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· Arousal · Exercise · Posture
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Temporomandibular Disorders (TMD) Note: TMD is
sometimes referred to as TMJ symdrome. ·
Symptoms ·
Causes ·
Posture ·
Warning ·
Exercise "Today,
researchers generally agree that temporomandibular disorders fall into three
main categories: · myofascial pain, the most common form of TMD, which is discomfort or
pain in the muscles that control jaw function and the neck and shoulder
muscles; · internal derangement of the joint, meaning a dislocated jaw or displaced disc, or injury
to the condyle; · degenerative joint disease, such as osteoarthritis or rheumatoid arthritis in the
jaw joint." NIDR: What are Temporomandibular Disorders? ·
"We know that severe injury to
the jaw or temporomandibular joint can cause TMD. A heavy blow, for example,
can fracture the bones of the joint or damage the disc, disrupting the smooth
motion of the jaw and causing pain or locking. Arthritis in the jaw joint may
also result from injury… ·
Some suggest, for
example, that a bad bite (malocclusion) can trigger TMD, but recent
research disputes that view. ·
Orthodontic treatment, such as braces and the use of
headgear, has also been blamed for some forms of TMD, but studies now show that
this is unlikely. ·
And there is no
scientific proof that gum chewing causes clicking sounds in the
jaw joint, or that jaw clicking leads to serious TMJ problems. In fact, jaw
clicking is fairly common in the general population. If there are no other
symptoms, such as pain or locking, jaw clicking usually does not need
treatment." "Injury to the jaw, temporomandibular joint, or muscles
of the head and neck – such as from a heavy blow or whiplash – can cause TMD.
Other possible causes include: ·
Grinding or clenching
the teeth, which puts
a lot of pressure on the TMJ ·
Dislocation of the soft cushion or disc between
the ball and socket ·
Presence of osteoarthritis
or rheumatoid arthritis in the TMJ ·
Stress, which can cause a person to tighten
facial and jaw muscles or clench the teeth" WebMD: Temporomandibular Disorders (TMD) Chewing-Side Preference ·
Laterality:
Change in Chewing-Side Preference May Cause TMD Stress "Stress and tension may awaken a
(quiet) asymptomatic TMD, aggravate or intensify an existing
temporomandibular condition. However, in order for stress to effect TMD there
must be an underlying physical predisposition for the disorder to cause TMD.
If a patient has healthy dental occlusion, muscle and jaw function, stress
would not cause TMD, but would likely produce effects elsewhere in the
body." Conservative and
Reversible Treatments "The key words to keep in mind about TMD treatment are
'conservative' and 'reversible.' Conservative treatments are as simple
as possible and are used most often because most patients do not have severe,
degenerative TMD. Conservative treatments do not invade the tissues of the
face, jaw or joint. Reversible treatments do not cause
permanent, or irreversible, changes in the structure or position of the jaw
or teeth." "Because most TMD problems are temporary and do
not get worse, simple treatment is all that is usually needed to relieve
discomfort. Self-care practices, for example, eating soft foods,
applying heat or ice packs, and avoiding extreme jaw movements
(such as wide yawning, loud singing and gum chewing) are useful in easing TMD
symptoms. Learning special techniques for relaxing and reducing stress may
also help patients deal with pain that often comes with TMD problems." "All too often patients are
classified as 'chronic pain patients' and their complaints pigeonholed as
stress or psychological disorders. These patients may be relegated to
treatment only with medication and counseling, with no treatment of the
physical cause of their illness. A valid analysis of each patient is
essential to give fair weight to the physical vs. psychological status before
that patient is told, in essence, "it's all in your head." "Early appropriate treatment of a
TMD may avoid the progression to a chronic pain state, much less easily
resolved." "Other conservative, reversible
treatments include physical therapy you can do at home, which focuses on gentle
muscle stretching and relaxing exercises, and short-term use of
muscle-relaxing and anti-inflammatory drugs." "Treatment
goals for TMD addressed by physical therapy are to relieve pain,
decrease muscle spasm in the masticatory and/or cervical musculature,
decrease intra-articular inflammation or tendonitis, restore normal
mandibular function and motion without restriction, normalize ROM, and manage
the problem to a level of tolerance, since there is no 'cure' for TMD (1,4).
Modalities implemented to address these treatment goals are ·
Heat in the form of a moist heat pack
or ultrasound/phonophoresis, ·
Cryotherapy in the form of an ice pack
or a fluoromethane vapocoolant spray, ·
Electrotherapy such as transcutaneous electrical
nerve stimulation (TENS) or electrical stimulation
(E-stim)/iontophoresis, and ·
Manual techniques such as soft tissue
mobilization (STM)/massage, joint mobilization/distraction, or
cervical traction (4)." University of Delaware Physical Therapy: TMJ
Dysfunction "TMJ
dysfunction is a complex disorder involving many aspects of physical therapy.
