted a qualitative systematic review of 5 RCTs and reported that NTI-tss devices may be successful in managing bruxism
and TMDs. Proper selection of patients is important to avoid
unwanted adverse eects.
Orthodontic Treatment
Whether or not orthodontic treatment increases the prevalence of TMD is unclear. It has been suggested that orthodontic treatment does not increase, sometimes even reduces, the
prevalence of TMD.
189
Kim et al
190
conducted a meta-analysis
to study the relationship between orthodontic treatment and
TMD. ey concluded that traditional orthodontic treatment
did not increase the prevalence of TMD. After reviewing the literature on the relationship between occlusion and TMDs, and
191
the need for orthodontic treatment, De Boever et al
conclud-
TMD and generalized prophylactic occlusal adjustment is not
70
justied. Magnusson et al
reported a 20-year, from childhood
to adult, longitudinal investigation of TMD. ey concluded
that occlusal factors were associated only weakly with TMD
signs and symptoms, and orthodontic treatment did not imply
a risk of development of TMD later in life.
192
According to Shro,
orthodontics as a treatment for patients with TMD is not recommended. It should be avoided in
patients with severe pain until the symptoms are resolved and
then used if masticatory ecacy or aesthetic outcome is desired.
e AAOP in Orofacial Pain: Guidelines for Assessment, Diag-
nosis, and Management states that orthodontics in the normal
population “neither produces nor cures” TMD.
SURGICAL MANAGEMENT
e surgical management of TMD should be reserved for
patients whose symptoms do not improve with non-surgical
therapy.
Arthroscopic Surgery and Arthrocentesis
e surgical management of TMD was popular in the
United States from the early 1980s to the late 1990s. An arthroscopic procedure for the TMJ was developed in the late
1970s based on arthroscopic procedures for larger joints. Despite controversies, most results of arthroscopy are satisfactory
in decreasing pain and improving amount of mouth opening.
e purpose of the arthroscopic procedure is to improve the kinematics of the disk-condyle component through the release of
connective tissue adhesions and capsular brosis. Repositioning
of the disk is not always successful. In the case of disk perforation, repair is also dicult.
56
Due to the requirements for general anesthesia and expensive equipment for arthroscopic surgery, arthrocentesis and
lavage have become more popular surgical choices in the past
20 years. Arthrocentesis is dened as the lavage of the joint
193
done without viewing the joint space.
joint arthrocentesis and lavage with manipulation is minimally
Temporomandibular
invasive and cost eective. It is a simple, in-oce procedure,
with little morbidity. e success of arthrocentesis and lavage of
the upper joint space to free up adhesions and improve mouth
opening has led to questioning if disk position is the sole cause
194,195
of TMJ closed-lock.
e current consensus is that surgical
procedures should be performed only after failure of non-surgical interventions, and if the patient’s quality of life (ie, pain and
reduced oral function) is signicantly aected.
Godden et al
195
reported that only 50% of patients who
56
underwent arthroscopic surgery for TMD reported a positive
outcome, with 66% of patients still complaining of limited jaw
196
opening 6 years after surgery. Reston et al
conducted a systematic review and meta-analysis of 30 studies to compare the
outcome of arthrocentesis, arthroscopy, disk repositioning, and
diskectomy. ey concluded that surgical treatment appeared
to provide some benets to patients who were refractory to
non-surgical therapies, especially arthrocentesis and arthroscopy for patients with disk displacement with reduction. Anoth-
197
er systematic review conducted by Rigon et al
reported that
arthroscopy led to greater improvement than arthrocentesis in
maximal mouth opening after 12 months; however, there was
no dierence in pain reduction.
193
Diracoglu et al
studied arthrocentesis versus non-surgical
methods in the treatment of temporomandibular disk displacement without reduction. ey concluded that early treatment
with either non-surgical methods (splint therapy, exercises,
massage, and relaxation) or arthrocentesis was benecial for patients with ADDwoR. However, arthrocentesis seemed to be
superior for pain management. erefore, arthrocentesis may
be indicated for patients who have continued signicant pain
despite receiving prior non-surgical treatments.
