Temporomandibular disorders. Part 2: conservative management

The mouth-opening muscular performance in adults and elderlies with and without dysphagia: A systematic review and meta-analysis

OBJECTIVES

To characterize mouth-opening muscular performance (MOMP) in adults and elderly individuals with dysphagia and healthy controls.

METHODS

We searched the PubMed, EMBASE, CINAHL, Cochrane, Scopus, and Web of Science databases from inception to Jan. 26, 2023. Two independent researchers considered the titles, abstracts, and full texts of potentially eligible papers from 1451 search results. Twenty-five studies that evaluated mouth-opening maximal strength (MOMS) in healthy adults, elderly individuals, and patients with dysphagia met the inclusion criteria.

RESULTS

We found comparable, reliable values with significant sex differences in maximal mouth opening strength (MMOS) in the meta-analysis for healthy elderly patients (females 5.31 ± 0.47 kg vs. males 7.04 ± 0.70 kg; mean difference of 0.84 kg). Age has also emerged as an essential factor in reducing strength. There was a significant reduction in the MMOS score in the only study that compared dysphagic individuals to healthy elderly individuals. In another study, the MMOS score was comparable to the meta-analysis of healthy elderly individuals.

CONCLUSIONS

Both sex and age play significant roles in the MMOS. There is no reliable data on the normal mouth-opening strength and endurance of healthy adults, patients with dysphagia, or individuals with other relevant clinical problems.

Changes in oral health-related quality of life after self-care treatment in patients with myofascial pain

OBJECTIVE

The aim of this study was to evaluate the changes in oral health-related quality of life (OHRQoL) of patients with myofascial pain treated by means of self-care measures.

METHODS

Fifteen patients with myofascial pain had OHRQoL evaluated by the Oral Health Impact Profile (OHIP-TMD) questionnaire and were instructed for self-care measures verbally and with a printed guide in the first consultation (T0), after 30 days (T1) and 60 days (T2). Paired t-test was performed to evaluate changes through time.

RESULTS

OHIP-TMD scores were 29.3 (SD 10.2) at T0, 18.9 (SD 11.2) at T1, and 15.9 (SD 10.7) at T2. There was a reduction of scores related to the OHIP-TMD domains of functional limitation, physical pain, psychological and social inability and incapacity (T1 and T2), and psychological discomfort (T2).

CONCLUSION

Self-care measures had positive effects on the myofascial pain treatment, reducing physical pain generated by TMD and improving patients' OHRQoL.

Occlusal splint and combined multiwave locked system laser therapy demonstrated differential patient-reported outcomes and clinical parameters: A randomized controlled trial in patients with temporomandibular disorder

PURPOSE

To evaluate the impact of occlusal splint plus laser therapy (OS + LT) compared with OS alone on the patient-reported outcomes and clinical parameters of patients with temporomandibular disorders (TMDs).

METHODS

Twenty-three patients with TMDs were randomly assigned to two treatment approaches: OS and OS + LT (multiwave locked system). The two outcomes were clinical parameters (mouth-opening distances, number of muscles and TMJs with pain) and patient-reported outcomes (pain score and oral health-related quality of life [OHRQoL] determined using the 14-item oral health impact profile [OHIP-14]). The outcomes were measured at four time points: baseline, 2 weeks, 1 and 3 months after treatment. According to DC/TMD Axis I classification, the participants were diagnosed as having pain only and pain with intraarticular joint disorder. Adjusting for age and sex, the outcome changes were analysed using generalized estimating models at a 5% significance level.

RESULTS

The pain-free mouth-opening distance of the patients who received OS + LT continuously increased from 2 weeks to 3 months. However, the value was significantly increased at 3 months in patients who received OS alone. The unassisted mouth-opening distance significantly increased after 3 months in both groups. In both treatment approaches, the number of muscles and TMJs with pain, as well as the pain and OHIP-14 scores gradually decreased from baseline to 3 months.

CONCLUSIONS

The patients who received OS and OS + LT demonstrated better OHRQoL and clinical parameters during 3 months after treatment. An improvement in the pain-free mouth-opening distance at 2 weeks was found only in OS plus LT group; however, this difference may not be clinically significant.

Biomechanical properties of masseter muscle assessed through myotonometry in patients with temporomandibular disorder treated with ultrasound therapy: a randomized comparative study

BACKGROUND

The aim of the study was to make an objective quantitative assessment of effectiveness of procedures with the use of a therapeutic dose of ultrasounds in this nosological entity, in connection with improved biomechanical properties and alleviation of pain experienced in masseter muscles.

METHODS

The study included 40 patients with temporomandibular disorder. In group 1 (N.=20) ultrasound therapy (1.2 W/cm2) was carried out, while in group 2 (N.=20) sham therapy was applied. A total of 10 procedures were performed. Myotonometric measurements and assessment of pain intensity were carried out before treatment and after the completion of procedures.

RESULTS

The analysis revealed a significant difference (P=0.011) between the values of decrement (D) measured on day 0 (2.08±0.45 [log]) and day 4 (1.80±0.55 [log]) in group 1. In group 2 no statistically significant differences were noted between the results obtained on consecutive days of the therapeutic cycle. A statistically significant difference in values of decrement (D) between group 1 (1.80±0.55 [log]) and group 2 (2.23±0.51 [log]) was noted on day 4 of the experiment (P=0.021). Both in group 1 and in group 2, a statistically significant reduction of pain intensity (VAS Scale) was obtained.

CONCLUSIONS

The masseter muscle was more elastic during ultrasound therapy. However, the effect was transient. The analgesic effect was also observed in the control group; therefore, a placebo effect cannot be excluded.

