Temporomandibular Disorders (TMJ/TMD)
Problem
TMJ/TMD are a major cause of non dental jaw and facial pain. Approximately 18 million word days are lost annually per 100 million full time working adults due to symptoms of TMD (2).
Women have a 3:1 greater ratio of incidence compared to men between age 30 and 50 (1).
Disk Displacement and Arthritic symptoms peak at age 30 and 50, respectively (1).
Symptoms can be broken down into 3 areas:
Muscle or myofascial pain (45%), Osteoarthritis (41%), and Osteoarthrosis
Physical Therapy Treatments
Review articles support a mulimodal approach for the management of TMD including: joint mobilization/manipulation, soft tissue mobilization, active exercise, proprioception training, and relaxation training (6,7,11).
Evidence for Physical Therapy Interventions
Shiffman et al. found rehabilitation was as effective as arthroscopic surgery or arthroplasty (4).
Manual therapy has been shown to be more cost effective and less prone to side effects than dental treatments (5).
Dry needling of the facial muscles has shown positive results in recent trials (12).
Neuromuscular re education and behavioral changes are more effective than splinting (6).
Nicolakis et al. demonstrated >85% of patients with TMD treated with PT report excellent functional improvement, reduce pain, and improved ROM. 76% of patients required no further care up to 3 years after treatment (8,9).
Furto et al. demonstrated improved short term outcomes following Physical Therapy treatments involving manual therapy and exercise (10).
Manual therapy interventions to the cervical and thoracic spines, as well as, dry needling has demonstrated further improvements in pain and disability (12).
When to Refer to Physical Therapy
Patients with TMD often display signs and symptoms including: TMJ pain and myofascial pain in the face, jaw or neck, TMJ sounds, restrictions, deviations, or deflections of the jaw during jaw opening and closing.
The American Association for Dental Research reports
“Unless there are specific and justifiable indications to the contrary, treatment of patients with TMD initially should be based on the use of conservative, reversible, and evidence based therapeutic modalities.”
References
1. Manfredini, D. et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Oct;112(4):453-62.
2. Okeson, J. et al. Temporomandibular disorders in medical practice. J Fam Pract. 1996. 43(4):347-56.
3. Truelove, E. The efficacy of traditional, low cost and non splint therapies for temporomandibular disorder. A randomized controlled trial. J Am Dent Assoc. 2006.
4. Schiffman et al. Randomized Effectiveness Study of Four Therapeutic Strategies for TMJ Closed Lock J Dent Res 1986(1):58-63, 2007
5. Kalamir A, Pollard H, Vitiello
myofascial therapy for chronic myogenous temporoman- dibular disorders: a randomized, controlled pilot study. J Man Manip Ther. 2010;18(3):139-146.
6. Medlicott, M. et al. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporo- mandibular disorders. Phys Ther. 2006;86:955-973.
7. Kalamir, A. et al. Manual therapy for temporomandibular disorders. A review of the literature. J Bodywork Movement Therapies. 2007.
8. Nicolakis, P et al. An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis. Cranio. 2001. 19(1):26-32.
9. Long term outcome after treatment of temporomandibular joint osteoarthritis with exercise and manual therapy. Cranio. 2002. 20(1):23-27.
10. Furto, E. et al. Manual physical therapy interventions and exdrcise for patients with temporomandibular disorders. Cranio. 2006. 24(4):283-91.
11. Shaffer, S. Temporomandibular disorders. Part 2: conservative management. JMMT. 2014.
12. Gonzalez-Iglesias, J. et al. Mobilization with movement, thoracic spine manipulation, cervical spine manipulation, and dry needling for the management of temporomandibu- lar disorder: A prospective case series. Phys Ther Theory and Prac. 2013.