198
Al-Moraissi et al
used a network meta-analysis of RCTs
to investigate the hierarchy of dierent procedures for arthrogenous TMD. ey found that minimally invasive procedures
such as arthroscopy and arthrocentesis, especially when combined with the use of PRP, HA, or corticosteroid, were signicantly more eective than non-surgical treatment (exercises and
splint therapy) for both pain reduction and mouth opening improvement. ey therefore recommended that these procedures
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41
should be considered in the early phase of TMD management
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when non-surgical approaches did not show timely benets.
165
Zotti et al
conducted a narrative review to compare the
eectiveness of arthrocentesis with PRP or PRP injection alone
versus arthrocentesis alone, arthrocentesis with HA, or HA injection alone. eir results indicated that arthrocentesis with
PRP or PRP injection alone was more eective than the other
procedures for pain relief, joint sound reduction, and mouth
opening improvement.
Orthognathic Surgery
Orthognathic surgery is used for treatment of malposition
of the bones of the jaw. Orthognathic surgery in combination
with orthodontic treatment is sometimes indicated for severe
189
malocclusions. Abrahamsson et al
conducted a systematic
review to study the eects of orthognathic surgery on TMD
symptoms. Due to methodological weaknesses of the primary studies, the authors were unable to draw a conclusion as to
whether orthognathic surgery aects the prevalence of TMD
signs and symptoms.
Open Joint Surgery
Open TMJ surgery includes arthrotomy, disk repositioning, diskectomy, modied condylotomy, disk replacement, and
TMJ prosthesis. e procedure of each approach is beyond the
194
scope of this monograph. Please refer to Dolwick et al
13
Garrigos-Pedron
for more details. Careful selection of each
patient and type of surgery is the key to a successful outcome.
and
194
PSYCHOSOCIAL MANAGEMENT
e importance of psychosocial factors in the management of TMD has been emphasized by many researchers.
Psychosocial management involves psychotherapy for problem
solving, cognitive behavioral therapy for stress management
through goal setting and behavior modication, biofeedback
for reduction of anxiety, and complementary training such as
meditation and hypnosis. Most of the time, these approaches
and their eects overlap.
201
Oakley et al
reported that cognitive behavioral therapy was benecial in helping patients who failed to respond
to non-surgical management. Cognitive behavioral therapy is
divided into cognitive restructuring and coping skills training.
e combination of cognitive skills training and biofeedback
training has been proven benecial in managing patients with
202
TMD. Suvinen et al
recommended this approach especially
for patients with a myofascial component in their clinical presentation. e rationale was that parafunctional activities and
psychosocial factors play a role in the pathogenesis of musculoskeletal pain.
Dworkin et al
203
204
reported that using the combination of
an intraoral appliance, biofeedback training, and stress management resulted in a better long-term outcome than any approach
used in isolation.
199,200
205
Wexler et al
used a validated and psychometrically developed symptom inventory, the TMJ Scale (97 items), to measure
symptom levels before and after non-surgical treatment (splint,
physical therapy, stress management, and pain management).
eir result indicated that patients with symptoms of internal
derangement presented fewer psychological symptoms initially
and demonstrated more improvement at the end of treatment
than those with predominantly muscular complaints. Suvinen
202
concluded that coping strategies and illness behavior
et al
should be taken into consideration while providing treatment
to patients with TMD. ey summarized that patients with
primarily joint involvement responded more favorably to treatment, and patients with predominantly muscular complaints
required more psychological support.
206
Dworkin et al
conducted an RCT to examine the eectiveness of cognitive behavioral therapy for patients with TMD.
After a 1-year follow-up, they found that the self-care group
with cognitive behavior training reported more improvement
than did the control group with usual treatment. e signicance was shown in some pain-related variables, such as intensity and frequency, and the ability to cope with TMD.
In individuals with acute and sub-acute TMD, biopsychosocial aspects of the condition need to be addressed, as psychological distress and pain amplication contribute to the devel-
207
opment of chronic TMD.
Yellow ags include, but are not
limited to, fear avoidance behavior, somatization, catastrophizing, anxiety, and depression. In the case of chronic pain, an interdisciplinary team approach that includes stress management,
relaxation, cognitive therapy, biofeedback training, pain neuroscience education, and self-care is eective in accomplishing
long-term goals for the patient.
