By Andy Parsons, PT, DPT, OCS
Originally published on MedBridgeEdcuation.com
Temporomandibular Disorder is defined by the American Dental Association as any pathology that affects the temporomandibular joint, masticatory muscles, or other closely related structures.1 Local jaw pain, limitations in mastication, clicking/popping when opening the mouth, and mandibular deviations are all signs and symptoms of TMD. TMD prevalence in adults has been reported between 25-52%,2 and as high as 16% in children and adolescents.3 However, only 5-10% of the symptomatic populations require or seek treatment for TMD.4
Physical therapists are part of the interdisciplinary team that manages and treats TMD. Recently Anne Harrison, PT, Phd adapted the American Academy of Orofacial Pain’s diagnostic classification scheme in the Journal of Orthopedic and Sports Physical Therapy to help manage this population.5 Below is a brief overview of this classification system and some basic management ideas for TMD.
Pain in preauricular area
Pain with end-range movements like jaw opening and lateral excursion
Pain with joint compression or biting on a tongue depression opposite to the site of compression
Disc displacement with reduction
Clicking with jaw opening and closing during at least 1 of 3 repetitions, or…
Clicking during lateral excursion or protrusion during 1 of 3 repetitions
Disc displacement without reduction
History of jaw locking or catching, but without current joint clicks or crepitus
Range of motion with opening less than 40mm
Capsular adhesions of a single joint
Possible limited mouth opening of less than 40mm
Limited contralateral lateral excursion, protrusion with the jaw deflecting towards the affected joint
Suspect if arthralgia and crepitus are present
Masticatory Muscle Disorder
Exhibits pain to palpation of masseter or temporalis
Pain with mouth opening or biting
May be limited to less than 40mm or less of mouth opening
Opening range of motion can be normal as well
Basic Management Principles
Further study by the reader is required to understand and treat this condition. Some basic ideas are useful for any skill level of clinician. Depending on classification, some basic treatment options are available:
Teeth should only touch when talking or chewing. A good subjective interview will identify bruxism or habitual grinding during the day. Habitual retraining may be necessary to avoid clenching. A good cue is “teeth apart and breath.”
Diet modification (start a soft diet)
Pain education and neuropsychological pain management
Joint mobilizations increase Temporomandibular Joint Dysfunction (TMJ) motion
Exercise should be prescribed to address the impairments noted during evaluation. It’s important to note that most exercise evidence and trials are low quality and at high risk for bias. Higher quality studies need to be performed to increase certainty that exercise is effective for TMD.6
That being said, the most well-known group of TMD exercises are the Rocabado Six.7
Resting tongue position maintained after making “cluck” sound
Stabilized neck flexion – grasp hands around back of neck and flex neck
Axial extension of neck – nod head into OA flexion and retract neck
Controlled opening of TMJ – tongue in position one, open jaw slowly with control, palpate in preauricular area with index fingers
Rhythmic stabilization of slightly open jaw
Tongue in correct position per first exercise
Maintain jaw positions with resistance into opening, closing, right, and left
Individualized TMD Treatment Plans
Dr. Harrison and colleagues have adapted this useful classification scheme for identifying and management TMD. Clinicians should be aware of competing diagnoses, such as primary headache, secondary headache, cranial neuralgias, CNS lesions, and central sensitization, to ensure an informed differential diagnosis. Thus, TMD is a more nuanced diagnosis and treatment than previously described in the literature. Behavior change, manual therapy, exercise, and pain science education are all options for individualized TMD treatment plans.
Image source: Henry Gray (1918) Anatomy of the Human Body. Revised by Warren H. Lewis. 20th Edition. Plate 995.
Griffiths, Robert H. "Report of the president’s conference on the examination, diagnosis, and management of temporomandibular disorders." The Journal of the American Dental Association (1983): 75-77.
de Godoi, Daniela Aparecida, et al. "Symptoms of temporomandibular disorders in the population: an epidemiological study." CEP 14801 (2009): 903.
da Silva, Cristhiani Giane, et al. "Prevalence of clinical signs of intra-articular temporomandibular disorders in children and adolescents: A systematic review and meta-analysis." The Journal of the American Dental Association1 (2016): 10-18.
Okeson, Jeffrey P. Management of temporomandibular disorders and occlusion. Elsevier Health Sciences, 2014.
Harrison, Anne L., Jacob N. Thorp, and Pamela D. Ritzline. "A proposed diagnostic classification of patients with temporomandibular disorders: implications for physical therapists." journal of orthopaedic & sports physical therapy3 (2014): 182-197.
Armijo-Olivo, Susan, et al. "Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis." Physical therapy1 (2016): 9.
Mulet, Mariona, et al. "A randomized clinical trial assessing the efficacy of adding 6 x 6 exercises to self-care for the treatment of masticatory myofascial pain." Journal of orofacial pain4 (2007): 318.