Evaluation and management of temporomandibular disorders. Part 2: an orthopaedic physical therapy update on examination and clinical reasoning

Temporomandibular (TM) disorders afflict many people globally and, despite the presence of existing peer-reviewed material that assists conservative orthopedic providers, recent advances in knowledge indicate that updated resources are required for students, clinicians, and educators. This two-part series builds off previously published material to present newer supplementary information that can be useful during the evaluation and management processes. Content in Part 1 of this series includes a discussion about the factors that have been shown to contribute to TM disorders, an updated perspective of relevant pain science, a discussion of self-report outcome measures, and various different topics related to the examination of patients with TM disorders. Part 2 addresses information related to the temporomandibular joint disc, joint hypermobility, oral splints, and clinical reasoning. In combination with other available publications, this two-part series provides clinicians an opportunity to improve their delivery of effective and efficient clinical services for people diagnosed with TM disorders.

Evaluation and management of temporomandibular disorders. Part 1: an orthopedic physical therapy update on examination and clinical reasoning

Temporomandibular (TM) disorders afflict many people globally and, despite the presence of existing peer-reviewed material that assists conservative orthopedic providers, recent advances in knowledge indicate that updated resources are required for students, clinicians, and educators. This two-part series builds off previously published material to present newer supplementary information that can be useful during the evaluation and management processes. Content in Part 1 of this series includes a discussion about the factors that have been shown to contribute to TM disorders, an updated perspective of relevant pain science, a discussion of self-report outcome measures, and various different topics related to the examination of patients with TM disorders. Part 2 addresses information related to the temporomandibular joint disc, joint hypermobility, oral splints, and clinical reasoning. In combination with other available publications, this two-part series provides clinicians an opportunity to improve their delivery of effective and efficient clinical services for people diagnosed with TM disorders.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Temporomandibular disorders-related videos on YouTube are unreliable sources of medical information: A cross-sectional analysis of quality and content

Objective

The amount of online medical information available is rapidly growing and YouTube is considered as the most popular source of healthcare information nowadays. However, no study has been conducted to comprehensively evaluate YouTube videos related to temporomandibular disorders (TMD). So this study aimed to evaluate the content and quality of YouTube videos as a source of medical information on TMD.

Method

A total of 237 YouTube videos that were systematically searched using five keywords (temporomandibular disorders, tmd, temporomandibular joint, tmj, and jaw joint) were included. Included videos were categorized by purpose and source for analysis. The quality (DISCERN, Health on the Net (HON), Ensuring Quality Information for Patients (EQIP), and Global Quality Scale (GQS)) and scientific accuracy of video contents were evaluated.

Results

Total content, DISCERN, HON, EQIP, and GQS scores were 7.5%, 38.9%, 35.2%, 53.0%, and 48.6% of the maximum possible score, respectively. Only 69 videos (29.1%) were considered as "useful" for patients. News media, physician, and medical source videos showed higher evaluation scores than others. Quality evaluation scores were not significantly correlated or negatively correlated with public preference indices. In the ROC curve analysis, content and DISCERN score showed above excellent discrimination ability for high-quality videos based on GQS (P < 0.001) and total score (P < 0.001).

Conclusions

YouTube videos related to TMD contained low quality and scientifically inaccurate information that could negatively influence patients with TMD.

Clinical Characteristics and Rehabilitation Strategies for the Stomatognathic System Disturbances in Patients with Stroke: A Systematic Review

Background: Understanding the stomatognathic system disturbances is key to diagnosing them early and implementing rehabilitation approaches to promote functional recovery. The objective of this study was to systematically review all published data that examined the assessment and rehabilitation strategies for the stomatognathic system disturbances in patients with stroke. Methods: Five databases (i.e., PubMed/MEDLINE, Scopus, Science Direct, Web of Science, and PEDro), were screened for manuscripts that included the assessment and rehabilitation strategies for stomatognathic system disturbances. The methodological quality was evaluated using the Mixed Methods Appraisal Tool. Results: Sixteen articles were included in this systematic review. The most frequently reported symptoms in patients with stroke included stiffness and thickness of the masseter muscle on the affected side and suprahyoid muscles; facial muscles' asymmetry and weakness; temporomandibular disorders; and a reduced maximum lip force, tongue pressure, and saliva flow rate. The rehabilitation strategies more frequently reported included exercises directed to the jaw, temporomandibular joint, tongue, and neck. The mean score for methodological quality was 85%. Conclusion: The stomatognathic system disturbances are frequently reported among patients with stroke, leading to dysfunction in masticatory performance or swallowing. More studies on interventions for stomatognathic system disturbances are required before conclusions may be drawn. Key Practitioner Message: This systematic review has clinical implications for rehabilitation practices, given that the results may help to develop early assessment and rehabilitation strategies for stomatognathic disturbances in patients with stroke.

Effectiveness of conservative therapeutic modalities for temporomandibular disorders-related pain: a systematic review

PURPOSE

The aim of this systematic review was to evaluate the effectiveness of conservative different therapeutic modalities for temporomandibular disorders (TMD) pain.

MATERIALS AND METHODS

An electronic systematic search was conducted in the MEDLINE (PubMed) database to identify the randomized clinical trials (RCTs) published between 2001 and 2021. The following, simple or multiple conjunctions, search keywords were selected: TMD pain, TMD management or conservative treatment or treatment strategies and TMD pain, therapeutic modalities or interventions and TMD. Studies included must have patients older than 18 years, with painful TMD, which diagnosis was performed by Research Diagnostic Criteria for TMD or Diagnostic Criteria for TMD. Outcome variables were pain relief and post treatment pain intensity reduction. Data were analysed with non-parametric tests and the level of significance was set at p<.05.

