Improving Outcomes For Clients With Temporomandibular Disorders

The management of Temporomandibular disorders (TMD) has now evolved from the realm of dentistry to include other healthcare professionals as TMD is multi-causal and hence a treatment approach involving various healthcare disciplines can and will improve the outcomes for the client.

Some accepted contributing factors of TMD include stress, malocclusions, poor posture, myofascial pain syndrome and chronic pain.

Areas which physiotherapy can assist in improving treatment outcomes for your clients

1. Poor posture

There is a strong correlation between poor posture and TMD and almost all TMD sufferers will complain of neck pain.  It has been theorized that a forward head posture increases stress over the posterior structures of the cervical spine which then creates muscle tensions in the masticatory muscles.  These muscles can refer pain to the TMJ area and also lead to the development of dysfunction in the TMJ. In addition, the forward head posture position itself can alter the position of the TMJ.

Physiotherapists can improve posture by

  1. Improve client’s office ergonomics
  2. Release tight muscles like the suboccipital muscles to reduce resistance to upper cervical flexion
  3. Strengthen the appropriate stabilizer muscles like the deep neck flexors and lower trapezius.  The latter is to correct rounded shoulders and slouched upper back
  4. Mobilisation and manipulation of the thoracic spine to allow for more extension.  This will improve the head-shoulder alignment.

2. Myofascial pain syndrome

Majority of TMD sufferers will have been diagnosed with myofascial pain syndrome.  This is not surprising as prolonged poor posture can lead to the wrong muscles being constantly activated like the upper trapezius and the sternocledoidmastoid.  This can result in the development of trigger points in such muscles.

The significance of this is that firstly, these trigger points can refer pain to the TMJ, the molars and the cheek area.  Secondly, trigger points in the sternocledoidmastoid can create secondary trigger points in the masseter and temporalis. Trigger in the superficial fibres of the masseter can restrict mouth opening.  Third, trigger points in the lateral pterygoid muscle can apply constant excessive traction of the disc leading to stretching of the inferior stratum.  It can also position the mandible forward resulting in poor articulation of the TMJ.

Physiotherapists can palpate these trigger points and release them as well as teach clients to do the same at home.

3. Prescription of exercises

As physiotherapists are usually not primary contact practitioners for clients with TMD, a diagnosis of a hypomobile or hypermobile TMJ would have been established prior to their first visit to the physiotherapist.

Exercises prescribed are those of Dr Rocabado.  In a hypermobile joint,  Rocabado advocates training stability in the functional range where mouth opening is achieved by the rolling of the mandible on the disc without the anterior translation.  This is done by maintaining the tongue on the hard palate as the range of motion exercises are done with a gradual increase in resistance.

In hypomobile joints, apart from mobility exercises, clients can be taught to distract their joints in a caudal direction and NOT a posterior-anterior direction.  Clients are also taught to self stretch their masseter as that can also be a cause of restriction in mouth opening.

Reference:

  1. Simons et al. Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction. The trigger point manual. Volume 1. 2nd ed., Baltimore: Williams & Wilkins, 1999.
  2. J. Langendoen, J.Miller, GA Jull.  Retrodiscal tissue of the temporomandibular joint, clinical anatomy and its role in diagnosis and treatment of arthropathies.  Manual Therapy (1997), 2(4), 191-198
  3. EF Wright, MA Domenech and  JR Fischer.  Usefulness of posture training for patients with temporomandibular disorders. J Am Dental Association (2000), 131(2), 202-210

(images reproduced from Travell and Simons)

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