Because not all 'TMJ patients' have the same clinical presentation, it
is very important for the therapist to establish the cause of the patient's
affliction. Once established, the therapist can create a better plan of care
for the patient." University of Delaware Physical Therapy: TMJ
Dysfunction "Although
it is important for patients to be treated for TMJ dysfunctions, it is just
as important for them to be educated on how to better take care of themselves
so that they may relieve their own pain, and prevent a further reoccurrence
of symptoms. Physical therapists are not always able to see their patients as
many times as they may like, so it is often times necessary to set them up
with a good home rehabilitation program in between visits and after
their physical therapy has been completed." University of Delaware Physical Therapy: TMJ
Dysfunction "A common presentation of TMJ
dysfunction is hypermobility of the joint. Although there are dozens
of other diagnoses involving TMJ dysfunction, hypermobility is perhaps the
most prevalent mechanical disorder, and thus warrants discussion of
treatment.(6) · No chewing gum, ice, or
fingernails. · No clenching teeth, or clenching
cigars or pipes between teeth. · No wide jaw opening when eating;
no eating tough, chewy, or crunchy foods. · No wide jaw opening when talking,
singing, or yawning. All of the above actions could
potentially cause further injury to the hypermobile TMJ.(1,3,7,10)" University of Delaware Physical Therapy: TMJ
Dysfunction "The
next thing that should be addressed is the patient's posture. A major cause
of many patients' TMJ dysfunctions is the way they carry their heads.(11)
When the head is protruded, the jaw (especially when chewing) is
placed in an awkward position that strains the masticatory muscles.(7)
Postural awareness should be broken down into three components: standing,
sitting, and sleeping. ·
Standing should be assessed, and focus
should be placed on
These
exercises promote standing up straight and retraction of the head, neck, and
shoulders. ·
Sitting should be assessed next, especially
in patients who work behind desks or drive regularly. Focus should be placed
on
·
Finally, sleeping posture should be assessed,
focusing on
Although
patient comfort needs to be taken into account, the supine sleeping position
[sleeping on your back] is preferable.(4) Sleeping prone [sleeping
on your stomach] puts the cervical [neck] spine in a rotated and extended
position, putting stress on the joints, muscles, and ligaments of the spine
and leading to trauma of the TMJ.(1,4)" University of Delaware Physical Therapy: TMJ
Dysfunction "Those
with dislocating jaws should not do these [jaw] exercises. Please
consult your doctor for further advice." Coventry Pain Clinic: Treatment - Exercises - Head,
Neck, Shoulder, Arms "The
patient should then be taught some stretching to relieve the strain on the
neck and masticatory [chewing] muscles.(1) Stretches should include a
Masseter / Temporalis stretch, a Sternocleidomastoid stretch, an Upper
Trapezius stretch, and Posterior Cervical muscle stretches." University of Delaware Physical Therapy: TMJ
Dysfunction "All of
these stretches should be ·
Performed bilaterally [on left and
right sides of the body] (with the exception of the Temporalis / Masseter
stretch) and Done at
least 3 times per day." University of Delaware Physical Therapy: TMJ
Dysfunction Stretching: Stretching the Jaw Note: Those
with dislocating jaws should not do these [jaw] exercises. Please consult
your doctor for further advice "If you
can comfortably get three or more knuckles between your front teeth [try
one or two first, see instructions on linked page], you have good jaw
opening and do not need to do this exercise." Coventry Pain Clinic: Treatment - Exercises - Head,
Neck, Shoulder, Arms "The Masseter
and Temporalis muscles can be stretched by having the patient pull the
jaw forward, down and to the side opposite the involved joint." University of Delaware Physical Therapy: TMJ
Dysfunction Stretching: Stretching the Neck ·
"The Sternocleidomastoids can be
stretched by having the patient extend the head, bending it to the side
opposite the muscle, and turning the head to the same side as the muscle. ·
The Upper
Trapezius can be stretched by having the patient tilt the head to
one side, while turning the face to the other side. ·
The Posterior Cervical muscles can be stretched
by having the patient flex the head and neck on the chest. Flexion
with rotation to both sides should also be done to stretch other
posterior cervical muscles.(14)" University of Delaware Physical Therapy: TMJ
Dysfunction Note: Please
consult your doctor before attempting these exercises. "In
addition to stretching and postural adjustments, a home exercise program
needs to be established. The Southside approach is a three-part
program that incorporates awareness, control, and stabilization, and seems to
be quite effective. ·
The first part is done to balance the upper
quarter of the body through awareness of RTTPB. RTTPB stands for
and
promotes a comfortable, relaxed jaw position that can be properly
exercised. ·
The second part is
With
the tongue on the roof of the mouth (to ensure pure rotation)
the mouth is passively, then actively opened. After proper rotation
has been established with exercises, the patient can progress to opening the
mouth passively, then actively without the tongue touching the roof of
the mouth. ·
The final part
With
the jaw in the neutral position, the patient pushes on the jaw with
his/her index finger to the
while
isometrically resisting the force applied. The
patient progresses with this exercise by repeating the steps with
the jaw
(This
exercise can be done while the patient is performing the rotation and
translation exercises).(14)" University of Delaware Physical Therapy: TMJ
Dysfunction "A
final method that a therapist can use to rehabilitate patients is through the
use of Biofeedback, or 'Jaw awareness.' Biofeedback is a means of behavior
modification that teaches the patient voluntary self-regulation and
awareness of muscle tone and tension. This is usually done using Electromyographic
(EMG) feedback, where an EMG machine amplifies minute muscle action
potentials to let the patient know when the muscle is over-active.(7) The
patient attempts to lower the signal and 'learns' what the relaxed state
should feel like.(11) Biofeedback can be used on the masticatory
[chewing] muscles, as well as cervical [neck] postural muscles to
decrease muscle guarding and fatigue, to retrain postural muscles, and to
enable the patient to become familiar with the 'feeling' of low levels of
muscle activity.(7)" University of Delaware Physical Therapy: TMJ
Dysfunction ·
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