RESULTS

Out of 1599 articles obtained, 28 RCTs fulfilled all selection criteria and were included. The results of this study show that there was a significant decrease in short-term post-treatment TMD pain with the use of occlusal splint alone or in combination with other therapeutic modalities when compared with the control group. Statistically significant differences were also detected between laser and photobiomodulation group and the control, in short-term treatment TMD-related pain.

CONCLUSIONS

The primary findings of the present systematic review showed that the occlusal splint alone or combined with other therapeutic intervention presented positive effect on short-term TMD pain reduction. Secondary outcome suggests that laser and photobiomodulation therapy had, also, a significant role in short term pain relief.

Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial

OBJECTIVE

To compare the effects of dry needling and upper cervical spinal manipulation with interocclusal splint therapy, diclofenac, and temporomandibular joint (TMJ) mobilization in patients with temporomandibular disorder (TMD).

METHODS

One hundred-twenty patients with TMD were randomized to receive six treatment sessions of dry needling plus upper cervical spinal manipulation (n = 62) or interocclusal splint therapy, diclofenac, and joint mobilization to the TMJ (n = 58).

RESULTS

Patients receiving dry needling and upper cervical spinal manipulation experienced significantly greater reductions in jaw pain intensity over the last 7 days (VAS: F = 23.696; p < 0.001) and active pain-free mouth opening (F = 29.902; p < 0.001) than those receiving interocclusal splint therapy, diclofenac, and TMJ mobilization at the 3-month follow-up.

CONCLUSION

Dry needling and upper cervical spinal manipulation was more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD.

Long-term efficacy and patient satisfaction of pulsed radiofrequency therapy in temporomandibular disorders: A randomized controlled trial

BACKGROUND

Pulse radiofrequency (PRF) therapy is one of effective physical therapy modalities for treat temporomandibular disorders (TMD). This prospective randomized controlled trial aimed to evaluate the long-term treatment efficacy and patient satisfaction with PRF therapy in TMD.

METHODS

Eighty-six female patients with TMD were randomly assigned to either pulsed radiofrequency or placebo therapy in combination with other conventional treatments once a week for 12 weeks. A final analysis was performed 12 weeks after the completion of treatment. Clinical parameters and patient satisfaction were analyzed at baseline, 4, 8, and 12 weeks of intervention and at 24 weeks from baseline.

RESULTS

Pain intensity, comfortable and maximum mouth opening, and pain on capsule and masticatory muscle palpation were significantly improved after treatment in both groups. Notably, the pulsed radiofrequency group showed a significantly lower pain intensity at the final evaluation performed 3 months after the completion of treatment. Significantly more patients reported subjective pain improvement and satisfaction with treatment following intervention at baseline in the PRF group. Most patients did not report any discomfort following treatment in either group. However, significantly more patients in the PRF group reported a burning sensation with intervention.

CONCLUSION

Long-term regular pulsed radiofrequency therapy was effective in significantly reducing TMD pain, and the effect was long-lasting following treatment completion. Pulsed radiofrequency therapy should be considered as a supportive physical therapy modality for TMD.

Evaluating the Effect of Conservative Therapy in Patients with Wilkes Stage III Temporomandibular Joint Derangement

The authors evaluated effects of physiotherapy in patients experiencing Wilkes III temporomandibular joint (TMJ) derangement with clinically limited joint mobility, but no pain. The group consisted of 31 patients with unilateral temporomandibular joint involvement, 3 men and 28 women (average age was 30.93, ranging from age 12 to 61). None of the patients in the group had experienced any previous TMJ therapy. The patients underwent conservative therapy in the form of home exercise (mobilisation and isometric exercises) as the first step in treatment. The authors evaluated the improvement in jaw movement (maximal interincisal opening - MIO) and the patients' subjective assessments of their condition. Disc position before and after two months of exercise was also evaluated using ultrasound examination. The average MIO value in patients before starting the exercises was 33.5 mm, and after two months of exercises, 42.4 mm. Subjective assessment by patients: 26 patients (83%) described their condition as completely satisfactory, not requiring further therapy. Of these patients, ultrasound examination showed 10 patients with complete disc reduction, 9 patients with a change in disc displacement with reduction, and 7 patients with a continuing (unchanged) state of disc displacement. Results of our study show the effect of conservative therapy in patients with painless TMJ due to disc displacement (WIII). Effect of home exercises which were easy to perform, simple and acceptable to the patient were demonstrated.

The Dental stick test - Useful to reveal intra-articular conditions in persons with temporomandibular disorder?

BACKGROUND

There is a need for clinical tests that can reveal intra-articular conditions in the temporomandibular joint to be able to give proper treatment. The Dental stick test, where participants bite with their molars on a wooden stick, is a pain provocation test for the temporomandibular joint.

OBJECTIVE

The purpose of this study was to explore if the Dental stick test can be used to reveal intra-articular conditions in the temporomandibular joint in persons with long-lasting painful disorders.

DESIGN

Cross-sectional.

MATERIALS AND METHODS

Forty persons with pain in one or both temporomandibular areas were examined using the Dental stick test. The participants were between 18 and 70 years, and had 65 symptomatic joints. Sensitivity, specificity, false positive and false negative responses, and area under the curve were calculated for the Dental stick test with MRI and/or CT as reference standards. The phi-correlation coefficient (phi) was used to measure the correlation between the Dental stick test and intra-articular findings.

