Patients with TMD require a multi-dimensional approach to address symptoms.

Psychosocial factors strongly associated with pain intensity, disability, and prognosis.

Recent systematic reviews show evidence to support the use of physiotherapy treatments in:

• Increasing active range of mouth opening
• Decreasing pain during active mouth opening
• Increasing pressure pain thresholds

Treatments used include:

• Intraoral myofascial release
• Massage of masticatory muscles
• TMJ mobilisations
• Upper cervical mobilisations
• Postural, jaw and neck exercises

Biopsychosocial Management

• Patho-anatomical factors
• Neurophysiological factors (increased pain sensitivity, centrally-mediated pain)
• Physical factors (joint or muscle loading, movement patterns, provocative functional behaviour/parafunction)
• Psychological factors (cognitive, emotional, affective, coping, self-efficacy)
• Social factors (family, relationships, work, education)
• Lifestyle (sleep, physical activity, body weight, smoking)
• General health, dental health, comorbidities
• Genetic factors

Useful Questions to Identify Psychosocial factors

• What do you understand is the cause of your symptoms?
• What are you expecting will help you?
• What are you doing to cope with your symptoms?
• How are other people responding to your symptoms?
• Have you had time off work with symptoms?
• Has your social life been restricted due to symptoms?
• Low mood, anxiety, life stress?

Education/Advice/self-management

• Reassurance
• Explain pain
• Dental assessment (for patients not referred by dental service)
• Reduce the threat of symptoms
• Listen and acknowledge their problem
• Validate and provide or reinforce benign nature of TMD diagnosis
• Challenge unhelpful beliefs
• Explain pain cycle management
• Emphasis on self management
• Set goals

Head position and sitting position:

Correct excessive forward head position which can affect jaw ROM, Masseter EMG activity, position of the condyles.

Correcting sustained postures:

Phone bracing, prone sleeping, chin resting on hands, keeping tooth contact, jaw bracing or tension, denture holding, jaw protrusion, lateral excursion, tongue against or between teeth.

Parafunction and oral behaviours checklist

Avoid oral habits: sleep bruxing, clenching or grinding teeth during the day, muscle hypertonicity, nail biting, gum, pen, hair chewing, lip, tongue, cheeks chewing or biting, chewing food on one side only.

Sustained talking.

Singing or playing a musical wind or brass instrument.

Promote good habits:

Eat a soft diet, chew slowly, avoid caffeine, use the no clenching app (available from the apple store and google-play), check the relaxed jaw position throughout the day.

Teach 'relaxed jaw' position:

Keep teeth apart (say Emma). Tongue on roof of mouth behind front teeth (clucking position) regularly check jaw rest position, relaxed diaphragmatic breathing.

Relaxation techniques and sleep hygiene

Reduce Muscle activity

1. Relax jaw muscles: blow out through the lips so the cheeks bulge out
2. Masseter massage: circular motion, 5 minutes, 3 times per day
3. Temporalis Massage: anterior to posterior fibres. Circular motion, 5 minutes, 3 times per day
4. Open and close mouth. Keep tongue on roof of mouth

Manual Therapy

• Intra-oral Masseter release
• Distraction/ Caudad (+/- active mouth opening)
• Posterior-anterior translation (+ distraction)
• Medial glide
• Lateral glide

Progress from using small movements to larger movements and using sustained techniques at end range mouth opening.

Stretching

Jaw opening active assisted stretch (scissor action).

Normalise Movement Pattern

1. Jaw Control Exercise

• Tongue in 'clucking' position and index finger on TMJ to feel any clicking.
• Use the index finger and thumb of the other hand o the chin to guide symmetrical opening and apply gentle retrusive pressure.
• Use mirror for feedback
• Repeat 3 times, 10 times per day

2. Jaw Retrusion Exercise

• Using a small hollow plastic tube between the teeth.
• Slowly slide the lower teeth backwards along the tube.
• Hold 5 seconds.
• Repeat 5 times, 3 times per day.

3. Strengthening/Stabilisation

• Activate posterior fibres of Temporalis (jaw retrusion action) with isometric contraction.
• Jaw relaxed position.
• Use the force of one finger on the lateral jaw.
• Resist 5 seconds.
• Repeat 10 times, 3 times per day.
• Progress by increasing the jaw opening starting position.

Acupuncture

Acupuncture has been suggested to help TMD symptoms (pain and clicking) by relaxing lateral pterygoid muscles

Recommended points:

• Local Points - ST6, ST7
• Distal Points - SI8, LI4, BL10, GB20, GV20

Other

Splint provision by dental staff (hard gumshield).

Botulinum toxin injections.