RELEVANT RESEARCH
Gares et al
and reported that non-surgical treatment (education, exercises,
splint therapy, and occlusal equilibration) was eective in stabilizing patient’s symptoms, with major improvement observed at
the 6-month examination. By the end of 2 years, 66.7% of the
patients were symptom free, 25.6% presented with slight symptomatology, and 3.1% had uctuating recurrence of symptoms.
Dworkin
self-limiting chronic pain illness not associated with progressive
physical deterioration or advancing age. With their longitudinal
epidemiologic studies, they suggested that chronic pain factors
should be taken into consideration for the management of this
condition, and that psychosocial aspects inuenced the clinical
course of TMD. Using the TMJ Scale as the outcome measure,
Brown et al
therapy, physical therapy, counseling, and NSAIDs demonstrated signicant improvement compared to a nontreated group.
eir ndings supported the hypothesis that TMJ symptom
improvement was related to treatment, not solely to the pas-
208
studied 195 patients during a 2-year period
199
suggested that TMD may be viewed as a
10
reported that a group who was treated with splint
42
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sage of time. is also was contrary to previous conclusions that
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TMD was a self-limiting condition.
209
Feine and Lund
conducted a meta-analysis of review articles and RCTs for TMD. ey reported that symptoms improved during treatment with most forms of physical therapy
(exercises, short wave, ultrasound, coolant spray, heat, etc.), and
ecacy increased in direct proportion to the amount of treatment the patient received. Yet, there was no evidence that most
of these therapies were better than placebo. ey recommended
that future research should be focused on nding the “optimal
dose of care” and cost-eectiveness.
10,12
Gaudet and Brown
conducted a large-scale (6500 patients), multi-center study using the TMJ Scale to compare the
dierence between treated (splint therapy, counseling, physical
therapy, and pharmacological treatment) and untreated patients. ey concluded that treated patients reported statistically and clinically signicant symptom improvement, while
untreated patients reported unchanged symptom levels. ey
11
conducted a second large-scale prospective clinical study
that
provided further support to their previous conclusion. In addition, there was no evidence of post-treatment relapse.
36
Nicolakis et al
studied the eects of jaw exercises, manual therapy, posture corrections, and relaxation techniques in
patients with ADDwR. ey concluded that those treatments
were benecial for decreasing pain, increasing jaw opening, and
sometimes abolishing joint noises. ey also showed that the
treatments were eective in both the short-term (46 days)
211
and long-term (3 years)
Michelotti et al
management of TMJ OA.
203
reported that after a period of 3 months,
210
ment, rehabilitation, arthroscopy with postoperative rehabilitation, and arthroplasty with postoperative rehabilitation. e
physical therapy rehabilitation program included electrophysical agents, joint mobilization, and a home exercise program.
e authors reported no between-group dierences at 3, 6, 12,
18, 24, and 60 months. ey concluded that primary treatment
for individuals with TMJ closed lock should consist of medical management (medication and education) or rehabilitation.
e use of this approach would avoid unnecessary surgical pro-
216
cedures. In a parallel study, the same group of researchers
compared the 4 treatment strategies for 106 individuals with
MRI-conrmed TMJ ADDwoR. e rehabilitation included
splint therapy, physical therapy, and cognitive-behavioral therapy. ey again reported no dierence in outcome measurement between treatment strategies at 3, 6, 12, 18, 24, and 60
months follow-up. ey therefore concluded that non-surgical
treatment should be employed for ADDwoR before considering surgery.
106
Jerjes et al
conducted a meta-analysis to review the etiology and management of TMD. ey concluded that muscle
disorders were most common in TMD, particularly in females.
Treatment could range from home care, physical therapy, splint
therapy, occlusal adjustment, analgesics, and cognitive behavioral therapy. However, future research in this area was warranted to provide scientic evidence of each approach. ey also
recommended using the RDC/TMD approach, which includes
assessment of distress and disability, psychological, and social
factors, to provide the exact diagnosis for classication.