RESULTS

The sensitivity and specificity for the Dental stick test, revealing intra-articular findings, were 0.62 and1.0 respectively. False positive and false negative responses were 0 and 0.41 respectively, and the area under the curve 81% with p < 0.001. The correlation between a positive Dental stick test and intra-articular findings was not significant (phi = 0.60).

CONCLUSIONS

When the Dental stick test is positive, intra-articular findings will most probably be present on MRI/CT, but the test alone cannot reveal intra-articular conditions in persons with long-lasting painful temporomandibular disorder.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

Efficacy of different combinations of physiotherapy techniques compared to exercise and patient education in temporomandibular disorders: A randomized controlled study

OBJECTIVE

This study aims to investigate the efficacy of different types of physiotherapy approaches in individuals with cervical myofascial painful temporomandibular disorders (TMDs).

METHODS

Seventy-five participants with myofascial pain of jaw muscles and cervical myofascial pain were randomized into three groups: exercise group (E), low-level laser therapy group (LLLT), and manual pressure release group (MPR). All patients were assessed before treatment and after 12 sessions of treatment.

RESULTS

Significant improvement was seen in all groups' pressure pain threshold (PPT) values (p < 0.01). Some masticatory and neck muscles' PPT changes in MRP and LLLT groups were significantly higher than the exercise group (p < 0.05).

CONCLUSION

Exercise therapy is an effective approach for treatment of TMDs. Additionally, LLLT combined with exercise and MPR combined with exercise have better effects than only exercise therapy. Multimodal treatment approaches should include exercise to achieve better results in clinical practice.

The effect of the ischaemic compression technique on pain and functionality in temporomandibular disorders: A randomised clinical trial

BACKGROUND

Interventions addressing pain and impaired functionality in individuals with temporomandibular disorders (TMDs) are needed.

OBJECTIVE

To compare the effects of 4 weeks of exercise combined with ischaemic compression and exercise alone in patients with TMDs.

METHODS

Fifty patients who were diagnosed with TMDs were randomised into Group 1 (exercise combined with ischaemic compression technique) (n = 25) or Group 2 (exercise alone) (n = 25). Both groups performed 4 weeks of Rocabado's exercise and 3 weeks of postural exercise, while Group 1 received ischaemic compression to the masseter muscle for a total of 3 sessions in addition to exercise. A ruler was used to assess range of motion (ROM) (painless mouth opening (PMO), maximum mouth opening, maximum assisted mouth opening (MAMO), left lateral movement and right lateral movement), the visual analogue scale and graded chronic pain scale were used to assess pain, an algometer was used to determine the pain pressure threshold (PPT), and the 8-item jaw functional limitation scale was used to assess, functionality. The assessments were performed at baseline, at week 1 and at week 4.

RESULTS

The participants in Group 1 exhibited larger PMO (F = 5.26, P = .02) and MAMO values (F = 6.71, P = .01) than did the patients in Group 2 at week 1. The effect size was small for MAMO (ES = 0.27) and moderate for PMO (ES = 0.51). However, there were no significant differences in any other outcomes between groups at week 1 or 4.

CONCLUSION

In summary, this randomised controlled trial indicates that exercise combined with ICT and exercise alone have similar effects on ROM, pain, the PPT and functionality in patients with TMDs.

Evaluation of Soft Tissue Mobilization in Patients with Temporomandibular Disorder-Myofascial Pain with Referral

The aim of the study was functional evaluation of soft tissue mobilization in patients with temporomandibular disorder-myofascial pain with referral. The study group consisted of 50 individuals-37 females and 13 males. The average age was 23.36 ± 2.14 years. All subjects were diagnosed with myofascial pain with referral (diagnostic criteria for temporomandibular disorders). Soft tissue mobilization was applied three times. Electromyography of selected masticatory muscles was performed six times-before and after the treatment. After each mobilization, a decreasing tendency of muscular activity was observed in the entire study group. The Friedman test indicated that mobilization altered the activity of the right temporal muscle (p = 0.00010), both masseters (p = 0.0000), right sternocleidomastoid (p = 0.00251), left sternocleidomastoid (p = 0.00033), and right and left digastric muscles (p = 0.00045 and p = 0.00000, respectively). With respect to symmetry a statistically significant difference was noted in the case of the sternocleidomastoid muscles (p = 0.00729). In conclusion, soft tissue mobilization seems to be effective in the relaxation of masticatory muscles in patients with temporomandibular disorders. Our findings proved that soft tissue mobilization does not improve the symmetry and synergy of the masticatory muscles limited by dental occlusion.

Oral health-related quality of life in patients with disc displacement with reduction after counselling treatment versus counselling associated with jaw exercises

OBJECTIVE

The aim of this study was to compare the effectiveness of two types of treatment (counselling programme versus counselling programme plus jaw exercises) to improve the quality of life of patients with disc displacement with reduction (DDWR).

MATERIALS AND METHODS

Patients were divided into two groups. The test group received guidelines for temporomandibular disorders (TMD) plus jaw exercises for DDWR, and the control group received only guidelines for TMD. The total number of investigated patients was 70, thus 35 per group. The oral health-related quality of life was assessed by the OHIP-14 questionnaire. Both groups were evaluated at the baseline and 30 days post-treatment.

RESULTS

In the counselling group, there was statistically significant decrease in pain (P = .015) and social disability (P = .046) subscales. In the counselling plus jaw exercise group, there was statistically significant decrease in all subscales (P < .05). At 30 days follow-up, there was a statically significant difference between the two groups in pain (P = .004), psychological discomfort (P < .001), psychological disability (P < .001) and social disability (P = .029) subscales.

CONCLUSION

The counselling programme plus jaw exercise protocol showed greater improvement in oral health-related quality of life than the group performing only the counselling programme in patients with DDWR.

Effects of 4-Week Diacutaneous Fibrolysis on Myalgia, Mouth Opening, and Level of Functional Severity in Women With Temporomandibular Disorders: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to assess the effects of 4-week protocol of diacutaneous fibrolysis (DF) compared with simulated DF (sham-DF) on myalgia and mouth opening.

METHODS

In a sham randomized controlled trial, 34 women with temporomandibular disorders and myofascial pain were randomly divided as intervention group (IG) and sham-DF group (SG). The IG received 4 weeks of real DF, and the SG received sham. Pain was assessed through the visual analog scale and pressure pain thresholds (PPTs) on the temporomandibular joint (TMJ), and over the temporal and masseter muscles. The Mandibular Function Impairment Questionnaire was used to classify the participants regarding to the severity of the functional limitation related to TMD.

RESULTS

Pain scores decreased for both groups, but the IG showed lower values at week 4, with between-group differences. Bilateral temporal PPT showed higher values at week 4, with between-group differences. The SG had lower PPTs but the IG had higher PPTs, both compared to baseline results. The time-by-group interaction and the frequency of participants above 40 mm of mouth opening showed a significant difference for the IG over time with higher results at the 4-week assessment compared to its own baseline. Both groups showed lower MFIQ scores from baseline to 4-week assessment. There was a lower frequency of a moderate level of severity for the IG. No differences were observed for TMJ or for the masseter muscles PPT.

CONCLUSION

Improvements were observed for visual analog scale scores and PPTs on temporal muscles. There was a group-by-time interaction in the IG, suggesting a possible potential use of DF for mouth opening.

Effectiveness of Cervical Spine High-Velocity, Low-Amplitude Thrust Added to Behavioral Education, Soft Tissue Mobilization, and Exercise for People With Temporomandibular Disorder With Myalgia: A Randomized Clinical Trial

OBJECTIVE

To determine the immediate and short-term effects of adding cervical spine high-velocity, low-amplitude thrust (HVLAT) to behavioral education, soft tissue mobilization, and a home exercise program on pain and dysfunction for people with a primary complaint of temporomandibular disorder (TMD) with myalgia.

DESIGN

Randomized clinical trial.

METHODS

Fifty individuals with TMD were randomly assigned to receive cervical HVLAT or sham manipulation for 4 visits over 4 weeks. Participants in both groups received other treatments, including standardized behavioral education, soft tissue mobilization, and a home exercise program. Primary outcomes included maximal mouth opening, the numeric pain-rating scale, the Jaw Functional Limitation Scale (JFLS), the Tampa Scale of Kinesiophobia for TMD (TSK-TMD), and a global rating of change (GROC). Self-report and objective measurements were taken at baseline, immediately after initial treatment, and follow-ups of 1 week and 4 weeks. A 2-by-4 mixed-model analysis of variance was used, with intervention group as the between-subjects factor and time as the within-subject factor. Separate analyses of variance were performed for dependent variables, and the hypothesis of interest was the group-by-time interaction.

RESULTS

There was no significant interaction for maximal mouth opening, the numeric pain-rating scale, or secondary measures. There were significant 2-way interactions for the JFLS (d = 0.60) and TSK-TMD (d = 0.80). The HVLAT group had lower fear at 4 weeks and improved jaw function earlier (1 week). The GROC favored the HVLAT group, with significant differences in successful outcomes noted immediately after baseline treatment (thrust, 6/25; sham, 0/25) and at 4 weeks (thrust, 17/25; sham, 10/25).

CONCLUSION

Both groups improved over time; however, differences between groups were small. There were significant differences between groups for the JFLS, TSK-TMD, and GROC. The additive clinical effect of cervical HVLAT to standard care remains unclear for treating TMD. J Orthop Sports Phys Ther 2020;50(8):455-465. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9175.

Effect of Manual Therapy and Splint Therapy in People with Temporomandibular Disorders: A Preliminary Study

Background: Isolated manual therapy techniques (MT) have shown beneficial effects in patients with temporomandibular disorders (TMD) but the effect of the combination of such techniques, together with the well-stablished splint therapy (ST) remains to be elucidated. Objective: This study was conducted to ascertain whether a combined program of MT techniques, including intraoral treatment, plus traditional ST improves pain and clinical dysfunction in subjects with TMD. Methods: A preliminary trial was conducted. 16 participants were assigned to either the MT plus ST-Experimental Group (EG, n = 8) or the ST alone—Control Group (CG, n = 8). Forty-five minute sessions of combined MT techniques were performed, once a week for four weeks. Three evaluations were conducted: baseline, post-treatment, and one-month follow-up. Outcome measures were pain perception, pain pressure threshold (PPT), TMD dysfunction, and perception of change after treatment. Results: EG showed significant reduction on pain, higher PPT, significant improvement of dysfunction and significantly positive perception of change after treatment (p < 0.05 all). Additionally, such positive effects were maintained at follow-up with a high treatment effect (R² explaining 26.6–33.2% of all variables). Conclusion: MT plus ST showed reduction on perceived pain (3 points decrease), higher PPT (of at least 1.0 kg/cm²), improvement of disability caused by pain (4.4 points decrease), and positive perception of change (EG: 50% felt “much improvement”), compared to ST alone.