217
List and Axelsson
conducted a systemic review of 30
imen (self-massage, heat, diaphragmatic breathing, and stretching and coordinating exercises) was slightly more clinically
eective than education alone for the treatment of myofascial
pain of the jaw muscles. ey further recommended physical
therapy as the rst line of treatment choice for patients with
TMD. e reasons included favorable cost benets, reversible
and non-invasive course, clinical evidence, and easy self-management by the patient.
McNeely et al
212
213
conducted a systematic review to examine
the eectiveness of physical therapy interventions for TMD and
reported that signicant improvement in mouth opening was
found after relaxation therapy, biofeedback training, and LLL
therapy. However, they recommended interpreting the ndings
cautiously because of the poor methodological quality of all reviewed studies.
214
Medlicott and Harris
conducted a systematic review
of the eectiveness of exercises, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of
TMD. ey showed favorable outcomes for all studied criteria,
but also voiced caution in the interpretation of the outcomes
due to the methodological weakness of the research reviewed.
215
Schiman et al
studied the eectiveness of 4 randomized
therapeutic strategies for TMJ closed lock: medical manage-
ey concluded that the following management approaches can
be eective in alleviating TMD pain: occlusal appliances, acupuncture, behavioral therapy, jaw exercises, postural training,
and some pharmacological agents. Evidence for the eect of
electrical stimulation and surgery was insucient, and occlusal
adjustment seemed to have no eect. However, they also stated
that most of the primary studies were heterogeneous regarding diagnosis and treatment method; therefore, the conclusions
drawn from these studies needed to be considered with caution.
218
Cranne et al
conducted an RCT to study the 1-year
eects of a 6-week physical therapy program for masticatory
muscle pain. e control group received education only, while
the experimental group received muscle stretching, exercises,
and a home program, in addition to the education. ey found
improvement in pain ratings and function in both groups over
the 1-year period. e dierence between groups was signicant at 3, 6, and 12 weeks, but was not signicant at 52 weeks.
erefore, they concluded that the long-term decrease in pain
and improvement in function were not related to active physical therapy. A potential aw of this study was that the experimental group did not receive any manual therapy, which is an
important physical therapy component for the management of
muscular dysfunction.
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43
Cranne et al
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219
conducted another RCT to study the 1-year
eects of physical therapy for TMJ closed lock. e experimental group received joint mobilization, exercises, and massage, in
addition to the same education information that was provided
to the control group. ey reported a signicant decrease in
pain and an increase in function over time for both groups, with
no signicant dierence between groups. e results suggest
that physical therapy has no additional eect, above education,
in patients with ADDwoR.
220
Homan et al
surveyed 1511 individuals with TMD using the web-based registry of e TMJ Association, Ltd. ey
discovered a high prevalence of comorbid conditions, which included bromyalgia, chronic fatigue syndrome, irritable bowel
syndrome, rheumatoid arthritis, chronic headache, depression,
and sleep disturbances. ey suggested that because TMD may
represent a spectrum of disorders, a multidisciplinary approach
would be required to provide eective management.
Tuncer et al
221
conducted an RCT to study the eectiveness
220
of manual therapy and home physical therapy in patients with
TMD. eir results suggested that a 4-week intervention had a
clinically signicant eect on both pain and pain-free maximal
mouth opening.
222
Durham et al
found no signicant dierences in outcomes between non-surgical and surgical interventions after a
systematic review of available and criteria accepted studies on
ADDwoR. ey therefore recommended that non-surgical
management (eg, education, self-care, physical therapy, oral
appliance, etc) should be the rst option. Reviewing dierent
223
RCTs, Morell
was able to conclude that manual therapy (my-
or mobilization) was eective in improving signs and symptoms
(pain, maximal mouth opening, and PPT) of TMD. However, methodological heterogeneity was the main aw of most of
224
the research designs. Pessoa et al
used a case study to report
the eectiveness of facial massage, dry needling, and laser therapy for TMD. ey were able to demonstrate post-treatment
improvement in pain reduction and maximal mouth opening,
along with normal EMG signals.