Efficacy of Maitland joint mobilization technique on pain intensity, mouth opening, functional limitation, kinesiophobia, sleep quality and quality of life in temporomandibular joint dysfunction following bilateral cervicofacial burns

BACKGROUND

Bilateral cervicofacial burn contracture initially affects facial expressions and later affects tempero mandibular joint (TMJ) function of the patient. It further tightens the ligaments and capsules around the TMJ and leads to tempero mandibular dysfunction. The consequences of temporomandibular joint dysfunction will be pain, limitation of mouth opening, functional disability and poor quality of life (Qol). However, studies examining the efficacy of Maitland joint mobilization technique in this population are lacking.

OBJECTIVES

To find the short term effects of Maitland joint mobilization technique on pain, mouth opening, functional limitation, kinesiophobia, sleep quality and Quality of life in tempero mandibular joint dysfunction following bilateral cervicofacial burns.

METHODS

Thirty subjects with temporomandibular joint dysfunction following cervicofacial burn (N=30) were allocated to Maitland joint mobilization group (n=15) and home based training group (n=15) randomly to receive Maitland joint mobilization technique and home based training for 4 weeks. All the participants received ultrasound therapy as common treatment. Primary (Numeric Pain Rating Scale - NPRS, maximal mouth opening - MMO & Tempero mandibular disability index - TDI) and secondary (Tampa Scale of Kinesiophobia - TSK-17, Sleep quality questionnaire - SSQ & Global Rating of Change - GRC) outcome measures were measured at baseline, after four weeks and three months follow up. Repeated measures of ANOVA and independent t test were performed for analyzing the dependent variables in both groups.

RESULTS

Baseline demographic characters and study variables show homogenous distribution between the groups (p>0.05). Four weeks following different training protocols Maitland joint mobilization group shows more significant changes in pain intensity, mouth opening, functional limitation, kinesiophobia, sleep quality and Qol than home based training group (p≤0.05). Also Maitland joint mobilization group show significant improvement in study variables than home based training group (p≤0.05) at three months follow up.

CONCLUSION

Both groups improved over time, however, differences between the groups were noticed small. However, physiotherapy management which includes Maitland joint mobilization technique and therapeutic exercise program has an effective strategy in the treatment of tempero mandibular joint dysfunction following cervicofacial burns.

Graded exposure and orthopedic manual physical therapy for kinesiophobia and function in chronic temporomandibular dysfunction: A case report

BACKGROUND

This case report describes the successful use of multi-modal physical therapy (PT), including orthopedic manual physical therapy (OMPT) and graded exposure, in a patient with chronic temporomandibular dysfunction (TMD).

CLINICAL PRESENTATION

A 41-yr old female presented with a five-year history of bilateral chronic myofascial TMD and comorbid neck/right arm pain. The patient was treated for 12 weeks with a focus on OMPT and graded exposure. The patient demonstrated clinically significant improvements on the Tampa Scale of Kinesiophobia-TMD, maximal mouth opening, Global Rating of Change, and Jaw Functional Limitation Scale.

CLINICAL RELEVANCE

Mechanisms underlying chronic TMD are complex. Current evidence supports PT management of physical impairments; however, neglecting central drivers or psychosocial factors may result in suboptimal outcomes. Physical therapists are able to address both peripheral and central mechanisms of pain, and future research should examine the utilization of multi-modal PT to improve kinesiophobia and function in patients with chronic TMD.

Prevalence of clinical manifestations of temporomandibular osteoarthrosis

Introduction. The two compartments, disco-temporal and condilo-discal, which make up the temporo-mandibular joint, fulfill the functions of the stomatognathic system, namely: phonation, mastication and swallowing. The temporo-mandibular degenerative pathology is one of the 5 clinical entities given by the American Academy of Orofacial Pain in 1993. The symptoms are varied, dominated by pain, impaired joint mobility, cracks, sensation of muscle fatigue in the masseter and temporal muscles. Most cases benefit from conservative treatment, consisting of anti-allergic and anti-inflammatory medication, specific orthodontic treatment, electrotherapy (TENS, ultrasound, magnetodiaflux, laser), kinesiotherapy. 2-5% of patients require surgery. Material and method. We performed a retrospective study, over a 9-year period (January 2010-March 2019), in which we included 503 patients who went to the Timisoara Oro-Maxillofacial Surgery Clinic, with a definite diagnosis of temporomandibular algodisfunctional syndrome, of different etiologies, between the ages of 6 and 85 years. We evaluated the etiology of temporomandibular algodisfunctional syndrome, the prevalence of clinical manifestations in temporomandibular osteoarthritis and their evolution after 10 days of conservative treatment. Results and discussions. Pain is present in 100% of cases, the values obtained in these patients with temporomandibular osteoarthritis are between 10 and 40mm. Cracks are present in women in the percentage of 40.8% and 37.9% in men; mobility limitation is found in women in 11% of cases, and in men in 15% of cases. Conclusions. The existence of a protocol for the diagnosis of TM osteoarthritis is essential to establish the treatment plan and prognosis of the disease. The pain from osteoarthritis TM is low intensity, present in all patients; cracks and limiting mobility are present in comparable proportions, regardless of gender. The response to treatment was optimal at 21 days of treatment.

Difference in Response to a Motor Imagery Task: A Comparison between Individuals with and without Painful Temporomandibular Disorders

The aim of the study was to investigate the difference in response to a motor imagery task between individuals with and without painful temporomandibular disorders (TMDs). The participants were 24 adults with and without TMD (TMD and control group, resp.). A set of photographic images of the profile view of a person's head and neck and a hand and a foot were presented in a random order. The set consisted of six different orientations with rotations of each image at 0, 60, 120, 180, 240, and 300 degrees and included left and right representations. The participants were required to view the image and make a decision as to whether it was a left or a right side presented, that is, mental rotation (MR) task. Data were collected on 48 tasks (including left and right) at each orientation for each body part. Reaction times (RTs) for correct answers and accuracy in making the left or right judgements were recorded. The RT was slower in the TMD group than in the control group. The RT for the profile image was slower than those for the hand and foot images. For images that were 180 degrees, the RT was slower and the accuracy was lower than those for five of the other image orientations. The judgements made about the 180-degree rotated image were more inaccurate compared to images of all other orientations among all types of stimuli.

The Efficiency of Anterior Repositioning Splints in the Management of Pain Related to Temporomandibular Joint Disc Displacement with Reduction

Background and Objective

Intra-articular temporomandibular disorders are often related to pain in the area of the temporomandibular joint, ear, and temple. The aim of the study was to investigate the efficiency of anterior repositioning splints in decreasing pain related to temporomandibular joint disc displacement with reduction.

Methods

The research material consisted of 112 patients, aged 24 to 45 years, of both genders, who reported for treatment at the Consulting Room of Temporomandibular Joint Dysfunctions at the Jagiellonian University in Cracow between 2014 and 2016 due to pain in the area of the temporomandibular joint(s) and noise(s) of temporomandibular joint(s) present during jaw movements with comorbid contracture of masticatory muscles. Subjects were examined according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocol and, after diagnosis of painful disc displacement with reduction and masticatory muscle contracture, they were assigned randomly to either the study or control groups (56 patients in each). In the study group, we used an anterior repositioning splint on the full lower arch for about 20 hours usage over a 4-month period. In the control group, a noninvasive therapy was applied using a biostimulation laser over 12 sessions performed every second day on the area of both temporomandibular joints with mouth open and while performing muscle self-exercises with a dominant protrusive position of the mandible. Pain intensity was evaluated using the Verbal Numerical Rating Scale (VNRS) immediately before the treatment and then after 4 and 16 weeks. The obtained data were analyzed using the Mann–Whitney U test (p ≤ 0.005).

Results

The VNRS values reported during the final examination for the study group were significantly lower than for the control group (p=0.0004).

Conclusions

The anterior repositioning splint is an efficient tool in decreasing pain related to disc displacement with reduction. This trial is registered with Clinicaltrials.gov NCT03057262.

Association between headache and temporomandibular disorder

Headaches are one of the most common conditions associated with temporomandibular disorder (TMD). In the present paper, we evaluated the relationship between headache and TMD, determined whether headache influences the symptoms of TMD, and reported two cases of TMD accompanied by headache. Our practical experience and a review of the literature suggested that headache increases the frequency and intensity of pain parameters, thus complicating dysfunctional diseases in both diagnostic and treatment phases. Therefore, early and multidisciplinary treatment of TMD is necessary to avoid the overlap of painful events that could result in pain chronicity.

Changes in cervical movement impairment and pain following orofacial treatment in patients with chronic arthralgic temporomandibular disorder with pain: A prospective case series

The purpose of this study was to investigate the influence of isolated temporomandibular joint (TMJ) manual therapy on pain and range of motion (ROM) of the TMJ and cervical spine including flexion-rotation test (FRT) in people suffering chronic pain arising from chronic arthralgic temporomandibular disorder (TMD). An experienced clinician managed a case series of 12 patients with TMD (mean duration 28.6 months +/- 26.9). The intervention comprised four-weekly sessions of transverse medial accessory TMJ mobilization and advice. Patients were examined prior to and one-week following the intervention period. Outcome measures included jaw disability (JFLS-20), jaw pain measured by Visual Analogue Scale (VAS), maximal mouth opening ROM, cervical ROM including FRT, and pain during cervical movement. A paired t-test revealed significant improvement following the intervention in disability (p < 0.001), VAS pain score at rest (p < 0.001) and at maximum mouth opening (p < 0.001), jaw opening ROM (p < 0.001), FRT ROM to the left (p = 0.024) and right (p = 0.001). In contrast, no significant change was identified for total cervical ROM (p = 0.905). After the intervention, five patients (41.66%) had no pain at rest or at maximal mouth opening, and all had a negative FRT. The effect sizes indicate a moderate to strong, clinically significant effect for all variables apart from total cervical ROM. While a case series cannot identify a cause and effect relationship, these results provide preliminary evidence for the influence of TMJ manual therapy on measures of TMD including pain, as well as upper but not whole cervical movement and associated pain in patients with a diagnosis of TMJ arthralgia.

Temporomandibular disorder in otolaryngology: systematic review

Background:

Temporomandibular disorder poses a diagnostic challenge to otolaryngologists as orofacial pain, headache and otology symptoms are very common in temporomandibular disorder, and mimic a number of otolaryngological conditions. Missed diagnosis of temporomandibular disorder can lead to unnecessary investigation and treatment, resulting in further patient suffering.

Objectives:

To review the current literature and propose management pathways for otolaryngologists to correctly differentiate temporomandibular disorder from other otolaryngological conditions, and to initiate effective treatment for temporomandibular disorder in collaboration with other health professionals.

Method:

A systematic review using PubMed and Medline databases was conducted, and data on temporomandibular disorder in conjunction with otolaryngological symptoms were collected for analysis.

Results:

Of 4155 potential studies, 33 were retrieved for detailed evaluation and 12 met the study criteria. There are questionnaires, examination techniques and radiological investigations presented in the literature to assist with distinguishing between otolaryngological causes of symptoms and temporomandibular disorder. Simple treatment can be initiated by the otolaryngologist.

Conclusion:

Initial temporomandibular disorder treatment steps can be undertaken by the otolaryngologist, with consideration of referral to dentists, oral and maxillofacial surgeons, or physiotherapists if simple pharmacological treatment or temporomandibular disorder exercise fails.