225
Calixtre et al
conducted a systematic review of RCTs on
manual therapy for patients with TMD. ey found that myofascial release and massage techniques applied on the masticatory muscles were more eective than control; and upper cervical
spine thrust manipulation or mobilization was more eective
than control. ey concluded that manual therapy techniques
can improve pain and maximal mouth opening in patients with
TMD. ey recommended better study designs be used in the
future for stronger clinical evidence.
226
Martins et al
conducted a systematic review with meta-analysis on the ecacy of manual approaches in the treatment of TMD. ey concluded that musculoskeletal manual
approaches were eective for treating TMD. Armijo-Olivo et
227
conducted a systematic review and meta-analysis to study
al
the eectiveness of manual therapy and therapeutic exercises for
TMDs. After analyzing 48 studies, they found that in the case
of arthrogenous TMD, manual therapy combined with exercises resulted in signicant improvement in pain and mouth
opening. In the case of mixed TMD, manual therapy targeted
to the orofacial region in combination with cervical treatment
resulted in signicantly better improvement in mouth opening
than exercise alone or cervical treatment alone. ey concluded
that although the evidence level was low, manual therapy and
exercises were safe and simple interventions for the management of TMD.
15
Wieckiewicz et al
reviewed 66 papers on pain management for TMD. ey concluded that non-surgical treatment
including counseling, exercises, splint therapy, massage, and
manual therapy should be considered as a rst option for TMD
pain management. In the case of more complicated conditions
and chronic pain, minimally invasive and invasive procedures
could be considered.
228
Al-Baghdadi et al
performed a systematic review on the
management of ADDwoR. ey were not able to draw any signicant conclusions due to the weakness in the research designs.
However, they did recommend that patients with symptomatic
ADDwoR should initially be treated by a non-surgical intervention.
13
Garrigos-Pedron et al
published an article in 2019 describing the dierent approaches for the management of TMD.
ey introduced a variety of tools that health care professionals
can use to treat this condition, suggesting a multidisciplinary
229
model as more eective. Durham et al
reported the results
from an international Delphi process, which included 11 international TMD experts, and 4 rounds of discussion to construct
an operationalized denition of self-management for patients
with TMD. e standardized denition of self-care management included: education, self-exercise, self-massage, thermal
therapy, dietary advice and nutrition, and parafunctional behavior identication, monitoring, and avoidance. is should
serve as a guideline for clinical practice.
Physical therapy and splint therapy are both considered the
230
rst line, non-surgical treatment for TMD. Shousha et al
performed an RCT to compare the eects of short-term physical
therapy versus occlusive splinting on pain and ROM in individuals with myogenic TMD. ey concluded that physical therapy was a better initial treatment than occlusive splint. Paco et
231
studied the eectiveness of physical therapy in the manage-
al
ment of TMD through a systematic review and meta-analysis.
ey concluded that physical therapy interventions were more
eective than other treatment modalities and sham treatment.
However, they indicated the results should be interpreted with
caution due to the low methodological quality and the small
sample size of most of the studies.
232
Butts et al
performed a literature review of the non-surgical management of TMD. ey reported limited clinical
eectiveness of therapeutic exercises, soft tissue work, electrophysical agents, and splint therapy, but the literature supported
44
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the use of joint mobilization, joint manipulation (to TMJ and
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cervical spine), dry needling, and acupuncture for the reduction
of TMD-related pain and disability.
233
In a prospective case series, Marcos-Martin et al
studied
the eects of a multimodal physical therapy treatment approach
based on a biobehavioral model for 9 patients with chronic cervico-craniofacial pain. e treatment approach included manual therapy (joint mobilization, neurodynamic mobilization,
and soft tissue mobilization), therapeutic exercises, and patient
education. ey observed a clinically meaningful improvement
in self-reported disability, psychological factors (catastrophizing and kinesiophobia), ROM, and cranio-cervical posture at
234
2- and 14-weeks post-treatment. Calixtre et al
conducted an
RCT to study the eectiveness of mobilization of the upper cervical region and training of the cranio-cervical exion musculature in female patients with TMD. ey found a signicant
decrease in orofacial pain and headache impact after 5 weeks of
treatment. However, no signicant eects on mandibular function or PPT of the masticatory muscles were found.