The effectiveness of exercise therapy for temporomandibular dysfunction: a systematic review and meta-analysis

Objective:

To investigate the effectiveness of exercise therapy on pain, function, and mobility outcomes in patients with temporomandibular joint dysfunction.

Study design:

Systematic review with meta-analysis.

Methods:

A systematic review and meta-analysis undertaken following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that met the inclusion criteria: (1) randomized controlled trials; (2) a population with the diagnosis of temporomandibular joint dysfunction; and (3) interventions that included exercise therapy were considered for review. When studies demonstrated homogeneity on outcome measures, the mean differences or standardized mean differences with 95% confidence interval were calculated and pooled in a meta-analysis for pooled synthesis.

Results:

Six articles with a total of 419 participants were included in the review and only four studies were included in the meta-analysis. Mobility and mixed exercise therapy approaches appear to be the most common exercise approaches utilized for management of temporomandibular joint dysfunction. Exercise therapy and the associated dosage provide moderate short-term and varying long-term benefits in reduction of pain and improvement of range of motion of the in patients with temporomandibular joint dysfunction.

Conclusion:

Included studies suggest a mobility or a mixed approach to exercise therapies have impact on reducing pain, significant impact for increasing range of motion, but lack a significant impact for functional improvement.

Level of evidence:

Therapy, level 1a-.

The status of temporomandibular and cervical spine education in credentialed orthopedic manual physical therapy fellowship programs: a comparison of didactic and clinical education exposure

OBJECTIVE

The purpose of this investigation was to establish a baseline of physical therapist education on temporomandibular disorders (TMD)-related topics during credentialed orthopedic manual physical therapy fellowship training and compare it to cervical spine disorders education.

METHOD

An online survey was distributed electronically to each fellowship program credentialed by the American Physical Therapy Association (APTA) and recognized by the Academy of Orthopedic Manual Physical Therapists (AAOMPT). Data were analyzed to compare overall exposure to TMD educational content, including a direct comparison of TMD and cervical spine disorders education.

RESULTS

The response rate was 79%. Thirteen programs (87%) reported providing both didactic and clinical training on both TMD and cervical spine disorders. Didactic education for cervical spine disorders ranged from 16-20 hours to over 25 hours, whereas TMD hours ranged from 0 to 6-10 hours. Clinical education for cervical spine disorders ranged from 11-15 hours to over 25 hours, whereas TMD hours ranged from 0 to 6-10 hours. The number of hours of exposure during didactic training and the number of patients exposed to during clinical training were significantly different when comparing TMD to cervical spine disorders exposure (P<0.0001).

DISCUSSION

The data indicate a lack of uniformity between credentialed fellowship programs in orthopedic manual physical therapy with respect to the extent to which programs expose trainees to evaluation and management of TMD. There is consistency in that all programs provided more training on cervical spine disorders than TMD. Despite a high level of clinical specialization, fellows-in-training receive minimal TMD education.

Immediate changes in temporomandibular joint opening and pain following vibration therapy: a feasibility pilot study

OBJECTIVE

The purpose of this pilot study was to determine the scientific and process feasibility in an effort to direct future larger trials.

METHODS

Scientific Feasibility: Twelve subjects were randomly allocated to an intervention and a control group. The intervention protocol consisted of intraoral vibration therapy on the muscles of mastication bilaterally for a period of 1 minute per muscle. Process Feasibility: Several feasibility outcomes were examined including recruitment and retention rates and consent.

RESULTS

Scientific Feasibility: Large effect sizes were generated for both mouth opening and VAS in favour of the intervention group. Process Feasibility: a recruitment ratio of 2.3 respondents to 1 participant was determined, along with a retention to loss ratio of 13:1 and a consent to loss ratio of 12:0.

CONCLUSION

Scientific Feasibility: The scientific results should be interpreted with caution due to the small sample sizes employed. The study seems to support the scientific feasibility of a future larger single treatment trial. Process Feasibility: Recruitment and retention rates and ratios seem to support future studies. Utilizing the feasibility results of the current study to direct a future larger multiple treatment trial consistent with other comparable TMD studies however is limited.

Use of orthopedic manual physical therapy to manage chronic orofacial pain and tension-type headache in an adolescent

Temporomandibular dysfunction (TMD) is frequently associated with multiple headache types. While the efficacy of orthopedic manual physical therapy (OMPT) intervention for TMD with/without headache symptoms has been investigated, it has received less attention than other musculoskeletal conditions. This case describes the OMPT treatment and outcome of a 14 year-old female with a 2-year history of facial pain surrounding the right temporomandibular joint (TMJ), and bilateral occipital and temporal tension-type headaches (TTHs). Intervention included manual mobilization of the TMJ and surrounding cervical/facial soft tissue structures, postural re-education, and patient/family education on prevention, self-treatment, and postural adaptations. Outcomes included pain free and maximal mouth opening (MMO), pressure pain threshold (PPT) over the masseter muscle belly, fear avoidance beliefs questionnaire-physical activity subscale (FABQ-PA), jaw pain and function questionnaire (JPFQ), visual analog pain scale (VAS) for facial pain, and headache frequency, duration, and intensity on a VAS. Results included increased pain free and MMO by 22 mm, improved PPT bilaterally by 403.05 kPa on the affected, and 360.88 kPa on the unaffected side, and decreased reported headache frequency, duration, and intensity. Score decreases of 5 points on VAS with MMO, 8 points on FABQ-PA, and 5 points on JPFQ were also noted. Further research is warranted to investigate the effects of OMPT on pain processing and functional outcomes in patients with TMD and headache.