Using a biopsychosocial model to manage patients with
TMD has gained popularity in recent years. Gil-Martinez et
5
proposed a multidisciplinary treatment approach based on
al
a biobehavioral concept, which included medical, physiotherapeutic, psychological, and dental treatment. ey also emphasized using a biobehavioral model in managing patients with
chronic painful TMD. While a biomedical model may be eective for acute or subacute pain, a biobehavioral approach to establish a diagnosis and management for chronic TMJ pain was
235
more comprehensive and eective. Randhawa et al
conducted
terventions for TMD. e evidence they studied suggested that
cognitive-behavioral therapy, intraoral myofascial therapy, and
self-care management were therapeutic options for persistent
TMD.
Summary of Relevant Research
e research done in the late 1980s and early 1990s has
resulted in conicting evidence about the best treatment approach and eectiveness of treatment for TMD. Some reasons
for this lack of agreement may be the complexity of TMD symptoms, the lack of standardized denitions of TMD, the lack of
uniform treatment interventions, and the low methodological
58
quality of many studies.
Clinicians should review conclusion
of each study using a critical appraisal process.
e RDC/TMD was developed by researchers for the purpose of clinical research.
200,206,236,237
ey classied TMD using a
dual-axis system. Axis I classies patients into 3 groups: masticatory muscle disorders, internal derangement of the TMJ, and
arthralgia. Axis II focuses on TMD-related behavioral, psychological, and psychosocial factors. Subsequently, the DC/TMD
28
was developed to further validate the RDC/TMD.
e intent
of these new guidelines was to create diagnostic standards for
both researchers and clinicians.
238
Most of the evidence that supports the use of physical therapy lacks adequate experimental controls, and outcome measures often are related to impairment such as pain and maximal mouth opening, rather than function or disability. Patients
with TMD often have limitations in social function, emotional
239
well-being, and energy levels. Di Fabio
recommended the use
of health-related quality of life (HRQOL) outcome measure for
treatment ecacy. e combination of disease-specic and generic assessments of HRQOL would provide a comprehensive
evaluation of the clinical outcome of a specic physical therapy
program. It can also provide a clinical index for comparisons
with other diagnoses.
Furto et al40 also recommended using
self-report instruments to assess the level of disability in patients
with TMD participating in clinical trials.
It is unrealistic to provide only one type of physical therapy
intervention for the treatment of TMD. Due to the complexity of the condition, which is multifactorial and multifaceted,
a combination of interventions is likely indicated. Kraus and
145
Prodoehl
reported favorable outcomes of an individualized
physical therapy management approach for patients diagnosed
with ADDwoR. ey also recommended specialty training and
improved methodology for research on TMD management.
In summary, future studies on the management of TMD
require large sample sizes, improved research designs (with homogeneous patient group, standardized treatment protocol,
etc), and greater involvement by physical therapists. Based on
current evidence, clinicians should use clinical reasoning and
experience, coupled with patient’s preferences, and develop an
individualized program based on research evidence to improve
the functional status of patients with TMD.
CONCLUSIONS
Temporomandibular joint disorder is a complicated syndrome that is multifactorial in causes and multifaceted in symptoms. Patients who have TMD and associated symptoms are
in great need of proper care to relieve their symptoms, restore
oral function, and improve the quality of their lives. Physical
therapists play a vital role in helping these patients reach their
goals. With proper training, a physical therapist can develop
competency in managing TMD. For more complicated, chronic cases, the physical therapist must work as a team member
with other health care professionals such as physicians, dentists,
and psychologists. Recognition of red ags and yellow ags, appropriate referrals made in a timely manner, frequent communication with other health care team members, and updating
current management knowledge are all important factors that
can ensure a positive treatment outcome.
It is the general consensus of the researchers in the eld of
13,15,227
TMD
therapy interventions (ie, education, electrophysical agents, soft
tissue release, joint mobilization, exercises, self-help instruction,
etc) is the rst choice for managing TMD. is recommendation is made despite recognizing the low to moderate level of ev-
that non-surgical treatment provided by physical
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45
idence for each intervention. Future research in this area should
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be conducted with high-quality research designs, larger sample
sizes, homogeneous study groups, and with the goals of answering clinically relevant questions.
240
List and Jensen
reviewed some old ideas and new concepts regarding TMD. e conclusion was that physical therapy
and other non-invasive therapies are among the rst choice of
interventions, and biopsychosocial factors need to be included
in the treatment program. Comorbidities associated with TMD
included headache, neck pain, back pain, bromyalgia, sleep
disturbance, anxiety, depression, pain catastrophizing, and kinesiophobia, among others.
A comprehensive physical therapy intervention should include education, electrophysical agents (as indicated), mobilization or manipulation of the cervical spine and TMJ, stretching and stabilization exercises, relaxation techniques, and a
self-management home program. A competent clinician must
keep an open mind to include holistic medicine (eg, herbal
medicine, nutrition, meditation, mindfulness, Tai Chi, etc) in
the management program when indicated and feasible. Timely
(better early than late) referral to other health care professionals
and creativity in designing individualized treatment program
are also important. Our recommendations to the physical therapist that is interested in advancing their skills in the management of TMD are to:
1. Recognize the complexity of this condition.
2.
Incorporate all available skills, based on research evidence.
3. Consider all aspects of the patient: biopsychosocial arena,
with proper timely referral.
4. Empower patients with self-management tools.
5. Engage in evidence-based research.
Promote physical therapy as the key player in the manage-
6.
ment of TMD by advocating for our contribution in this
area to other health care professionals and by joining interdisciplinary professional groups.
Lateral excursion: right: 10 mm; left: 12 mm.
•
•
Palpation: Tightness palpable over bilateral masseters (left >
right), and bilateral upper trapezius.
•
Cervical spine ROM: within normal limits in all directions.
•
Cervical spine joint mobility: hypermobility noted at C4-5
and C5-6 segments.
Patient reports that she does grind and clench at night, but
•
she does not wear a night splint.
1.
With the information gathered, what is your provisional diagnosis of this patient?
TMJ anterior disk displacement with reduction
a.
(ADDwR).
b.
TMJ anterior disk displacement without reduction
(ADDwoR).
c.
TMJ spontaneous dislocation.
d. Trismus.
e correct answer is a. TMJ anterior disk displacement
with reduction (ADDwR). Patient’s reciprocal clicks, normal
opening after click, and the opening pattern with early deviation to left side are all signs of an ADDwR. If patient had
an ADDwoR, she would have limited opening, deection to
the left side at end of mouth opening, and no reciprocal clicks.
ere was no history that would indicate either trismus or spontaneous dislocation.
Do you think physical therapy is indicated for this patient?
2.
a.
No, because this is a chronic, natural condition that the
patient will have for the rest of her life.
b. No, reciprocal clicks are benign and cannot be abolished
by physical therapy.
c. Yes, physical therapy can always abolish reciprocal clicks.
d.
Yes, there are many aspects that physical therapy can
address to stabilize this patient’s condition.
CASE SCENARIOS
Case Scenario 1
RH is a 29-year-old female who has had reciprocal clicks of
her left TMJ since she was 16 years old. Patient recently noticed
an increased frequency of her clicks (without pain) and is worried about the negative progression of her symptoms. erefore,
she is seeking physical therapy for assessment and recommendation. Upon initial evaluation, the following information was
obtained:
• e patient has a forward head, slouching posture.
• TMJ opening: 34 mm before rst click, then, patient was able
to reach 48 mm opening without pain. A faint second click
was noted when patient closed her mouth.
• Pattern of opening: early deviation to left side, then returned
to almost neutral position.
e correct answer is d. Yes, there are many aspects that
physical therapy can address to stabilize this patient’s condition. Physical therapy can provide education regarding proper
posture, oral habit, stress management, stabilization exercises,
and manual therapy to restore normal kinematics of the TMJ
and prevent progression of her symptoms. Even though this is
likely a chronic condition, physical therapy can make a dierence in management of symptoms. Yet, abolishing joint noises
is not a realistic goal.
What is the cause of reciprocal clicks? e disk is anteriorly
3.
displaced and _________________.
a. Reciprocal clicks can happen during any range of the
mouth closing.
b. Reciprocal clicks can happen during any range of the
mouth opening.
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